r . A~ F~ ssa, oeoervmm d m . rTmM im i ReYViue Servlca A For the 2001 calendar 2001 Under section 501(c) . 527, a 4947(a)(7) 01 the Internal Revenue Code (except black lung benefit bust or private foundation) Open to Public 6/30/2002 OR tax year beginning 7/1/2001 , and C Name d aganimtbn D Empbiar NerMfcatbn number B Check If applicable F1 Address diange Q Name change F-1 1ndial return Final realm F-JArterded realm F1 Application pending use IRS Drone Providence Hosp ital label o, - s4eel sueel Number WO (u P O Ow d mall U n0'JhaeE b sdde) print « tpe Sea 1100 Gramp ian Boulevard Specific iGy or town Sate cr country Williams port time PA Section 507(c)13) organization and 4947(a)(1) nonexempt charitable busts moat attach a completed Schedule A (Form 990 or YB0 .EQ E Telephone number LP i 1 F Accounting method u Cash u Accrual 17701 I 0 Other I end I ere not applcade b section 527 orpenuortbrq H(a) Is thus a group raNm for affiliates? Li Yes 1XI No H(b) If'Ves,' inter number of afilutro H(a) Am all offillabas Included? 1:1 Yes 1:1 No (Ifmo"atted .ftsI .seei) H(d) Is ties e separate notion tried by enorger-~r a , 0on covered by a 0~+0 ruling? U Yes Q No 3 1 (insert no or I 1527 J K Check tare 1:1 n ms wvntcaaan a PMs+racelohen nmAlly na Mme owe fxs o00 The pp3nmCOn need rrol file B RMn w~N IM IRS, WI N IM organization ncahaC " Fpm BDO PYilp! In the rtsll. II sMilO file B RNn wIHiM Ilrondel deb Some states naWn a owqllb rob" to Excess or (deficit) for the year (subtract line 17 from line 72) Net 19 Net assets or fund balances at beginning of year (from line 73, column (A)) Assets I 20 Other changes m net assets or fund balances (attach explanation) Statement 4 Form 990(2007) For Papenwrk Reduction Act Notice . see the separate instructions ffTA) Return of Organization Exempt From Income Tax M Check Oaths organ~6on u not requned Gross receipts Add Ones 61 5 . Bb and tOb b line 12 63,540,506 b attach Sdh B (Fpm 990, BBOFZ v BBO?F rt I Revenue, Ex penses, and Chan ges In Net Assets or Fund Balances (See Specific Instructions on page 16 ) 1 Contributions, gifts, grants, and similar amounts received a Direct public support . . 7a b Indirect public support tb 176 .510 Q e Government contributions (grants) 1c 383 , 263 N d Total (add lines 1a through 1c) (cash $ 559,773 noncash $ Schedule B ) td 2 Program service revenue including government fees and contracts (from Part VII, line 93) 2 43 3 Membership dues and assessments 3 4 Interest on savings and temporary cash investments 4 5 Dividends and interest from securities 5 ,., 6a Gross rents Statement 1 6a 1 791 360 b Less rental expenses . 6b 1 489 291 e Net rental income or (loss) (subtract line 6b from line 6a) ec: 7 Other investment income (describe 7 ea Gross amount from sales of assets other A Securities B Other than inventory 17 ,059 , 766 1 Be 50 u b Less cost or other basis and sales expenses 17 , 144 , 705 1 Bb e c Gam or (loss) (attach schedule) -84,939 1 ec 50 d Net gain or (loss) (combine line Bc, columns (A) and (B)) Statement 2 Statrnent 3 ed 9 Special events and activities (attach schedule) a Gross revenue (not including $ ~ contributions reported on line 1a) + :.- 9a b Less direct expenses other than fund isu~g expert 9b e Net income or (loss) from special even ~ li e 9b in 9e ~ ~a~ 7oa Gross sales of inventory, less returns a,'~r I ~ 1oa b Less cost of goods sold ! 10b c Gross profit or (loss) from sales of invertory ( qp VI subValine 10b from line 70a) ~Oc 11 Other revenue (from Part Vll, line 103) ~ - - - - » 113 Program services (from line 44, column (B)) Ex- 114 Management and general (from line 44, column (C)) pen- I 75 Fundraising (from line 44, column (D)) SOS is Payments to affiliates (attach schedule)
Transcript
r . A~
F~ ssa,
oeoervmm d m. rTmM im i ReYViue Servlca
A For the 2001 calendar
2001 Under section 501(c) . 527, a 4947(a)(7) 01 the Internal Revenue Code (except black lung benefit bust or private foundation)
Open to Public
6/30/2002 OR tax year beginning 7/1/2001 , and C Name d aganimtbn D Empbiar NerMfcatbn number B Check If applicable
F1 Address diange
Q Name change
F-1 1ndial return
Final realm
F-JArterded realm
F1 Application pending
use IRS Drone Providence Hosp ital label o, - s4eel sueel Number WO (u P O Ow d mall U n0'JhaeE b sdde) print « tpe Sea 1100 Grampian Boulevard
Specific iGy or town Sate cr country
Williams port time
PA
Section 507(c)13) organization and 4947(a)(1) nonexempt charitable busts moat attach a completed Schedule A (Form 990 or YB0.EQ
E Telephone number
LP i 1 F Accounting method u Cash u Accrual
17701 I 0 Other I end I ere not applcade b section 527 orpenuortbrq H(a) Is thus a group raNm for affiliates? Li Yes 1XI No H(b) If'Ves,' inter number of afilutro
H(a) Am all offillabas Included? 1:1 Yes 1:1 No
(Ifmo"atted .ftsI.seei) H(d) Is ties e separate notion tried by enorger-~r
a
,
0on covered by a 0~+0 ruling? U Yes Q No
3 1 (insert no or I 1527 J
K Check tare 1:1 n ms wvntcaaan a PMs+racelohen nmAlly na Mme owe fxs o00 The
pp3nmCOn need rrol file B RMn w~N IM IRS, WI N IM organization ncahaC " Fpm BDO PYilp! In the rtsll. II sMilO file B RNn wIHiM Ilrondel deb Some states naWn a owqllb rob"
to Excess or (deficit) for the year (subtract line 17 from line 72) Net 19 Net assets or fund balances at beginning of year (from line 73, column (A))
Assets I 20 Other changes m net assets or fund balances (attach explanation) Statement 4
Form 990(2007) For Papenwrk Reduction Act Notice . see the separate instructions ffTA)
Return of Organization Exempt From Income Tax
M Check Oaths organ~6on u not requned Gross receipts Add Ones 61 5. Bb and tOb b line 12 63,540,506 b attach Sdh B (Fpm 990, BBOFZ v BBO?F rt I Revenue, Expenses, and Changes In Net Assets or Fund Balances (See Specific Instructions on page 16 )
1 Contributions, gifts, grants, and similar amounts received a Direct public support . . 7a b Indirect public support tb 176 .510
Q e Government contributions (grants) 1c 383 ,263 N d Total (add lines 1a through 1c) (cash $ 559,773 noncash $ Schedule B ) td
2 Program service revenue including government fees and contracts (from Part VII, line 93) 2 43 3 Membership dues and assessments 3 4 Interest on savings and temporary cash investments 4 5 Dividends and interest from securities 5
,., 6a Gross rents Statement 1 6a 1 791 360 b Less rental expenses . 6b 1 489 291 e Net rental income or (loss) (subtract line 6b from line 6a) ec: 7 Other investment income (describe 7 ea Gross amount from sales of assets other A Securities B Other
than inventory 17 ,059,766 1 Be 50 u b Less cost or other basis and sales expenses 17,144,705 1 Bb e c Gam or (loss) (attach schedule) -84,939 1 ec 50
d Net gain or (loss) (combine line Bc, columns (A) and (B)) Statement 2 Statrnent 3 ed 9 Special events and activities (attach schedule) a Gross revenue (not including $
~ contributions reported on line 1a) +:.- 9a b Less direct expenses other than fund isu~g expert 9b e Net income or (loss) from special even ~ li e 9b in 9e
~ ~a~ 7oa Gross sales of inventory, less returns a,'~r I ~ 1oa b Less cost of goods sold ! 10b c Gross profit or (loss) from sales of invertory ( qp VI subValine 10b from line 70a) ~Oc 11 Other revenue (from Part Vll, line 103) ~ - ---
»
113 Program services (from line 44, column (B)) Ex- 114 Management and general (from line 44, column (C)) pen- I 75 Fundraising (from line 44, column (D)) SOS is Payments to affiliates (attach schedule)
(A) Total I (B) Program I (C) Management I (D) Fundraising
Joint Costs Check U if you are follomng SOP 98-2
What is we organization's primary exempt purpose? Statement 7 All organizations must describe their exempt purpose achievements in a dear and whose manner State the number of diems served, publications issued, eta Discuss achievements that are not measurable (Section 501(c)(3) and (4) organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and
23 Specific assistance to individuals (attach schedule) 24 Benefits paid to or for members (attach schedule) 25 Compensation of officers, directors, etc 26 Other salaries and wages 27 Pension plan contributions 28 Other employee benefits 29 Payroll faxes 30 Professional fundraising fees 31 Accounhngfees 32 Legal fees . . 33 Supplies 34 Telephone 35 Postage and shipping 36 Occupancy 37 Equipment rental and maintenance 38 Printing and publications 39 Travel 40 Conferences, conventions, and meetings 41 Interest 42 Depreciation, depletion, etc (attach schedule) 43 Other menses not covered above (item¢e) e
f Global Budget 4i Total functional expenses (add lines 22 through 4:
Organizations completing columns (B) - (D), carry
Are any point costs from a combined educational campaign and fundraising solicitation reported m (B) Program services If 'Yes." enter (p the aggregate amount of these joint costs $_, (n) the amount allocated to Program services
Yes ~X No S
Program Saints Expenses
(ReaWmd ror 5ot(cN7)
W(I)ups end
4Gt7(e)(tlmeo bud
Drone Providence Hospital 24-0799343 Pace 3
Part IV Balance Sheets (See Specific Instructions on page 24 )
Note : Where required, attached schedules and amounts within the description (B)
49 Grants receivable 5o Recervables from officers, directors, trustees, and key employees
(attach schedule) Sta Other notes and loans receivable (attach schedule) b Less . allowance for doubtful accounts 52 Inventories for sale or use 53 Prepaid expenses and deferred charges 5a Investments -securities (attachschedule)cost 55a Investments -land, buildings, and equipment
basis
X FMV Statement 8
b Less accumulated depreciation (attach schedule) SSb
SB Investments - other (attach schedule) 57a Land, buildings, and equipment basis 57a 71 ,123.93 b Less accumulated depreciation (attach schedule) Statement 9 57b 50.928.02 58 Other assets (describe Statement 10 )
Liabilities 60 Accounts payable and accrued expenses 61 Grants payable 62 Deferred revenue 83 Loans from officers, directors, trustees, and key employees (attach schedule) eaa Tax-exempt bond liabilities (attach schedule) Statement 17 b Mortgages and other notes payable (attach schedule) 65 Other Ilabilihes (describe Statement 12 )
Organizations that do not follow SFAS 117, check here and complete lines 70 through 74
70 Capital stock, trust principal, or current funds 71 Paid-in or capital surplus, or land, building . and equipment fund 72 Retained earnings, endowment, accumulated income, or other funds 73 Total net assets or fund balances (add lines 67 through 69 OR lines
70 through 72, column (A) must equal line 19, column (B) must equal line 21)
Form 990 is available for public inspection and, for same people, serves as the primary or sole source of information about a particular organization Haw we public perceives an organization in such cases may be determined by the information presented on it return Therefore, please make sure we retain is complete and accurate and fatty describes, in Part Ill, the organization's programs and accomplishments
4
/lasers as Cash - non-interest-beanng . . 48 Savings and temporary cash investments
47a Accounts receivable b Less allowance for doubtful accounts
48a Pledges receivable b Less' allowance for doubtful accounts
Net Assets or Fund Balances Organizations that follow SFAS 177, check here ~X and complete lines
67 through 69 and lines 73 and 74 67 Unrestricted 68 Temporarily restricted 69 Permanently restricted
Rental expense Add amounts on lines (1) thru (4)
e Line a minus line b d Amounts included on line 77,
Form 990 but not on line a (7) Investment expenses not
included on line 6b, Form 990 (2) Other (specify)
Intra-entity Rental elimination Add amounts on lines (1) and (2)
e Total expenses per line 17,
Rental expense $ -1 .48 Add amounts on lines (1) and (2)
e Total revenue per line 12,
Part V List of Officers, Directors, Trustees, and Key Employees (ust each one even if not
75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your organization and all related organizations . of which more than $10,000 was provided by the related organizations'? ~X Yes If 'Yes,' attach schedule - see Specific Instructions on page 27 Statement 13
990 (200t)
4
Part N-A Reconciliation of Revenue per Audited Financial Statements with Revenue per
a Total revenue, gains, and other support per audited financial statements
b Amounts included on line a but not on line 12, Form 990
(1) Net unrealized gams on investments $ 11,1
(2) Donated services and use of facilities $
(3) Recoveries of prior year grants $
(4) Other (specify) Infra-Entity Rent elimination $ 31,8 Add amounts on lines (1) thru (4)
e Line a minus line b d Amounts included on line 12,
Forth 990 but not on line a (7) Investment expenses not included on
line 6b, Form 990 $ (s) Other (specify)
Part IV-B Reconciliation of Expenses per Audited Financial Statements with
a Total expenses and losses per audited financial statements
b Amounts included on line a but not on line 17, Forth 990
(7) Donated services and use of facilities $
(2) Prior year adjustments reported on line 20, Forth 990 $
(3) Losses reported on line 20, Form 990
(d) Other (specify)
(B) TiHeandaverage I (C) ComPen- I Nlca~mdmorom (A) Name and address hours per week week sahon pi not enc"euwnn pse a
(E) Expense account and other
No
and check whether It is LJexempt OR "nonexempt. eta Enter dared or indirect political expenditures See line 81 instructions 81a b Did the organization file Form 1120-POL for this year?
B2a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge or at substantially less than fair rental value?
b If -Yes," you may indicate the value of these items here Do not include this amount as revenue in Part I or as an expense m Part II (See instructions in Part III ) I 82b ~ N/A
83a Did the organization comply with the public inspection requirements for returns and exemption applicabons? b Did the organization comply with the disclosure requirements relating to quid pro quo contributions?
84a Did the organization solicit any contnbutions or gifts that were not tax deduc4ble? b If 'Yes," did the organization include with every solicitation an egress statement that such
contributions or gifts were not tax deductible? 85 501(c)(4), (5), or (6) organ¢ahons e Were substantially all dues nondeductible by members? b Did the organization make only in-house lobbying expenditures of $2,000 or less?
If 'Yes" was answered to either 85a or 85b, do not complete BSc through BSh below unless the organization received a waiver for proxy tax owed far the prior year
c Dues, assessments, and similar amounts from members 85e N/A d Section 162(e) lobbying and political expenditures BSd N/A e Aggregate nondeductible amount of section 6033(ex1)(A) dues notices N/A t Taxable amount of lobbying and political expenditures (line 85d less 85e) 85f N/A g Does the organization elect to pay the section 6033(e) tax on the amount on line 85Y? h If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount on line 85f to its
reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year? . . .
88 501(c)(7) ores Enter a Initiation fees and capital contributions Inducted on line 12 868 N/A
b Gross receipts, Inducted on line 12, for public use of dub facilities I
6b N/A 87 501(c)(12) orgs Enter a Gross income horn members or shareholders 87a N/A
Gross income horn other sources (DO not net amounts due w paid to other sources against amounts due a received from them ) 87b N/A At any time during the year, did the aganQahon own a 5096 or greater interest m a taxable corporation or partnership, a an entity disregarded as separate from the organization under Regulations sections 301 7701-2 and 3017701-37 If "Yes," complete Part IX 501(c)(3) organizations Enter Amount of tax imposed on the organization during the year under section 4911 0 , section 4912 0 , section 4955 501(c)(3) and 501(cx4) orgs Did the organization engage in any section 4958 excess benefit transaction during the year or did d became aware of an excess benefit transaction from a prior yeah If -Yes,* attach a statement explaining each transaction Enter Amount of tax imposed on the organization managers or disqualified persons during the year under
0 0
sections 4912, 4955, and 4958 Enter Amount of tax on line 89c, above, reimbursed by the organization List the states with which a copy of this return is filed Pennsylvania 90a
b Number of employees employed in the pay period that inGudes March 12, 2001 (See instructions ) 190b I 415 97 The books are In care of Management Telephone no (570) 320-7900
Located at 1205 Grampian Boulevard, W illiamsport, PA ZIP " a 17701
82 Section 4947(a)(1) nonexempt charitable trusts filing Forth 990 in lieu of Forth 1047 - Check here and enter the amount of tax-exempt interest received or accrued during the tax year ~ 92
Forth 990 (2001)
Other 76 Did the brganizatlon engage m any activity not previously reported to the IRS? If 'Yes,' attach a detailed description of each activity 77 Were any changes made in the organizing or governing documents but not reported to the IRS?
If -Yes," attach a conformed copy of the changes 78a Did the organization have unrelated business gross income of $1,000 or more during the year covered
by this return? b If 'Yes,* has R filed a tax return on Forth 990-T for this year? 7s Was there a liquidation, dissolution, termination, or substantial contraction during the yeah If 'Yes,"
attach a statement Boa Is the organization related (other than by association with a statewide or nationwide organization)
through common membership, governing bodies, trustees . officers, etc , to any other exempt or nonexempt organization?
b If "Yes." enter the name of the organization Statement 14
88
89a
UKW parlYa d puny, l Mdve that I I~ bmmroE Ws ieGVn ena wile) n b true cmxl eM tmpete Deftraom of VFteQ
Please ) Sign Here signamrewofficer
0-h Ck v ~t 12 Typo a goof name and trGe
Paid s~ahrta ~~r° ~,(~s+l~" Preparers F,~,n~.�~(Q~,++ ~ PdFOFr~pANDDLPH FC Use Only It .mplo�a) .
r Form 990 (2001) Divine Providence Hospital 24-0799343 Pane 6
Note Enter gross amounts unless otherwise Unrelated business income Excluded b section 512 513 w 514 (E) indicated (/) (B) (C) (D) Related a exempt 93 Program service revenue Business code Amount Exclusion code Amount function Income a Net Patent Service Revenue 29 611 776 b e d e t Medicare/Medicaid payments 13 ,443 ,000 g Fees and contract horn government agencies 94 Membership dues and assessments 95 Interest on savings and temporary cash Investments 14 248 ,971 96 Dividends and interest from securities 14 282 913 97 Net rental income or (loss) from real estate a debt-financed properly b not debt-financed property 16 302,069 98 Net rental Income a (loss) horn personal property 99 Other investment income 100 Gam w pons) from sales of assets other than inventory . 18 -84 ,889 101 Net income or (loss) from special events 102 Gross profit or (loss) from sales of inventory 703 Other revenue e Statement 15 542 ,896 b c d e 104 Subtotal (add cols (B), (D), and (E)) 01,291.960 43.054,776 105 Total (add line 104, columns (B), (D), and (E)) 44,346.736
t VIII Relationship of Activities to the Accomplishment of Exempt Pu rposes seas insauctiorts tin pace 32 Line No Explain how each activity for which income is reported m column (E) of Part VII contributed Importantly to the
accomplishment o1 the o aniuNon's exempt u other than b rovldin funds for such u
Patient services are direct) related to Divine Providence Hospital's exempt purpose of providing healthcare to L cumin surrounding counties
t IX Information Re ardin Taxable Subsidiaries and Disregarded Entities sees ind, as ca (e) cc~ (D) (E)
Name, address, arid EIN of corporation, veCweap~ a Nature oT acLrhes Total End-of-year
(a) Did the organization . during the year, receive any funds, directly a indirectly, to pay premiums on a personal benefit contract? [-]Yea aX No (b) Did the organization, during the year, pay premiums, directly a indirectly, on a personal benefit contract? n Vsa n Ne
Organization Exempt Under Section 501(c)(3) (Except Private Foundation) and Section 501(e), 5010, 507(k),
501(n), or Section 4947(a)(1) Nonexempt Charitable Trust
Supplementary Mtortnation - (See separate instructions Deprtarern of the Treasury
cpense account and other
number of other employees paid
Name and address of each independent contractor I (b) Type of service
$50,000 firorofess professional motes over I 4
e For Paperwork Reduction Act Notice, see the Instructions for form 990 and Form 990-EZ (Hrn) Schedule A (Form 990 a 990-EZ) 2001
SCHEDULE A (Form 990.or 990
(a) Name and address of each (b) Tide and average (a) ca,maman m employee paid more than $50,000 hours par week (c) Compensation WrOafeebermfilptOM&
devoted to ikon deferred Medical Director
K Miller M D Community Hith Ctr
Medical Director Occupational Health
Senior VP/ Campus Administrator
Assoc Medical Drtec Occupational Health
Physician
2001 number
3 Does the organization make grants for scholarships, fellowships, student loans, etc ? (See Note below ) 4 Do you have a section 403(b) annuity plan for your employees?
Note Attach a statement to explain how we organization determines that individuals or organizations receiving grants
Part N Reason for Non-Private Foundation Status (See pages 3 through 6 of the instructions )
me o anvaLon is not a private foundation because it is (Please check only ONE applicable box ) 5 A church, convention of churches, or association of churches Section 170(b)(1)(A)(i) 8 DA school Section 170(b)(1)(A)(n) (Also complete Part V ) 7 X A hospital or a cooperative hospital service organization Section 170(b)(1)(A)(m) 8 DA Federal, state, or local government or governmental unit Section 1170(b)(1)(A)(v) 9 =A medical research organization operated in conjunction with a hospital Sec4on 170(b)(1)(A)(w) Enter the hospital's
name, city, and state 10 =M organization operated for the benefit of a college or university owned or operated by a governmental unit
Section 170(b)(1)(A)(rv) (Also complete the Support Schedule in Part IV-A ) 17a =M organization that normally receives a substantial part of its support from a governmental and or from the
general public Section 170(b)(1)(A)(vi) (Also complete we Support Schedule in Part IV-A ) 11b=A community trust Sec4on 170(b)(1)(A)(vi) (Also complete the Support Schedule m Part IV-A) 12 =M organization that normally receives (1) more than 33 1/3% of its support from contributions,
membership fees, and gross receipts from activities related to its charitable, etc , functions- subbed to certain exceptions, and (2) no more than 33 1/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975 See section 509(a)(2) (Also complete the Support Schedule in Part IV-A )
13 OM organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations descnbed in (1) lines 5 through 12 above, or (2) section 501(c)(4), (5), or (6), if they
Line number (a) Name(s) of supported organization(s)
Schedule A (Forth 990 w
Part III Statements About Activities (See page 2 of we instructions ) I Yea I No During we year, has the organization attempted to influence national, state, or local legislation . including any attempt to influence public opinion on a legislative matter or referendum? If 'Yes,' enter the total expenses paid or incurred in connection with the lobbying activities $ 5.204 (Must equal amounts on line 38, Part VI-A, w line I of Part VI-8 ) Organizations that made an election under section 501(h) by filing Forth 5768 must complete Part VI-A Other organizations checking 'Yes,' must complete Part VI-B AND attach a statement giving a detailed clescripbon of the lobbying activities . During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any substantial contributors, trustees, directors, officers, creators, key employees, or members of their families, or with any taxable organization with which any such person is affiliated as an officer, director, trustee, majority owner, or principal beneficiary? (If we answer to any question is "Yes." attach a detailed statement explaining the transactions )
a Sale, exchange, or leasing of property? . .
b Lending of money or other extension of credit?
c Furnishing of goods, services, or facilities? Statement 16
d Payment of compensation (or payment or reimbursement of expenses H more than $1,000)1
e Transfer of any part of its income or assets?
14 LJAn organization organized and operated W test for public safety Section 509(a)(4) (See page 6 of the instructions )
28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any unusual grants during 1997 through 2000, prepare a list for your records to show, for each year, the name of the contributor, the date and amount of we grant, and a brief description of we nature of the grant Do not file this list with your retain Do not include these grants in line 15
Schedule A (Form 990 or 99D-EZ) 2001
Schedule A (Form 990 a 990-EZ) 2001 Divine Providence Hospital 240799343 Pace 3 Part N-A Support Schedule (Complete only if you checked a box on line 10, 11, or 12.) Use cash method of accounting
77 Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to the
Gross income from Interest, dividends, amounts received ham payments on securities loans (section 512(aH5)), rents . royalties, and unrelated business taxable income (less section 517 faxes) from businesses acquired by the organization
income from unrelated business activities
Tax revenues leered for the organization's benefit
The slue of services or facilibes furnished to the organization by a governmental and without charge Do not Include the value of services or facilities
Other income Attach a schedule Do not include
26 Organizations desanbad on lines 10 or 77 : a Enter 2% of amount m column (e), line 24 b Prepare a list for your records to show the name of and amount contributed by each person (other than a governmental unit or publicly supported organization) whose total grits for 1997 through 2000 exceeded the amount shown m line 26a Do not file this list with your retain Enter the total of all these excess amounts
c Total support for section 509(a)(1) test Enter line 24, column (e) d Add Amounts from column (e) for lines 18 0 19 0
22 0 26b 0 e Public support (line 26c minus line 26d total) f Public suooort oercentaae (line 28e (numerator) divided by line 26c (denominator)) . . . . . .
27 Organizations described on line 12: a For amounts included in lines 15, 16, and 17 that were reserved from a "disqualified person," prepare a list for your records to show the name of, and total amounts reserved in each year from, each 'disqualified person ' Do not file this list with your retain Enter the sum of such amounts for each year
(2000) (1999) (1998) (1997) b For any amount included in line 17 that was reserved from each person (other than 'disqualified persons'), prepare a list for your records to show the name of, and amount reserved for each year, that was more wan the larger of (1) the amount on line 25 for the year or (2) $5,000 (Include m the list organizations described in lines 5 through 11, as well as individuals ) Do not file this list with your retain After computing the difference between the amount received and the larger amount described in (1) or (2), enter we sum of these differences (we excess amounts) for each year
(2000) (1999) (1998) (1997)
c Add Amounts from column (e) for lines 15 0 16 0 17 0 20 0 21 0
d Add Line 27a total 0 and line 27b total 0 e Public support (line 27c total minus line 27d total) f Total support for section 509(a)(2) test Enter amount from line 23, column (e) L27f p Public support percentage (line 27e (numerator) divided by line 27f (denominator))
Schedule A (Form 990 w 990-EZ) 2007 Divine Providence Hospital 24-0799343 Pace a Part V Pnvate,School Questionnaire (See page 7 of the instructions )
No
a Students' rights or privileges?
b Admissions policies?
c Employment of faculty or administrative stafr?
d Scholarships or other financial assistance? . .
e Educational polices?
f Use of facilities?
g Athletic programs?
h Other extracurricular activities?
If you answered "Yes' to any of the above, please explain (If you need more space, attach a separate statement )
Schedule A (Form 990 a 990FZ) 2001
29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, other governing instrument, or in a resolution of its governing body?
30 Does the organization include a statement of its mealy nondiscriminatory policy toward students in all its brochures, catalogues, and other written communications with the public dealing with student admissions, programs, and scholarships?
31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during the period of solicitation for students, or during the regisVaUOn period if it has no solicitabon program, in a way that makes we policy known to all parts of the general community it serves? If 'Yes," please describe, rf'No,' please explain (If you need more space, attach a separate statement)
32 Does the organization maintain we following a Records indicating the racial composition of the student body, faculty . and administrative staff! b Records documenting that scholarships and other financial assistance are awarded on a racially
nondiscriminatory basis? c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing with student admissions, programs, and scholarships?
d Copies of all material used by the organization or on its behalf to solicit contributions?
If you answered "No" to any of we above, please explain (If you need more space, attach a separate statement )
33 Does the organization discriminate by race in anyway with respect to
34a Does the organization receive any financial aid or assistance from a governmental agency?
b Has the organization's right to such aid ever been revoked or suspended? If you answered "Yes' to either 34a or b, please explain using an attached statement
35 Does the organization certify that it has complied with the applicable requirements of sections 4 01 through
Schedule A (Form 990 or 990.EZ) 2001 Divine Providence Hospital 24-0799343 pane 5 Part VI-A Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions )
Check a 0 f( the organization belongs to an affiliated group Check b []if you checked 'a' and -limited control" provisions
(a) I (b) Affiliated TOWm,a�rc�uy m~~nMf~la ~O
36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 37 Total lobbying expenditures to influence a legislative body (dared lobbying) 38 Total lobbying expenditures (add lines 36 and 37) 39 Other exempt purpose expenditures 40 Total exempt purpose expenditures (add lines 38 and 39) 41 Lobbying nontaxable amount Enter the amount from we following table -
M the amount on line 40 la - The lobbying nontaxable amount Is Not over $500,000 20% a the amount on line 40
Lobbying Expenditures During 4-Year Averaging Period
1 (e)
During the year, did the organization attempt to influence national, stale or local legislation, Including any attempt to influence public opinion on a legislative matter or referendum, through the use of a Volunteers b Paid staff or management (include compensation m expenses reported on lines c through h ) c Media advertisements d Mailings to members, legislators, or the public e Publications, or published or broadcast statements f Grants to other organizations for lobbying purposes g Direct contact with legislators, their staffs, government officials, or a legislative body h Rallies, demonstrations, seminars, conventions, speedier, lectures . a any other means X I Total lobbying expenditures (Add lines c through h ) ~/ l/ p
If 'Yes' to any of the above, also attach a statement giving a detailed description of the lobbying activities Schedule A (Form 990 or 990-EZ) 2001
Limits on Lobbying Expenditures
Over $500,000 but not aver $1,000,000 $700,000 plus 15% of the excess over $500,000 1, Over $1,000,000 but not over $1,500,000 $175,000 plus 10% of the excess over $7,000,000 y Over $1,500,000 but not over $17,000,000 $225,000 plus 5% of the excess over $1,500,000 , over $17.000,000 si .ooo,ooo
42 Grassroots nontaxable amount (enter 25°h of line 41) 43 Subtract line 42 from line 36 Enter-0- dime 42 is more than line 36 44 Subtract line 41 from line 38 Enter-0- if line 41 is more than line 38
4 - Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below
Calendar year (or
Part VI-B
Schedule a (Forth 990 or 990-EZ) 2001 Divine Providence Hospital 24-0799343 Page 6 Part VII Information Regarding Transfers To and Transactions and Relationships With
Noncharitable Exempt Organizations (See page 12 of the instructions ) 57 Did the reporting organization directly or indirectly engage in any of the following with any other organization descnbed in
section 501(c) of we Code (other wan section 501(c)(3) organizations) or m section 527, relating to political organizations? a Transfers from the reporting organization to a nonchantable exempt organization of yes
(i) Cash 513(l) X (II) Other assets
b Other transactions (I) Sales or exchanges of assets with a nonchantable exempt organization bill X (ii) Purchases of assets from a nonchantable exempt organization bill) X (in) Rental of facilities, equipment, or other assets b(m) X (iv) Reimbursement arrangements (v) Loans or loan guarantees (vi) Performance of services or membership or fundraising solicitations
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees d If the answer to any of the above is 'Yes .' complete we following schedule Column (b) should always show we fair market value of the goods, other assets, or services given by the reporting organization If the organization received less wan fair market value in any transaction or shanng arrangement, show in column
(a) I (b)
52a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described m section 501(c) of we Code (other than section 501(c)(3)) or in section 5277 = Yes = No
1,791,360 Total to Forth 990, Part I, Line 6a
Divine Prowdenoe Hospital
Forth 990, Part 1, Line 6a Rental Income Statement 1
Description
Office space rental to various healthcare providers
240799,'id3
Amount
1,791,360
Form 990, Part I, Line 8 (l) Gain (Loss) From Sale of Securities Statement 2
17,144,705 84,939 Total to Form 990, Part 1, Line 8 (A) 17,059,766
Dmne Promdence Hospital
Description
Marketable Equity Securities
Date Gross Sold Sales Price
Various 17,059,766
24-0799343
Cost or Net Gain Other Basis or Loss
17,144,705 84,939
Forth 990, Part 1, Line 8 (B) Gain (Loss) From Sale of Other Assets Statement 3
Accum Book Sales Depreciation Value Price Gain (Loss
0 0 50 50 03/02 Maw Moveable Equipment
Tots m Form 990, Part I, Line 8 (B) 0 0 0 50 50
DM* PmvNance HosP+al
Description Date Cwt or Sold Other Basis
2I-07993x3
24-0799343
(402,697)
2,979
8,132
37,848
(353,738) Total to Form 990, Part 1, Line 20
Drone Providence Hospital
Forth 990, Part I, Line 20 Other Changes In Net Assets Statement 4
Description
Change in Net Unrealized Gams and Losses on Investments
Net Assets Released from Restrictions used for Purchase of P8E
Net Assets Released from Restrictions used for Operations
Increase m Interest in Net Assets of Affiliate
Donee's Donee's Address Relationship Amount
1100 Grampian Boulevard Affiliated Entity 1,600,000 Wdhamsport, PA 77701
Transfer to Affiliate Providence Health System Foundation
Dmne Rvnftrce Hospital
Forth 990, Part 11, Line 22 Cash Grants and Allocations Statement 5
Total to Form 990, Part IV, Line 65, Column B 5,059,180
Divine Prohderroe Hospital
Form 990, Part N, Line 65, Column B Other Liabilities Statement 12
Amount
163,742
4,895,438
Employee Title and Ben Plan Expense
Name and Address Avp Hrs / Week Compensation Contrlb Account
Peyton D McDonald Chairperson 0 0 0 Wdilamsport, PA 17707 Various
John V Calce, M D Vice Chairperson 0 0 0 Wdliamsport, PA 17701 Various
Birch Phillips, Jr Secretary 0 0 0 Cogan Station, PA 17728 Various
Steven P Johnson Asst Secretary 0 0 0 Williamsport, PA 17701 Various
Dale B Stebner Treasurer 0 0 0 Williamsport, PA 17701 Various
Charles J Santangelo Asst Treasurer 0 0 0 Wdliamsport, PA 17701 Various
Sister Vincent Huber Director 0 0 0 Wdliamsport, PA 17701 Various
James E Mothersbaugh Director 0 0 0 Muncy,PA 17756 Various
Naresh C Nagpal, M D Director 0 0 0 Muncy, PA 17756 Various
Ralph Nardi, Jr Director 0 0 0 Wdliamsport, PA 17701 Various
Kathleen Pagana, R N , Ph D Director 0 0 0 Williamsport, PA 17701 Various
Sister Mana Assumpta Shurer Director 0 0 0 Mendham, NJ 07945-0800 Various
Marvin H Staiman Director 0 0 0 Williamsport, PA 17701 Various
Paul E Heise Director 0 0 0 Hugesville, PA 17737 Various
Dmne Prwidence Hospital 24-0799343
Forth 990, Part V List of Officers, Directors, Trustees, and Key Employees Statement 13
24-0799343 Divine Providence Hospital
Forth 990, Part V List of Officers, Directors, Trustees, and Key Employees Statement 13
Employee Title and Ben Plan Expense
Name and Address Ava Hrs / Week Compensation Contrlb Account
Peter J Goodwm Director 0 0 0 Montoursvdle, PA 17754 Various
Ruth K Keller Ex-Officio 0 0 0 Cogan Station, PA 17728 Various
Sister Jean Mohl Ex-Officio 0 0 0 Wdliamsport, PA 17701 Various
Demetri T Poulis, M D Ex-Officio 0 0 0 Wdliamsport, PA 17701 Various
Stephen F Weber, M D Ex-Officio 0 0 0 Wdliamsport, PA 17701 Various
Sister Mary Edward Sphorer Ex-Officio 0 0 0 Mendham,NJ 07945 Various
Daniel E Wolfe, M D Ex-Officio 0 0 0 Williamsport, PA 17701 Various
Ralph Cranmer Dir Ementus 0 0 0 Williamsport, PA 77701 Various
Richard M Dore Dir Emeritus 0 0 0 Williamsport, PA 17701 Various
Dwight E Waltz, D D S Dir Emeritus 0 0 0 Wdliamsport, PA 17701 Various
240799343
Forth 990, Part V, Line 75 List of Officers, Directors, Trustees, and Key Employees Supplemental Statement
In addition, Sister Jean Mohl, Vice Chairperson of Susquehanna Health System, 23-2751183, is provided compensation for her responsibilities which is paid directly to the Sisters of Christian Charriy
DMne ProvlOence Hospital
Contributions to Expense Name Compensation Emp Benefit Plans Account
Naresh C Nagpal, M D 299,887 29,160 0
Stephen F Weber, M D. 200,320 24,038 0
The above compensation was paid by Susquehanna Physician Services, EIN : 23-2449454 .
Name of Organization Exempt
Sisters of Christian Charity Health Care Corporation X
Providence Health System Foundation X
Providence Health Services, Inc X
Providence Imaging, Inc
Susquehanna Regional Home Health Services, Inc X
Muncy Valley Hospital X
Holy Spirit Corporation X
Holy Spent Hospital X
Comfort Care of Holy Spent, Inc X
Holy Spirit Ventures, Inc
West Shore Advanced Life Support Services, Inc X
Susquehanna Regional Healthcare Alliance DB/A X Susquehanna Health System
Susquehanna Phyisican Services X
Susquehanna Ventures, Inc
Providence Cancer Treatment Services, Inc X
X
Divine Prohdence Hospital
Forth 990, Part VI, Line BOb Identification of Related Parties Statement 14
24-0799343
Non-Exempt
X
X
240799343
Exclusion Excluded Code Amount Description
Sports Medicine 03 177,591 Cafeteria 03 157,593 Kid Care 03 83,832 VHA Rebate 03 41,101 Telephone Triage 03 35,600 Other Mental Health 03 22,151 Breast Health 03 11,110 Selmsgrove Dialysis 03 6,000 Telephone 03 3,719 Miscellaneous 03 2,864 Fitness Center 03 1,335
Total to Form 990, Part VII, Line 103 542,896
Dine Providence Hospital
Forth 990, Part VII, Line 103 Other Revenue Statement 15
24-0799343
Investment management services are provided by Smith Barney, where Peyton McDonald, a board member, is employed as First Vice President All transactions occur at fair market value
Divine Providence Hospital
Form 990, Schedule A, Part III, Line 2 Statement Regarding Activities with Directors, Trustees, or Principal Officers Statement 16
24-0799343
On occasion, HAP requests the help of member providers to communicate concerns to legislators regarding pending legislation which could impact hospitals This can involve direct contact with legislators or letter-writing This occurs infrequently, and the cost to the Hospital is negligible
Divine Providence Hospital
Forth 990, Schedule A, Part VI-B Lobbying Activity Statement 17
The Hospital holds membership in the American Hospital Association, (AHA) and the Hospital Association of Pennsylvania, (HAP), bow of which engage m lobbying as part of their mission to represent the interests of hospitals at both the Federal and the State levels For the year ended 06/30/02, the amount of dues paid to HAP totaled $13,266 which 219'0, $2,786, was used for lobbying purposes Dues paid to AHA totaled $10,724, of which 22 55%, $2,418, was used for lobbying purposes
Form 8868 (12-2000)
..
0 II you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II and check this box . Note : Only complete Part 11 f/ you hive already been granted an automata 3-month extension an a previously filed Form 8868, a If u are film for an Automatic ]-Month Extension, complete only Part I (on page 1)
. AOnal not automatic 3-Month Extension of Time-Must File Ori final and One Co
or ddUName of Exempt OrgamuWn Employer identification number Type °' poor Divine Providence Hospital <r,", "̀;y~`~;~s- 24 :0799J43 File by the Number street. and room or suite no If a P O box, see instructions For IRS use only
kn ~:~4x. eldemed 7205 Grampian Blvd, 2nd Floor due date for So ; ~^9 return ~+~ee C. tmm a post office state and ZIP code for a fore ig n address see instructions s WdhamsPR PA 1T101 ms w rnom
-
wrnom x�~,. zsF-:" , ' Q Check type of realm W be filed (File a separate application for each return)
Form 990 El Form 990-EZ C3 Form 990~T (sec 401 (a) or 408(a) wsQ 0 Form 1041-A 0 Form 5227 13 Form 8870 Form 990-BL 0 Form 990-PF C1 Form 990-T (trust other than above) 0 Form <720 0 Form 6069
STOP Do not complete Part 11 d you were not already granted an automatic 7-month extension on a previously filed Form 886&
a If the organization does not have an once or place of business in the United States, check this box R, If this is for a Group Return, enter the oManiuuon's four digit Group Exemption Number (GEN) If this is for the whole group, check this box " LJ If rt is for part of the group, diedc this box " 0 and attach a list with the names and EINS of all members the extension is (or
03. 4 I request an additional 3-month extension of time until May 15 . . . . . . . . . . ._________ . 20 . pp 0~ and ending dune 30 . ._ . . . . .__ . 20 02 5 For calendar year or other tax year beginning ~ulYOt
6 If this tax year is for less wan 12 months, check reason 0 Initial return ~ Final return C3 Change in accounting period 7 State in detail why ou need the extension al information necessary to file a complete and accurate return has not
yet been fill
Be If this application 0-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable cre its ~~LWq~
. b If this appli cauon bf r Form - 472 , or 6069, enter any refundable credits and estimated tax payments m A6 IBF r'rior year rpaymrst allowed as a credit and any amount paid pre~ously wiN F r 8868"` li ~
2003 .
c Balance Due S bva 8b from line 8a I de your payment with this form, or, if required deposit with F7D coup n or, rQ61~d ~-b PS (Electronic Federal Tax Payment System) See instructions S
attire and Verification UnM pmirtes d 7erjuy I aeclue that I MW examined tnrs loan mt7uMy eccamperyrtg xteCUks and striemerrts and to use best of my knowledge am bet!! rt n true tmeR era c pe a d that I auunnie m Pill tms'mm
Nonce to Applicant-To Be Completed by the IRS We have approved this applKZiron Please attach this form to the wganinuon s return We have not approved this applcaUOn However we have granted a 10-day grace period from the later of the date shown below or the due date of the orgarnzaum 5 return (inctuWng any prior extensions) This grace period i5 considered to be a "lid extension of time !or elections otherwise requires to be made on a timely return Please attach this loan to the organization s return
pRENION p ~~,~ We have pat approveG this application After considering the reasons stated in uem 7 we cannot grant your request or an eat n to file We are not granting a 70-day grace period We cannot consider this application because it was riled after the due date of the return !or which an exter6~0~ was requq5]laq Olher
LINDA WEISKOPF, FIELD DIRECTOR, By SU_uISS10N PROCESSING,OG_=M -
Gate Deecmr Alternate Mailing Address - Enter the address d you want the copy of this application for an additional 3-month extension returned to an address different than we one entered above
Name
Type or I Number and street (elude suite, room, or app no ) Or a P O box cumber pool
r City or town. prmnnce or state. aid country (ncludmg postal or ZIP code)
