Form '9o Return of Organization Exempt From Income Tax OMB No. 154&0047 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung O %pert en~ibf the treasury benefit trust or private foundation) Internal venue Service " The organization may have to use a copy of this return to satisfy state reporting requirements . . - A For the 2003 calendar ear or tax ear be innin 2003 and endin 06 /30 /2004 B Chock If applicable please C Name of Organization SAINT JOSEPH HEALTHCARE , INC . D Employer identification number Address use IR change S D /WA SAINT JOSEPH EAST 6 SAINT JOSEPH H03P . 61-1334601 ICI Of "'e'"° change print or Number and street (or P.O box if mail is not delivered to street address) Room/suite e Telephone number India[ ratum type . Final r.t= See 150 N . EAGLE CREEK DR . (859)313-1000 - H AmeWed Specific -1 IF Accounting " return Insbruc- City or town, state or country, and ZIP + 4 method . Cash I X1 Accrual Application dons. pending XIN T N Other s ec 1 ~ Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable H and I are not applicable to section 527 organizations. trusts must attach a completed Schedule A (Form 990 or 990-EZ). H(a) Is this a group return for affiliates? F-l Yes Fx-]No G Website : 1 WWW , SJHLEX . COM H(b) If "Yes," enter number of affiliates 1 N A J Organization type (check only one) lo- I X 501(c) ( 3 ) ~ (insert no ) 947(a)(1) or 527 H(c) Are all affiliates included? Yes frNo (If "No," attach a list See instructions K Check here 0' if the organization's gross receipts are normally not more than $25,000 The H(d) Is this a separate velum filed by an organization need not file a velum with the IRS, but if the organization received a Form 990 Package or anization covered b a rou rulln ? X Yes No in the mad, it should file a velum without financial data Some states require a complete return. I Group Exem lion Number 1110~ 0928 M Check 1 U if the organization is not required L Gross receipts: Add lines Bb, 8b, 9b, and 10b to line 12 1 332 , 382 , 174 . to attach Sch . B (Forth 990, 990-EZ, or 990-PF) . 19 Net assets or fund balances at beginning of year (from line 73, column (A)) , , , , , , , , , , , , 19 189 , 642 , 345 . m 20 Other changes in net assets or fund balances (attach explanation) , , , , , ,S,2, , , $TM, .3 , 20 1 , 970 , 228 . 21 Net assets or fund balances at end of ear combine lines 18 19 and 20 " " 21 207 , 792 , 838 . n For Paperwork Reduction Act Notice, see the separate Instructions . Form 990 (2003) 1 JSA 'kE 1010 2 000 PB1097 552B 05/09/2005 14 :35 :03 V03-8 10852447 emu Revenue, Ex p enses, and Chang es in Net Assets or Fund Balances See page 18 of the instructions . 1 Contributions, gifts, grants, and similar amounts received a Direct public support , , , , , , , , , , , , , , , . , , , , , , , , 1 a 40 b Indirect public support , 1 b c Government contributions (grants) , , , , , , , , , , , , , , , , , 1 c d Total (add lines 1a through 1c) (ash $ noncash $ ) 1 d 31 2 Program service revenue including government fees and contracts (from Part VII, line 93) , , , , , , , , 2 324 , 660 , 224 . 3 Membership dues and assessments , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 3 4 Interest on savings and temporary cash investments , , , , , , , , , , , , , , , , , , , , , , , , , 4 972 , 403 . 5 Dividends and interest from securities , , , , , , , , , , , , , , , , , , , , , , , 5 769 , 784 . B a Gross rents , , , , , , , , , , , , , , , , , , , , , , , , , , , , 8a b Less rental expenses , , , , , , , , , , , , , , , , , , , , , , , 6b C Net rental income or (loss) (subtract line 6b from line 6a) , , , , , , , , , , , , , , , , , , , , , , . 6c 3 7 Other investment income (describe " 7 m 8 a Gross amount from sales of assets other (A) Securities (e) Other than inventory , 2 , 970 , 692 . 8a 3 , 009 , 071 . b Less cost or other basis and sales expenses . 8b 940 . 714 . c Gain or (loss) (attach schedule) .STMT 1A . 2 , 970 , 692 . 8c 2 , 068 , 357 . d Net gain or (loss) (combine line 8c, columns (A) and (B)) . . . . , , , . , , . , . . . . , , . , 8d 5 , 039 , 049 . 9 Special events and activities (attach schedule) If any amount is from gaming, check here " .~ . a Gross revenue (not including $ of contributions reported on line 1a), , , , , , , , , , , , , , , , , , 98 b Less direct expenses other than fundraising expenses , , , , , , , , 9b c Net income or (loss) from special events (subtract line 9b from line 9a) " . . . . . . . . . . . . . . 9c 10 a Gross sales of inventory, less returns and allowances , , , , , , , , 0a b Less cost of goods sold , , , , , , , , , , , , , , , , , , , , , , Ob c Gross profit r (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) , , , , , I Oc ;S 'rvenue from Part VII, line 103) , , , , , , , , , , , , , , , , , , , , , , , , , , , . . . , , 11 7"2~Y o add lines 1d 2 3 4 5 6c 7 8d 9c 10c and 11 " . 12 331 441 460 . 13 Program s s (from line 44, column (B)) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 13 271 490 486 . 141 ~la2~n d general (from line 44, column (C)) , , , , , , , , , , , , , , , , , , , , , , , , , 14 39 , 748 , 105 . e- 15 Fundrais' m line 44, column (D)) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 15 '~6 ~ ~yrr~~to of liates (attach schedule) , , , , , , , : : $~,'I~jT ~ : : : : : : : : : : : : : : : : : . 16 4 , 022 , 604 . ~~l Total exp s (add lines 76 and 44, column (A)) . " 17 315 . 2 61 _ 19-9; .
Transcript
Form '9o Return of Organization Exempt From Income Tax OMB No. 154&0047
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung O %pert en~ibf the treasury benefit trust or private foundation) Internal venue Service " The organization may have to use a copy of this return to satisfy state reporting requirements . . - A For the 2003 calendar ear or tax ear be innin 2003 and endin 06/30/2004 B Chock If applicable please C Name of Organization SAINT JOSEPH HEALTHCARE , INC. D Employer identification number Address use IR change S D /WA SAINT JOSEPH EAST 6 SAINT JOSEPH H03P . 61-1334601
ICI Of
"'e'"° change print or Number and street (or P.O box if mail is not delivered to street address) Room/suite e Telephone number India[ ratum type .
Final r.t= See
150 N . EAGLE CREEK DR . (859)313-1000 -
H
AmeWed Specific
-1
IF Accounting " return Insbruc- City or town, state or country, and ZIP + 4 method
. Cash I X1 Accrual Application dons.
pending XIN T N Other s ec 1 ~ Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable H and I are not applicable to section 527 organizations.
trusts must attach a completed Schedule A (Form 990 or 990-EZ). H(a) Is this a group return for affiliates? F-l Yes Fx-]No G Website: 1 WWW, SJHLEX . COM H(b) If "Yes," enter number of affiliates 1 N A J Organization type (check only one) lo- IX 501(c) ( 3 ) ~ (insert no ) 947(a)(1) or 527 H(c) Are all affiliates included? Yes frNo
(If "No," attach a list See instructions K Check here 0' if the organization's gross receipts are normally not more than $25,000 The H(d) Is this a separate velum filed by an organization need not file a velum with the IRS, but if the organization received a Form 990 Package or anization covered b a rou rulln ? X Yes No in the mad, it should file a velum without financial data Some states require a complete return. I Group Exem lion Number 1110~ 0928
M Check 1 U if the organization is not required L Gross receipts: Add lines Bb, 8b, 9b, and 10b to line 12 1 332 , 382 , 174 . to attach Sch . B (Forth 990, 990-EZ, or 990-PF).
19 Net assets or fund balances at beginning of year (from line 73, column (A)) , , , , , , , , , , , , 19 189 , 642 , 345. m 20 Other changes in net assets or fund balances (attach explanation) , , , , , ,S,2, , , $TM, .3 , 20 1 , 970, 228 .
21 Net assets or fund balances at end of ear combine lines 18 19 and 20 " " 21 207 , 792 , 838. n For Paperwork Reduction Act Notice, see the separate Instructions. Form 990 (2003) 1
JSA 'kE 1010 2 000
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emu Revenue, Expenses, and Changes in Net Assets or Fund Balances See page 18 of the instructions . 1 Contributions, gifts, grants, and similar amounts received a Direct public support , , , , , , , , , , , , , , , . , , , , , , , , 1 a
40 b Indirect public support � � � � � � � � � � � , 1 b c Government contributions (grants) , , , , , , , , , , , , , , , , , 1 c d Total (add lines 1a through 1c) (ash $ noncash $ ) 1 d
31 2 Program service revenue including government fees and contracts (from Part VII, line 93) , , , , , , , , 2 324 , 660 , 224 . 3 Membership dues and assessments , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 3 4 Interest on savings and temporary cash investments , , , , , , , , , , , , , , , , , , , , , , , , , 4 972 , 403 . 5 Dividends and interest from securities , , , , , , , , , , , , , , , , , , , , , , , 5 769 , 784 . B a Gross rents , , , , , , , , , , , , , , , , , , , , , , , , , , , , 8a b Less rental expenses , , , , , , , , , , , , , , , , , , , , , , , 6b C Net rental income or (loss) (subtract line 6b from line 6a) , , , , , , , , , , , , , , , , , , , , , ,
. 6c
3 7 Other investment income (describe " 7 m 8 a Gross amount from sales of assets other (A) Securities (e) Other
than inventory � � � � � � � , 2 , 970 , 692 . 8a 3 , 009 , 071 . b Less cost or other basis and sales expenses . 8b 940 . 714 . c Gain or (loss) (attach schedule) .STMT 1A . 2 , 970 , 692 . 8c 2 , 068 , 357 . d Net gain or (loss) (combine line 8c, columns (A) and (B)) . . . . , , , . , , . , . . . . , , . , 8d 5 , 039 , 049 .
9 Special events and activities (attach schedule) If any amount is from gaming, check here " .~ . a Gross revenue (not including $ of
contributions reported on line 1a), , , , , , , , , , , , , , , , , , 98 b Less direct expenses other than fundraising expenses , , , , , , , , 9b c Net income or (loss) from special events (subtract line 9b from line 9a) " . . . . . . . . . . . . . . 9c
10 a Gross sales of inventory, less returns and allowances , , , , , , , , 0a b Less cost of goods sold , , , , , , , , , , , , , , , , , , , , , , Ob c Gross profit r (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) , , , , , I Oc
Statement of All organizations must complete column (A). Columns (B), (C), and (D) are required for section 501(cx3) and (4) organizations " Functional Expenses and section 4947(a)(1) nonexempt charitable trusts but optional for others (See page 22 of the instructions.)
Do nat include amounts reported on line (A) Total (B) Program (C) Management (D) Fundraising 6b 9b lab, or 16 f l. services and general i
22 Grants and allocations (attach schedule)
(cash S 465 1794, noncasr,E ) 22 465 794 . 465 794 23 Specific assistance to individuals (attach schedule) 23 r 1 , ,, - x 24 Benefits paid to or for members (attach schedule) 24
Joint Costs. Check 0 Ix if you .are following SOP 9&2 . Are any joint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? , , , , , " a Yes X No If "Yes," enter (i) the aggregate amount of these joint costs $ ; (11) the amount allocated to Program services $ III the amount allocated to Management and general $ , and Iv the amount allocated to Fundraising $ ffWffM Statement of Program Service Accomplishments See page 25 of the instructions .
-_-----------_----_-- Program Service What is the organization's primary exempt purpose? " _ STMT 8 -------------------- Expenses
All organizations must describe their exempt purpose achievements in a clear and concise manner State the number (Required for 501 (c)(3) and
of clients served, publications issued, etc. Discuss achievements that are not measurable. (Section 507(cx3) and (4) (a) orgs., and asa7(a)(1)
organizations and 4947(a)( 1 ) nonexempt charitable trusts must also enter the amount of grants and allocations to others trusts ; but optional for
e Other program services (attach schedule) (Grants and allocations $ ) f Total of Program Service Expenses (should equal line 44, column (B), Program services) . . , , " 271, 490 , 486 .
Balance Sheets (See page 25 of the instructions .)
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. Note : Where required, attached schedules and amounts within the description (A) (B) column should be for end-of-year amounts only. Beginning of year End of year
m 69 Permanently restricted . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 . 69 Organizations that do not follow SFAS 717, check here 10 and
complete lines 70 through 74 . 0 70 Capital stock, trust principal, or current funds , , , , , , , , , , , , , , , , , , 70 w 71 Paid-in or capital surplus, or land, building, and equipment fund , , , , , , , , 71 w 72 Retained earnings, endowment, accumulated income, or other funds , , , , , 72 a 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) , , , , , , , , 189 642 345 . 73 207 , 792 , 838 .
total-lta-bflifies an ne asse s 1 fund -balances a fines 66 and 73 . 297 , 9 81 472 . 74 315 535 476 . Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about a
particular organization. How the public perceives an organization in such cases may be determined by the information presented on its return . Therefore, please make sure the return is complete and accurate and fully describes, in Part III, the organization's programs and accomplishments.
4
per
S Add amounts on lines (1) through (4) , , " b
c Line a minus line b , , , , , , , , , " c d Amounts included on line 17,
Form 990 but not on line a : (1) Investment expenses
not included on line 6b, Form 990 , , , s
(2) Other (specify)
c Line a minus line b t d Amounts included on line 12,
Form 990 but not on line a : (1) Investment expenses
not included on line 6b, Form 990 , , , $
(2) Other (specify)
S S Add amounts on lines (1) and (2) . , " d Add amounts on lines (1) and (2) , ,
e Total revenue per line 12, Form 990 e Total expenses per line 17, Form 990 III 1w c w,% mm u P`1 a nnC c ius moC u
JjM List of Officers, Directors, Trustees, and Key Employees (List each one even if not compensated; see page 27 of
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Forth 990 (2003)
" r%rs&unI k%->aW Nayo 41 v1 uU 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 gains NOT APPLICABLE
on investments , , $ (2) Donated services
and use of facilities ; (3) Recoveries of poor
year grants , , , , $ (4) Other (specify)
Add amounts on lines (1) through (4) " 1 b
61-1334601
a iotai expenses and losses per audited financial statements
b Amounts included on line a but not on line 17, Form 990:
(1) Donated services and use of facilities $
(2) Prior year adjustments reported on line 20, Form 990 , , , , , $
(3) Losses reported on line 20, Form 990 $
(4) Other (specify)
75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your organisation and all related organizations, of h more than $10,000 was provided by the related organizations? " Yes ~No
If "Yes," attach schedule - see page 28 of the instructions SEE STATEMENT 18
Form 980 (2003)
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rvnn aye cw~ o~.-t.~o~ovi ra
" Other Information See page 28 of the instructions . Yes No 78 , Did the organization engage in any activity not previously reported to the IRS If "Yes," attach a detailed description of each activity , , 76 X 77 were anychanges made in the organizing or governing documents but not reported to the IRS? , , , , , , , , , , , , , , , , , , , 77 X
If "Yes," attach a conformed copy of the changes . 78 a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return? , , , , , , , , , 78a X
b If "Yes," has it filed a tax return on Form 990-T for this year? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 78b X 79 Was there a liquidation, dissolution, termination, or substantial contraction during the years If "Yes," attach a statement , , , , , , , , 79 X 80 a 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? . , . , . . . . . . . . . . . . 80a X b If "Yes," enter the name of the organizationt SEE STATEMENT B
and check whether it is X exempt or nonexempt . 87 a Enter direct and indirect political expenditures . See line 81 instructions, , , , , , , , , , , , , , , , 81a NONE b Did the organization file Form 1120-POL for this year? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 81b X
82 a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge or at substantially less than fair rental values , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 82a X
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 in Part II (See instructions in Part III .) , , , , , , , , , , , , , , 1 82b I NOT DETERMINABLE
83 a Did the organization comply with the public inspection requirements for returns and exemption applications? , , , , , , 83a X b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? , , , , , , , , , , , , , , , , , 83b N
84a Did the organization solicit any contributions or gifts that were not taxdeductiblel 84a
;N1
b If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductibles , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , . , , . . . . . 84b
85 501(c)(4), (5), or (6) organizations. a Were substantially all dues nondeductible by members , , , , . , , , , . , . , , , . . . , . . 85a b Did the organization make only in-house lobbying expenditures of $2,000 or less? , . . . . . . , , . . . . . . . . . . . . . . . , . 85b
if "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization received a waiver for proxy tax owed for the prior year
c Dues, assessments, and similar amounts from members , , , , , , , . , , . . . , , , , , 85c N/A d Section 162(e) lobbying and political expenditures , , , , , , , , , , , , , , , , , , , , , , , , , 85d N/A e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices , , , , , , , , , , , , , , , 85e N/A f 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 85f? . . , . . . , , , 85 N 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?, , , . . , , . , , , . , , 85h N 86 501(c)(7) orgs. Enter. a Initiation fees and capital contributions included on line 12 , . . , , 86a N/A b Gross receipts, included on line 12, for public use of dub facilities , , , , , , . , , , , , , 86b N/A
ST 501(c)(12) orgs . Enter a Gross income from members or shareholders , , , , . , , . . , 878 N/A b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them ) . , , , , , , , , , , . . , , . , , , , . , , . 87b N/A
88 At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or partnership, or an entity disregarded as separate from the organization under Regulations sections 301 .7701-2 and 301 7701-3? If "Yes," complete Part LX . . . . . . . . . . . . . . . , . . . . . , , . . . . . . . . . . . . . . . . 88
89a 501(c)(3) organizations. Enter Amount of tax imposed on the organization during the year under : section 4911 " NONE ; section 4912 " NONE ; section 4955 " NONE
b 501(c)(3) and 501(c)(4) orgs Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a prior year? If "Yes," attach a statement explaining each transaction , , , , , , , , , , . , , . . , , , . , . . . , , , . , , . . , , . . , , . . , , . . , . . 89b X
c Enter . Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912,4955,and4958 . . , , , . , . . . . . . . . . . . , . . . . . , . . . . . . . . , . . . . . , . . . . . . , " NONE
d Enter . Amount of tax on line 89c, above, reimbursed by the organization . . . . . . . . . . . . . . . . . . . . . . . . , . . . 1 NONE 90 a List the states with which a copy of this return is filed JO.KENTUCKY
b Number of employees employed in the pay period that includes March 12, 2003 (See instructions) , , , , , , , , , , , , , , , , , , I 90b 13161 91 The books are m care of " GARY E12MERS Telephone no " 859-313-1000
Located at lio. ONE ST . JOSEPH DR . LEXINGTON, KY ZIP + 4 jlp~ 40504 92 Section 4947(a)(1) nonexempt charitable trusts filing Form 990 in lieu of Form 7041- Check here , , , , , , , , , , , ,
. " , . , , , , . 1 U
and enter the amount of tax-exempt interest received or accrued during the tax year . . " 192 1 NONE Form 990 (2003)
JSA 3E7041 2 000
JSA 3E1050 1 .000
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1-
Note : Enter grass amounts unless otherwise Unrelated business income Excluded by section 512, 513, or 514 (E) indicated. (A) (8) (C) (p) Related or
Business toes Amount Exclusion code Amount exempt function 93 Program service revenue income
a STMT 19 1619 , 125 . 973 290 . 182 828 664 . b c d e f Medicare/Medicaid payments , , , , , , 139 239 145 . g Fees and contracts from government agencies ,
94 Membership dues and assessments , ,
95 Interest on sarongs and temporary cash investments 14 972 , 403. 86 Dividends and interest from securities . . 14 769 , 784 . 97 Net rental income or (loss) from real estate .
a debt-financed property . . . . . . . .
b not debt-financed property . . . . . . .
98 Net rental income or (loss) from personal property 99 Other investment income . . . . . . . . 100 Gain or (loss) from sales of assets other than inventory 18 5 , 039, 049 . 101 Net income or (loss) from special events .
102 Gross profit or (loss) from sales of Inventory , ,
103 Other revenue a
b c d e
104 Subtotal (add columns (B), (D), and (E)) . . 1 619 125 . 7 , 754 , 526 . 1 322,067,809 . 105 Total (add line 104, columns (B), (D), and (E)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ 331,441,460 . Note : Line 105 plus line 1d, Part l, should equal the amount on line 12, Part 1
Relationshi of Activities to the Accomplishment of Exempt Purposes See page 34 of the instructions. Line No. Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the accomplishment
of the organization's exempt purposes (other than by providing funds for such purposes) 93A REVENUE FROM PROVIDING HOSPITAL SERVICES INCLUDING INPATIENT
AND OUTPAT
Information Regarding Taxable Subsidiaries and Disre arded Entities See page 34 of the instructions .
Name, address, and EIN of corporation, Percentage a Nature of activities Total income End=of=year `B' I `C' I '°' I partnership, or disregarded entity ownership interest assets
Information Regarding Transfers Associated with Personal Benefit Contracts See page 34 of the instructions . (8) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? , , , , , , , Yes g NO (b) Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? Yes g No Note : If "Yes" to (b), file Form 8870 and Form 4720 (see instruction
Under penalties of per1ury, I declare that I have examined this ret and belief, it is true .p6rrect, and comoJeta.Declaration of oreoa
Please Sign I Signa ure of officer Here w~ v r S
Type or print A me and title.
Preparers \ /*) , -n n Af n
Preparer's Finn's name,14-urs Use Only If self-employed), ,
address, and ZIP + 4
SCHEDULER Organization Exempt Under Section 501(c)(3) (Form 990 or 990-EZ)
(Except Private Foundation) and Section .501(e), 5010, 501(k), 501(n), or Section 4947(a)(1) Nonexempt Charitable Trust
department of the Treasury Supplementary Information - (See separate instructions .) Internal Revenue Service " MUST be completed b the above organizations and attached to their Form 990 a 990-EZ Name of the organization SAINT JOSEPH HEALTHCARE, INC . Em
OMB No. 1545-0047
2003 D B A SAINT JOSEPH EAST & SAINT JOSEPH H03P . 61-1334601
Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (See page 1 of the instructions . List each one . If there are none, enter "None.")
(a) Name and address of each employee paid more (b) Title and average (d) Contributions to (e) Expense
than 50,000 hours per week (c) Compensation employee benefit plans & account and other
Total number of other employees paid over $50 ,000 .
. . " 569
' 1111 Compensation of the Five Highest Paid Independent Contractors for Professional Services (See page 2 of the instructions . List each one (whether individuals or firms) . If there are none, enter "None .
(a) Name and address of each independent contractor paid more than $50,000 (b) Type of service (c) Compensation
MEDICAL STAFFING NETWORK
DALLAS . TX
PERFUSION CONCEPTS
2089 BAHAMA RD ., LOUISVILLE, KY 40509
CONGLETON HACKER
KY 40522 P .O . BOX 22
Total number of others receiving over $50,000 for profess ion al se rvi ces For Paperwork Reduction Act Notice, see the Instructions for Form 890 and Form 990-EL JSA
3E 7 210 2 000
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Schedule A (Form 990 or 990-EZ) 2003
JANE-V . E'ERGUS CIO 150 N . EAGLE CREEK DRIVE LEXINGTON KY 40509 50 HR3 W
MELODY- K . - GILLETTE DIR SURGICAL 150 N . EAGLE CREEK DRIVE LEXINGTON . KY 40509 50 HR31W
ERIC MILLER DIR OF P8AR1ACY
150 N. EAGLE CREEK DRIVE
LEXINGTON, KY 40509 50 HRS/WK
BLANDON-CHERRY-------------------- -I~ s~ Paai~cisx 150 N . EAGLE CREEK DRIVE .I
INTELLISTAFF HEALTHCARE
DESIGN GROUP
097 .
844,275 .
3,479,493 .
7
1
X
4 Did you maintain any separate account for participating donors where donors have the right to provide advice on the use or distribution of funds? . . . . . . . . . . , . . . . . , , , , , , , . . , . , , , , , , ,
The or anization 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)(1xAxi) B A school . Section 170(b)(ixA)(ii). (Also complete Part V ) 7 X A hospital or a cooperative hospital service organization . Section 170(b)(1)(A)(iii) 8 A Federal, state, or local government or governmental unit . Section 170(b)(1)(A)(v) 9 A medical research organization operated in conjunction with a hospital Section 170(bx1)(A)(iii) Enter the hospital's name, city,
and state 1 10 a An organization operated for the benefit of a college or university owned or operated by a governmental unit Section 170(b)(1)(A)(iv)
(Also complete the Support Schedule in Part IV-A.) 11 a E1 An organization that normally receives a substantial part of its support from a governmental unit or from the general public
Section 170(b)(1)(A)(vi). (Also complete the Support Schedule in Part IWA ) 11b B A community trust Section 170(b)(1)(Axvi) (Also complete the Support Schedule in Part IV-A 12 An organization that normally receives : (1) more than 33 113% of its support from contributions, membership fees, and gross
receipts from activities related to its charitable, etc ., functions - subject to certain exceptions, and (2) no more than 33 113% 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 a An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations described in (1) lines 5 through 12 above, or (2) section 501(c)(4), (5), or (6), if they meet the test of section 509(ax2) (See section 509(aH3)
(b) Line number from above (a) Name(s) of supported organization(s)
Schedule A (Form 990 or 990-EZ) 2003
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Schedule A (Form 990 or 990-EZ) 2003 61-1334601 Statements About Activities (See page 2 of the instructions .)
1 During the 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 " $ (Must equal amounts on line 38, Part VI-A, or line I of Part VI-13 ) , , , , , , , , , , , , , , _ , , , . . . . , . , , . . . . . , . . . . . . . , . . . . . , Organizations that made an election under section 501(h) by filing Form 5768 must complete Part VI-A Other organizations checking "Yes," must complete Part VI-13 AND attach a statement giving a detailed description of the lobbying activities .
2 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 the answer to any question is "Yes," attach a detailed statement explaining the transactions )
d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)? . , , , , , , , . , , ,$TkPT , 2Q
e Transfer of any part of its income or assets? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 3a Do you make grants for scholarships, fellowships, student loans, etc? (If "Yes," attach an explanation of how
you determine that recipients qualify to receive payments ) , , , , , , , , , , , , , , , , , , , , , . , , , , , , . , . , b Do you have a section 403(b) annuity plan for your employees , , , , , , , , , , , , , , , , , , , , , , , , , , , . , . ,
Page Z Yes No
Reason for Non-Private Foundation Status (See pages 3 through 6 of the instructions .)
2202000
Schedule A (Form 990or990-EZ 2003 61-1334601 P 3 Support Schedule (Complete only if you checked a box online 10, 11, or 12 .) Use cash method of accounting.
18 Gross income from interest, dividends, amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable income (less section 511 taxes) from businesses acquired by the organization after June 30, 1975
19 Net income from unrelated business activities not included in line 18 . . . .
20 Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf
21 me value of services or facilities furnished to the organization by a governmental unit without charge . Do not include the value of services or facilities generally furnished to the public without charge
22 Other income Attach a schedule Do not include Qain or (loss) from sale of caaital assets
28 Organizations described on lines 10 or 11 : a Enter 2% of amount in column (e), line 24 XTQT, AV$IiTWJA 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 gifts for 1999 through 2002 exceeded the amount shown in line 26a Do not file this list with your return . Enter the total of all these excess amounts 1110.
c Total support for section 509(a)(1) test. Enter line 24, column (e) . . . . . . , , . . . , , . . . . , . . . . , . . . . , . 1 d Add . Amounts from column (e) for lines 18 19
22 26b � � � � � � " 26d e Public support (line 26c minus line 26d total) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , " 26e f Public support percentage line 28e numerator divided b line 2Bc denominator . " 26f
27 Organizations described on line 12 : a For amounts included in lines 15, 16, and 17 that were received from a "disqualified person," prepare a list for your records to show the name of, and total amounts received in each year from, each "disqualified person ." Do not file this list with your return. Enter the sum of such amounts for each year
(2002) ___-_____-__-_-_ (2001) __-_____-________-- (2000) _-_ NOT APPLICABLE _ (1999) _______-______ b For any amount included in line 17 that was received from each person (other than "disqualified persons"), prepare a list for your records to
show the name of, and amount received for each year, that was more than the larger of (1) the amount on line 25 for the year or (2) $5,000 (include in the list organizations described in lines 5 through 11, as well as individuals) Do not file this list with your return . After computing the difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year (2002) ---------------- (2001) ------------------- (2000) ------------------- (1999)---------------
c Add : Amounts from column (e) for lines 15 16 17 20 21 . . .
d Add . Line 27a total . . and line 27b total , , . . . 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) . . . . . . . . . . 1L g Public support percentage dine 27e (numerator) divided by line 27f denominator)) . . . . . . . . .
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. �o. ~... . o. ~o... ..`a. . .. . . . .n . . .~ i 15 Gifts, grants, and contributions received (Do
not include unusual grants See line 28 .) 16 Membership fees received . . 17 Gross receipts from admissions, merchandise
sold or services performed, or furnishing of facilities in any activity that is related to the
28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any unusual grants during 1999 through 2002, prepare a list for your records to show, for each year, the name of the contributor, the date and amount of the grant, and a brief description of the nature of the grant . Do not file this list with your return . Do not include these grants in line 15
JSA Schedule A (Form 990 or 990-EZ) 2003 3E 1227 2 000
If you answered "No" to any of the above, please explain. (If you need more space, attach a separate statement.) ----------------------------------------------------------------------------------------------------------------------------------------------------------
33 Does the organization discriminate by race in any way with respect to :
If you answered "Yes" to any of the above, please explain . (If you need more space, attach a separate statement.) ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 4.05 of Rev. Proc . 75-50. 1975-2 C.B . 587, covering racial nondiscrimination? If "No." attach an explanation .
" .
. 35
3E1230 2 .000 Schedule A (Form 990 or 990-EZ) 2003
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Schedule A (Form 990 w 990-EZ) 2003 61-1334601 Page 4
Private School Questionnaire (See page 7 of the instructions .) (To be completed ONLY by schools that checked the box on line 6 in Part IV) NOT APPLICABLE
29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, Yes No other governing instrument, or in a resolution of its governing body? . . . . . . . . . , . . . . . . 29
30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its brochures, catalogues, and other written communications with the public dealing with student admissions, programs, and scholarships? . , . . . . . . . , , . . . . . . . . . . 30
31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during the period of solicitation for students, or during the registration period if it has no solicitation program, in a way that makes the policy known to all parts of the general community it serves? . . . . . , . . . . 31 If "Yes," please describe ; if "No," please explain. (If you need more space, attach a separate statement ) --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
32 Does the organization maintain the following : a Records indicating the racial composition of the student body, faculty, and administrative staff? , . . . 32a b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory
basis? 32b c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing
with student admissions, programs, and scholarships? . . . . . . . . . . . . . . . . , . . . 32c d Copies of all material used by the organization or on its behalf to solicit contributions? . . . . . , . . . . . , , , . . 32d
Schedule A Form 990 or 990-EZ 2003 61-1334601 Page 5 Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions .) To be com pleted ONLY by an eligible organization that filed Form 5768 NOT APPLICABLE
Check 1 a if the organization belongs to an affiliated group Check " b if you checked "a" and "limited control" provisions apply .
Affiliated group To be completed totals I for ALL electing
organizations (The term "expenditures" means amounts paid or incurred .)
36 Total lobbying expenditures to influence public opinion (grassroots lobbying) . . . 38 37 Total lobbying expenditures to influence a legislative body (direct lobbying) 37 38 Total lobbying expenditures (add lines 36 and 37), , . , , , , , , , , , , , , , , , 38 39 Other exempt purpose expenditures , , , , , , , , , , , , , , , , , , , , , , , , , 39 40 Total exempt purpose expenditures (add lines 38 and 39) 40 41 Lobbying nontaxable amount . Enter the amount from the following table -~
If the amount on line 40 is - The lobbying nontaxable amount is -
Not over $500,000 , , , , , , , , , , , , 20% of the amount on line 40 , , , , , , , , ,
Over $500,000 but not over $1,000,000 , , , $100,000 plus 15% of the excess over $500,000
Over $1,000,000 but not over $1,500,000 . . $175,000 plus 10% of the excess over $1,000,000 41
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 , , , , , ,
~
, , $1,000,000 . , , . , , . . . , , , , ,
42 Grassroots nontaxable amount (enter 25% of line 41) . . . . . . . . , . . , . . 42 43 Subtract line 42 from line 36 . Enter -0- if line 42 is more than line 36 43 44 Subtract line 41 from line 38 . Enter -0- if line 41 is more than line 38 . . . . . . 44
Lobbying Expenditures During 4-Year Averaging Period
(b) I (c) 2002 2001
Grassroots lobbying
Lobbying Activity by Nonetecting Public Charities (For reporting only by organizations that did not complete Part VI-A) (See pE
During the year, did the organization attempt to influence national, state 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 in expenses reported on lines c through h.) , c Media advertisements d Mailings to members legislators or the public
Amount
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, speeches, lectures, or any other means , , , , , , i Total lobbying expenditures (Add lines c through h.), , , , , , , , ,
If "Yes" to any of the above, also attach a statement giving a detailed description of the lobbying activities . JSA Schedule A (Form 990 or 990 "EZ) 2003 3E1240 2 000
PB1097 552B 05/09/2005 14 :35 :03 V03-8 10852447
Limits on Lobbying Expenditures
on: If there is an amount on either line 43 or line 44, you must ale Form 4720.1 I 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. See the instructions for lines 45 through 50 on page 11 of the instructions .)
Calendar year (or fiscal (a) ear beginning in " 2003 Lobbying nontaxable amount Lobbying ceiling amount
Grassroots nontaxable
Grassroots ceding amount
(d) I (e) 2000 Total
12 of the instructions .
52a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501 (c) of the Code (other than section 501(c)(3)) or in section 527? , , , , , , , , , , " E] Yes OX No
(a) Name of organization
(c) Description of relationship
Schedule A (Form 990 or 990-EZ) 2003 JSA 3E1250 2 000
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Schedule A Form 990 or 990-EZ 2003 61-1334601 Pa 8 " information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations (See page 12 of the instructions .) 5,7 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section
501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations? a Transfers from the reporting organization to a noncharitable exempt organization of :
(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 the following schedule Column (b) should always show the fair market value of the
goods, other assets, or services given by the reporting organization. If the organization received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, a services received :
(a) (b) (c) (d) Line no . Amount involved Name of nonchantable exempt organization Description of transfers, transactions, and sharing arrangements
Gain from CHI Operating Investment Program, LP 3,062,440 Loss from Secunti~ outside CHI Operating Investment Program, LP (91,748)
Total Grin From Securities 2,970,692
PROCEEDS ORIGRVAL ACCUFhfULATED NET BOOK ATE SOLD FROM SALE COST DEPRECIATION VALUE GAIN LOSS
1913 Westminster ve Buildings 07/01/69 1913 Westminster Dr - Central Air Buildings 10/01/90 1913 Westminster -Replace Roof Buildings 11/01/98 1913 Westminster - Vinyl Trim Buildings 12/01/95 1913 Westminster -Wiodows Buildings 06/01/88 Building ECMP Buildings 11/01/98 Dr Campbell Frt-U Buildings OZ/01/03 Install Floor MOB Bmldmgs 06/01/01 Install Tempered GI: Buildings 09/01/03 NeaIntFrt-Up Buildings 06/01/03 ReCuibComdors Buildings 06/01/01 Cooling Towers Fixed Equipment Jume 1999 Data Outlets Fixed Equipment 02/01/99 Host Pimps Fixed Equipment 07/01/99 Install Elevator Fixed Equipment 06/01/01 Steam Line Fixed Equipment 02/01/00 Venous Non-Capi tal Items Fused Equipment 1913Wesamiavter E) r -Iand Leaseholdimprovemeors 06/01/88 Bmldmg Impravem is - ECMP Leasehold Improvements 11/01199 Demolish Offices Leasehold Improvements 11/01/98 Demolish Suite L.easeLold improvements 09/01/99 Dr Bameaa Office Leasehold Improvements 12/01/99 IArKofflaFrtvp Leageholdtmpmvemmts 06/01/00 IkKoffiaFrtup Leaaeholdimprovemencs 05/01/96 Dr OHutt Fuup Leasehold Improvements 06/01/01 Dr Wood Fnup lsare6old Improvements 06101101 Dr James Offices Lcasebold improvements 01/01/99 Dr lama Offices Leasehold Improvements 04/01/99 Dr Owo Offices Leasehold improvements 01/01/99 Filup Ness & Martin Leasehold improvements 06101/01 Fnup Rooney Leasehold improvements 06/01/01 Improvements -EC h (P Leasehold Improvements 11/01/98 KKAFuup Leaseholdlmprovemrnts 06/01/01 Replace Floors l-5 Leasehold Improvements 06/01/01 Waiting Area MOB Leasehold Improvements 10/01/00 Blinds Major Moveable Equipment 02/01/99 Curtains Mayor Moveable Equipment 02/01/99 F]ectmsurgicat Gent ors Major Moveable Equipment 10/01/02 MedtrooicPro a Major Moveable Equipment 09/01/00 Nitrogrn Memfold Major Moveable Equipment 06/01/03 PegasysUmtt Major Moveable Equipment 02/01/03 Table Major Moveable Equipment 02/01/99
STATEMENT to
St Joseph HeaNhare, Inc. EIN: 81 .193801 TAX YEAR ENDED : 0613012004
STATEMENT 1
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Saint Joseph HealthCare, Inc .
FORM 990, PART I - PAYMENTS TO AFFILIATES
DESCRIPTION
CATHOLIC HEALTH INITIATIVES 1999 BROADWAY, SUITE 2600, DENVER, CO 80202 NATIONAL ASSESSMENT
TOTAL
61-1334601
AMOUNT
4,022,604 . ------------
4,022,604 .
61-1334601
TOTAL
STATEMENT 2
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Saint Joseph HealthCare, Inc .
FORM 990, PART I - OTHER INCREASES IN FUND BALANCES
DESCRIPTION
CHANGE IN UNREALIZED GAINS ON SECURITIES
AMOUNT
4,679,831 . ------------
4,679,831 .
61-1334601
TOTAL
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Saint Joseph HealthCare, Inc .
FORM 990, PART I - OTHER DECREASES IN FUND BALANCES
DESCRIPTION
MISSION AND MINISTRY FUND CAPITAL RESOURCE POOL CONTRIBUTION PRIOR PERIOD ADJUSTMENT
AMOUNT
529,140 . 2,117,568 .
62,895 . ------------2,709,603 .
STATEMENT 3
SAINT JOSEPH SALTS , INC . 61-1334601
FORM 990, PART II - GRANTS AND ALLOCATIONS PAID DARING THE YEAR
RELATIONSHIP TO SUBSTANTIAL CONTRIBUTOR
RECIPIENT NAME
AND
Ate DRESS FOUNDATION STATUS OF RECIPIENT PURPOSE OF GRANT OR CONTRIBUTION --------------------------- ------------------------------ --------------------------------
GRANTS PAID
LEXINGTON - FAYETTS CO HEALTH DEPARTMENT NONE SCHOOL NORSE PROGRAM
650 NEWTOWN PIKE EXMIPT
LEXINGTON, AY 4050
AMERICAN HEART ASSOCIATION NONE EDUCATION & AWIRENSSS
2201 REG3NCY ROAD, SUITE 401 EXIMPT
LEXINGTON, KY 4050
BLUEGRASS TOMORROW NONE COMM UNITY BEFIT
465 HIGH STREET, SUITE 208 EXEMPT
LEXINGTON, KY 4050
UNITED 115 OF BLUEGRASS NONE CCb2fUNITY BENEFIT
2480 FORTUNE DRIVE, SUITE 250 EXEMPT
LEXINGTON, KY 4059
LN LEXINGTON CATHOLIC HIGH SCHOOL NONE COMMUNITY BENEFIT
2250 CLAYS MILL ROAD EXEMPT
LEXINGTON, Kr 4050
RONALD MCD0141LD HOUSE NONE LIGHTS OF DOVE
P .O . BOX 22414 EST
LEXINGTON, KY 4052
Al4MCAN CANCER SOCIETY NONE CANCER RESEARCH
160 MDORB DRIVE, SUITE 201 EXEMPT
LEXINGTON, KY 4050
AMERICAN LUNG ASSOCIATION NONE HEALTH RELATED EDUCATION 6 RESEARCH
1636 NICHOLASVILLE ROAD EXEMPT
7.ESIIJGTON, KY 4050
UNIVERSITY OF KENTUCKY NONE FOND EDUCATION 6 RESEARCH EFFORTS
SAD DEBT EXPENSE CONSULTING FEES INSURANCE XPENSE PROFESSION FEES PURCHASED ERVICES ADVERTISIN & RECRUITMENT DUES & SUB CRIPTIONS OTHER TAB PROVIDER T MISCELLANE US EXPENSE IaINTENAN & REPAIRS BANK FEES STORAGE HIPAA EXPE SE
St Joseph HeaIthCare, Inc. EIN : 61-1334601 TAX YEAR ENDED: 0613012004
Fiscal Year 2004 Saint Joseph HealthCare Community Benefit: A Report to the Community
The Mission of Saint Joseph HealthCare and Catholic Health Initiatives is to nurture the healing ministry of the Church by bringing it new life, energy and viability in the 21S`
century. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities.
The Faith-Based Mission of Saint Joseph HealthCare compels us to work toward the creation of healthier communities, emphasizing the human dignity of all persons. This inspires our work to provide access for the poor and commit to subsidize programs that work to improve health status for the communities we serve. Our efforts are guided by our core values of Reverence, Integrity, Compassion and Excellence . These values are the foundation of our commitment to superior quality, service and safety for each person that is part of this sacred place; associates (employee), patients, physicians and volunteers alike.
This commitment has resulted in Saint Joseph sponsored services and collaboration with other organizations that provide a comprehensive array of direct health service, social services, wellness and education initiatives, economic development, research and medical education.
In Fiscal Year 2004 Saint Joseph HealthCare Inc. (SJHC) has continued its significant commitment to support access to healthcare for low-income persons and to live out the mission to support development of a healthier community. Community benefit expense as a percentage of both SJH and SJE expenses was 11 .6%.
Reimbursement for Hospital Based In and Outpatient Care
Saint Joseph HealthCare has placed considerable time and effort to support collaborative partnerships within the context of community health for the poor and the broader community health initiatives while meeting the demands of caring for the poor, medically indigent and elderly who look to Saint Joseph .
During the fiscal year ending June 30, 2004, Saint Joseph HealthCare provided benefits to the poor and broader community of more than $27 million, excluding subsidies assonoia~ with lVe-rlirara reimbursement. The major components off these cnmmnn;tcr
benefits are summarized on the following table :
STATEMENT A
Saint Joseph HeaIthCare Inc . Community Benefit
Benefits for the Poor: Cost of charity care provided $ 10,141,267 Unpaid costs of Medicaid 4,359,689 Kentucky Provider Tax to Fund Care 6,609,852 Community Services for the Poor 645,384
Total Benefits to the Poor 21,756,192
Benefits for the Broader Community: Unpaid costs of Medicare 13,984,442 Non-billed services for the community 304,045 Medical Education 292,516 Cash and in-kind donations for the Broader Community 389,830 Community Building 138,714
Total Benefits for the Broader Community 15,109,547 CHI Fund for Mission & Ministry 400,000
Total Quantifiable Community Benefits $37,265,739
Uncompensated Care
As described in the above table, Saint Joseph HealthCare (SJHC) provides a significant level of free hospital based care each year . In fiscal year 2004, the cost of charity care provided was over 10 million dollars. SJH also incurred $4.36 million in unreimbursed costs for services provided to Medicaid patients . In Kentucky, hospitals are the source of funds for healthcare and other services provided by the State. SJHC paid $6.6 million for this Provider Tax last year . Uncompensated care for the poor was 5.8% higher in fiscal year 2004 over 2003 . The uncompensated care attributed to Medicare increased by 4.13 million dollars over fiscal year 2003 .
Behind the significant financial numbers are real people who are touched by the employees, physicians and volunteers of Saint Joseph through the many programs and services that provide care to the poor, the underserved and to those who want to live healthier lives. Community building as a basis of collaborating with others in a spirit of mutual respect is a significant point of emphasis in our mission to create healthier communities. The programming associated with Community building as a component of broader community services was tied to several major initiatives in FY2004:
School based clinics initiative Partnership Easter Kentucky Mobile collaboration initiative
" Lexington Health United effort to impact second hand smoke " Building coalitions to partner on improving access to health care.
STATEMENT A
Community Outreach for the Poor
Saint Joseph serves the poor in many ways that extend outside the doors of the 2 hospitals. We are working diligently to improve the access to healthcare and support efforts to improve the health and well being of the communities we serve in Central and Eastern Kentucky.
Mobile Health Clinics
A forty-foot state of the art, mobile clinic offers primary health care services to the uninsured and poor residents of Fayette County. The Mobile Clinic provided over 3000 patient contacts in FY 2004 for an increase of 270 from the prior year. Saint Joseph HealthCare fully funded this primary care service for the community at a cost of 575,000 dollars . Many physicians from the SJHC medical staff provide specialty clinics through the mobile or work with the staff to provide necessary specialty care and surgery at no charge for these medically indigent persons.
The Eastern Kentucky Mobile Health Service completed its second year of operation in five communities in three of the most underserved counties of the rural Appalachian region ; Wolfe, Morgan and Lawrence. The State of Kentucky provides the financial support for the core operations of the mobile clinic, while Saint Joseph provides the in-kind management and information technology support of 33,545 dollars. Grantsmanship provided by Saint Joseph Foundation resulted in the successful award of 235,000 dollars to enhance telemedicine capabilities of the mobile van and community organizations. 970 patient contacts were provided and 432,100 dollars of free pharmaceuticals were accessed by the clinic .
Appalachian Outreach Program
Saint Joseph's Appalachian Outreach Program is a fully funded ministry that provides pastoral care and nutrition services for discharged patients in counties of Eastern Kentucky that have limited resources to draw upon for social and health services needs. In 2004 the associates provided over 13,255 follow-up contacts with people in this region including 900 nutrition consultations. The staff works to link people with the social and health services that are available and to establish a caring relationship post acute care discharge .
Healthy Kids Centers
Saint Joseph is a collaborator with the Fayette County Public Health Department, Fayette County Schools and Central Baptist Hospital to provide nurses, social workers and health educators in 3 elementary schools with children in need of preventive and primary care services . This represents an annual financial contribution of $125,000. Saint Joseph was honored as a Business of Promise for its contributions to this important service in 2004 .
STATEMENT A
Patient and Family Assistance Fund :
Prescription Drug Program
While as a nation we face exorbitant costs for medications and a crisis of access for the chronically ill and poor, Saint Joseph provided 48,000 dollars on prescription medications for persons who do not have the means to purchase them. Provision of these medications helps the recipients to recover more quickly from their illnesses, better manage chronic conditions and avoid costly hospitalizations and interventions . In fiscal year 2004 medication vouchers were provided to 690 low-income, elderly and uninsured patients at both hospitals . Additionally the Fayette Mobile Clinic works with pharmaceutical companies to provide over 14,000 prescriptions for people whose needs would otherwise go unmet. These prescriptions were worth approximately 1 .7 million dollars.
Meal Tickets and Taxi Vouchers
Because 65% of SJHC patients come from outside Fayette County we find that the broader social needs of the whole family present in the form of hunger and transportation to return home. In 2004 11,300 dollars were spent on meals provided and 5400 dollars on taxis for transportation home.
National and International Outreach
Saint Joseph HealthCare contributes to our national system's fund to support initiatives to provide for healthier communities, Mission and Ministry Fund. That contribution exceeds $400,000 and is important seed money for collaborative planning efforts and programs that commit to measurable outcomes to improve health . Saint Joseph continues to partner with its medical staff to provide surgery and hospitalization for persons with acute conditions that cannot be treated in their homeland.
STATEMENT A
Community Outreach for the Broader Community
Saint Joseph fulfills its mission by initiating services and collaborating with others to invest in initiatives that will improve the health of the community. Collaboration ranges from working to more effectively integrate SJHC services with those of other providers and community organizations to participating in fund raising to building services in partnership with others .
Collaborative Efforts to Improve Community Health
A. Medical Education
In support of the effort to prepare more physicians and nurses to serve Kentucky Saint Joseph provides funding for residents to train at Saint Joseph Hospital . This has resulted in salary support of $292,156.
B. YMCA
Saint Joseph collaborates with the YMCA to provide wellness services . Our commitment to wellness programming and the Y amounted to $220,000 . Classes are offered to help people of all ages work toward healthy lifestyles . We also serve the community and work in collaboration with others to provide health screening to identify early interventions in the battle of cancer, heart disease and diabetes .
C. Wise and Well
Wise and Well is funded by Saint Joseph and is designed to meet the needs of people age 50 and above in their quest to live healthy and active lives. Members enjoy a wide range of benefits that range from health education and wellness activities, to social events, claims filing support and discounts for a variety of services . Over 100 persons per month attend events and a newsletter is sent to 6500 households four times per year.
D. Health Fairs and Screenings
At Saint Joseph East a Maternity Health Fair was held that reached over 700 members of the community. Physicians provided education and numerous agencies and other service providers were a part of the fair. This event has evolved into the single largest health fair event in the community and required a $5,000 commitment.
E. Kentucky Children's Health Insurance Program
A two year $5,000 commitment was made to help educate the population that will benefit from access to the Kentucky Children's Insurance Program. The program is built on a principle of grass roots impact and advocates for changes to remove regulatory barriers to access .
STATEMENT A
F. Central Kentucky Blood Bank
Funds were provided to the Central Kentucky Blood Bank to help with technology needs to improve blood processing that could not be achieved without new equipment . A pledge was also made to assist with the replacement of a mobile van critically needed to for blood donation events .
Keeneland Health Education Center
The Keeneland Health Education Center provided free meeting time to community organizations at a value of over $32,000. This education center was build to meet the needs of SJHC but to also provide a resource to the larger community for health related events .
Community Fundraisers Supported
Saint Joseph HealthCare and its associates provided assistance to several community fundraisers that support the service, education and research needs of health and social service related organizations .
American Heart Association Walk Relay for Life to benefit American Cancer Society Diabetes Walk Race for the Cure for Breast Cancer March of Dimes United Way
Research Programs
Staff at Saint Joseph HealthCare is active in researching new treatment protocols to discover new care alternatives for our cardiac, orthopedic, neurology and cancer patients .
Community Development
Saint Joseph Healthcare has supported various educational and economic development organizations that serve to preserve the community, provide business growth, and support educational opportunities; Lexington Strides Ahead, Bluegrass Tomorrow, Bluegrass Area Development, KET.
Our Partners In The Ministry
STATEMENT A
Saint Joseph Foundation
During fiscal year 2004, the Saint Joseph Foundation raised approximately $ 1 million in cash and irrevocable deferred gift agreements that is in addition to Saint Joseph HealthCare services and contributions. These donations help fund capital equipment and renovation, indigent service programs, nursing scholarships, and health education . In fiscal year 2004, the Foundation distributed funds to the hospital for a wide variety of programs, all of which benefited the patients and families served by Saint Joseph HealthCare. Examples of programs partially funded by Foundation donations included :
Nursing Scholarships Appalachian Outreach Program Patient & Family Assistance Fund Mobile Health Clinic Employee Assistance Fund
Saint Joseph Volunteers
One of Saint Joseph's most important gifts is the personal service provided to our patients and their families through the 38,500 hours of time given by over 200 active volunteers from our community. These people make our ministry richer. They offer comfort to patients with the gift of pillows and teddy bears. They are vital to our hospitality and service to patients and their families . They are important assistants with our Wise and Well program. The collaboration with Mended Hearts is long standing and an important support to the cardiology service.
EXEMPT ENTITY NAME CITY STATE NONEXEMPT
STATEMENT B Form 990, Part VI, Question 80a/b
S.E .T. For Health New Mexico Albuquerque NM Exempt St Joseph Development Corp. Albuquerque NM Nonexempt St Joseph Healthcare Foundation Albuquerque NM Exempt St Joseph Healthcare PSO, Inc. Albuquerque NM Nonexempt St. Joseph Healthcare System Albuquerque NM Exempt St. Joseph Healthcare System Auxiliary Albuquerque NM Exempt St Joseph Community Health Services Albuquerque NM Exempt Franciscan Healthcare Corporation Aston PA Exempt St Elizabeth Health Care Foundation Baker City OR Exempt St Elizabeth Health Services, Inc Baker City OR Exempt Flaget Healthcare Inc. Bardstown KY Exempt Lakewood Health Center Baudette MN Exempt Berea Hospital, Inc. Berea KY Exempt Appletree Court Breckenridge MN Exempt St Francis Home Bredcenridge MN Exempt SL Francis Medical Center Breckenridge MN Exempt Nazareth Assurance Company Burlington VT Nonexempt Certington Health Center Cartinpton ND Exempt Caduoeua Medical Associates, Inc Chattanooga TN Nonexempt Memorial Health Care System Foundation Chattanooga TN Exempt Memorial Health Care System, Inc. Chattanooga 1'N Exempt Mountain Management Services Inc Chattanooga TN Nonexempt OccuNet Chattanooga TN Nonexempt MHP Foundation Chattanooga TN Exempt Memorial Mission Ambulatory Chattanooga TN Nonexempt Community Limited Care Dialysis Center Cincinnati OH Exempt Good Samaritan Hospital Cincinnati OH Exempt Good Samaritan Hospital Foundation of Cincinnati Cincinnati OH Exempt Healthcare Employment Solutions Cincinnati OH Nonexempt Universal Health Corp Cincinnati OH Exempt Catholic Health initiatives Colorado Foundation Colorado Springs CO Exempt Total Healthcare Colorado Springs CO Exempt Audubon Lend Company, LLC Colorado Springs CO Nonexempt Good Samaritan Hospital & Health Center Dayton OH Exempt Samaritan FIeaHh Foundation Dayton OH Exempt Samaritan Health Partners Dayton OH Exempt The Maria-Joseph Living Care Center Dayton OH Exempt Alternative Insurance Management Services Denver CO Nonexempt Bachmann Really Investments Denver CO Nonexempt Bachmann Services, Inc. Denver CO Nonexempt CatFaBc Health Initiatives Denver CO Exempt CHI Operating Investment Program LP Denver CO Nonexempt Comeare Services, Inc. Denver CO Nonexempt First Initiatives Insurance Co LM Denver CO Nonexempt Franciscan Services, Inc. and Subsidiaries Denver CO Nonexempt HMSO, Inc Denver CO Nonexempt National Pension Trust Denver CO Nonexempt SJH Services Corp Denver CO Nonexempt CHI Welfare Benefit Administration and Development Trust Denver CO Nonexempt Bishop Drumm Retirement Center Des Moines IA Exempt Charles T. Cownie Annuity Trust #1 Des Moines IA Nonexempt CHI - Iowa, Corp . Des Moines IA Exempt House of Mercy Des Manes IA Exempt Iowa Kidney Stone Center Des Moines IA Exempt Joseph A Schuster Annuity Trust #1 Des Moines IA Nonexempt Mercy Clinics, Inc Des Moines IA Exempt Mercy College of Health Sciences Des Moines IA Exempt Mercy Foundation of Des Moines, IA Des Moines IA Exempt Mercy Medal Center- Centerviile Des Moines IA Exempt Mercy Pant Apartments Des Moines IA Nonexempt Mercy Professional Practice Associates, Inc Des Moines IA Exempt Heart Partners, LLC Des Moines IA Nonexempt Mercy Hospital Of Devils Lake Devils Lake ND Exempt Greater Plains Health Group Dickinson ND Nonexempt St. Joseph Lifecare Foundation Dickinson ND Exempt St Joseph's Hospital & Health Center Dickinson ND Exempt Mercy Medical Center Durango CO Exempt Catholic Health Initiatives - Colorado Englewood CO Exempt Sisters of Charity VEBA Erlenger KY Exempt Villa Nazareth, Inc Fargo ND Exempt -
STATEMENT B Form 990, Part VI, Question 80a/b
.. EXEMPT ENTITY NAME CITY STATE NONEXEMPT Catherine Hospital Garden city K Exempt
Saint Funds Foundation Grand Island NE Exempt Saint Francis Medical Center Grand Island HE Exempt Health Support Services Grand Island NE Nonexempt Central Kansas Health Services Association Great Bend KS Nonexempt Central Kansas Medical Center Great Bend KS Exempt St . Joseph Memorial Hospital Great Bend KS Exempt Samaritan Health Partners Insurance Lid. Hamilton Bermuda Exempt Health First Inc .loplin MO Nonexempt Maude Norton Memorial Hospital Joplin MO Exempt Mercy Agency Services-Nevada, Inc. Joplin MO Nonexempt Mercy Clinics Joplin MO Exempt Mercy Health Services Inc & Subsidiaries Joplin MO Nonexempt Mercy LHecare Systems Joplin MO Exempt Mercy Regional Health Foundation Joplin MO Exempt Nevada Medical Center, Inc. Joplin MO Nonexempt NEVO, Inc. JopAn MO Nonexempt St John's Regional Medical Center Joplin MO Exempt Central Nebraska Home Care Services Keamey NE Nonexempt (good Samaritan Health System. Inc. Keamey NE Exempt Good Samaritan Hospital Keamey NE Exempt Good Samaritan Hospital Foundation Kearney HE Exempt Good Samaritan Outreach Services Keamey NE Nonexempt Health Systems Enterprises, Inc. Keamey NE Nonexempt 8achmenn Realty Investment Inc, Lancaster PA Nonexempt BacFunann Realty Corp Lancaster PA Exempt 8echmann Services, Inc. Lancaster PA Nonexempt St Joseph Health Ministries Lancaster PA Exempt St Joseph Health Ministries Foundation Lancaster , PA Exempt Bluegrass Regional Imaging Center Lexington KY Nonexempt Continuing Care Hospital Lexington KY Exempt St Joseph Healthcare Inc. Lexington KY Exempt St Joseph Office Park Condos Lexington KY Nonexempt SL Joseph Hospital Medical Foundation, Inc. Lexington KY Exempt St Joseph Hospital Foundation Lexington KY Exempt Health Care Management Inc Lincoln NE Nonexempt LincCana Lincoln NE Nonexempt Nebraska Surgery Center Lincoln NE Nonexempt Saint EIluabeth Foundation Lincoln NE Exempt Saint Elizabeth Hearth Services Lincoln NE Exempt Saint Elizabeth Health Systems Uncoln NE Exempt Saint Elizabeth Physician Network Lincoln NE Exempt Saint Elizabeth Regional Medical Center Lincoln NE Exempt Lisbon Area Health Services Lisbon ND Exempt qheme apartments Little Falls MN Exempt St Gabriel's Centracare tLC Little Falls MN Nonexempt Unity Family Heaifhcare Little Falls MN Exempt St Vincent Infirmary Medial Center Little Rock AR Exempt St Vincent Community Health Services, Inc. Little Rods AR Nonexempt St. Anthony's Hospital Association Little Rock AR Exempt Si Vincent Foundation Little Rods AR Exempt St Vincent Medical Group Little Rock AR Exempt St. Vincent Physician Hospital Organization Little Rock AR Nonexempt MerymouM Medical Center London KY Exempt Caritas Health Services, Inc Louisville KY Exempt CaAtas Physicians Group Louisville KY Exempt BC Holding Company, Inc Louisville KY Nonexempt Carttas Foundation Louisville KY Exempt Caritas Rehab Services, lLC Louisville KY Nonexempt Our Lady of the Way Hospital, Inc Martin KY Exempt Good Samaritan Health Center Foundation Of Mertill WI, Inc Merrill WI Exempt Good Samaritan Health Center Of Mertill WI, Inc. Mertill WI Exempt Mednow, Inc Nampa ID Nonexempt Mercy Medical Center Nampa ID Exempt Mercy Medical Center Employee Health Care Plan Nampa ID Exempt Mercy O/P Surgery Center, LLC Nampa ID Nonexempt St Mary's Hospital Foundation NE City NE Exempt St Mary's Hospital NE City NE Exempt Oakes Community Hospital Oakes ND Exempt Alegent Health - Began Mercy Health System Omaha NE Exempt Bergen Mercy Foundation Omaha NE Exempt
STATEMENT B Form 990, Part VI, Question 80a1b
y EXEMPT ENTITY NAME CITY STATE NONEXEMPT Mercy Health Care Foundation Omaha NE Exempt Mercy Hospital , Coming IA Omaha NE Exempt Mercy Hospital Foundation Council Bluffs Omaha NE Exempt Mercy Medical Office Building Omaha NE Exempt The Mercy Center Omaha NE Exempt Auxiliary of Holy Rosary Hospital Ontario OR Exempt Holy Rosary Hospital Medical Benefit Trust Ontario OR Exempt Pathway Hospice LLC Ontario OR Nonexempt The Dominican Sisters of Ontario, Inc Ontario OR Exempt St Joseph's Area Health Services Park Rapids MN Exempt St Anthony Development Company Pendleton OR Nonexempt St Anthony Hospital Pendleton OR Exempt St Anthony Hospital Foundation Pendleton OR Exempt Gettysburg Medical Center Pierre SD Exempt St Mary's HeaIQxare Center Pierre SD Exempt Mt St Joseph, Ina Portland OR Exempt St Mary CorvvM AuxNNary Pueblo CO Exempt Bomemann Heallhcare Corp Reading PA Exempt CGH Realty Co, Inc. Reading PA Exempt Community General Hospital Reading PA Exempt SJH Awes Corp Reading PA Nonexempt St Joseph Medical Center Foundation Reading PA Exempt St Joseph Regional Health Network Reading PA Exempt Ambulatory Surgery Center Of Roseburg, LLC Roseberg OR Nonexempt Cariyonvllle Health Clinic, Inc Roseberg OR Nonexempt Unus Oaken Roseberg OR Exempt Mercy Foundation Roseberg OR Exempt Mercy Healfhcare, Inc. Roseberg OR Exempt Mercy Medical Center, Inc. Roseberp OR Exempt Mercy Rehabilitation 8 Cane Center, Inc Roseberg OR Exempt Mercy Service Corporation Roseberg OR Nonexempt Therapeutic Services, Inc Roseberg OR Nonexempt Franciscan Villa of South Milwaukee South Milwaukee WI Exempt Franciscan Foundation Tacoma WA Exempt Franciecen Health System - West Tacoma WA Exempt Franciscan Medical Group Tacoma WA Exempt Management Service Organization Tacoma WA Nonexempt Physician Health System Network Tacoma WA Nonexempt St Joseph Development Corp Tacoma WA Nonexempt O'Oea Mme! Arts Umited Partnership Towson MD Nonexempt St Joseph Medical Center Towson MD Exempt St Joseph Medical Center Foundation Tuwson MD Exempt Towson Management, Inc. Towson MD Nonexempt Tawson Physician Services Towson MD Exempt Mercy Hospital of Valley City Valley City ND Exempt Nlecfquest Incorporated WNliston ND Nonexempt Mercy Hospital of Williston Williston ND Exempt Mercy Medical Foundation Wfltiston ND Exempt
1f you are filing for an Automatic 3-Month Extension, complete only Part 1 and check this box , , , , , , , , , , , , , , , , t U If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II (on page 2 of this form).
Note : Do not complete Part N unless you have already been granted an automatic 3-monUr extension on a previously flied Form 8868.
" Automatic 3-Month Extension of Time - Only submit original (no copies needed) Note: Form 990-T corporations requesting an automatic 6-month extension - check this box and complete Part 1 only , , , , All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to file income tax returns. Partnerships, REMICs end trusts must use Form 8738 to request an extension of time to file Form 1065, 1088, or 1041 . Type or Name of Exempt Organization SAINT JOSEPH HEALTHCARE, INC . Employee Identification number
Print D/B/A SAINT JOSEPH EAST & SAINT JOSEPH HOSP . I 61-1334601 room or surce no . IT a r.u. uox, see File by the due
date fog filing your return See Instructions City, town or post office, state, and ZIP code. For a foreign address, see
instructions , Signature and Verification
Under penalties of perjury, I declare that 1 have examined this form, including accompanying schedules and statements, and 1o the best of my knowledge and belief It Is true, correct, and complete, and that I am authorized to prepare this form
Date 00, otice, see 8868 X12-2000
JSA 3F8054 1 000
PB1097 552E 11/09/2004 15 :03 :32 V03-8 10852447
Fam- 8868 Application for Extension of Time To File an (Decem6tr2000) Exempt Organization Return OMB No, ,sae-,7os Department of the Treasury Internal Revenue seMce " File a separate application for each return .
Check type of return to be filed (file a se crate application for each return) : g Form 990 Form 990-T (corporation) Form 4720
Form 990-8L Form 990-T(sec . 401(a) or 408(a) trust) Form 5227 Forth 99o-EZ Form 990-T (trust other than above) Form 6069
U Form 990-PF U Form 1041-A Form 8870
If the organization does not have an office or place of business in the United States, check this box . . ~ If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) 0928 .If this is
for the whole group, check this box " F ~ . !f it is for part of the group, check this box " and attach a list with the names and EMS of all members the extension will cover. 1 I request an automatic 3-month (6-month, for 980-T corporation) extension of time until 02/15 , 2005
to file the exempt organization return for the organization named above. The extension is for the organization's return for: 1111. calendar year or 110. RX tax year beginning 07/01 . 2003 , and ending 06/30 . 2004
2 If this tax year is for less than 12 months, check reason : E] Initial return 0 Final return El Change in accounting period
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits . See instructions
b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments made . Include any prior year overpayment allowed as a credit
c Balance Due. Subtract line 3b from line 3a. Include your payment with this form, or, if required, deposit with FTD coupon or, if required, by using EF[PS (Electronic Federal Tax Payment System). See
Signature " `J Q For Paperwork Reduction
Title 1111-
" Additional not automatic 3-Month extension of Time - Must Flle original anC! One Go
Type or Name of Exempt Organization SAINT JOSEPH HEALTHCARE, INC. Employer Identification number
print D 8 A SAINT JOSEPH EAST & SAINT JOSEPH H03P . 61-1334601
File by the Number, street, and room or suite no. If a P.O . box, see instructions For IRS use only extended due date for 150 N. EAGLE CREEK DR . filing the City, town or post office, state, and ZIP code . For a foreign address, see instructions . " return . See instructions. T.FXTNfST(1N_ KY df15AQ
Form 52270 Form 8870
STOP: Do not complete Part II if you were not already granted an automatic 3-month extension on a previously flied Form 8868.
Name
Type or print
Number and street (Include suite, room, a apt. no .) Or a P.O. box number
City or town, province or state, and country (Including postal or ZIP code)
Form 8888 (12-2000
PH1097 552B 02/09/2005 17 :39:26 V03-8 10852447
Form 8888 (12.2000) Page 2
* If you 'are filing for an Additional (not automatic) 3-Month Extension, complete only Part II and check this box , , , , , , , , 10, IX I Note : Only complete Part u If you have already been granted an automatic 3-month extension on a previously filed Form 8868. e If you are filing for an Automatic 3-Month Extension. comulete only Part I (on aaae 1).
" If the organization does not have an office or place of business in the United States, check this box, , , , , , , , , , , , , , , , "U *If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN 0928 . If this is for the whole group, check this box " . If it is for part of the group, check this box " and attach a fist with the names and EINs of all members the extension is for. 4 I request an additional 3-month extension of time until 05/16/2005 5 For calendar year , or other tax year beginning 07 / 01 /2003 and ending 06 / 30 /2004 6 If this tax year is for less than 12 months, check reason: Initial return Final return Change in accounting period 7 State in detail why you need the extension ADDITIONAL TIME I3 NEEDED TO GATHER THE
INFORMATION NECESSARY TO FILE A COMPLETE AND ACCURATE TAX RETURN .
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits . See instructions � � � � � � � � . � � � � � , . � � � , $
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit and any amount paid previously with Form 8868 ��������������������� , $
c Balance Due. Subtract line 8b from line 8a. Include your payment with this form, or, if required, deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System) . See instructions $
Signature and Verification Under penalties of perjury, 1 declare that I have examined this forth, Including accompanying schedules and statements, and to the best of my knowledge and belief, k IS true, correct, and complete, and that I am authorized to prepare this forth .
Signature 1 Title 1 Date 1
Notice to Applicant - To Be Completed by the IRS We have approved this application Please attach this forth to the organization's return
R We have not approved this application However, we have granted a 10-day grace period from the later of the date shown below or the due date of the organization's return (including any prior extensions) . This grace period is considered to be a valid extension of time for elections otherwise required to be made on a timely return . Please attach this form to the organization's return We have not approved this application . After considering the reasons stated in item 7, we cannot grant your request for an extension of time
R to file We are not granting a 10-day grace period . We cannot consider this application because it was filed after the due date of the return for which an extension was requested. Other
By: Director Date Alternate Mailing Address - Enter the address ff you want the copy of this application for an additional 3-month extension returned to an address different than the one entered above .
