Form Return of Organization Exempt From Income Tax990s.foundationcenter.org/990_pdf_archive/370/370635502/... · 2017-06-22 · OMB No 1545-0047 Form 990 Return of Organization Exempt

OMB No 1545-0047

Form 990 Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung

benefit trust or private foundation) Department of the Treasury\ internal Revenue Service III- The organization may have to use a copy of this return to satisfy state reporting requirements .

2004

A For the 2004 calendar y,

B, Check if applicable Please C use IRS

D Address change label or

o Name change print or

D Initial return See Specific

D Final return

Amended return nose.

:ar, or tax year beginning , 2004, and 7yre of organization f1_f L-.=a ;r+ (1'l~?rr, nr i~1rr; 0A I, Ca ~ n=pr Number and street (or P O box If mail is not delivered to street address

`150() M4 mn ri 13 / ,car ~ v ~, Cd or town, state or country, and ZIP + 4

~e11P Vi1/e ,V1il')Ot 5 ln~~.a1~-534'

20 D Employer Identification number

`~ r ~ ~ ZG 1'r%'~1 )

RooMswte E Telephone number I

( n ~ ) U ~'~ - 1!~ ~~~ F Accountng metlwd: [-]Cash N Accrual

a Othe< <SpeciN, H and I are not applicable to section 527 ortza-,n¢ahons H(a) Is this a group return for affiliates? LJ.~es 0 No

H(b) If "Yes," enter number of affiliates ~ _ _ _N ~ A . .

H(c) Are all affiliates included D Yes -X '-H(c) (if "No," attach a list. See instructions ~

H(d) Is this a separate return filed by an organization covered by a group rulings El Yes ,1KNo

I Group Exemption Number

Application pending a Section 501(e)(3) organizations and 4947(a)(1) nonexempt charttable trusts must attach a completed Schedule A (Form 990 or 990-EZ).

G Website: " (,V r

J Organization type (check only one) " ,~ 501(c) (_3 ) -4 (insert no) El 4947(a)(1) or 0 527

K Check here " El if the organization's gross receipts are normally not more than $25,000 The organization need not file a return with the IRS, but if the organization received a Form 990 Package in the mail, it should file a return without financial data Some states require a complete return .

M Check " L_j if the organization is not required L Gross receipts Add lines 6b, 8b, 9b, and 10b to line 12 " ,? 7 to attach Sch. B (Form 990, 990-EZ, or 990-PF).

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 . . . . . . . . , . . . 1a b Indirect public support . . . . . . . . . . , ib c Government contributions (grants)

. . ! .~ d Total (add lines 1 a through 1 c) (cash $ ` noncash $ 2 Program service revenue including government fees and contracts (from Part VII, line 93) 3 Membership dues and assessments . . 4 Interest on savings and temporary cash investments 5 Dividends and interest from securities

6a ~ ~3 ", ~/?4 6a Gross rents . . b Less . rental expenses . . . . . . . , , 6b c Net rental income or (loss) (subtract line 6b from line 6a) .

7 Other investment income (describe " )

8a Gross amount from sales of assets other (A) Securities (s) timer

than inventory . . . . . `-D53 8a cc 'W1 b Less cost or other basis and sales expenses. / 0 , 06 j- 8b

c Gain or (loss) (attach schedule~oe. , ~ a ~ ~~ 8c d Net gain or (loss) (combine line BcA~u~rr~t~ (A) and (B))

0 9 Special events and activities (attach schedule . If any amount is from gaming, check here " El a Gross revenue (not including $ of

contributions reported on line 1a) 9a b Less : direct expenses other than fundraising expenses . 9b

v c Net income or (loss) from special events (subtract line 9b from line 9a) 10a C] 10a Gross sales of inventory, less returns and allowances

_ b Less : cost of goods sold . . . . . . , , , , . 10b c Gross profit or (loss) from sales of inventory (attach sc nee-49bife . . .. a) .

t~ . , ., .. ., .. .. .. . . . . .

11 Other revenue (from Part VII, line 103) . . . v ~ EI VE~D 12 Total revenue (add lines 1d, 2, 3, 4, 5, 6c, 7, 8d, 9% 1

13 Program services (from line 44, column (B)) . ~ N~p~ 1 5 ~~u 14 Management and general (from line 44, column ( ~ . CIL 15 Fundraising (from line 44, column (D)) . . a . w 16 Payments to affiliates (attach schedule) 0 G D E N - V T 17 Total expenses (add lines 16 and 44, column (A . i.

18 Excess or (deficit) for the year (subtract line 17 from line 12) 19 Net assets or fund balances at beginning of year (from line 73, column (A))

. ;, 20 Other changes m net assets or fund balances (attach explanation)5ee 1'.~~ 1'1~=a :+_ 21 Net assets or fund balances at end of ear combine lines 18, 19, and 20 `

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions . Cat. No . i1282v

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Form 990 (2004)

12

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PROTESTANT MEMORIAL MEDICAL CENTER, INC . EIN 37-0635502

Form 990 (2004) 1'age 2

,~ Statement 4f All organizations must complete column (A) . Columns (B), (C), and (D) are required for section 501(c)(3) and (4) organizations Functional Expenses and section 4947(a)(1) nonexempt charitable trusts but optional for others . (See page 22 of the instructions)

Do not include amounts reported on line 1W (A) Total IS) Program (c) Management ' 6b, 8b, 9b, lOb, or 16 Of pelt 1, services and general Ip1 Ft'ndrausmg

22 Grants and allocations (attach schedule) , (cash $ noncash $

23 Specific assistance to individuals (

22

attach schedule) 23 24 24 Benefits paid to or for members (attach schedule

25 Compensation of officers, directors, etc. . . 25 ?fib . 3a0 26 Other salaries and wages . 26 .6 27 Pension plan contributions . . . . . . 28 Other employee benefits , . . . . . . 28 1O 35 13 I ~~C 29 Payroll taxes . . . . . . . . . . . 29 5 5 30 Professional fundraising fees . . . , , , 30 31 Accounting fees . 31 IA2 935 L1935 32 Legal fees . . . . . . . . . . . . 32 '757 57 33 Supplies . . 34 Telephone . . . . . . . . . . . . 34 . 7 d 35 postage and shipping . . . . . , , , 35 ~Ua 4 36 Occupancy . , . . . . . . , , , 36 ~ f r) d D $5 37 Equipment rental and maintenance . . . . 37 5a 3 , (ofl g (n/ 38 Printing and publications . . . . . . . 38 5/g 7 1 1 a . a{n 39 Travel . . . . . . . . . . , , , 39 60 A5 A /1 40 Conferences, conventio s, a d meet)ri~~gs 1 40

41 Interest . . . . . ~~~? 3,trrz0.chp~a, 41 42 Depreciation, depletion, tc . (attach schedule) 42 as R a., qgq 5 43 er expenses n t covered above (i~te~ize) . a . . . . . . . . . b CQ~I_SLQn~~_ .bCt(i_ C~21d1~--------------- 43b gc1, ! 3

43c ~ to, 01 .1763 -----------~1.t'_ otl,.Qr_-p?~ ~?-~----------------- d 43d 7, 13E' ~J

e 43e

44 Total functional expenses (add lines 22 through 43) Organizations completing columns (B}(D), carry these totals to lines 13-15 . 44 /(07 72(o 2,3 f $14 90~6

Joint Costs. Check " E] if you are following SOP 98-2 . Are any joint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? " El Yes $~ Na If "Yes," enter (i) the aggregate amount of these point costs $ ; (ii) the amount allocated to Program services $ (iii) the amount allocated to Management and general $ , and (iv) the amount allocated to Fundraising $

i i

I i

----------------------------------------------------------------------------------------- --------------------------------(Grants and allocations $ )

----------------------------------------------------------------------------------------- --------------------------------(Grants and allocations $ )

e Other program services (a1 f Total of Program Service

and allocations $ Id equal line 44, column " ~

Statement of Program Service Accomplishments See page 25 of the instructions . What is the organization's primary exempt purposes " o-~rRYidQ .1. u~~J . '~._~~'aS'~ ;y2.{?Q~~!IF Program Service

C' 4r~-o -ft~e n~'~,,~ 5 Oaf8 C~J Expenses All organizations must describe their exempt purpose achieve en s m c e n e~n~3nner Sta e the number (Required for so1(c1(3) and of clients served, publications issued, etc Discuss achievements that are not measurable . (Section 501(c)(3) and (4) (4) ores, aria asa7(a)(1) organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of rants and allocations to others trusts, but optional for

9 ) others)

a ~?er~~r%~~_Shor AC 1,+,, (10 rz~ 1--

------~' ~ _err}s-- ~J 5 -- ------------------------- _ ~ , mpr-E__Yrs

// O 0 ediea; PQfi ' hg ,1 ' (Grants and allocations $ ) b --~.lSiIJF- I-A1)

, . . ~QC~ilif~ c~------- "- . .--------------------~QS--I~08 ------------------------------

---- (Grants and allocations $ ) 5, ~'fL,,'`l,'� ~'~

C --_i1_~l~?Il'7LC/7~:% ---- -----------

--------------------------------------------------------------------------------------- --------------------------------

Foam yyu (zooa)

ortn 990 (2004) Page 3

Balance Sheets (See page 25 of the instructions .)

Note: Where required, attached schedules and amounts within the description (A) (B) column should be /or end-of-year amounts only Beginning of year End of year

45 Cash--non-interest-bearing . . . . . . . . . . . . , _~ In Q 0 45 4, a0'

46 Savings and temporary cash investments . . . . . . . , , rl, 0 Q 7, 33$ 46 5. 4143 4,L11

47a Accounts receivable . . . . , , , 47a " 555 b Less: allowance for doubtful accounts . 47b g 5 lQ a (n 550" 47c Iq 7a n . q '1Q

W! MINING= 48a Pledges receivable . . . . . . . 48a Im

b Less : allowance for doubtful accounts . 48b 48c

49 Grants receivable . . . . . . . . . . . . . . . . . 49

50 Receivables from officers, directors, trustees, and key employees (attach schedule) . . . . . . .

51a Other notes and loans receivable (attach 21 schedule) . . . . . . . . , , 51a

b Less : allowance for doubtful accounts , 51b 51c

a 52 Inventories for sale or use . . . . . . . . . . . . . , 03 N37 52 0 . Nr/

53 Prepaid expenses and deferred charges . . . . . 931,430 53 971 , 545

54 Investments-securities (attach schedule)Saa, " 0 Cost 9 FMV 545(0, 75 54 (o

55a Investments-land, buildings, and equipment: basis

b Less : accumulated depreciation (attach schedule) . . . . . . . . . . . 55b 55c

56 Investments-tether (attach schedule) 56 57a Land, buildings, and equipment: basis . 57a M'I, . b Less : accumulpted de llreciation (attach a schedule)?-ra9Q7 i0Q~had_~ ~2 57b lJ7(~~f , ~rJ J~ 51-f5a10 57c ~+~ I

58 Other assets (describe " js~ rc7~ak .S P44cc h.Q ) ? ~ 1`~ 7j9 58 13 `f 5

59 Total assets (add lines 45 through 58) (must equal line 74 59 15D, a 60 Accounts payable and accrued expenses . . . . . . . . . a I 51 61 Grants payable . . . . . . . 62 Deferred revenue . . . . . . . . . . . . . . . . . 62

m 63 Loans from officers, directors, trustees, and key employees (attach schedule) . . . . . . . . .

A 64a Tax-exempt bond liabilities (attach schedule) . b Mortgages and other notes payable (attach schedule) .

65 Other liabilities (describe " ) 65

66 Total liabilities (add lines 60 through 65) J9, .51.i.~ O 66 3a, Jfo

Organizations that follow SFAS 117, check here " ~ and complete lines q 67 through 69 and lines 73 and 74 . v 67 Unrestricted . . . . . . . . . . . . . . . . . . . /07 0r155367 /d ar /

68 Temporarily restricted . . . . . . m 69 Permanently restricted . . . . . . . . . . . . . . . 69

c Organizations that do not follow SFAS 117, check here " D and u~, complete lines 70 through 74 . `0 70 Capital stock, trust principal, or current funds .

71 Paid-in or capital surplus, or land, building, and equipment fund 71

y 72 Retained earnings, endowment, accumulated income, or other funds

.+

72

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) . ~ ;� 1(),) 73 ~' f S' ~ p r. C~c~7C~j

74 Total liabilities and net assets / fund balances (add lines 66 and 73) ~/, S,/) 74 /50 . 1~=1u " 7E~ 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 .

.f


EIN 37-0635502 PROTESTANT MEMORIAL MEDICAL CENTER, INC . Form 990 (2004) 4

1

Form 990 (2004)

Reconciliation of Revenue per Audited Reconciliation of Expenses per Audited Financial Statements with Revenue per Financial Statements with Expenses per Return (Seepage 27 of the instructions .) Return

`,.a Total revenue, gains, and other support ° a Total expenses and losses per --

per audited financial statements . " a' q ~~ U, 35 audited financial statements . . " a l - , ~ ̀ , `J( b Amounts included on line a but not on b Amounts included on line a but not

line 12, Form 990: M, , on line 17, Form 990: (1) Net unrealized gains (1) Donated services `

on investments . . $ ~ and use of facilities (2) Donated services ' (2) Prior year adjustments

and use of facilities $ reported on line 20, (3) Recoveries of prior Form 990 . . . . $ ,, .

year grants . . . $ (3) Losses reported on (4) Other (specify) : line 20, Form 990 . $

E r (specify~ $

Sd Imou 410%1%-Arough (4) 1111~ ji- /103~01 19LAO P r ',-r I o -- ---- ~ l~ J? %ky, "4

dialirno&K-01n' UAJ~ through (4)" b c Line a minus line b . . . . . " c S~ 7l5 c Line a minus line b . d Amounts included on line 12, d Amounts included on line 17,

Form 990 but not on line a : Form 990 but not on line a :

(1) Investment expenses (1) Investment expenses not included on line not included on line 6b, Form 990. . . $ ` , 6b, Form 990

(2) Other (specify) : (2) Other (specify): w8

---------------------- -------------------------------------------- $ ' ---------------------- Add amounts on lines (1) and (2) " d Add amounts on lines (1) and (2) p. d

e Total revenue per line 12, Form 990 e Total expenses per line 17, Form 990 line c p lus line d) . . . " e 1 / (, 7 ~a~o.7i5 line c plus line d . " e /

GEW List of Officers, Directors, Trustees, and Key Employees (List each one even if .not compensated ; see page 27 of the instructions .)

(D) Contributions to (E) Expense (A) Name and address (B) Title and average hours per I (~ got

Compensation s enter em week devoted to osition ( paid, ployee benefit plans & account and other

_n~ d.,a.. .. ...~ .. .,. .,.,.�. ...~� .., .,u ... ., ...., . .. ..

--------- \ ------- ------ --- Cl ---- ? -.--------------------------- --------------------------------------------------------------

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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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? ." D Yes % No If "Yes," attach schedule-see page 28 of the instructions .

PROTESTANT MEMORIAL MEDIC"CENTER, INC . E47-0635502 Forth 990 (2004) Page rJ

Other Information See page 28 of the instructions . Yes No 76 Did the organization engage in any activity not previously reported to the IRS? If "Yes," attach a detailed description of each actively. 76 & 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 it filed a tax return on Form 990-T for this years . , . , , . . . . , . , . , , 78b

79 Was there a liquidation, dissolution, termination, or substantial contraction dunng the years If "Yes," attach a statement 79 80a 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 r nonexempt organization? . . b If "Yes," enter the name of the organization " ._ . J~Z_ _ .~QChoG~.__C~~_ JZ2 _ ._ .__ .___ . ._ _ _ ._ --------

--

____ . ._ . ._ . . . .______ . ._ . . . ._ . .___ . . . . ._ . ._ . ._ ._ . . . . . . . . and check whether it is `~ exempt or El nonexempt. 81a Enter direct and indirect political expenditures. See line 81 instructions . . 8l a - O - Nil b Did the organization file Form 1120-POL for this year? . . . , , , . , . , , , , , 81b

82a 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? . . . . . . . . , , . , . , , , , , . , 82a

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 m Part III . . 82b o1,0e3ermina 610-

83a Did the organization comply with the public inspection requirements for returns and exemption applications? b Did the organization comply with the disclosure requirements relating to quid pro quo contributions?. . 83b X

84a Did the organization solicit any contributions or gifts that were not tax deductible? b If "Yes," did the organization include with every solicitation an express statement that such contributions

or gifts were not tax deductible? . . . . . . . . . , . . . , , , , , , 84b ~j I 85 501(c)(4), (5), or (6) organizations. a Were substantially all dues nondeductible by members? . . 85a A11 .4 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 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 . . . . . . . . 85cs d Section 162(e) lobbying and political expenditures . e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices . f Taxable amount of lobbying and political expenditures (line 85d less 85e) . 85f l g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f? . , . . . . 859

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 IZff

86 501(c)(7) orgs . Enter: a Initiation fees and capital contributions included on line 12 . 86a ~ . . b Gross receipts, included on line 12, for public use of club facilities .

87 501(c)(12) orgs . Enter: a Gross income from members or shareholders . . , 87a r, A.1 It)

b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) . . . . . , , . 87b

88 At any time during the year, did the organization own a 50% or greater interest m 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 IX . . . . .

89a 501(c)(3) organizations . Enter: Amount of tax imposed on the organization during the year under : section 4911 " " D- ; section 4912 " - 0 " ; section 4955 " - D -

b 501(c)(3) and 501(c)(4) orgs Did the organization engage m 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 _i a statement explaining each transaction . . . . . . . . . . . . . . . . . . . . . 89b I~

c Enter: Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 . . . . . . . . . . . . . . . . . . . . t

d Enter : Amount of tax on line 89c, above, reimbursed by the organization . . . . . , . . " '> 90a List the states with which a copy of this return is filed " -__ . . . ._ . . . .___ . . . . . . . . . ._ . . .____ . . .__ . . ._ ._ .__ . ._ ._ .__ ._ . . . .

b Number of employees employed in the pay period that includes March 12, 2004 (See instructions ) 90b 91 The books are in care of " ~Y~!e%nr~~!1_ ~~ ---- Telephone no .

Located at " a-~---- --_ ------ - - 'rvIlt 1~;~-'" -~'---- /Ya ~-~~-- .-=~------ ZIP +4 " ~~~4---------------- 92 Section 4947(a)(1) nonexempt charitable trusts filing Form 990 in lieu of Form 1041-Check here .

and enter the amount of tax-exempt interest received or accrued during the tax year . . . * 1 92 I W(IM11-4 4113 ("111 Form 990 (2004) spas4010 oNAW it COMB ws .14 M

PROTESTANT MEMORIAL MEDOL CENTER, INC . ~ 37-0635502

Form 990 (2004) Page s Anal sis of Income-Producing Activities See page 33 of the instructions .

Note : Enter gross amounts unless otherwise Unrelated business income Excluded by section 512, 513, or 514 (E) 'Related or indicated. (A) (B) (C) (b) exempt function

93 Ppgralm service revenue : Business code Amount Exclusion code Amount incorrie

-of' -14.q4c a

rulte are hose,fct b Pat,err* Serv;co c-SKilled Nurs,n,, jl"5 .^Illty q 3 ' c d e f Medicare/Medicaid payments g Fees and contracts from government agencies

94 Membership dues and assessments . 95 Interest on savings and temporary cash investments 96 Dividends and interest from securities . . I 53! 8 8 97 Net rental income or (loss) from real estate : WHMR6°

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 g 'S S 1 101 Net income or (loss) from special events 102 Gross profit or (loss1from sales of inventory 103 Q~her revenue : a I,Q4WPrio, S[1IQS f

LWEe Sho So 1 5 03 c N A 4f'ro n o Pr42- o a mrn_, ,3(n

d' e ~ ' Fe e all Ofhar ~yp~nuP ~81a3o `f J%lD, 4 F ~''~, a 8~8 Xu~ o ~ 7l)~ 104 Subtotal (add columns (B), (D), and (E)) .

105 Total (add line 104, columns (B), (D), and (Q) . . . . . . . . . . . . . . , t / (0 7~ Q~ 1., ; 7[~ Note : Line 105 plus line 1d, Part l, should equal the amount on line 12, Part l.

Relationship 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) . 7 ,. ~ . n ~ , , _ . . . . . . . , . _ . _

I

Car , +v Sk illed ~,ina ~'ae~l~~ 1n iie~tf- , ~a Sa e5 an d rI rc o '5Dn u r hq ,PS n rm gcu+e care r10;Pi~I o 5iii IiP, nur_3t!' Disregarded Entities See page 34 of the instructions :

(C) (D) End st Nature of activities Total income

k'r'om JirecL~ 0 ,'oI!i morn F~hp.r ~ n c ~ c1 P n

era+inv~ Of a-, Shorf-+e Taxable Subsidiaries and

h e 1/_Q n u 'U .u n evenue. 2r

relate fo +i Information Re

Name, address, and EIN of corporation, partnership, or disregarded entity

of

Sign ' Signature of office Here ( r~

Type or ,erime and title

Paid P9 Pares s signature

Pf2perEr'S Fum's name (or yours 1 Use 011h1 if salt-employed), ~� , ~* w__

f

81 r

ova I

%I Information Regarding Transfers Associated with Personal Benefit Contracts (See page 34 of the instructions .) ;

(a) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contracts E ] Yes D No (b) Did the organization, during the year, pay premiums, directly or indirect) on a ersonal . ben fit ntra t? Note: !f " Yes" to (b), file Form 8870 and Form 4720 (see rnsfru

Under penalties of perjury, I declare that I have examined this return, inc and belief, it is true, correct, and complete Declaration of preparer (ot

Please

-fl~~!- . . . . . . . . . . . --------

14

C~t.pns

--------------------- --------------------- i I) S ~ ~ ~ ~ o ho _s / 1 /q - t n ~,! f9" i ~)1" r r

. - lP'I ls 4& no-s /q,573,? 11 )W? Total number of other employees paid over +

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.")

ta) Name and address of each independent contractor paid more Ulan $50,000 (b) Type of service (c) Compensation

pC---------------- .J J

1 1 ~ 1~~ . " L) h s~ ~a ~ erYice~ 3,9,E 7 0

----`~ (--~-- ~ Q- ~~ U`~' Lou'! n l"`h!.51(ij O r c.J-rVIC' °S l, 070s la'y

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~~?iiJvil/~ =/q(?- /5 Total number of others receiving over $50,000 for 2 s' professional services . " ..>J

For Paperwork Reduction Act Notice, see the Instructions for Forth 990 and Form 990-EZ Cat No 11285F Schedule a (Form 9W or 990-EZ) 20114

SCHEDULE A Organization Exempt Under Section 501(c)(3) OMB No 1545-0047

(FoRn 990 or 990-E2) (Except Private Foundations and Section so1(e), so1m, so1(k), 501(n), or Section 4947(a)(1) Nonexempt Charitable Trust G~

Department o1 the Treasury Supplementary Information-(See separate instructions.) (S0 0 4

internal Revenue Service lo- MUST be completed by the above organizations and attached to them Form 990 or 990-EZ NT; of the organization Employer Identification number

o~Ps~a4 _m 11~ecli cal Cen-- .a n 3`1 :ocn3-'~5o2J 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 hours (d) Contributions to (e) Expense than $50,000 per week devoted to position (c) Compensation employee benefit plans 8 account and other

deferred compensation allowances

~L C0.10lfer

4O hour 5 aiv 7$~ ,s

. ... . . . . . . . . . . . . . . .

P,-f1~0~(I1lQ Xllnnrs `~0 hours 135,55q .~J~~l?~ - U-

EIN 37-0635502 2 Schedule A (Forth 990 or 990-EZ) 2004

Statements About Activities (See page 2 of the instructions .) Yes I No

a Sale, exchange, or leasing of property? . . . . . . . . . . . . . b Lending of money or other extension of credit? /~, ~~ . c Furnishing of goods, services, or facilities? ~° 2. ~u d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)?JU_ Frl1.7 9.9p . e Transfer of any part of its income or assets? . . . , , . . . , . . . , . . . . ~a!+ T .

3a Do you make grants for scholarships, fellowships, student loans, e~ c~ .? (If "Yens 1 ~" attach an explanation of how you determine that recipients qualify to receive payments .} jep .l'QR~ a" frnQC~;ID_~J.

b Do you have a section 403(b) annuity plan for your employees? . . . . . 4a Did you maintain any separate account for participating donors where donors have the right to prowls advice

on the use or distribution of funds? . . . . . . . . . . . . . . b Do you provide credit counseling, debt management, credit repair, or debt negotiation services?

4a

Provide the following information about the supported organizations . (See page 5 of the instructions (b) Line number

from above (a) Name(s) of supported organization(s)

PROTESTANT MEMORIAL MEDICAL CENTER, INC .

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 r~ferendu ? If "Yes," enter the total expenses paid or incurred m connection with the lobbying activities " $~ .,, . (Must equal amounts on line 38, Part VI-A, or line I of Part VI-B) . . . . . . . . . . . . ~ " . ~ Organizations that made an election under section 501(h) by fling 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, masonry owner, or principal beneficiary? (If the answer to any question is "Yes," attach a detailed statement explaining the transactions.)

2a 2b

38

OEM Reason for Non-Private Foundation Status (See pages 3 through 6 of the instructions .)

The organization is not a private foundation because d is : (Please check only ONE applicable box

5 El A church, convention of churches, or association of churches . Section 170(b)(1)(A)(i) . 8 El A school . Section 170(b)(1)(A)(ii) . (Also complete Part V .) 7 )R A hospital or a cooperative hospital service organization . Section 170(b)(1)(A)(ui). 8 0 A Federal, state, or local government or governmental unit. Section 170(b)(1)(A)(v) . 9 El A medical research organization operated in conjunction with a hospital . Section 170(b)(1)(A)(ui). Enter the hospital's name, city,

and state 1 --------------~----------------~---------------------------------------------------------------------------------------------- 10 0 M organization operated for the benefit of a college or university owned or operated by a governmental unit . Section 170(b)(1)(A)(1v) .

(Also complete the Support Schedule in Part IV-A) 1!a 0 M organization that normally receives a substantial part of its support from a governmental unit or from the general public. Section

170(b)(1)(A)(w) . (Also complete the Support Schedule in Part IV-A.) 11b 0 A community trust . Section 170(b)(1)(A)(vi). (Also complete the Support Schedule in Part IV-A .) 12 0 An organization that normally receives : (1) more than 33'/a% 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'/a% 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 0 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 50t(c)(4), (5), or (6), if they meet the test of section 509(a)(2). (See section 509(a)(3).)

14 E] An organization organized and operated to test for public safety . Section 509(a)(4) . (See page 5 of the instructions ) Schedule A (Forth 990 or 990-EZ) 2004

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) . . " 1 27f I g Public support percentage (line 27e (numerator) divided by line 271 (denominator)) . h Investment income percentage (line 18, column (e) (numerator) divided by line 27f (denominator) .

or


Schedule A (Form 990 or 990-EZ) 2004 Page

Support Schedule (Complete only if you checked a box on line 10, 11, or 12 .) Use cash method of a ynting. Note: You may use the worksheet in the instructions for converting from the accrual to the cash method of accounting. Calendar year (or fiscal year beginning in) " (a) 2003 (b) 2002 (c) 2007 (d) 2000 v (e) Total 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 m any activity that is related to the organization's charitable, etc , purpose .

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 m line 18.

20 Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf .

21 The 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 gain or (loss) from sale of capital assets

23 Total of lines 15 through 22 , 24 Line 23 minus line 17 . 25 Enter 1 % of line 23

26 Organizations described on lines 10 or 11 : a Enter 2% of amount in 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 gifts for 2000 through 2003 exceeded the amount shown in line 26a . Do not file this list with your return . Enter the total of all these excess amounts 11P, 26b

c Total support for section 509(a)(1) test: Enter line 24, column (e) . . . . d Add : Amounts from column (e) for lines . 18 19

22 26b . . . . , . " 26d e Public support (line 26c minus line 26d total) , . . . . , . . . , . . , . , . . . . " 26e t Public support percentage (line 26e (numerator) divided by line 28c (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' 04

(2003) -------------------------- (2002) --------------------------- (2001) --------------------------- (2000) -------------------------- 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 m 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 : (2003) ----~--------------------- (2002) --------------------------- (2001) ------~-------------------- (2000) --------------------------

28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any unusual grants during 2000 through 2003, prepare a list for your records to show, for each year, the name of the contributor, the date and amount of the grant, ~n~i a brief description of the nature of the grant Do not file this list with your retain . Do not include these grants in line 15 .

d Scholarships or other financial assistance . . . . . . . . . .

e Educational policies . , . . . . . . . . . . . . . . .

PROTESTANT MEMORIAL MEDICAL CENTER, INC . EIN 37-0635502 Schedule A (Form 990 or 990-EZ) 2004 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 IV1

29 Does the organization have a regally nondiscriminatory policy toward students by statement in its charter, bylaws, Yes Na

other governing instrument, or m a resolution of its governing body? . . . . 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, 30 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 registration period if it has no solicitation program, m a way that makes the policy known to all parts of the general community it serves? . 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 staffs , , , , , 32a

b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory 32b basis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing with student admissions, programs, and scholarships . . . . . . . . . . . . . . . , , . 32c

d Copes of all material used by the organization or on it behalf to solicit contributions? . . . . . . . . 3?d. . ,

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 .

a Students' rights or privileges? . , . . . . , . . . . . . . . .

b Admissions policies? . . . . . . . . . . . . . . . . . .

c Employment of faculty or administrative staff? . . . . . . . . . .

f Use of facilities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, 6;9 1 1

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.) ----------------------------------------------------------------------------------------------------------------------------------------------- ------- - --------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ----------------------------------------------------

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

i 35 Does the organization certify that it has complied with the applicable requirements of sections 4.01 through 4 OS

of Rev Proc 75-50, 1975-2 C B . 587, covering racial nondiscrimination? If "No," attach an explanation . . 35 Schedule A (Foam 990 or 990-EZ) 2004

1

i

PROTESTANT MEMORIAL MEDICAL CENTER, INC . EIN 37-0635502 ichedule A (Form 990 or 990-EZ) 2004 Page)

Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions .) (To be completed ONLY by an eligible organization that filed Form 5768)

;heck " a D if the organization belongs to an affiliated group Check " b 0 if you checked "a" and "limited control" provisions apply

Limits on Lobbying Expenditures Affi ate group To be completed totals for ALL electing

(The term "expenditures" means amounts paid or incurred ) organizations

36 Total lobbying expenditures to influence public opinion (grassroots lobbying) . , , , 36

37 Total lobbying expenditures to influence a legislative body (direct lobbying) . 38 Total lobbying expenditures (add lines 36 and 37) . , , , , , , , _ , . . _ 38

39 39 Other exempt purpose expenditures . . . . . , , . , , , . , , , J4 10 Total exempt purpose expenditures (add lines 38 and 39) . . . . . . . . ,

41 Lobbying nontaxable amount Enter the amount from the following table- `If the amount on line 40 is- The lobbying nontaxable amount is- '`F~~ * `

7H, 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 . 44 Subtract line 41 from line 38 Enter -0- if line 41 is more than line 38,

Caution: If there is an amount on either hne 43 or Ime 44, you must file Form 4720 ;fy.

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 .)

Lobbying Expenditures During 4-Year Averaging Period

Calendar year (or (a) I (b) (c) I (d) (e) fiscal year beginning in) " 2004 2003 2002 2001 Total

45 Lobbying nontaxable amount

46 Lobbying ceding amount (150% of line 45(e))

47 Total lobbying expenditures .

48 Grassroots nontaxable amount .

49 Grassroots ceiling amount (150% of line 48(e))

50 Grassroots lobbying expenditures . Lobbying Activity by Nonelecting Public Charities (For reporting only by organizations that did not complete Part VI-A) (See page 11 of the in

During the year, did the organization attempt to influence national, state or local legislation, including any Yes No Amount attempt to influence public opinion on a legislative matter or referendum, through the use of

a Volunteers . . . . . . . . . . . . . . . . . . ~ f b Paid staff or management (Include compensation in expenses reported on lines c through h.) . . , x ~t 4 ~ . . _

c Media advertisements . . . . . . . . . 271 17 d Mailings to members, legislators, or the public . . . . e Publications . or published or broadcast statements . . . . AJ,'. f Grants to other organizations for lobbying purposes . . . . . ~ ~ N 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 .) , . . . . . . . . ~ -~_ul~~`_~'S1-__

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) 2004

Schedule A (Form 990 or 990-EZ) 2004 Page s

Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations (See page 11 of the instructions .

51 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 nonchantable exempt organization of : Yes No

51 a i )( (i) Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(ii) Other assets . . . . . . . . . . . . . . . . . . . .

b Other transactions : (i) Sales or exchanges of assets with a nonchantable exempt organization . . . . . . . . . . , b iX

(ii) Purchases of assets from a noncharitable exempt organization . . , . . . . . . . , . , , b ii X

(iii) Rental of facilities, equipment, or other assets . . . . . . . .

(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 . . . . . . . . . . . SC 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, or services received .

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 m section 527? , . , , . , " El Yes 0 No

Schedule A (Form 990 or 990-EZ) 2004

--PROTESTANT MEMORIAL MEDICAL CENTER, INC . EIN 37-0635502 1

. . PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 FORM 990 2004

PAGE 1

8d TOTAL NET GAIN/(LOSS) ($258,521)

------- ---------------------- --------------------------- ---------------------------------- --- ---------- --------- --- ----------------

PART l, LINE 8 - GAIN (LOSS) FROM SALE OF ASSETS OTHER THAN INVENTORY

Gross Net Amount Gain/ from Sale Basis (Loss)

(A) SECURITIES (see also attached pagesl a & 1b)

Capstone (detail pg 1a) 4,992,152 5,576,583 (584,431) US Bank (detail pg 1b) 4,751,401 4,425,491 325,910

---------------------------------- -------------------- ---------------------- Total Securities $9,743,553 $10,002,074 ($258,521)

al

YTD 4,992,152 04 5,576,583 25 000 (584,431 21)

PROTESTANT MEMORIAL MEDICAL CENTER, INC PAGE 1a

EIN-37-0635502

FORM 990 2004 ''

CAPSTONE

SUMMARY OF GAINS(LOSSES)

PROCEEDS AMORT FROM (DISCT) GAIN

DATE ITEM SALE COST PREMIUM (LOSS)

01120/04 Piper Jaffray Co 625 458 1 67 02118/04 Piper Jaffray Co 233 shares 11,929 04 7,11688 4,81216 02/27/04 USTN 6 500% 05/15/05 1,062,968 75 1,103,125 00 (40,156 25) 03102/04 Associates Corp 5 800% 04/20104 603,480 00 563,580 00 39,900 00 03125/04 W yeth 8,645 shares 317,101 77 382,532 61 (65,430 84)

000 Pools 101,563 26 102,763 15 (1,199 89)

000 1ST QTR 2,097,049 07 2,159,122 22 000 (62,073 15)

04/01104 Lehman Bros Holding 6 625% 411104 250,000 00 264,255 00 (14,255 00) 04120!04 FNMA MTN 2 410% 04/20106 500,000 00 499,300 00 70000 04123/04 Washington Mutual Inc 12,315 shares 494,007 11 425,305 55 68,701 56 05126104 Intuit, Inc 3,660 shares 138,198 36 195,627 00 (57,428 64)

000 000 000 000

Pools 119,167 35 120,456 60 (1,289 25)

2ND QTR 1,501,372 82 1,504,944 15 000 (3,571 33)

07108/04 Cardinal Health 5,420 shares 281,454 00 355,451 60 (73,997 60) 07129/04 Omincare Inc 5,700 shares 154,694 37 245,195 19 (90,500 82) 09/20104 Coca-Cola Co 15,140 shares 621,028 24 837,946 33 (216,918 09)

Pools 73,588 14 74,672 84 (1,084 70)

3RD QTR 1,130,76475 1,513,265 96 000 (382,501 21)

11/2912004 Forest Labs 5,430 shares 202,534 25 338,063 66 (135,529 41) Pools 60,431 15 61,18726 (75611)

4TH QTR 262,965 40 399,250 92 000 (136,285 52)

10/15104 GNMA 555516 1,28152 1,29514 (1362) 1012112004 Vanguard Inflation Protect Sec 20,000 Un 251,400 00 248,482 70 2,91730 10122/2004 Black & Decker Corp 1,000 units 78,561 91 57,253 34 21,308 57 10122/2004 Honeywell Intl 2,000 units 70,160 85 61,180 00 8,98085 1012212004 United Health Group 1,500 units 99,372 68 73,435 00 25,937 68 10/2812004 Vanguard Inflation Protect Sec 8,000 Unit 100,000 00 98,727 34 1,27266 11112/2004 Vanguard Inflation Protect Sec 8,006 405 100,000 00 94,530 46 5,46954 1115/2004 Medco Health Solutions 1904 Shares 66,019 17 56,009 14 10 .010 03 12115104 GNMA 555516 645 97 65283 (686)

12/1412004 Wells Fargo 2,000 shares 125,197 O6 85,600 00 39,597 06 4TH QTR 892,639 16 777,165 95 000 115,473 21

YTD 4,751,401 40 4,425,491 52 000 325,909 88

PROTESTANT MEMORIAL MEDICAL CENTER, INC PAGE 1b EIN-37-0635502 FORM 990 2004'

US BANK SUMMARY OF GAINS(LOSSES)

PROCEEDS AMORT FROM (DISCT) GAIN

DATE ITEM SALE COST PREMIUM (LOSS)

01107/04 Fanrne Mae 1,000 shares 74,597 50 63,660 00 10,937 50 01/13/04 Forest Labs Inc 1,500 shares 101,556 91 75,411 50 26,145 41 01115/04 GNMA 555516 24,860 27 25,124 41 (26414) 01/23104 Fidelity Low Priced Stock Fd 1,367 989 50,000 00 46,757 86 3,24214 01127104 Coors Adolph Co 1,000 shares 55,487 40 64,250 00 (8,762 60) 01/27/04 HCA Inc 3,000 shares 134,821 68 97,360 00 37,461 68 01127/04 AON Corp 2,500 shares 61,215 12 55,283 00 5,93212 01127/04 ChevronTexaco Corp 1,500 shares 130,340 89 141,846 00 (11,505 11) 01127/04 Dominion Resources Inc 1,000 shares 62,955 15 63,643 00 (68785) 01/27104 W al-Mart Stores Inc 2,000 shares 106,599 60 67,497 50 39,102 10 01127104 Toys R Us 6,000 shares 87,876 67 97,402 .00 (9,525 33) 01/27104 Mattel Inc 2,000 shares 37,378 24 39,583 20 (2,204 96) 01/27104 Waste Mgmt Inc 1,500 shares 41,608 04 44,220 00 (2,611 96) 01127/04 Staples Inc 3,000 shares 76,856 39 59,888 00 16,968 39 02102!04 Biogen [DEC Inc 2,000 shares 88,009 27 77,437 20 10,572 07 02117/04 GNMA 555516 60449 61091 (642) 02/17104 USTN 5 875% 2115/04 500,000 00 506,796 88 (6,796 88) 02124104 Vanguard GNMA Fund 28,480 028 300,000 00 302,128 45 (2,128 45) 02!27/04 Altna Group Inc 2,000 shares 111,550 64 95,869 00 15,681 64 03103/04 Kohis Corp 2000 shares 104,890 90 86,940 00 17,950 90 03115104 GNMA 555516 60777 61423 (646)

1ST QTR 2,151,816 93 2,012,323 14 000 139,493 79

04/15/04 GNMA 555516 61303 61954 (651) 04/26104 Tenet Healthcare Corp 3,000 shares 31,499 25 56,560 00 (25,060 75) 05/17/04 GNMA 555516 61439 62092 (653) 05/26104 State Street Corp 118,748 61 111,155 00 7,59361 06/09/04 Exxon Mobil Corp 2,000 shares 86,677 97 82,640 00 4,03797 06/15/04 GNMA 555516 61771 62427 (656) 06/17/04 Constellation Brands 4,000 shares 146,872 15 95,711 50 51,160 65 06/17104 Century Tel, Inc 88,122 93 103,187 00 (15,064 07)

2ND QTR 473,766 04 451,118 23 000 22,647 81

07/01104 Mellon Financial Corp 4,000 shares 119,037 21 124,334 00 (5,296 79) 07/02104 Merck & Co 2,000 shares 94,877 77 112,703 94 (17,826 17) 07102/04 Big Lots 6,000 shares 84,898 00 84,625 00 27300 07115104 GNMA 555516 1,66536 1,68305 (1769) 08/10!04 MBNA Corp 2,500 shares 60,594 57 65,625 00 (5,030 43) 08110/04 W al-Mart Stores 500,000 units 500,000 00 499,135 00 86500 08/16/04 GNMA 555516 62950 63619 (669) 09/07104 TCF Financial 3,000 shares 191,275 50 114,400 00 76,875 50 09115/04 GNMA 555516 63557 64232 (675) 09/28/04 General Mills 4,000 shares 179,565 79 181,099 70 (1,533 91)

3RD QTR 1,233,179 27 1,184,884 20 000 48,29507

Net unrealized gains/losses on investments for 2004 3,258,695

$2,559,525

PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 FORM 990 2004

PART I, LINE 20 - OTHER CHANGES IN NET ASSETS

PAGE

--- -------------------- -- -------------------- ---------------

Transfers from Protestant Memorial Medical Center, Inc to (1,074,052) Memorial Group, Inc (EIN 37-1186035) to conduct qualified business activities

Transfers from Protestant Memorial Medical Center, Inc to (500) Memorial Hospital Self Insurance Trust Fund (EIN 37-1064809) to conduct qualified business activities

Change in interest m the nets assets of Memorial Foundation, Inc (EIN 37-1186034) 375,382

PAGE

--- ------------------- ---

$9,082,221

Depreciation is computed by the straight-line method over estimated useful lives as suggested by the American Hospital Association


PART II, LINE 42 - DEPRECIATION

DEPRECIATION' LAND IMPROVEMENTS $213,719 BUILDINGS 1,854,125 FIXED EQUIPMENT 1,421,336 MOVABLE EQUIPMENT 5,593,041

-------------- --------------

The value of community benefits provided by Memorial Hospital in 2004 exceeded $27 million dollars .

In 2004 Memorial provided the following community outreach services to area residents at no cost or for a nominal fee :

PROTESTANT MEMORIAL MEDICAL CENTER, INC. EIN 37-0635502 FORM 990 2004

--------------

COMMUNITY BENEFITS REPORT FYE 12/31104

l . SUMMARY

PAGE 4a

Community Benefit Value

Unreimbursed Costs :

Medicaid and Medicare $16,382,103

Bad Debts 8,887,785

Charity Care 1,299,146

Volunteer Services 232,304

Subsidized Health Services 232,245

Unreimbursed Expenses as Resource Hospital for Emergency Medical Services 158,516

Education, Other Activities 328,487

$27 .520,586

II . MISSION STATEMENT

The mission of Memorial Hospital is to provide high-quality, cost-effective services to people residing in Southwest Illinois which promote health, prevent disease, and treat and manage illness . It pursues this as an independent, community-based institution in cooperation with physicians and other healthcare providers .

III . COMMUNITY BENEFITS PROVIDED IN 2004

Pacesetters - mall walkers Men's heart check Women's health fair Skin cancer Women's heart check Seniors (Seniorama) Depression Seniors (Senior Celebration) Respiratory therapists Blood pressure checks by Home Health School sports screening by Physical Therapy Other health fairs

120 71 150 275 79

2000 22

3250 Not available Not available Not available 225


------------- -------------

Service

1 . Community Health Education

Lectures Heart disease Incontinence Heart disease in women Foot pain Foot surgery Sleep apnea Asthma Outpatient diabetes instruction

Self Help Programs Smoking cessation Weight management Meditation

Other Education Older adult driving course Family safety Safe sitter class Youth Health Fair School presentations Car safety seat check CPR class Dietitians

2 . Health Screenings

PAGE 4b

--------------

Persons Served

25 50 45 60 40 25

Not available 205

24 107 125

42 100 59

1800 421 390 84

Not available

PROTESTANT MEMORIAL MEDICAL CENTER, INC . EIN 37-0635502 FORM 990 2004 -------------- --------------

58 45 155 306 150 256 Not available 78

Health Fairs St. Clair County Health Department YMCA Casino Queen employees Shrine of Our Lady of the Snows employees Landshire employees American Society of Military Comptrollers Volunteer Inter-Faith Caregivers Pontiac/William Holliday School Belleville News Democrat employees Programs and Services for Elderly Persons (PSOP)

These outreach programs benefited approximately 11,000 persons in the communities served by Memorial, however, they represent only a small fraction of the benefits provided in 2004.

3 . Support Groups

Cancer Cardiac Panic/Anxiety Diabetes Alzheimer's Pulmonary Sleep Apnea Lupus

4 . Other Community Services

Speakers Bureau Programs and Services for Elderly Persons (PSOP) Triad School District Turkey Hill residents Obesityhelp .com Belleville East High School Southwest Illinois College Women's History Group Belleville West High School Parkview Church of the Nazarene Women's Group District 118 pre-school program Millstadt Civic Group Southern Missouri Oral Health Association St . Clair Associated Vocational Enterprises (SAVE) Lupus Support Group Collinsville Public Library Abraham Lincoln School Cahokia High School William Bedell Achievement/Resource Center Marissa School District

PAGE 4c

-------------- ------------Encounters

8 . Health Care Potential health Address workforce Southwestern $109,095 Education care workers shortage with Illinois College 17 nursing

scholarships, train scholarships,

" PROTESTANT MEMORIAL MEDICAL CENTER, INC. EIN 37-0635502 PAGE 4d FORM 990 2004 -------------- ---------- - -- - - - --------- ------------ - -------------- -------------------- - ---------- ------ - ------ ------- - -- --

TOTAL COMMUNITY BENEFITS

Total community benefits, activities including outreach programs, are summarized below :

Community Costs/Other Activity Target Populations Objectives Partners Outcomes

1 . Unpaid costs of Medicaid and Provide needed $16,382,103 providing care Medicare enrollees inpatient and to Medicaid and outpatient services Medicare patients in the community .

2 . Glennon Care Children lacking Provide after hours Cardinal 6,450 patient for Kids primary care access urgent pediatric Glennon visits (Costs

care services Children's included in Hospital Unpaid Costs

of Medicaid and Medicare

3 Bad Debts Broad community Provide needed $8,887,785 inpatient and outpatient services in the community .

4 . Charity Care Low income, Provide medical $1,299,146 uninsured, under- services to insured residents patients unable to

pay for part or all of their care .

5 Volunteer Memorial patients Promote Memorial 42,237 hours Services and visitors, broad employee and $232,304

community volunteer participation in community benefit activities .

6 Community Broad community, Provide health, Various $232,245 Outreach' the uninsured, low wellness, safety, local groups 11,000 Education, income residents, early disease persons Screenings, residents without detection, disease served Support Groups, a primary care maintenance) Self Help physician support . Programs

7 IDPH-designated All residents Train emergency Southwestern $158,516 Regional Re- of St Clair medical services Illinois College, Provided source Hospital County and (EMS) personnel ambulance automatic for Emergency four surrounding and provide medical companies, defibrillator Medical Services counties direction to EMS police, fire, 17 training to

personnel providing municipality 1,200 personnel pre-hospital leaders, at 69 sites emergency services . health

department

emergency medical personnel .

9 IDPH-designated Disaster victims Pod Hospital in St . Clair for Region IV County and Disaster Planning surrounding nine

counties

10 Cash and Broad community, In Kind low income Donations residents

Provide funds, services, staff, space to support local agencies and community programs .

All Other

2004 TOTAL COMMUNITY BENEFITS

$ 140,808

$27.520.586

. .


---------------

Enable Memorial and partners to respond effectively to disaster victims .

PAGE 4e

-------------- --------------

400 EMS workers trained

Area police, $41,932 fire, health departments, ambulance companies, blood centers, hospitals, utilities, etc .

Social $36,652 service agencies, churches, schools, health care providers

PAGE 5

67.568 72.12

Admissions 14,556 14,701 Discharges 14,580 14,703 Average length of stay - days 4 .6 4 .9 Average daily bed capacity 313 341 Average daily occupancy 185 198 Percentage of occupancy 59 1% 58 .0%

Other operating statistics Emergency room visits 42,199 42,316 Outpatient departmental visits 229,184 227;535 Operating room visas 11,080 11,773 GI Lab visits 5,153 5,411 Open heart procedures 230 282 Laboratory tests 732,02 721,045 EKG exams 28,236 28,3 5 1 EEG exams 845 987 Diagnostic x-ray procedures 97,857 98,327 Nuclear medicine procedures 8,99 8,747 MR.I scans 6,671 6.84 CT scans 27.220 2,026 Cardiac cathetenzation procedures 1,961 1,876 Respiratory care treatments 212,669 217,796 Home health agency visas 12,332 10,796 Physical therapy treatments 171,921 172,071


PART III-PROGRAM SERVICE ACCOMPLISHMENTS

Protestant Memorial Medical Center, Inc . Memorial Hospital Service Statistics

Years Ended December 3'i, 2004 and 2003 (Unaudited)

2004 2003 Adult and pediatric

Patient days Medical and surgical division 56,881 60,372 CMU division _ 3 Intensive care unit 4,700 5,174 Obstetrical division 3,921 4,089 Pediatrics division 2.066 2.437

Nursery Patent days 3,38 3,276 Admissions 1,468 1,403 Discharges 1,476 1 .42 Average length of stay - days - 2 4 2.3 Average daily crib capacity ;2 32 Average daily occupancy 9 9 Percentage of occupancy 29% 28 .1%

U S TREASURY BILLS 8 NOTES GOVERNMENT AGENCY OBLIGATIONS CORPORATE OBLIGATIONS COMMON STOCK CERTIFICATES OF DEPOSIT

$60,624,513


------------------- -- PART IV, LINE 54 - INVESTMENTS

RECORDED AT FAIR MARKET VALUE

PAGE

$1,072,580 10,038,786 11,052,053 37,683,094

778,000

PAGE

ACCUM DEPREC NBV

(b) (c) COST (a)

Land Land Improvements Buildings Fixed Equipment Movable Equipment Construction in Progress

$162,087,423 $107,696,375 $54,391,048

PROTESTANT MEMORIAL MEDICAL CENTER, INC E I N 37-0635502 FORM 990 2004

PART IV, LINE 57 - LAND, BUILDINGS & EQUIPMENT

--- ----------------- ---

$1,486,451 - $1,486,451 4,551,524 $3,126,300 1,425,224 35,633,928 24,184,302 11,449,626 48,599,531 29,543,877 19,055,654 70,420,898 50,841,896 19,579,002 1,395,091 - 1,395,091

$8,136,457

PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 PAGE 8 FORM 990 2004

--- -------------------- ---

PART.IV, LINE 58 - OTHER ASSETS

Interest in Net Assets of Memorial Foundation, Inc (37-1186034) $7,984,948 Accrued Interest Income Receivable 44,855 Auxiliary Scholarships Outstanding 63,000 Auxiliary Gift Shop Inventory 35,589 Auxiliary Other Assets 8,065

Contributions To Avg Hours/Work Employee Benefit Expense

Name & Address Title Status Compensation Plans Account

Mr Roger Lowery Chairman 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr . Les Mehrtens Vice-Chairman 2 Hrs Per Month $0 $0 $0 Millstadt, Illinois Volunteer

Mr . Randall Ganim Secretary 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr Thomas Holloway Treasurer 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr . Arthur Baltz Director 2 Hrs Per Month $0 $0 $0 Columbia, Illinois Volunteer

Mr . Thomas Barnett Director 2 Hrs Per Month $0 $0 $0 Bellevdle, Illinois Volunteer

Mr Lary Eckert Director 2 Hrs Per Month $0 $0 $0 Millstadt, Illinois Volunteer

Mr Thomas Lippert Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr . Jeffry Lutz Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr Arthur Parnsh Director 2 Hrs Per Month $0 $0 $0 Smithton, Illinois Volunteer

Dr Edward Rose Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Mr . Roland Thouvenot Director 2 Hrs Per Month $0 $0 $0 Swansea, Illinois Volunteer

Dr James Vest Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Dr Robert Wanless Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

Rev. Ann Asper Wilson Director 2 Hrs Per Month $0 $0 $0 Belleville, Illinois Volunteer

PROTESTANT MEMORIAL MEDICAL CENTER, INC. Page 9 EIN 37-0635502 FORM 990 2004

PART V - LIST OF OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES

"These wages include employer paid excess life insurance These benefits are not included in Part II, Line 25, Compensation of officers, directors These benefits, however, are included in Part II, Line 28, Other employee benefits

PROTESTANT MEMORIAL MEDICAL CENTER, INC. Page 10 EIN 37-0635502 FORM 990 2004 - - - - --------------------------------- - - ---------------------------- ---------------------------------------- - ---- - ----------- - - -

PART V -LIST OF OFFICERS, DIRECTORS, TRUSTEES AND KEY EMPLOYEES

Contributions To Avg Hours/ Work Employee Benefit Expense

Name & Address Title Status' Compensation Plans Account Mr Harry R Maier President 75 Hrs Per Week $377,582 $97,312 $0 Belleville, Illinois Full Time

Mr Mark Turner Executive 55 Hrs Per Week $119,707 $9,631 $0 O'Fallon, Illinois Vice President Full Time

Mr . Joe H Lanius Vice President 56 Hrs Per Week $205,230 $41,182 $0 Belleville, Illinois Finance Full Time

Mr Terry Walther Vice President 55 Hrs Per Week $170,213 $40,766 $0 Belleville, Illinois General & Full Time

Rehab Services

Ms Nancy Weston Vice President 63 Hrs Per Week $150,858 $19,352 $0 Belleville, Illinois Nursing Services Full Time

Mr. Edward French Vice President 55 Hrs Per Week $135,850 $24,595 $0 Belleville, Illinois Human Resources Full Time

Mr Mano Gioia Vice President 50 Hrs Per Week $114,213 $18,799 $0 High Ridge, Missouri Environmental Full Time

Services

Mrs. Cathy Osborn Vice President 40 Hrs Per Week $129,258 $27,595 $0 Chesterfield, Missouri Corporate Full Time

Development $1,402,910 *' $279,231

PAGE 11

- Ors an ongoing basis, Memorial's Board expects its senior managers to insure that Memorial continues to be, when compared to various healthcare industry benchmarks, an efficiently-operated, independent, full-service, financially-viable, community:-based healthcare institution . This includes maintaining Memorial as a debt-free institution . As another example, compared to St . Louis and Metro-East

PROTESTANT MEMORIAL MEDICAL CENTER, INC

EIN 37-0635502 FORM, 990 2004

PROTESTANT MEMORIAL MEDICAL CENTER, INC.

NOTES TO MEMORIAL'S SENIOR MANAGEMENT COMPENSATION

Elected Board -members are non-compensated community volunteers .

Benefit costs for Senior Managers include non-vested, actuarially-determined supplemental retirement amounts set aside to provide retirement income percentage levels similar to those for- staff employees . Senior Managers are not eligible for such benefits unless they remain employed in their senior management positions until normal retirement age .

Senior Managers do not have employment contracts and serve solely at the Board's discretion. Senior management salaries and benefits are evaluated annually by the Board's Executive Committee (serving as a board compensation committee) . This Committee recommends any adjustments based upon the hospital's performance in meeting various industry-accepted financial, operational, and management benchmarks as well as comparisons with the compensation and benefits paid at comparably-sized and performing St. Louis area institutions . Full Board approval is required for any adjustments . The overall compensation philosophy utilized by Memorial's Board provides that, when compared to the compensation and benefits paid by other comparably-sized and performing St . Louis and Metro-East healthcara institutions, Memorial's senior management staff compensation and benefits should appropriately utilize the financial resources entrusted to the Board and should produce a cost-effective value for the communities which Memorial serves throughout Southwest Illinois . This conservatively-based senior management compensation structure is reflective of the Memorial Board's conservative approach to governance since the hospital's inception in 1458.

In evaluating senior management compensation, Memorial's Board utilizes several independent compensation surveys of St . Louis area hospitals 2s well as regional and national surveys . When Memorial is compared with a majority of St. Louis area hospitals with similar annual operating budgets (over $100 million) and full-time equivalent employees, the average total cash compensation paid at these other hospitals has consistently been greater than Memorial's senior managers received . In addition, these surreys show that Memorial's senior managers do not receive incentive compensation payments as do many of their peers at St. Louis area hospitals . Nor do Memorial's senior managers receive many or the other management fringe benefits typical at other St. Louis area hospitals .

PAGE 12

l

" PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 FORM 990 2004

hospitals, Memorial has traditionally maintained a low length of patient stay, a low charge per say and average charge structure, and has done so while providing a comprehensive range healthcare services to the residents of Southwest Illinois, regardless of ability to pay.

As an independent stand-along hospital and the area's largest civilian employer, Memorial's Board has set performance expectations for its senior managers which include a variety of important management and support services typically provided within multi-hospital systems by centralized corporate management s -aff personnel . It

Memorial's Board also utilizes ifs senior management compensation structure to encourage stability, consistency, and longevity which the, Board believes have contributed significantly to Memorial's overall success.

PAGE 13

---- --- -------------------- ---

5 Memorial Captive Insurance Company Non-Exempt #20-1267507

PROTESTANT MEMORIAL MEDICAL CENTER, INC ESN 37-0635502 FORM 990 2004

PART VI, LINE 80 - RELATED ORGANIZATIONS

1 Memorial Group, Inc Exempt #37-1186035

2 Memorial Foundation, Inc Exempt #37-1186034

3 Memorial Hospital Self-Insurance Trust Fund Exempt #37-1064809

4 Southwest Illinois Health Ventures, Inc. Exempt #37-1413286

PAGE

--- -------------------- ---

The above activities were conducted with the knowledge and approval of the Board of Directors and are believed to be at arm's length

PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 FORM 990, SCHEDULE A 2004

PART III, LINE 2

Three Directors are physicians and received compensation for professional services provided to the Corporation and/or a related organization

One Director is a partner in an accounting firm which provides professional services to the Corporation and/or a related organization .

One Director is the owner of a lumber company with which the Corporation and/or a related organization conducts business .

One Director is an employee of an engineering firm with which the Corporation and/or a related organization conducts business

One Director is an insurance agent with which the Corporation and/or a related organization conducts business

One Director is an employee of a bank with which the Corporation and/or a related organization conducts business

--- ------------------- --- --------------------- -------------

The Memorial Hospital Auxiliary provides educational assistance loans on a nondiscriminatory basis to students pursuing health-related careers Loan recipients are chosen based on financial need, academic performance and other relevant and appropriate criteria

PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 FORM 990, SCHEDULE A 2004

PART Ill-LINE 4b - EDUCATIONAL ASSISTANCE LOANS

PAGE

$ 36,186

PROTESTANT MEMORIAL MEDICAL CENTER, INC EIN 37-0635502 PAGE FORM 990, SCHEDULE A 2004 -------- ---------------------- --------------------------- ---------------------------------- --- ------------------ --- ---------------------- PART VI-B - LOBBYING ACTIVITY BY NONELECTING PUBLIC CHARITIES

The Corporation incurred the following expenses related to Illinois medical malpractice reform

Newspaper advertising to educate the public on Illinois medical malpractice reform $ 9,776

T-shirts, wristbands, and banners provided to the public to advertise Illinois medical malpractice reform $ 26,410

Protestant Memorial Medical Center, Inc . December 31, 2004 and 2003

Independent Accountants' Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Financial Statements

Balance Sheets . . . 2

Supplementary Information

Divisional Balance Sheets 15

Divisional Statements of Operations 16

Memorial Hospital Service Statistics (Unaudited) . 17

Memorial Convalescent Center Service Statistics (Unaudited) 18

Contents

Statements of Operations . 3

Statements of Changes in Net Assets . . . . . 4

Statements of Cash Flows . . . . . . . . . . . . . .

Notes to Financial Statements . . . . . . . . . . , . . 6

Independent Accountants' Report on Supplementary Information . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 14

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501 N Broadway, Sune 600 St Loins, MO 63102-2102 314 231-5544 Fax 314 231-9731

bkd.com Beyond Your Numbers /unesAb~,a inn

Independent Accountants' Report

Board of Directors Protestant Memorial Medical Center, Inc Belleville, Illinois

We have audited the accompanying balance sheets of Protestant Memorial Medical Center, Inc as of December 31, 2004 and 2003, and the related statements of operations, changes in net assets and cash flows for the years then ended These financial statements are the responsibility of the Medical Center's management. Our responsibility is to express an opinion on these financial statements based on our audits

We conducted our audits m accordance with auditing standards generally accepted in the United States of America Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation We believe that our audits provide a reasonable bass for our opinion

In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Protestant Memorial Medical Center, Inc as of December 31 ; 2004 and 2003, and the results of its operations, the changes in its net assets and its cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America

P IP /!/ C- L 14

April 6, 200

Protestant Memorial Medical Center, Inc . Balance Sheets

December 31, 2004 and 2003

1 19,9 ;1,891 117,995 .324 7.984.948 7 .609.66

127.916.839 12~ .604_890

1 X9 .982 .51 ~ S 154,170940

See Notes to Financial Statements 2

Assets

Current Assets Cash Patient accounts and other receivables, net of allowance for

uncollectible receivables of $8,835,00 in 2004 and $9,020,938 in 2003

Supplies Prepaid expenses Estimated balance due from third-party payers Due from affiliates

Total current assets

Assets Limited As To Use

Interest in the Net Assets of Memorial Foundation, Inc

Property and Equipment, net of accumulated depreciation

Total assets

Liabilities and Net Assets

Current Liabilities Accounts payable and accrued expenses Accrued wages and related payroll taxes Estimated balance due to third-party payers Estimated self-insurance costs, current Due to affiliates

Total current liabilities

Estimated Self-Insurance Costs . net of current portion

Total liabilities

Net Assets Unrestricted Temporarily restricted

Total nit assets

Total liabilities and net assets

2004 2003

$ 3,792,681 $ 3,790;570

19,720,970 19,926,52 1,080,87 1,034,437 871 ;45 931,431

304,19 62,067

25,465,783 26,049,216

72,140,736 67,966,848

7,984,948 7,609,66

54,391,048 52.545 .210

$ 1~9 9b2 ~1~ $ l :54 170_840

$ 7,998,267 $ 7 .131,068 7,69,527 6,812,910 470,990

3,941,000 3,881,000 1 .391 .309

21, X71,093 17,824,978

10.694,83 10.740,972

32,06 .676 28_5 65 ,9-) 0

2004 2003

(1 .074 .052) (2,86,000)

$ 1 .9 ~6.i67 $ 3 .=27.242


Protestant Memorial Medical Center, Inc . Statements of Operations

Years Ended December 31, 2004 and 2003

Unrestricted Revenues and Other Support Net patient service revenue Other

Expenses Salaries and wages Employee benefits Specialists' fees Medical supplies Food Utilities Repairs and maintenance Drugs and intravenous solutions Insurance Supplies and other Provision for uncollectible accounts Depreciation

Operating Loss

Other Income Investment return Donations

Deficiencv of Revenues Over Expenses

Investment return-change in unrealized gains and losses on assets limited as to use

Transfers to affiliates

Increase in Unrestricted Net .Assets

$ 163,998,197 $ 160,220,347 2 .124,286 2.188 .897

166,122_453 162.409,244

72,961.163 72.020,212 22,88,627 20,942,19 6,901,763 6,43,171 19,176;248 18,510,933 1 ;883,714 1 ;841,233 2,190;600 2,129,007 3,499;157 3,607,149 7,024,272 6,390,500 3,794,086 3,148,798 11 .30,1 16 11,327,019 8,682_183 9.675 .408 9 .082.221 9 .076.476

169.3 86.1 50 165 .122,065

(3 .263,667 ) (2 .712.821 )

2,206,716 2;022.686 18,436 558_489

2 .725 .152 2 .581 .175

(538,515) (131,646)

3_549 .134 6.323 .888

2004 2003

37 .382 913,169

2.3 11 .949 4.240.411

12 .604.890 121,364.479

$ 127.916_839 $_125604 890


Protestant Memorial Medical Center, Inc . Statements of Changes in Net Assets


Unrestricted Net Assets Deficiencies of revenues over expenses Investment return -change in unrealized gains and losses on assets limited as to use

Transfers to affiliates

Increase in unrestricted net assets

Temporarily Restricted Net Assets Net change in interest in the net assets of

Memorial Foundation, Inc

Increase in Net Assets

Net Assets, Beginning of Year

Net Assets, End of Year

$ (538,515) $ (131,646)

3,549,134 - 6,323 ;888 (1.074_Q52) (2.86 .000)

1,936.67 3,327242

'_790.i70 5,5l5_830

S 3792,681 S- 3,790,570

5 See Notes to Frnancial Statements

Protestant Memorial Medical Center, Inc . Statements of Cash Flows


Operating Activities Change in net assets Adjustments to reconcile change in unrestricted net assets to

net cash provided by operating activities Deprecation Change m unrealized gains and losses on assets limited

as to use Transfers to affiliates

Change m interest in the net assets of Memorial Foundation, Inc .

Changes m assets and liabilities Patent accounts and other receivables, net Estimated balance due to/from third-party payers Supplies Prepaid expenses Due to/from affiliates Accounts payable and accrued expenses Accrued wages and related payroll taxes Estimated self-insurance costs

Net cash provided by operating activities

Investing Activities Change in assets limited as to use Purchase of property and equipment

Net cash used in investing activities

Financing Activity Transfers to affiliates

Net cash used m financing activity

Net Increase (Decrease) in Cash

Cash, Beginning of Year

Cash- End of Year

2004 2003

$ 2,311,949 S~ 4,240,411

9,082,221 9,076;476

(3,49,134) (6,323;888) 1 .074;052 2,86,000

(37,382) (913,169)

205 .82 (42,342) 775,149 (831,452) (46,1 50) 93,182 59,856 (17,321)

1,43;376 (52,314) 273,949 110,006 76,617 (74,979) 1 .611 623,71

12,03 .726 7,915,181

(624,74) 181,962 (10.334.809) (6.97,403)

(10.959,563) (6 .77 .441)

(1_074,02 ) (2_86_000 )

(1_074 .02) (2 .86 .000)

2_]1l (1,72 .260)

Memorial Foundation, Inc (the "Foundation") seeks private support for and holds net assets on behalf of the Medical Center The Medical Center accounts for its interest in the net assets of the Foundation (the '-Interest") in a manner similar to the equity method The Interest is stated at fair value . and chances in the Interest are included in temporarilv iestncted net assets

Protestant Memorial Medical Center, Inc . Notes to Financial Statements December 31, 2004 and 2003

Note 1 : Nature of Operations and Summary of Significant Accounting Policies

Operations

The financial statements of Protestant Memorial Medical Center, Inc . (the "Medical Center") are prepared on the accrual bass of accounting and include the accounts of the Medical Center's two operating units, Memorial Hospital and Memorial Convalescent Center, located ui Belleville, Illinois The Medical Center provides health care services to residents of Southwestern Illinois

Memorial Group, Inc is the parent corporation of Protestant Memorial Medical Center, Inc ., Memorial Foundation, Inc, Southwest Illinois Health Ventures, Inc and Memorial Captive Insurance Company . All corporations, except Memorial Captive Insurance Company, have been recognized as qualified not-for-profit, tax-exempt organizations under Section 501(c)(3) of the Internal Revenue Code and are located in Belleville, Illinois Memorial Captive Insurance Company is a taxable corporation domiciled in Phoenix, Arizona

Patient Accounts Receivable

The Medical Center reports patient accounts receivable for services rendered at net realizable amounts from third-party payers, patents and others The Medical Center provides an allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information and existing economic conditions As a service to the patient, the Medical Center bills third-party payers directly and bills the patent when the patients liability is determined Patient accounts receivable are due m full when billed Accounts are considered delinquent and subsequently written off as bad debts based on individual credit evaluation and specific circumstances of the account

Supplies

Supply inventories are stated at the lower of cost using the first-in, first-out method, or market

Investments and Investment Return

Investments include marketable equity and debt securities which are carved at fair value Total investment return includes dividend, interest and other investment income and realized and unrealized gams and losses nn investments Net changes in unrealized gains and losses are recorded as increases or decreases in unrestricted net assets

Interest in Memorial Foundation, Inc.

Certain reclassifications have been made to the 2003 financial statements to conform to the 2004 financial statement presentation These reclassifications had no effect on the change in net assets


Note 1 : Nature of Operations and Summary of Significant Accounting Policies (Continued)

Transfers of assets between the Foundation and the Medical Center are recognized as increases or decreases in the Interest . Transfers from the Foundation to the Medical Center have no effect on the change in net assets as they are reflected as increases in unrestricted net assets and decreases in temporarily restricted net assets when they are received, or when any restnctions imposed by the Foundation are satisfied

Property and Equipment

Property and equipment are stated at cost. Depreciation is computed by the straight-line method over estimated useful lives

Net Patient Service Revenues

The Medical Center has agreements with third-party payers that provide for payments to the Medical Center at amounts different from its established rates Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payers and others in the period the related services are rendered and adjusted in future periods as final settlements are determined

Use of Estimates

The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period Actual results could differ from those estimates

Reclassifications

2004 2003

$ 28_162.933 $ 24.903.727

Note 3 : Net Patient Service Revenue

Board-designated assets represent funds set aside for the acquisition of depreciable assets and other capital-related purposes


Note 2 : Charity Care

In support of its mission, the Medical Center provides care to patients who lack financial resources and are determined to be medically indigent Because the Medical Center does not pursue collection of amounts determined to qualify as charity care, these amounts are not reported as net patient service revenue . In addition, the Medical Center provides services to other medically indigent patients under the state Medicaid program The program pays providers amounts that are substantially less than the established charges for the services provided to the recipients

The following is a summary of uncompensated charges related to these services

Medicaid allowances Chanty care allowances

$ 24;847,483 $ 22,72,652 3 .315 .40 2.331 .07

Under the Medicare Program's prospective payment systems ; the Medical Center is reimbursed on a fixed price per case for hospital inpatients and a fixed price per test or procedure for outpatients

Inpatient and outpatient services rendered to Medicaid program beneficiaries are reimbursed on a fixed price per case for hospital inpatients and a fired price per test or procedure for outpatients

Approximately G2°/o and 40% of net patient service revenues are from participation m the Medicare and Medicaid programs for the years ended December 31, 2004 and 2003, respectively .

The Medical Center has also entered into payment agreements with certain commercial insurance careers, health maintenance organizations and preferred provider organizations The basis for payment to the Medical Center under these agreements includes discounts from established charges and prospectively determined rates per case, day or service

Note 4: Assets Limited as to Use

Board-Designated Assets

4

Assets limited as to use include :

$ 3,118,649 2.679.30 8,821,182 9,924,863

32.23,179

9, 1,44,702 1,072;580

10,038,786 11 .02.053 37,653,094

(17,441) (11_953 )

10.019,789

191 .719 778,000 103 .x,5

1 .073,27

$ 67_966_84$

9

Auxiliarv fund Money- market accounts Certificates of deposit Other assets

$ 7~_ 140_736


Note 4 : Assets Limited as to Use (Continued)

Self-Insurance Fund

The Medical Center maintains a trust fund for the purpose of funding self-insured professional and general liability losses Funding of the trust is based upon actuarial estimates of the potential liability and the lag time in the payment of claims Investment income is retained by the trust and reinvested

Auxiliary Fund

The Auxiliary Fund provides educational assistance to students pursuing health-related careers and is administered by the Auxiliary

Board-designated assets Money market accounts U S Treasury bills and notes U .S Government Agency obligations Corporate obligations Equity securities Amortized premium discount and accrued income

receivable

Self-insurance fund Money market accounts U S Treasurti, bills and notes U S Government Agency obligations Corporate obligations Equity securities Amortized premium/discount and accrued income

receivable

2004 2003

44,855 76,399

61,337.070 56 .873.802

381,981 306,990 845,572 877,248 148,066 661,088

1,622,753 1,273,30 6,708 .828 6,913,066

9_6£q,7i9

??9 ;?; ; 77s_ooo 1(16.64

1-113.907

2004 2003

$ 5_755.850 $ 8.346.74 Total investment return

10


Note 4: Assets Limited as to Use (Continued)

Investment return is reflected in the statements of operations as other non-operating income The net change in unrealized gains and losses is recorded as an increase or decrease m unrestricted net assets Total investment return is comprised of the following

Interest and dividend income Realized gains and losses on sale of securities

Realized investment return

Net change in unrealized gams and losses

$ 1,943,468 $ 1,96,227 263 .248 66.49

2,206,716 2 ;022,686

3,49.134 6,323.888

Certain investments in debt and marketable equity securities are reported in the financial statements at an amount less than their historical cost Total fair value of these investments at December 31. 2004, was $15,203 .168, which is approximately 21 percent of the Medical Center's investment portfolio These declines pnmarily resulted from recent increases in market interest rates and failure of certain investments to maintain consistent credit qualit}- ratings or meet projected earnings targets

Based on evaluation of available evidence, including recent changes in market interest rates, credit rating information and information obtained from regulatory films. management believes the declines m fair value for these securities are temporary

Should the impairment of any of these securities become other than temporary; the cost basis of the investment will be reduced and the resulting loss recognized in the excess (deficiency) of revenues over expenses

1 V

The following table summarizes our investments' gross unrealized losses and fair value, aggregated by investment category and length of time that uidividual securities have been m a continuous unrealized loss position

Less than 12 Months 12 Months of More Total Description of Unrealized Unrealized Unrealized Securities Fair Value Losses Fair Value Losses Fair Value Losses

$ 9,260,906 $ (125,680) $2,301.065 $ (185,489) $11,561,971 $ (311,169)

2 .814213 25! 9.885) 526,954 ( 152 ,965 3,641,197 (412.8501

$12.075.119 $ 38( 5.565 $3 128.049 $ 338 454) $15,203 ,168 $-(124 019

December 31, 2003 Debt securities

Equity securities

Total temporarily impaired secunties

$ 5,389,023 $ 140,544 $1,083,09 $ 42,721

1 .599.092 52,602 3,150_25 n 3f4 .472

$ 11 .22 .124 $ 590.339 $6 .988.115 $ 193.146 X4 .233 309 $ 397.193

Less accumulated deprecation

11

Protestant Memorial Medical Center, Inc. Notes to Financial Statements December 31, 2004 and 2003

Note 4: Assets Limited as to Use (Continued)

December 31, 2004 Debt securities

Equity securities

Total temporarily impaired securities

$6,472,082 $ 183,265

4.749.342 407,07

Note 5 : Property and Equipment

Land Land improvements Buildings Fixed equipment Movable equipment Alterations and projects in progress

2004 2003

$ 1,486,451 $ 17486,451 4.551 .24 4,416,06

~~,63 ;;92F 3,339.749 48 .i99.5=1 46.228.61 70,420,898 67,874,413

l . 395,091 L' 46_361

162.07,423 156,691 .645

10 7_696_37~ 104.I46,43~

$ 54_391 .048 $ ~25.45 210

12


Note 6 : Pension Plan

The Medical Center has a pension plan covering full and part time employees who have completed one year of service, attained age 21 and have at least 1,000 hours of service within one year The plan is a defined-contribution money-purchase plan The total pension expense was $2,902,427 and $2,667,565 for the years ended December 31, 2004 and 2003, respectively It is the Medical Center's policy to fund total pension expense incurred Upon three years of credited service, the employee obtains a 20 percent vested interest, in each of the succeeding four years of credited service, the employee obtains an additional 20 percent vested interest

Note 7 : Professional and General Liability

The Medical Center maintains a self-insurance program to provide for losses related to professional and general liability clams Since July 1, 2004, a portion of the Medical Center's professional liability claims are insured by Memorial Captive Insurance Company A provision for expected uninsured losses is recorded based upon the Medical Center's estimate of the potential bability for asserted and unasserted claims and unreported incidents During 2004 and 2003, the Medical Center charged $1,386;000 and $2,»7,709 to operations, respectively, as the estimated loss for all asserted and unasserted claims and unreported incidents The ultimate resolution of these matters may result in amounts that differ materially from those recorded at December 31, 2004

Note 8: Related Parties

Amounts due from affiliates, as presented in the accompanying balance sheets, represent intercompany advances between the Medical Center, Memorial Group, Inc , Southwest Illinois Health Ventures, Inc ; Memorial Foundation. Inc and Memorial Captive Insurance Company

Transfers totaling $1,074,02 and $2,86 .000 for the years ended December 31, 2004 and 2003, respectively, were made from the Medical Center to Memorial Group, Inc to conduct qualified business activities

Several members of the Board of Directors of the Medical Center, the Foundation . Memorial Group, Inc , Southwest Illinois Health Ventures . Inc and Memorial Captive Insurance Company serve in this capacity for more than one of these corporations

~' o

Note 9 : Functional Expenses

The Medical Center's expenses as presented in the Federal Tax Form 990 are as follows :

2004 2003

Program services Management and general

$ 169.386.10 $ 16;~ 122-065

13


$ 149;37,224 $ 147,476,261 19.848,926 17,64,804

. 0 O

Supplementary information

14

Independent Accountants' Report on Supplementary Information

Board of Directors Protestant Memorial Medical Center, Inc Belleville, Illinois

Our audits were made for the purpose of forming an opinion on the basic financial statements taken as a whole The nature of our audit procedures is more fully described in our report on the basic financial statements The accompanying supplementary information is presented for purposes of additional analysis and is not a required part of the basic financial statements Such information has been subjected to the procedures applied in the audits of the bask financial statements and, ui our opinion, is fairly stated, m all material respects, in relation to the basic financial statements taken as a whole, except for the portion marked "unaudited", on which we express no opinion

R tl~)l 1, (- /'

St Louis, Missouri April 6, 200

2004 2003 Memorial Memorial

Memorial Convalescent Memorial Convalescent Hospital Center Total Hospital Center Total

Assets

Current Assets Cash PaUcnt accounts and other receivables,

net Estimated balance due from third-party

payei s Supplies Prepaid expenses Due fioni affiliates

Total current asses

Assets Limited As To Use

Interest in the Net Assets of Memorial Foundation, Inc

Property- and Equipment, net

Total assets

7,984,98 7,984,948 7,609,566 7,609,566

53,328,571 1,062,477 54,391,048 51,384,802 1,160,408 52,545,210

$ 158 283,248 $ 1 .699,2G7 $ 159.982 515 $ 152,227,242 $ 1,943,598 $154,170.840

Protestant Memorial Medical Center, Inc. Divisional Balance Sheets December 31, 2004 and 2003

$ 3 ;792,356 $ 325 $ 3,792,681 $ 3,790,245 $ 325 $ 3,790,570

19,087,142 633,828 19,720,970 19,150,584 775,968 19,926,552

305,865 (1,706) 304,159 1,080,587 1,080,587 1,034,437 1,034,437 868,908 2,637 871,545 922,828 8,603 931,431

62.067 62,067

24,828,993 636,790 25,465,783 25,266,026 783,190 26,049,216

72,140,736 72,140,736 67,966,848 67,966,848

i

Net Assets Unresti icled I 18,92,730 Temporarily testnclccl 7,984,948

Total net asses 126,927,678

Total liabilities and net assets $ 158 .83 248

15

Liabilities and Net Assets

Current Liabilities Accounts payable and accrued expenses $ 7,858,520 Accrued ~Nages and related payroll taxes 7.414,584 Estimated balance due to third-party

payei s 473,574 Estimated self-iusuiauce costs; current 3,941,000 Due to affiliates 1,391,309

Total current liabilities 21,078,987

Estimated Self-Insurance costs, net of current portion 10,276,583

Total liabilities 3 1,355,570

$ 139,717 $ 7,998,267 $ 7,024,446 $ 106,622 $ 7,131,068 14,943 7,569,27 6,673,812 139,098 6,812,910

(2,584) 470,990 3,941,000 3,881,000 3,881,000 1,391,309

292,106 21,371,093 17,579,258 245,720 17,824,978

418,000 10,694,583 10,358,972 382,000 10,740,972

710,106 32,065,676 27.938,230 627,720 28,565,950

989,161 119,931 ;891 116,679.446 1,315,878 117,995,324 7,984,948 7,609,566 7,60 566

9$9.161 127,91 6,839 124,289,0 12 1,315,878 125,604,890

~ L699.2G7 $ 19,982 51~ X 152 227,242 $ . t,943,599 $ 154.170.840

Protestant Memorial Medical Center, Inc . Divisional Statements of Operations


159,978,114 6,1 44,369 166,122.483 156,851,476 5,557,768 162,409,244

Expenses Salaues and «ages 68,973,002 3,938,161 72,961,163 68,230,478 3,789,734 72,020,212 Employee benefits 22,204,993 680,634 22,885,627 20,279,757 662,402 20,942,159 Specialists fees 6,875,463 26,300 6,901,763 6,422,715 30,456 6,453,171 Medical supplies 19,011,303 164,945 19,176,248 18,344,63 166,370 18,510,933 Food 1,75,958 307,756 1,883,714 1,40,211 301,022 1,841,233 Utilities 2,118,025 72,575 2,190,600 2,053,921 75,086 2,129,007 Repairs and maintenance 3,492,749 6,408 3,499,157 3,592,298 14,851 3,607,149 Drugs and intravenous solutions G,671,697 352,575 7,024,272 6,105,703 284,797 6,390,500 li1surance 3,744,199 49,887 3,794,086 3,100,000 48,798 3,148,798 Supplies and other 10,953,258 351,858 11,305,116 11,013,921 313,098 11,327,019 Prop-isjon for uncollectible accounts 8,630,906 51,277 8,682,183 9.616,502 58,906 9,675,408 Depreciation 8,940,01 142,207 9,082,221 8,938,070 138,406 9,076,476

Operating Loss (2,386,663 ) (3,213,453) (3,263 .667) (50,2 14) (326,158 ) (2,712,821 )

t

2004 Memorial

Memorial Convalescent Hospital Center Total

Uni estricted Rep enue and Other Support Net patient service revenue $ 157,854,949 $ 6,143,248 $ 163,998,197 Othei 2,123,165 1,121 2.124,286

2003 Memorial

Memorial Convalescent Hospital Center Total

$ 154,664,114 $ 5,556,233 $160,220,347 2.187,362 1,535 2,188_897

163,191,567 6,194,583 169,386.150 159,238,139 5.883,926 165,122,065

a

C

Excess (DelicieucN) of Revenues Over Expenses

T'iansfcrs

Investment retuni-change in unrealized gains and losses on assets limited as to use

Tia»sfers to affiliates

Increase (Decrease) in Unrestricted Net Assets

6,323,888

(2,865,000)

3,549,134 3,549,134 6,323,888

(1,074,052) (1,074,052) (2,865,000)

$ 2 263 234 $ (326 .7(7 ) $ 1 936 X67 $ 3 196.841 $ 130.401 $ 3.327 .242

16

Other lncome Investment return Donations

2,206,716 2,206,716 2,022,686 504,126 14,310 518 .436 558,099 390

2,710,842 14,310 2,72,152 2,580,785 390

(502,611) (3,904) (538,515) 194,122 (325,768)

290,813 (290,813) (456,169) 456,169

2,022,686 558,489

2,581,175

(131,646)

Other operating statistics Emergency room visits 42 .199 42,316 Outpatient departmental visits 229,184 227,535 Opcratmg room visits 11,080 11 ;773 GI Lab visits -5,1 5 3 51411 Open heart procedures 230 282 Laboratory tests 732.02 721,045 EKG exams 25 .236 28,35 1 EEG exams 845 987 Diagnostic x-ray procedures 97;87 98 .327 Nuclear medicine procedures 8_99 8 ;747 MRI scans 6,671 6.841 CT scans 27,220 2 .026 Cardiac cathetenzation procedures 1.961 1 ;b76 Respiratory care treatments 212 .669 217J96 Home health age= visits 1? ;332 10.790 Physical therapy treatments 171 .921 172 .071

17

Protestant Memorial Medical Center, Inc . Memorial Hospital Service Statistics

Years Ended December 3'i, 2004 and 2003 (Unaudited)

2004 2003 Adult and pediatric

Patient days Medical and surgical division X6;881 60,372 CMU division 3 Intensive care unit 4,700 5,174 Obstetrical division 3.921 4,089 Pediatrics division 2.066 2.487

67,68 72 .125

Admissions 14,56 14.701 Discharges 14;580 14,703 Average length of stay - days 4 6 4 9 Average duly bed capacity 313 341 Average daily occupancy 185 198 Percentage of occupancy X9.1°/o 58 0%

Nursery Patent days 3,38 3 .276 Admissions 1,468 1,403 Discharges 1,76 1 .42 Average length of stay - days 2 4 2 3 Average daily crib capacity 32 32 Average daily occupancy 9 9 Percentage of occupancy 29% 28 I

q~ '@ :1

2004 2003

Patient days 27,60 27,046

Percentage of occupancy 70 1 % 68 6%

Patients admitted 963 990

18

Protestant Memorial Medical Center, Inc . Memorial Convalescent Center Service Statistics

Years Ended December 31, 2004 and 2003 (Unaudited)

" If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box . . . , If you are fling for an Additional (not automatic) 3-Month Extension, complete only Part II (on page 2 of this form)

Do not complete Part 11 unless you have already been granted an automatic 3-month extension on a previous) fled Form 8868 Automatic 3-Month Extension of Time - Only submit original (no copies needed)

Form 990-T corporations requesting an automatic 6-month extension - check this box and complete Part I 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, and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041

Electronic Filing (e-file) . Form 8868 can be fled electronically if you want a 3-month automatic extension of time to file one of the returns noted below (6 months for corporate Form 990-T filers) However, you cannot file it electronically if you want the additional (not automatic) 3-month extension, instead you must submit the fully completed signed page 2 (Part II) of Form 8868 For more details on the electronic filing of this form, visit www.irs .gov/efde Type Of Name of Exempt Organization Employer identification number

print Protestant Memorial Medical Center, Inc. ~37-0635502 Number, street, and room or suite no If a P O . box, see instructions . 4500 Memorial Drive

File by the due date for filing your return See Lity, town or post office, state, and ZIP code For a foreign address, see instructions instructions Igelleyxlle, IL 62226-5399

Check type of return to be filed (file a se crate application for each return) X Form 990 Form 990-T (corporation)

Form 990-BL Form 990-T(sec 401(a) or 408(a) trust) Form 990-EZ Form 990-T (try~t,o~p~Na,~a~)COPY Fortn990-PF Form 1041-A vL l: I "J

Form 4720 Form 5227 Form 6069 Form 8870

JSA aF805a 3 000

Form 8868 Application for Extension of Time To File an (Rev December 2004) Exempt Organization Return OMB No 1545-1709 Department of the Treasury Internal Revenue Service " File a separate application for each return

The books are m the care of " Valorie

Telephone No . " FAX No .

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) ~ ~ ~ ~ If this is

for the whole group, check this box " F-] . If it is for part of the group, check this box " and attach a list with the names and EINs of all members the extension will cover 1 I request an automatic 3-month (6-months for a Form 990-T corporation) extension of time until August 15 , 2005

to file the exempt organization return for the organization named above. The extension is for the organizations return for t 10. B calendar year 2004 or

tax year beginning - , and ending

2 If this tax year is for less than 12 months, check reason a Initial return 1:1 Final return a Change m 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 $ NONE

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 . . . . . . . . . . . . . . . . . . . . . . . . . $ NONE

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 EFTPS (Electronic Federal Tax Payment System) See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S NONE

Caution . If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instructions For Privacy Act and Paperwork Reduction Act Notice, see Instructions . Form 8868 (Rep 1z-zoom

a\

By Date Director

Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-month extension returned to an address different than the one entered above

Name

BKD, LLP ATTN : D . LARSON Type or print

Number and street (include suite, room, or apt. no .) a a P.O. box number

501 N. BROADWAY, SUITE 600 City or town, province or state, and country (including postal a ZIP code)

ST . LOUIS . MO 63102-2102

J-/

Form 66150 (Rev 12-2004) 4 F 8055 3 000

Form 8868 (Rev 12-2004) Page 2

" If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part II and check this box, Ix I Note : Only comolgte Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868 . " If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1) .

Adtiit~onal (not automatic) 3-Month Extension of Time - Must File Original and One Copy. Name of Exempt Organization Employer Identification number Type or .. . .

print PROTESTANT MEMORIAL MEDICAL CENTER, INC . 37-0635502

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 4500 MEMORIAL DRIVE filing the City, town or post office, state, and ZIP code For a foreign address, see instructions return See instructions HELLEVILLE, IL 62226-5399

Check type of return to be filed (File a se crate application for each return) X Form 990 Form 990-T(sec 401(a) or 408(a) trust) Form 5227

Form 990-BL Form 990-T (trust other than above) Form 6069 Form 990-EZ Form 1041-A Form 8870 Form 990-PF ~ ~ Form 4720

STOP: Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868 .

The books are in the care of " MEMORIAL HOSPITAL-CONTROLLER Telephone No " (618) 257-5607 FAX No

o if the organization does not have an office or !ace of business .n ;he United States, checK this box, . , , , . . . , . , . , . , , " U " If this is for a Group Return, enter the or anization's four digit Group Exemption Number (GEN If this is for the whole group, check this box " If it is for part of the group, check this box " and attach a list with the names and EINs of all members the extension is for 4 I request an additional 3-month extension of time until NOVEMBER 15, 2005 5 For calendar year 2004 , or other tax year beginning and ending 6 If this tax year is for less than 12 months, check reason' _=I nitial return " Final return a Change m accounting period 7 State in detail why you need the extension ADDITIONAL TINE IS NEEDED TO GATHER THE INFORMATION

NECESSARY TO FILE A COMPLETE AND ACCURATE RETURN

Sa 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 $ NONE

Signature and Verification Under penalties of perjury . I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, co ect, d complete, and ~ m autho to prepare this form

Sirnah re ~ (J 1~l Title J0 CPA Date 111~ a` r

Notice to Applicant - To Be Completed by the IRS u We have approved this application. Please attach this form to the organization's return . 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 poor 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 to file We are not granting a 10-day grace period

We cannot consider this application because it was filed after the extended due date of the return for which an extension was requested

Other

Documents

Form Return of Organization Exempt From Income Tax990s.foundationcenter.org/990_pdf_archive/370/370635502/... · 2017-06-22 · OMB No 1545-0047 Form 990 Return of Organization Exempt