2013-05-13T07:28:26-05:00 2012-06-30 990 2011-07-01 311439334 MOUNT CARMEL HEALTH SYSTEM MOUN 6145464300 6150 EAST BROAD STREET COLUMBUS OH 432131574 KEITH COLEMAN 6145464300 2013-05-13 2011 2016-02-24 21:20:13Z CLAUS VON ZYCHLIN 6150 EAST BROAD STREET COLUMBUS OH 432131574 204653044 0 0928 X WWW.MOUNTCARMELHEALTH.COM X 1995 OH HEALTHCARE SYSTEM MANAGEMENT AND SUPPORT 13 7 9681 34 2802285 -85858 7222 0 161040579 171549312 22497162 14049935 17528551 19053797 201073514 204653044 754254 741954 0 0 69644837 80306225 0 0 0 117254472 132344138 187653563 213392317 13419951 -8739273 802050566 875364804 473568234 531620072 328482332 343744732 X MOUNT CARMEL HEALTH SYSTEM'S PURPOSE IS TO GOVERN, MANAGE AND PROVIDE ADMINISTRATIVE SERVICES TO ITS SUBSIDIARIES. THE ADMINISTRATIVE SERVICES PROVIDED BY MOUNT CARMEL HEALTH SYSTEM FOR THE SUBSIDIARIES ALLOW FOR ECONOMIES OF SCALE THAT PERMIT THE SUBSIDIARIES TO PROVIDE HEALTHCARE SERVICES TO PATIENTS AT A REASONABLE COST. 0 0 168137720 741954 182606940 MOUNT CARMEL HEALTH SYSTEM, AN OHIO NOT-FOR-PROFIT CORPORATION, OWNS AND/OR OPERATES FIVE HOSPITALS IN THE COLUMBUS, OHIO AREA CONTAINING 1,195 BEDS AND VARIOUS OTHER ACUTE AND NONACUTE HEALTH SERVICE PROVIDERS AS WELL AS A LICENSED HEALTH MAINTENANCE ORGANIZATION. THE HEALTH SYSTEM PROVIDES SERVICES TO PATIENTS WHO RESIDE IN CENTRAL OHIO. OHIO NOT-FOR-PROFIT MEMBER ORGANIZATIONS INCLUDE MOUNT CARMEL HEALTH, SAINT ANN'S HOSPITAL, MOUNT CARMEL NEW ALBANY SURGICAL HOSPITAL, DILEY RIDGE MEDICAL CENTER, MOUNT CARMEL CARE CONTINUUM SERVICES CORPORATION, MOUNT CARMEL COLLEGE OF NURSING, MOUNT CARMEL HEALTH SYSTEM FOUNDATION, MOUNT CARMEL HEALTH PLAN, INC., AND MOUNT CARMEL HEALTH INSURANCE COMPANY. OHIO FOR-PROFIT MEMBER ORGANIZATIONS INCLUDE MOUNT CARMEL HEALTH PROVIDERS, INC. AND MOUNT CARMEL BEHAVIORAL HEALTHCARE SERVICES.MOUNT CARMEL HEALTH SYSTEM IS A MEMBER OF TRINITY HEALTH.FOR MORE INFORMATION ON SPECIFIC SERVICES PROVIDED, PLEASE SEE MOUNT CARMEL HEALTH SYSTEM'S WEBSITE AT WWW.MOUNTCARMELHEALTH.COM. MISSIONTHE MISSION STATEMENT FOR MOUNT CARMEL HEALTH SYSTEM IS AS FOLLOWS:WE SERVE TOGETHER IN TRINITY HEALTHIN THE SPIRIT OF THE GOSPELTO HEAL BODY, MIND AND SPIRITTO IMPROVE THE HEALTH OF OUR COMMUNITIESAND TO STEWARD THE RESOURCES ENTRUSTED TO US. 168137720 1 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 1 0 1 1527 0 1 9681 1 1 1 0 0 0 0 0 0 0 0 0 0 X 13 7 0 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 X CAROLYN WHITE 6145464130 6150 EAST BROAD STREET COLUMBUS OH 43213 X MATTHEW HABASH 2.00 X X 0 0 0 STAMPP CORBIN 2.00 X X 0 0 0 JOHN PEREZ 2.00 X X 0 0 0 SR RUTH M NICKERSON CSC 2.00 X X 0 0 0 DAVID STEWART MD 2.00 X 0 0 0 CLAUS VON ZYCHLIN 16.00 X X 0 742791 100792 MICHAEL GONSIOROWSKI 2.00 X 0 0 0 PHILLIP SHUBERT MD 2.00 X 512753 0 41622 SUSAN TOMASKY 2.00 X 0 0 0 J RICHARD O'CONNELL 2.00 X 0 943237 118221 CARL BERASI DO 2.00 X 0 0 0 JORGE GOMEZ 2.00 X 0 0 0 VALERIANA MOELLER 2.00 X 0 0 0 SR JOY O'GRADY 2.00 X 0 0 0 ANANTHA PADMANABHAN MD 2.00 X 0 0 0 LISA STEIN 2.00 X 0 0 0 JACQUELINE PRIMEAU 16.00 X 0 435000 40553 RONALD WHITESIDE 15.00 X 0 1842081 56546 CYNTHIA SHEETS 40.00 X 0 935788 45290 PAULA AUTRY 2.00 X 0 357678 35771 JANET MEEKS 2.00 X 0 379099 90476 JOHN HEISLER 13.00 X 0 413570 36981 HUGH JONES 13.00 X 0 284314 35570 JOSEPH SWEDISH 2.00 X 0 5186660 576202 KEDRICK ADKINS 2.00 X 0 1405226 117120 MICHAEL MURPHY 2.00 X 0 474370 75538 RICHARD STRECK 50.00 X 0 511658 40585 THOMAS BRONKEN 50.00 X 282246 0 34735 MICHELE HELBIG 50.00 X 229415 0 38868 MARY ANN WOLF 50.00 X 227645 0 37672 GAYLE O'BRIEN 50.00 X 201477 0 23220 MICHAEL SLUBOWSKI 0.00 X 0 150838 1101 1453536 14062310 1546863 307 1 1 0 COMTEX 575 HARMON AVE COLUMBUS OH 43223 LAUNDRY SERVICES 5311790 BRUNER CORPORATION PO BOX 75683 CLEVELAND OH 44101 CONSTRUCTION SERVICES 3941198 DAWSON HEALTHCARE 3650 OLENTANGY RIVER ROAD COLUMBUS OH 43214 TEMPORARY SERVICES 3873589 BVK DIRECT 250 WEST COVENTRY CT STE 300 MILWAUKEE WI 53217 MARKETING & ADVERTISING 2417232 PREMIER COURIER INC 3687 INTERCHANGE ROAD COLUMBUS OH 43204 DELIVERY SERVICES 1090542 55 SUBSIDIARY FEES 900099 170109932 170109932 GIFT SHOPS 453220 1439380 1439380 171549312 8855005 8855005 3754504 0 3754504 3754504 3754504 5194930 0 5194930 5194930 5194930 MANAGEMENT FEES 561499 4717196 4162587 554609 PROFESSIONAL FEES 900099 1410234 420898 989336 9171863 7913523 1258340 15299293 204653044 182606940 2802285 19243819 741954 741954 6573176 6573176 110301 110301 60181637 38521112 21660525 2485674 1569869 915805 6550909 3892279 2658630 4404528 2558590 1845938 1283024 1283024 143000 143000 9338988 9336978 2010 4619435 4619435 5453854 5372973 80881 48739692 48736491 3201 3236788 2801919 434869 539997 537912 2085 98733 98160 573 18801797 18523607 278190 850438 850438 INTERCO. PURCHASED SERV 22916408 19208098 3708310 CONTRACT LABOR 8179796 5120685 3059111 MEDICAL SUPPLIES 3109696 3109696 UBI TAXES 450303 450303 4582189 693896 3888293 213392317 168137720 45254597 0 650 260 17372206 30938512 23206731 19974968 858455 1022678 1505706 1240400 237941751 144066243 85510055 93875508 233014438 199459321 272793665 324201601 1077614 1003295 166711046 203648261 802050566 875364804 58789074 63901458 313 5740 414778847 467712874 473568234 531620072 X 328482332 343744732 328482332 343744732 802050566 875364804 X -8739273 24001673 X X 0 1 1 X 1 1 X X X 0 0 0 MOUNT CARMEL NEW ALBANY SURGICAL HOSPITAL 870790288 3 0 1 1 0 MOUNT CARMEL HEALTH 314379602 3 0 1 1 0 ST ANN'S HOSPITAL 314412701 3 0 1 1 0 TRINITY HEALTH CORPORATION 351443425 11 1 1 1 13914000 DILEY RIDGE MEDICAL CENTER 342032340 3 0 1 1 0 5 13914000 0 1 0 0 0 1 10620 1 143808 0 0 154428 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MOUNT CARMEL HEALTH SYSTEM HAS MADE GRANTS TO OTHER ORGANIZATIONS IN THE FORM OF MEMBERSHIP DUES PAID TO A NATIONAL HEALTH CARE ORGANIZATION. THIS ORGANIZATION HAS PROVIDED MOUNT CARMEL HEALTH SYSTEM WITH AN ESTIMATED PERCENTAGE OF DUES PAYMENTS WHICH ARE USED FOR LOBBYING ACTIVITIES. IN ADDITION, PAYMENTS WERE MADE TO LOBBYING FIRMS TO ASSIST WITH FEDERAL EARMARK REQUESTS AND STATE LEGISLATIVE ADVOCACY. MOUNT CARMEL HEALTH SYSTEM MADE NO CONTRIBUTIONS TO ANY LEGISLATORS OR CANDIDATES. 32742051 32742051 75581611 38070828 37510783 120414431 105980168 14434263 6930323 2273335 15247 9188411 93875508 COMMINGLED FUNDS DIRECTLY HOLDING SECURITIES 183017033 F EQUITY METHOD INVESTMENTS 141184568 C 324201601 OTHER RECEIVABLES 4749372 INTERCOMPANY ACCOUNTS RECEIVABLES 118660896 INVESTMENT IN AFFILIATES 26244066 INTERCOMPANY OTHER LONG TERM ASSET 53849600 OTHER 144327 203648261 INTERCOMPANY ACCOUNTS PAYABLE 6008920 DEFERRED COMPENSATION LIABILITY 755114 OTHER CURRENT LIABILITIES 236575 OTHER LONG TERM LIABILITIES 2805659 INTERCOMPANY NOTES PAYABLE 456347724 LEASE OBLIGATION 1558882 467712874 0 CAPITAL PARK FAMILY HEALTH CENTER INC 882 HAMILTON ROAD WHITEHALL OH 43213 383765547 501(C)3 266666 COMMUNITY BENEFIT AMERICAN HEART ASSOCIATION INC 7272 GREENVILLE AVE DALLAS TX 75231 135613797 501(C)3 25000 COMMUNITY BENEFIT ARTHRITIS FOUNDATION INC 3740 RIDGE MILL DRIVE HILLIARD OH 43026 314419290 501(C)3 5000 COMMUNITY BENEFIT WESTERVILLE AREA CHAMBER OF COMMERCE 99 COMMERCE PARK DRIVE WESTERVILLE OH 43082 310737083 501(C)6 8325 COMMUNITY BENEFIT LOWER LIGHTS CHRISTIAN HEALTH CENTER 1251 WEST BROAD STREET COLUMBUS OH 43222 311810355 501(C)3 202500 COMMUNITY BENEFIT MARCH OF DIMES FOUNDATION 1275 MAMARONECK AVENUE WHITE PLAINS NY 10605 131846366 501(C)3 5000 COMMUNITY BENEFIT GAHANNA CONVENTION AND VISITORS BUREAU 181 GRANVILLE STREET GAHANNA OH 43230 800322167 501(C)6 25020 COMMUNITY BENEFIT WESTERVILLE PARKS FOUNDATION 350 N CLEVELAND AVE WESTERVILLE OH 43081 311719247 501(C)3 7280 COMMUNITY BENEFIT COUNCIL ON HEALTHY MOTHERS AND BABIES PO BOX 3384 DUBLIN OH 43016 421546970 501(C)3 7050 COMMUNITY BENEFIT WESTERVILLE SUNRISE ROTARY FOUNDATION PO BOX 1200 WESTERVILLE OH 43086 311481931 501(C)3 10000 COMMUNITY BENEFIT FOUNDATION OF THE CATHOLIC DIOCESE OF COLUMBUS 257 EAST BROAD STREET COLUMBUS OH 43215 311116640 501(C)3 5500 COMMUNITY BENEFIT CHARITABLE PHARMACY OF CENTRAL OHIO 200 E LIVINGSTON AVE COLUMBUS OH 43215 270147099 501(C)3 25000 COMMUNITY BENEFIT DRESS FOR SUCCESS COLUMBUS 2239 EAST 55TH STREET CLEVELAND OH 44103 205112085 501(C)3 5000 COMMUNITY BENEFIT YOUNG MEN'S CHRISTIAN ASSOCIATION OF CENTRAL OHIO 40 WEST LONG STREET COLUMBUS OH 43215 314379594 501(C)3 5000 COMMUNITY BENEFIT NATIONWIDE CHILDREN'S HOSPITAL 700 CHILDRENS HOSPITAL COLUMBUS OH 43205 010782751 501(C)3 15000 COMMUNITY BENEFIT CHILDREN'S HUNGER ALLIANCE 370 SOUTH FIFTH STREET COLUMBUS OH 43215 237303509 501(C)3 5000 COMMUNITY BENEFIT GROVE CITY AREA CHAMBER OF COMMERCE 4069 BROADWAY GROVE CITY OH 43123 310922925 501(C)6 15000 COMMUNITY BENEFIT ROTARY INTERNATIONAL CLUB OF WESTERVILLE PO BOX 595 WESTERVILLE OH 43086 316050404 501(C)4 7500 COMMUNITY BENEFIT SIMON KENTON COUNCIL BOYSCOUTS OF AMERICA 1901 E DUBLIN GRANVILLE RD COLUMBUS OH 43229 314388520 501(C)3 6050 COMMUNITY BENEFIT VIOLET FESTIVAL INC PO BOX 361 PICKERINGTON OH 43147 311518034 501(C)4 20000 COMMUNITY BENEFIT 15 5 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: DONATIONS MADE BY MOUNT CARMEL HEALTH SYSTEM TO CHARITABLE ORGANIZATIONS ARE MADE IN FURTHERANCE OF THE RECIPIENT ORGANIZATION'S EXEMPT PURPOSE AND ARE CONSIDERED UNRESTRICTED WITH REGARD TO THE USE OF THE FUNDS. 0 1 0 0 0 0 0 0 0 CLAUS VON ZYCHLIN 0 482336 0 173932 0 86523 0 72419 0 28373 0 843583 0 0 PHILLIP SHUBERT MD 502329 0 0 0 10424 0 22297 0 19325 0 554375 0 0 0 J RICHARD O'CONNELL 0 571942 0 230946 0 140349 0 85919 0 32302 0 1061458 0 0 JACQUELINE PRIMEAU 0 366292 0 65158 0 3550 0 30625 0 9928 0 475553 0 0 RONALD WHITESIDE 0 378136 0 94027 0 1369918 0 36370 0 20176 0 1898627 0 555919 CYNTHIA SHEETS 0 319151 0 75983 0 540654 0 35619 0 9671 0 981078 0 83384 PAULA AUTRY 0 287579 0 69138 0 961 0 15925 0 19846 0 393449 0 0 JANET MEEKS 0 304777 0 71350 0 2972 0 69889 0 20587 0 469575 0 0 JOHN HEISLER 0 297988 0 61070 0 54512 0 20751 0 16230 0 450551 0 0 HUGH JONES 0 232540 0 51014 0 760 0 19514 0 16056 0 319884 0 0 JOSEPH SWEDISH 0 1279458 0 677642 0 3229560 0 548602 0 27600 0 5762862 0 2698342 KEDRICK ADKINS 0 743978 0 316652 0 344596 0 103857 0 13263 0 1522346 0 143708 MICHAEL MURPHY 0 402598 0 0 0 71772 0 48365 0 27173 0 549908 0 0 RICHARD STRECK 0 404035 0 103629 0 3994 0 20564 0 20021 0 552243 0 0 THOMAS BRONKEN 262523 0 18583 0 1140 0 18856 0 15879 0 316981 0 0 0 MICHELE HELBIG 187739 0 40553 0 1123 0 22527 0 16341 0 268283 0 0 0 MARY ANN WOLF 199550 0 26154 0 1941 0 28428 0 9244 0 265317 0 0 0 GAYLE O'BRIEN 176626 0 21063 0 3788 0 15129 0 8091 0 224697 0 0 0 MICHAEL SLUBOWSKI 0 13394 0 0 0 137444 0 500 0 601 0 151939 0 136445 PART I, LINE 3 MOUNT CARMEL HEALTH SYSTEM IS A SUBSIDIARY IN THE TRINITY HEALTH SYSTEM. MOUNT CARMEL HEALTH SYSTEM'S CEO IS PAID DIRECTLY BY THE SYSTEM'S PARENT ENTITY, TRINITY HEALTH CORPORATION. TRINITY HEALTH CORPORATION USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF MOUNT CARMEL HEALTH SYSTEM'S CEO: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY, AND - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THE FOLLOWING ARE PARTICIPANTS IN THE TRINITY HEALTH PENSION RESTORATION PLAN, A NONQUALIFIED PLAN, WHICH PROVIDES RETIREMENT BENEFITS FOR CERTAIN ASSOCIATES WITH EARNINGS ABOVE THE IRS PAY CAP FOR QUALIFIED PLANS ($245,000 FOR 2011). THE FOLLOWING ACCRUALS FOR 2011 FOR THIS PLAN ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: KEDRICK ADKINS - $91,607 MICHAEL MURPHY - $27,513 J. RICHARD O'CONNELL - $66,279 JOSEPH SWEDISH - $255,902 CLAUS VON ZYCHLIN - $52,433 PART I, LINE 4B: THE FOLLOWING ARE PARTICIPANTS IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE FOLLOWING SERP ACCRUALS FOR 2011 ARE INCLUDED IN COLUMN C OF SCHEDULE J, PART II: JANET MEEKS - $46,500 JOSEPH SWEDISH - $265,000 PART II: THE FOLLOWING INDIVIDUALS BECAME VESTED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) DURING CALENDAR 2011. AS A RESULT, THE VESTED AMOUNTS WERE INCLUDED IN THEIR 2011 TAXABLE INCOMES. THE FOLLOWING VESTED SERP AMOUNTS ARE INCLUDED IN COLUMN B(III) OF SCHEDULE J, PART II: JOSEPH SWEDISH - $2,740,000 KEDRICK ADKINS - $220,648 RONALD WHITESIDE - $1,364,200 CYNTHIA SHEETS - $539,020 COLUMN F OF SCHEDULE J INCLUDES THE PORTION OF THESE AMOUNTS THAT WERE REPORTED AS DEFERRED COMPENSATION IN PRIOR YEARS. NEW ALBANY HOSPITAL MANAGEMENT COMPANY II LLC (NAHMC) CARL BERASI, MCHS TRUSTEE, IS A PART OWNER, BD MEMBER & EMPLOYEE OF NAHMC 2223168 NEW ALBANY MANAGEMENT COMPANY II LLC CONTRACTS WITH MOUNT CARMEL HEALTH SYSTEM TO PROVIDE MANAGEMENT SERVICES TO MOUNT CARMEL NEW ALBANY SURGICAL HOSPITAL. THESE TRANSACTIONS WERE ALL AT ARMS LENGTH. 0 PNC BANK MICHAEL GONSIOROWSKI, MCHS TRUSTEE, IS REG. PRES. OF PNC'S CNTRL OH REGION 227131 PNC BANK PROVIDES COMMERCIAL BANKING SERVICES TO MOUNT CARMEL HEALTH SYSTEM. 0 ANGELA SMITH FAMILY MEMBER OF CYNTHIA SHEETS, KEY EMPLOYEE 99407 EMPLOYMENT ARRANGEMENT 0 THERESA ROSE SHUBERT FAMILY MEMBER OF PHILLIP SHUBERT, MD, TRUSTEE 10894 EMPLOYMENT ARRANGEMENT 0 MCMC PROFESSIONAL OFFICE BUILDING III DAVID STEWART, MCHS TRUSTEE, HAS A >5% OWNERSHIP INTEREST IN THIS J/V 250317 MCHS RECEIVES INCOME AND DISTRIBUTIONS FROM ITS OWN PARTNERSHIP INTEREST IN MCMC PROF. OFFICE BLDG. III. 0 GREEN STREET SURGERY CENTER ANANTHA PADMANABHAN, MCHS TRUSTEE, HAS A >5% OWNERSHIP INTEREST IN THIS J/V 482950 MCHS RECEIVES RENTAL INCOME AND DISTRIBUTIONS FROM ITS OWN PARTNERSHIP INTEREST IN GREEN STREET SURGERY CENTER. 0 CARDINAL HEALTH INC JORGE GOMEZ, MCHS TRUSTEE, IS AN OFFICER OF CARDINAL HEALTH 401475 CARDINAL HEALTH PROVIDES MEDICAL PRODUCTS AND SERVICES TO MOUNT CARMEL HEALTH SYSTEM. 0 FORM 990, PART VI, SECTION A, LINE 5 A SENIOR MANAGEMENT ASSOCIATE OF MOUNT CARMEL HEALTH SYSTEM (MCHS) DIVERTED MCHS FUNDS TO PURCHASE GOODS AND SERVICES FOR PERSONAL USE THROUGH COLLUSION WITH ONE OR MORE MCHS VENDORS. THE APPROXIMATE VALUE OF THE GOODS AND SERVICES WAS $863,000. MOUNT CARMEL HEALTH SYSTEM TERMINATED THE EMPLOYEE. THE RESULTS OF MCHS' INVESTIGATION WERE REFERRED TO LAW ENFORCEMENT OFFICIALS. THE FILING OF CRIMINAL CHARGES IS PENDING. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF MOUNT CARMEL HEALTH SYSTEM IS TRINITY HEALTH CORPORATION. SEE LINE 7 FOR ADDITIONAL INFORMATION. FORM 990, PART VI, SECTION A, LINE 7A TRINITY HEALTH CORPORATION IS THE SOLE MEMBER OF MOUNT CARMEL HEALTH SYSTEM. TRINITY HEALTH CORPORATION HAS THE RIGHT TO APPOINT ALL PERSONS TO THE BOARD OF TRUSTEES OF MOUNT CARMEL HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7B AS SOLE MEMBER, TRINITY HEALTH CORPORATION MUST APPROVE CERTAIN DECISIONS OF THE GOVERNING BODY, INCLUDING THE STRATEGIC PLAN, ANNUAL CAPITAL PLAN, AND ANNUAL OPERATING BUDGET. TRINITY HEALTH CORPORATION MUST ALSO APPROVE SIGNIFICANT CHANGES SUCH AS A MERGER, DISSOLUTION, SALE OF ASSETS IN EXCESS OF CERTAIN LIMITS, A MATERIAL CHANGE IN MISSION, AND MODIFICATIONS TO GOVERNING DOCUMENTS. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, THE FORM 990 FOR MOUNT CARMEL HEALTH SYSTEM IS REVIEWED BY SENIOR MANAGEMENT. IN ADDITION, CERTAIN KEY SECTIONS OF THE FORM ARE REVIEWED BY THE FINANCE COMMITTEE AS WELL AS THE BOARD OF TRUSTEES. THE BOARD RECEIVES A COPY OF THE RETURN IN ITS FINAL FORM BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C MOUNT CARMEL HEALTH SYSTEM HAS ADOPTED A CONFLICT OF INTEREST POLICY WHICH CONTAINS THE ELEMENTS IN THE MODEL CONFLICT OF INTEREST POLICY ISSUED BY THE IRS. IT APPLIES TO ALL "INTERESTED PERSONS" OF MOUNT CARMEL HEALTH SYSTEM, WHICH INCLUDES TRUSTEES, PRINCIPAL OFFICERS AND EXECUTIVES, AND MEMBERS OF COMMITTEES WITH BOARD DESIGNATED POWERS. INTERESTED PERSONS ARE REQUIRED TO ACT AT ALL TIMES IN A MANNER CONSISTENT WITH MOUNT CARMEL HEALTH SYSTEM'S CHARITABLE PURPOSE AND SERVICE TO THE COMMUNITY AND TO AVOID CONFLICTS OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO MAKE FULL DISCLOSURE TO MOUNT CARMEL HEALTH SYSTEM OF ANY FINANCIAL OR BUSINESS INTERESTS THAT MIGHT RESULT IN OR HAVE THE APPEARANCE OF A CONFLICT OF INTEREST. INTERESTED PERSONS ARE REQUIRED TO RECUSE THEMSELVES FROM DISCUSSION AND VOTING ON MATTERS INVOLVING A CONFLICT OF INTEREST. THE BOARD OF TRUSTEES OF MOUNT CARMEL HEALTH SYSTEM IS RESPONSIBLE FOR THE REVIEW AND APPROVAL OF TRANSACTIONS WITH INTERESTED PERSONS, INCLUDING DETERMINING THAT SUCH TRANSACTIONS ARE FAIR AND REASONABLE TO MOUNT CARMEL HEALTH SYSTEM. ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT AND TO AFFIRM THEIR RECEIPT OF THE CONFLICT OF INTEREST POLICY, COMPLIANCE WITH ITS REQUIREMENTS, AND AGREE TO NOTIFY THE ORGANIZATION OF CHANGES IMPACTING THEIR ANNUAL DISCLOSURE IN ACCORDANCE WITH THE POLICY. THE ANNUAL DISCLOSURES ARE REVIEWED WITH THE BOARD OF TRUSTEES OF MOUNT CARMEL HEALTH SYSTEM ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 TRINITY HEALTH FOLLOWS A PROCESS AND POLICY THAT IS INTENDED TO MIRROR THE IRC SECTION 4958 GUIDELINES FOR OBTAINING A "REBUTTABLE PRESUMPTION OF REASONABLENESS" WITH REGARD TO COMPENSATION AND BENEFITS. AS PART OF THAT PROCESS, THE COMPENSATION AND BENEFITS OF CERTAIN OFFICERS AND KEY MANAGEMENT OFFICIALS OF MOUNT CARMEL HEALTH SYSTEM ARE REVIEWED AT LEAST ANNUALLY BY THE TRINITY HEALTH BOARD OR THE TRINITY HEALTH HUMAN RESOURCES AND COMPENSATION COMMITTEE (HRCC) OF THE BOARD, AUTHORIZED TO ACT ON BEHALF OF THE BOARD WITH RESPECT TO CERTAIN COMPENSATION MATTERS. AS PART OF ITS REVIEW PROCESS, THE HRCC RETAINS AN INDEPENDENT FIRM EXPERIENCED IN COMPENSATION AND BENEFIT MATTERS FOR NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS TO ADVISE IT IN THE DETERMINATIONS IT MAKES ON THE REASONABLENESS OF PROPOSED COMPENSATION AND BENEFITS ARRANGEMENTS. FORM 990, PART VI, SECTION C, LINE 19 MOUNT CARMEL HEALTH SYSTEM IS A SUBSIDIARY ORGANIZATION IN THE TRINITY HEALTH SYSTEM. TRINITY HEALTH MAKES CERTAIN OF ITS KEY DOCUMENTS AVAILABLE TO THE PUBLIC ON ITS WEBSITE, WWW.TRINITY-HEALTH.ORG, IN THE "ABOUT US" SECTION. IN THIS SECTION, THE ANNUAL REPORT (WHICH INCLUDES COMMUNITY BENEFIT MINISTRY INFORMATION) AND CONSOLIDATED AUDITED FINANCIAL STATEMENTS ARE PUBLICLY AVAILABLE. ESTIMATE OF THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: FORM 990, PART VII, SECTION A, COLUMN B: THE HOURS LISTED IN COLUMN B OF PART VII, SECTION A, LINE 1 REFLECT ONLY THE INDIVIDUALS' AVERAGE WEEKLY HOURS SPENT DIRECTLY ON THE ACTIVITIES OF THE REPORTING ORGANIZATION. IN ADDITION, THESE ARE THE AVERAGE HOURS PER WEEK DEVOTED TO RELATED ORGANIZATIONS: KEDRICK ADKINS - 53 HOURS PAULA AUTRY - 53 HOURS JOHN HEISLER - 39 HOURS HUGH JONES - 39 HOURS JANET MEEKS - 53 HOURS MICHAEL MURPHY - 53 HOURS J. RICHARD O'CONNELL - 53 HOURS JACQUELINE PRIMEAU - 48 HOURS CYNTHIA SHEETS - 16 HOURS PHILLIP SHUBERT, MD - 53 HOURS JOSEPH SWEDISH - 53 HOURS CLAUS VON ZYCHLIN - 48 HOURS RONALD WHITESIDE - 44 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -19,027,436. EQUITY TRANSFERS FROM AFFILIATES: 34,174,971. OTHER: 8,854,138. TOTAL TO FORM 990, PART XI, LINE 5: 24,001,673. FORM 990, PART XII, LINE 2: MOUNT CARMEL HEALTH SYSTEM'S FINANCIAL INFORMATION WAS INCLUDED IN THE FY12 CONSOLIDATED FINANCIAL STATEMENTS OF MOUNT CARMEL HEALTH SYSTEM, AS WELL AS THE CONSOLIDATED FINANCIAL STATEMENTS OF TRINITY HEALTH. BOTH SETS OF CONSOLIDATED FINANCIAL STATEMENTS WERE AUDITED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM. ADVANTAGE HEALTHSAINT MARY'S MEDICAL GROUP 245 STATE ST SE GRAND RAPIDS MI 49503 272491974 HEALTHCARE SERVICES MI 501(C)(3) 9 TRINITY HEALTH-MICHIGAN 0 AMICARE HOSPICE SERVICES INC 20555 VICTOR PARKWAY LIVONIA MI 48152 382949053 PROVIDE HOSPICE SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 AUXILIARY OF HOLY ROSARY HOSPITAL 351 SW 9TH STREET ONTARIO OR 97914 943059469 SUPPORTS SERVICES OF RELATED HOSPITAL OR 501(C)(3) 9 SAINT ALPHONSUS MEDICAL CENTER-ONTARIO 0 BAUM HARMON MERCY HOSPITAL 255 NORTH WELCH AVENUE PRIMGHAR IA 51245 421500277 ACUTE/AMBULATORY HEALTHCARE SERVICES IA 501(C)(3) 3 MERCY HEALTH SERVICES-IOWA CORP 0 BAUM HARMON MERCY HOSPITAL & CLINICS FOUNDATION 255 NORTH WELCH AVENUE PRIMGHAR IA 51245 262973307 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I BAUM HARMON MERCY HOSPITAL 0 CATHERINE MCAULEY HEALTH SERVICES CORP PO BOX 995 ANN ARBOR MI 48106 382507173 FURTHER TRINITY HEALTH ACTIVITIES, ORGANIZE AND DEVELOP MEDICAL SERVICES MI 501(C)(3) 11, TYPE II TRINITY HEALTH-MICHIGAN 0 COMMUNITY HEALTH PARTNERS OF SOUTH BEND PO BOX 3998 SOUTH BEND IN 46619 263051440 HEALTHCARE SERVICES IN 501(C)(3) 3 SAINT JOSEPH REGIONAL MEDICAL CENTER INC 0 CRANBROOK HOSPICE CARE 281 ENTERPRISE COURT BLOOMFIELD HILLS MI 48302 383320699 PROVIDE HOSPICE HEALTH SERVICES MI 501(C)(3) 11, TYPE I TRINITY HOME HEALTH SERVICES INC 0 DILEY RIDGE MEDICAL CENTER 6150 EAST BROAD STREET COLUMBUS OH 43213 342032340 HOSPITAL CAMPUS IN FAIRFIELD COUNTY OHIO OH 501(C)(3) 3 MOUNT CARMEL HEALTH SYSTEM 1 DUBUQUE MERCY HEALTH FOUNDATION INC 250 MERCY DRIVE DUBUQUE IA 52001 262227941 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP 0 DYERSVILLE HEALTH FOUNDATION INC 1111 3RD STREET SW DYERSVILLE IA 52040 205383271 SUPPORT THE SERVICES OF RELATED HOSPITAL IA 501(C)(3) 11, TYPE I MERCY HEALTH SERVICES-IOWA CORP 0 GOTTLIEB COMMUNITY HEALTH SERVICES CORPORATION 701 W NORTH AVE MELROSE PARK IL 60160 363332852 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