2011-01-28T13:24:15-06:00 2010-06-30 Blue & Co LLC One American Square 2200 Indianapolis IN 46282 990 2009-07-01 352134193 MIDWEST PROTON RADIOTHERAPY INSTITUTE LLC MIDW 8123495074 2425 N MILO B SAMPSON LN BLOOMINGTON IN 474081368 John R Kerstiens 8123495028 2011-01-28 1 Carrie A Merrill CPA 3176334705 2009 2016-02-24 21:20:13Z JOHN R KERSTIENS 2425 N MILO B SAMPSON LN BLOOMINGTON IN 474081368 18100442 0 X www.mpri.org X 2001 IN MEDICAL CLINIC that uses unique proton beam technology to treat cancer victims. 5 5 65 5 0 0 1700397 1626408 22135448 16462551 26942 9368 3940 2115 23866727 18100442 26477 8112 0 5545109 4980223 0 0 13175215 13516484 18746801 18504819 5119926 -404377 29151131 29841210 19750454 20844910 9400677 8996300 TO LEVERAGE OUR UNIQUE TECHNOLOGY TO IMPROVE OUR PATIENTS' HEALTH, AND PROMOTE INNOVATION IN EDUCATION AND RESEARCH. 0 0 15702687 8112 16462551 Midwest Proton Radiotherapy Institute uses proton beam energy to treat cancer victims. Our patients are selected based on type of cancer, efficiency of treatment and without regard to the patients' ability to pay. Uninsured care was approximately $241,449 for the year ended June 30, 2010. 15702687 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 4 0 65 1 0 0 0 0 0 0 0 0 0 5 5 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 0 0 1 0 IN X JOHN KERSTIENS CPA 8123495074 2425 N Milo B Sampson LN Bloomington IN 47408 Richard S Helsper 16.00 X X 0 0 0 Dr Peter Johnstone 16.00 X X 0 0 0 Thomas E O'Brien 1.00 X 0 0 0 Marvin Pember 1.00 X 0 0 0 Neil D Theobald 1.00 X 0 0 0 Isadore Rivas 1.00 X 0 0 0 William Stephan 1.00 X 0 0 0 John Kerstiens 40.00 X 131240 0 19629 Karin Campbell 40.00 X 71027 0 19452 Edward Dickey 40.00 X 149993 0 7426 Dr Allan Thornton 40.00 X 844225 0 42543 Chris Allgower 40.00 X 128138 0 33809 Mark Wolanski 40.00 X 105015 0 30020 Marybeth Sullivan-Dickey 40.00 X 129477 0 20432 1559115 0 173311 6 0 1 0 University Radiation Oncology Assoc 535 Barnhill Drive Indianapolis IN 46202 Physician and physicists 1982676 DUNlap Construction PO Box 328 Columbus IN 47202 Construction Services 368011 Siemens Medical Solutions PO Box 120001 Dept 0733 Dallas TX 75312 Medical Equipment Solutions/Service 206497 Bloom Physicians PO Box 2121 Dept 1438 Memphis TN 38159 Anestheiologists 198985 Comput IT Services 13723 Corporate Lake Dr Maryland heights MO 63043 Computerized Medical System Services 172600 7 1626408 1626408 Patient service revenu 621110 16462551 16462551 16462551 9368 9368 2115 2115 2115 18100442 16462551 0 11483 8112 8112 1004949 854207 150742 3002615 3002615 322422 274059 48363 399977 339980 59997 250260 212721 37539 93330 93330 37804 37804 3518966 3518966 50048 50048 419919 352732 67187 1470955 1176764 294191 69817 69817 6595 6595 1686921 1686921 1840064 1564054 276010 90269 90269 Proton Beam Expense 4100004 4100004 Bad Debt 65847 65847 Dues & Subscriptions 14830 14830 Recruiting 13330 13330 37785 37785 18504819 15702687 2802132 0 157635 100 2821281 2638865 2594896 2512929 45522 1387 20905979 4368050 14781797 16537929 8750000 8150000 29151131 29841210 17323972 17091244 2426482 3753666 19750454 20844910 X 9400677 8996300 9400677 8996300 29151131 29841210 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 14772495 2293456 12479039 4558130 2074594 2483536 1575354 1575354 16537929 18100442 18504819 -404377 0 -404377 18100442 0 18100442 0 18100442 18504819 0 18504819 0 18504819 Part X: Description of Uncertain Tax Positions Under FIN 48: line 2: not applicable. The current audited financial statements do not include a footnote regarding any uncertain tax positions. 1 X Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: All grants are provided to 501(c)(3) public charities for general support. Midwest Proton Radiotherpahy Institute, LLC does not monitor the use of these funds by these public charities. 1 0 0 0 0 0 0 0 0 John Kerstiens 131240 0 0 0 0 0 14420 0 5209 0 150869 0 0 0 Edward Dickey 60957 0 0 0 89036 0 6140 0 1286 0 157419 0 0 0 Dr Allan Thornton 844225 0 0 0 0 0 36662 0 5881 0 886768 0 0 0 Chris Allgower 128138 0 0 0 0 0 32115 0 1694 0 161947 0 0 0 Part I, Line 4a Severance payment: Clinic Operations Directors $89,036. X InKind Contribution: Forgiveness of Accrued Int. 1 1624105 Fair Market Value 0 0 0 Method for Determining Number of Contributors: Part I, Column (b): InKind Contribution: Forgiveness of accrued interest for fiscal year 2010 on accounts payable to Indiana University not payable within one year. The inkind contribution is estimated using the most current available interest rate and recorded as a revenue and expense on the audited financial statements. Form 990, Part VI, Section A, line 6 The organization is organized as a domestic limited liability company with two corporate members and a board of managers. Form 990, Part VI, Section A, line 7a The corporate members Indiana University Research and Technology Corporation and Clarian Health Partners each select two board managers and unanimously vote on one "elected" manager to the governing board of managers. Form 990, Part VI, Section B, line 11 The process of reviewing the Form 990 entails a detailed review of the Form 990 by MPRI's CFO and by the corporate members' tax departments. The governing body reviews and approves the Form 990 and the final Form 990 including requested schedules, as ultimately filed with the IRS, are provided electronically to each voting member of the organization's governing body prior to filing. Form 990, Part VI, Section B, line 12c The written Conflict of interest policy is regularly and consistently monitored and compliance is enforced by the director of human resources/ administration and director's team. The scope of this policy includes all members of the MPRI board of managers, all employees, and all contracted professionals. The policy is in place to prevent any potential conflicts of personal profit or gain, directly or indirectly, by reason of his or her participation with or employment by MPRI. In addition covered persons are to refrain from obtaining any list of MPRI's patients, referring physicians and vendors for personal or private solicitation purposes. A self disclosure from covered persons to MPRI leadership is required on any potential interest with vendors, patients or other matters. Any potential conflicts disclosed are reviewed and researched by compliance personnel and brought to the board of managers for review. The covered persons are to recuse from participating in any deliberation or decision on such transactions. Form 990, Part VI, Section B, line 15b The CEO and COO (top management official) of the organization have been selected by the organization's corporate members to serve as board members and management officials for the organization. These officers do not receive compensation from the organization and therefore compensation determination is not required by the organization. The process for determining the compensation of all other organization's officers and Key employees included a review and approval by the governing body. Comparison with member institutions and local providers was made during the review of the compensation. The deliberation and decision made on the compensation was contemporaneously substantiated in the minutes of the board of managers. In addition a written compensation agreement outlines all compensation arrangements. Form 990, Part VI, Section C, line 19 Governing documents, conflict of interest policy, and financial statements are available to the public. Requests can be made by phone or mail. Form 990, Part XI, Line 2C Oversight of the Audit The board of managers assumes responsibility for oversight of the audit of the financial statements and no processes have changed from prior year. Schedule A, Part I, Line 3 Hospital MPRI has been determined by the IRS to be a public charity under IRS code section 170(b)(1)(A)(III). Per Schedule H instructions only organizations that operate at least one facility that is, or is required to be, licensed, registered, or similarly recognized by a State as a hospital is required to complete the schedule. MPRI is a cancer treatment center and is not licensed as a hospital for the State of Indiana.