OMB No. 1545-0047
Return of Organization Exempt From Income TaxForm ½½´ Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung
benefit trust or private foundation)
À¾´¼
Open to Public
Department of the Treasury
Internal Revenue Service I The organization may have to use a copy of this return to satisfy state reporting requirements. Inspection
, 2008, and ending , 20A For the 2008 calendar year, or tax year beginning
Please
use IRS
label or
print or
type.
See
Specific
Instruc-
tions.
D Employer identification numberC Name of organizationB Check if applicable:
Address
change Doing Business As
E Telephone numberNumber and street (or P.O. box if mail is not delivered to street address) Room/suiteName change
Initial return
Termination City or town, state or country, and ZIP + 4
Amended
return
G Gross receipts $
Application
pending
H(a) Is this a group return for
affiliates?
F Name and address of principal officer: Yes No
Are all affiliates included? Yes NoH(b)
If "No," attach a list. (see instructions)Tax-exempt status:I
JJ501(c) ( ) (insert no.) 4947(a)(1) or 527
I IWebsite:J H(c) Group exemption number
I Year of formation: State of legal domicile:K Type of organization: L MCorporation Trust Association Other
SummaryPart I
1 Briefly describe the organization's mission or most significant activities:
Check this box
Number of voting members of the governing body (Part VI, line 1a)
Number of independent voting members of the governing body (Part VI, line 1b)
Total number of employees (Part V, line 2a)
Total number of volunteers (estimate if necessary)
Total gross unrelated business revenue from Part VIII, line 12, column (C)
Net unrelated business taxable income from Form 990-T, line 34
2
3
4
5
6
7
I if the organization discontinued its operations or disposed of more than 25% of its assets.
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Activities&Governance
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Contribution and grants (Part VIII, line 1h)
Program service revenue (Part VIII, line 2g)
Investment income (Part VIII, column (A), lines 3, 4, and 7d)
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)
Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), line 12)
Grants and similar amounts paid (Part IX, column (A), lines 1-3)
Benefits paid to or for members (Part IX, column (A), line 4)
Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10)
Professional fundraising fees (Part IX, column (A), line 11e)
Total fundraising expenses, Part IX, column (D), line 25)
Other expenses (Part IX, column (A), lines 11a-11d, 11f-24f)
Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25)
Revenue less expenses. Subtract line 18 from line 12
Total assets (Part X, line 16)
Total liabilities (Part X, line 26)
Net assets or fund balances. Subtract line 21 from line 20
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Revenue
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Expenses
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NetAssetsor
FundBalances
Signature BlockPart II
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
M Signature of officer Date
M Type or print name and title
M I
Date Check if
self-
employed
Preparer's identifying number
(see instructions)Preparer's
signature
I
Paid
Preparer's
Use Only M I
EIN
Phone no.
Firm's name (or yours
if self-employed),
address, and ZIP + 4
m m m m m m m m m m m m m m m m m m m m m m m mMay the IRS discuss this return with the preparer shown above? (See instructions) Yes No
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2008)
JSA
8E1010 2.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
07/01 06/30 09
(937)641-3338
31-0672132
ONE CHILDREN'S PLAZA
X
X 3
WWW.CHILDRENSDAYTON.ORG
X 1967 OH
DAVID KINSAUL
ONE CHILDREN'S PLAZA DAYTON, OH 45404
235,558,146.DAYTON, OH 45404
TO IMPROVE THE HEALTH STATUS OF ALL CHILDREN THROUGH SERVICE,
EDUCATION, RESEARCH AND ADVOCACY.
18
14
2,100
818
-91,210.
NONE
8,720,485. 8,916,670.
169,126,922. 175,711,348.
16,244,553. -253,779.
2,325,447. 3,117,228.
196,417,407. 187,491,467.
NONE 74,903.
NONE NONE
102,604,795. 99,972,731.
NONE NONE
1,065,079.
62,425,630. 74,135,973.
165,030,425. 174,183,607.
31,386,982. 13,307,860.
332,394,076. 318,433,896.
28,757,257. 41,561,040.
303,636,819. 276,872,856.
ERNST & YOUNG U.S. LLP 34-6565596
317-280-34005451 LAKEVIEW PARKWAY SOUTH DRIVE INDIANAPOLIS, IN 46268
X
“Public Disclosure Requirements”
Form 990 (2008) Page 2
Statement of Program Service Accomplishments (see instructions)Part III
1 Briefly describe the organization's mission:
2 Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mIf "Yes" describe these new services on Schedule O.
3 Did the organization cease conducting, or make significant changes in how it conducts, any program
services? Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mIf "Yes," describe these changes on Schedule O.
4 Describe the exempt purpose achievements for each of the organization's three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and
allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a including grants of $(Code: ) (Expenses $ ) (Revenue $ )
4b including grants of $(Code: ) (Expenses $ ) (Revenue $ )
4c including grants of $(Code: ) (Expenses $ ) (Revenue $ )
4d Other program services. (Describe in Schedule O.)
(Expenses $ including grants of $ ) (Revenue $ )
I4e Total program service expenses $ (Must equal Part IX, Line 25, column (B).)
Form 990 (2008)JSA
8E1020 1.000
89354K 3987 V08-8.3
31-0672132
TO IMPROVE THE HEALTH STATUS OF ALL CHILDREN THROUGH SERVICE,
EDUCATION, RESEARCH AND ADVOCACY.
162,625,195.
X
X
162,625,195. 74,903. 178,469,083.
SEE STATEMENT 1
Form 990 (2008) Page 3
Checklist of Required SchedulesPart IV
Yes No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes,"
complete Schedule A
Is the organization required to complete Schedule B, Schedule of Contributors?
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to
candidates for public office? If "Yes," complete Schedule C, Part I
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If "Yes," complete
Schedule C, Part II
Sections 501(c)(4), 501(c)(5), and 501(c)(6) organizations. Is the organization subject to the section 6033(e)
notice and reporting requirement and proxy tax? If "Yes," complete Schedule C, Part III
Did the organization maintain any donor advised funds or any accounts where donors have the right to
provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete
Schedule D, Part I
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part
X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes,"
complete Schedule D, Part IV
Did the organization hold assets in term, permanent, or quasi-endowments? If "Yes," complete Schedule D, Part V
Did the organization report an amount in Part X, lines 10, 12, 13, 15, or 25? If "Yes," complete Schedule D,
Parts VI, VII, VIII, IX, or X as applicable
Did the organization receive an audited financial statement for the year for which it is completing this return
that was prepared in accordance with GAAP? If "Yes," complete Schedule D, Parts XI, XII, and XIII
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
Did the organization maintain an office, employees, or agents outside of the U.S.?
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising,
business, and program service activities outside the U.S.? If "Yes," complete Schedule F, Part I
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any
organization or entity located outside the United States? If "Yes," complete Schedule F, Part II
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance
to individuals located outside the United States? If "Yes," complete Schedule F, Part III
Did the organization report more than $15,000 on Part IX, column (A), line 11e? If "Yes," complete Schedule G, Part I
Did the organization report more than $15,000 total on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II
Did the organization report more than $15,000 on Part VIII, line 9a? If "Yes," complete Schedule G, Part III
Did the organization operate one or more hospitals? If "Yes," complete Schedule H
Did the organization report more than $5,000 on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts I and II
Did the organization report more than $5,000 on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III
Did the organization answer "Yes" to Part VII, Section A, questions 3, 4, or 5,? If "Yes," complete
Schedule J
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than
$100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer questions
24b-24d and complete Schedule K. If "No," go to question 25
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?
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m m m m m mSection 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction
with a disqualified person during the year? If "Yes," complete Schedule L, Part I m m m m m m m m m m m m m m m m m m mDid the organization become aware that it had engaged in an excess benefit transaction with a disqualified
person from a prior year? If "Yes," complete Schedule L, Part I
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or
disqualified person outstanding as of the end of the organization's tax year? If "Yes," complete Schedule L, Part II
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, or
substantial contributor, or to a person related to such an individual? If "Yes," complete Schedule L, Part III
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8E1021 1.000 Form 990 (2008)
89354K 3987 V08-8.3
31-0672132
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Form 990 (2008) Page 4
Checklist of Required Schedules (continued)Part IV
Yes No
During the tax year, did any person who is a current or former officer, director, trustee, or key employee:
Have a direct business relationship with the organization (other than as an officer, director, trustee, or
employee), or an indirect business relationship through ownership of more than 35% in another entity
(individually or collectively with other person(s) listed in Part VII, Section A)? If "Yes," complete Schedule L,
Part IV
Have a family member who had a direct or indirect business relationship with the organization? If "Yes,"
complete Schedule L, Part IV
Serve as an officer, director, trustee, key employee, partner, or member of an entity (or a shareholder of a
professional corporation) doing business with the organization? If "Yes," complete Schedule L, Part IV
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified
conservation contributions? If "Yes," complete Schedule M
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N,
Part I
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete
Schedule N, Part II
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations
section 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Parts II,
III, IV, and V, line 1
Is any related organization a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete
Schedule R, Part V, line 2
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related
organization? If "Yes," complete Schedule R, Part V, line 2
Did the organization conduct more than 5% of its activities through an entity that is not a related organization
and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part
VI
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b
c
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28b
28c
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Form 990 (2008)
JSA
8E1030 1.000
89354K 3987 V08-8.3
31-0672132
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Form 990 (2008) Page 5
Statements Regarding Other IRS Filings and Tax CompliancePart V
Yes No
1a
1b
2a
7d
1a
b
c
2a
b
3a
b
4a
b
5a
b
c
6a
b
a
b
c
d
e
f
g
h
a
b
a
b
a
b
12a
Enter the number reported in Box 3 of Form 1096, Annual Summary and Transmittal of
U.S. Information Returns. Enter -0- if not applicable
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable
gaming (gambling) winnings to prize winners?
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax
Statements, filed for the calendar year ending with or within the year covered by this return
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note: If the sum of lines 1a and 2a is greater than 250, you may be required to e-file this return. (see instructions)
Did the organization have unrelated business gross income of $1,000 or more during the year covered by
this return?
If "Yes," has it filed a Form 990-T for this year? If "No," provide an explanation in Schedule O
At any time during the calendar year, did the organization have an interest in, or a signature or other authority
over, a financial account in a foreign country (such as a bank account, securities account, or other financial
account)?
If “Yes,” enter the name of the foreign country:
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
If "Yes," to question 5a or 5b, did the organization file Form 8886-T, Disclosure by Tax-Exempt Entity Regarding
Prohibited Tax Shelter Transaction?
Did the organization solicit any contributions that were not tax deductible?
If "Yes," did the organization include with every solicitation an express statement that such contributions or
gifts were not tax deductible?
Organizations that may receive deductible contributions under section 170(c).
Did the organization provide goods or services in exchange for any quid pro quo contribution of more than $75?
If "Yes," did the organization notify the donor of the value of the goods or services provided?
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was
required to file Form 8282?
If "Yes," indicate the number of Forms 8282 filed during the year
Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal
benefit contract?
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
For all contributions of qualified intellectual property, did the organization file Form 8899 as required?
For contributions of cars, boats, airplanes, and other vehicles, did the organization file a Form 1098-C as
required?
Section 501(c)(3) and other sponsoring organizations maintaining donor advised funds and section
509(a)(3) supporting organizations. Did the supporting organization, or a fund maintained by a sponsoring
organization, have excess business holdings at any time during the year?
Section 501(c)(3) and other sponsoring organizations maintaining donor advised funds.
Did the organization make any taxable distributions under section 4966?
Did the organization make a distribution to a donor, donor advisor, or related person?
Section 501(c)(7) organizations. Enter:
Initiation fees and capital contributions included on Part VIII, line 12
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
Section 501(c)(12) organizations. Enter:
Gross income from members or shareholders
Gross income from other sources (Do not net amounts due or paid to other sources against
amounts due or received from them.)
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
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If "Yes," enter the amount of tax-exempt interest received or accrued during the yearb m m m m Form 990 (2008)
JSA
8E1040 2.000
89354K 3987 V08-8.3
31-0672132
94
NONE
2,100
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X
BERMUDA
Form 990 (2008) Page 6
Governance, Management, and Disclosure (Sections A, B, and C request information about policies not
required by the Internal Revenue Code.)
Part VI
Section A. Governing Body and Management
Yes No
For each "Yes" response to lines 2-7b below, and for a "No" response to lines 8 or 9b below, describe the
circumstances, process, or changes in Schedule O. See instructions.
Enter the number of voting members of the governing body
Enter the number of voting members that are independent
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with
any other officer, director, trustee, or key employee?
Did the organization delegate control over management duties customarily performed by or under the direct
supervision of officers, directors or trustees, or key employees to a management company or other person?
Did the organization make any significant changes to its organizational documents since the prior Form 990 was filed?
Did the organization become aware during the year of a material diversion of the organization's assets?
Does the organization have members or stockholders?
Does the organization have members, stockholders, or other persons who may elect one or more members
of the governing body?
Are any decisions of the governing body subject to approval by members, stockholders, or other persons?
Did the organizations contemporaneously document the meetings held or written actions undertaken during
the year by the following:
The governing body?
Each committee with authority to act on behalf of the governing body?
Does the organization have local chapters, branches, or affiliates?
If "Yes," does the organization have written policies and procedures governing the activities of such chapters,
affiliates, and branches to ensure their operations are consistent with those of the organization?
Was a copy of the Form 990 provided to the organization’s governing body before it was filed? All organizations
must describe in Schedule O the process, if any, the organization uses to review the Form 990
Is there any officer, director or trustee, or key employee listed in Part VII, Section A, who cannot be reached at
the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O
Does the organization have a written conflict of interest policy? If "No," go to line 13
Are officers, directors or trustees, and key employees required to disclose annually interests that could give
rise to conflicts?
Does the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes,"
describe in Schedule O how this is done
Does the organization have a written whistleblower policy?
Does the organization have a written document retention and destruction policy?
Did the process for determining compensation of the following persons include a review and approval by
independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision:
The organization’s CEO, Executive Director, or top management official?
Other officers or key employees of the organization?
Describe the process in Schedule O. (see instructions)
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement
with a taxable entity during the year?
If "Yes," has the organization adopted a written policy or procedure requiring the organization to evaluate
its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard
the organization’s exempt status with respect to such arrangements?
List the states with which a copy of this Form 990 is required to be filed
Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only)
available for public inspection. Indicate how you make these available. Check all that apply.
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest
policy, and financial statements available to the public.
State the name, physical address, and telephone number of the person who possesses the books and records of the
organization:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
a
b
a
b
a
b
a
b
1a
1b
m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m
2
3
4
5
6
7a
7b
8a
8b
9a
9b
10
11
12a
12b
12c
13
14
15a
15b
16a
16b
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m
m m m m m
m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m
m m m m m m m m m m
m m m m m m m m m m m m
Section B. Policies
Yes No
a
b
c
a
b
a
b
m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
Section C. Disclosure
I
Own website Another's website Upon request
I
Form 990 (2008)JSA
8E1042 1.000
89354K 3987 V08-8.3
31-0672132
18
14
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
DAVID T. MILLER ONE CHILDREN'S PLAZA DAYTON, OH 45404
937-641-3338
Form 990 (2008) Page 7
Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated
Employees, and Independent Contractors
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Use Schedule J-2 if additional space is needed.
%
%
%
%
List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of
compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.
List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who
received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and
any related organizations.
List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of
reportable compensation from the organization and any related organizations.
List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization,
more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated
employees; and former such persons.
Check this box if the organization did not compensate any officer, director, trustee, or key employee.
(A) (B) (C) (D) (E) (F)
Name and Title Average
hours per
week
Position (check all that apply) Reportable
compensation
from
the
organization
(W-2/1099-MISC)
Reportable
compensation
from related
organizations
(W-2/1099-MISC)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
Individualtrustee
ordirector
Institutionaltrustee
Officer
Keyemployee
Highestcompensated
employee
Former
Form 990 (2008)
JSA
8E1041 1.000
89354K 3987 V08-8.3
31-0672132
SEE SCHEDULE J-2
Form 990 (2008) Page 8
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)Part VII
(A) (B) (C) (D) (E) (F)
Name and title Average
hours per
week
Position (check all that apply) Reportable
compensation
from
the
organization
(W-2/1099-MISC)
Reportable
compensation
from related
organizations
(W-2/1099-MISC)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
Individualtrustee
ordirector
Institutionaltrustee
Officer
Keyemployee
Highestcompensated
employee
Former
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m I1b Total
2 Total number of individuals (including those in 1a) who received more than $100,000 in reportable compensation from the
organization I Yes No
3 Did the organization list any former officer, director or trustee, key employee, or highest compensated
employee on line 1a? If "Yes," complete Schedule J for such individual 3m m m m m m m m m m m m m m m m m m m m m m m m m m
4 For any individual listed on line 1a, is the sum of reportable compensation and other compensation from
the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual 4m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization for
services rendered to the organization? If "Yes," complete Schedule J for such person 5m m m m m m m m m m m m m m m m m mSection B. Independent Contractors
1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of
compensation from the organization.
(A)
Name and business address
(B)
Description of services
(C)
Compensation
2 Total number of independent contractors (including those in 1) who received more than $100,000 in
compensation from the organization I Form 990 (2008)
JSA
8E1050 1.000
89354K 3987 V08-8.3
31-0672132
2,849,077. NONE 648,802.
42
X
X
X
11
SEE STATEMENT 2
Form 990 (2008) Page 9
(C)
Unrelated
business
revenue
Statement of RevenuePart VIII
(B)
Related or
exempt
function
revenue
(D)
Revenue
excluded from tax
under sections
512, 513, or 514
(A)
Total revenue
1a
1b
1c
1d
1e
1f
1a
b
c
d
e
f
g
2a
b
c
d
e
f
6a
b
c
b
c
8a
b
9a
b
10a
b
11a
b
c
d
e
Federated campaigns
Membership dues
Fundraising events
Related organizations
Government grants (contributions)
All other contributions, gifts, grants,
and similar amounts not included above
Noncash contributions included in lines 1a-1f:
m m m m m m m m
m m m m m m m m m
m m m m m m m m m
m m m m m m m m
m m
Contributions,gifts,grants
andothersimilaramounts
m
$
ITotal. Add lines 1a-1f m m m m m m m m m m m m m m m m m mh
Business Code
ProgramServiceRevenue
All other program service revenue m m m m m
Ig Total. Add lines 2a-2f m m m m m m m m m m m m m m m m m m m
3
4
5
Investment income (including dividends, interest, and
other similar amounts)
Income from investment of tax-exempt bond proceeds
Royalties
I
I
I
I
I
I
I
I
I
m m m m m m m m m m m m m m m m m m
m m mm m m m m m m m m m m m m m m m m m m m m m m m m(i) Real (ii) Personal
Gross Rents
Less: rental expenses
Rental income or (loss)
m m m m m m m
m m m
m md Net rental income or (loss) m m m m m m m m m m m m m m m m m(i) Securities (ii) Other
7a Gross amount from sales of
assets other than inventory
Less: cost or other basis
and sales expenses
Gain or (loss)
m m m m
m m m m m m md Net gain or (loss) m m m m m m m m m m m m m m m m m m m m m
Gross income from fundraising
events (not including $
of contributions reported on line 1c).
See Part IV, line 18.
Less: direct expenses
m m m m m m m m m m m a
b
a
b
a
b
OtherRevenue
m m m m m m m m m mc Net income or (loss) from fundraising events m m m m m m m m
Gross income from gaming activities.
See Part IV, line 19. m m m m m m m m m m m
Less: direct expenses m m m m m m m m m mc Net income or (loss) from gaming activities m m m m m m m m m
Gross sales of inventory, less
returns and allowances m m m m m m m m m
Less: cost of goods sold m m m m m m m m mc Net income or (loss) from sales of inventorym m m m m m m m mMiscellaneous Revenue Business Code
All other revenue
Total. Add lines 11a-11d
Total Revenue. Add lines 1h, 2g, 3, 4, 5, 6d, 7d, 8c,
m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m I12
m m m m m m m m m m m m m m m m m m m m m9c, 10c, and 11e
Form 990 (2008)JSA
8E1051 1.000
89354K 3987 V08-8.3
31-0672132
28,428.
NONE
49,390.
NONE
745,641.
8,093,211.
22,682.
8,916,670.
175,711,348.
6,361,555.
NONE
NONE
374,250.
222,561.
151,689.
151,689.
6,361,555.
151,689.
PATIENT SERVICE REVENUE 900099 121,655,370. 121,655,370.
MEDICARE/MEDICAID 900099 54,147,188. 54,147,188.
URGENT CARE CENTER 621400 112,725. 112,725.
SURGERY CENTER 621400 -203,935. -203,935.
40,635,528. 30,950.
47,041,659. 240,163.
-6,406,131. -209,213.
-6,615,334.
49,390.
384,543.
85,529.
299,014.
NONE
688,772.
476,767.
212,005.
-6,615,334.
299,014.
212,005.
2,454,520.
187,491,467. 178,469,083. -91,210. 196,924.
CAFETERIA 722210 1,379,309. 1,379,309.
CCC 624410 765,127. 765,127.
PARKING LOT 812930 310,084. 310,084.
Form 990 (2008) Page 10
Statement of Functional ExpensesPart IX
Section 501(c)(3) and 501(c)(4) organizations must complete all columns.
All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
(A) (B) (C) (D)Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII.
Total expenses Program service
expenses
Management and
general expenses
Fundraising
expenses
Grants and other assistance to governments and
organizations in the U.S. See Part IV, line 21
1
m m
Grants and other assistance to individuals in
the U.S. See Part IV, line 22
2
m m m m m m m m m m
3 Grants and other assistance to governments,
organizations, and individuals outside the
U.S. See Part IV, lines 15 and 16 m m m m m m m mBenefits paid to or for members4 m m m m m m m m m
5 Compensation of current officers, directors,
trustees, and key employees m m m m m m m m m m
6 Compensation not included above, to disqualified
persons (as defined under section 4958(f)(1)) and
persons described in section 4958(c)(3)(B) m m m
Other salaries and wages7 m m m m m m m m m m m m
8 Pension plan contributions (include section 401
(k) and section 403(b) employer contributions) m m
9 Other employee benefits
Payroll taxes
Fees for services (non-employees):
Management
Legal
Accounting
Lobbying
m m m m m m m m m m m m
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
m m m m m m m m m m m m m m m m m m
a
b
c
d
e
f
g
m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m
Professional fundraising services. See Part IV, line 1 7
Investment management fees m m m m m m m m m
Other
Advertising and promotion
Office expenses
Information technology
m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m
m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m
Royalties
Occupancy
Travel
m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m
Payments of travel or entertainment expenses
for any federal, state, or local public officials
Conferences, conventions, and meetings
Interest
Payments to affiliates
Depreciation, depletion, and amortization
Insurance
m m m m
m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m
m m m m
m m m m m m m m m m m m m m m m m m mOther expenses. Itemize expenses not
covered above. (Expenses grouped together
and labeled miscellaneous may not exceed
5% of total expenses shown on line 25 below.)
a
b
c
d
e
f All other expenses
25
26
Total functional expenses. Add lines 1 through 24f
IJoint Costs. Check here If following
SOP 98-2. Complete this line only if the organization
reported in column (B) joint costs from a
combined educational campaign and fundraising
solicitation m m m m m m m m m m m m m m m m m m mJSA
Form 990 (2008)8E1052 1.000
89354K 3987 V08-8.3
31-0672132
NONE
74,903. 74,903.
NONE
NONE
160,089. 160,089.
NONE
14,433,876. 14,313,870.
627,127. 627,127.
29,750,147. 29,087,142.
2,814,152. 2,814,152.
NONE
NONE
120,006.
490,165. 172,840.
NONE
2,138,988.
74,372,331. 69,960,420.
3,587,825. 3,374,988.
12,406,618. 11,742,384.
7,466,969. 7,024,014.
NONE
175,936.
203,346.
NONE
2,138,988.
3,798,024. 613,887.
183,222. 29,615.
561,197. 103,037.
381,321. 61,634.
175,936.
203,346.
3,132,977. 3,005,439.
496,265. 314,004.
NONE
64,003. 64,003.
NONE
13,275,375. 12,888,194.
741,916. 741,916.
174,183,607. 162,625,195.
118,360. 9,178.
156,226. 26,035.
355,488. 31,693.
10,493,333. 1,065,079.
PURCHASED SERVICES 7,772,639. 6,067,357. 1,688,122. 17,160.
TAXES 122,932. 122,932.
MISCELLANEOUS 365,193. 365,193.
Form 990 (2008) Page 11
Balance SheetPart X
(A)
Beginning of year
(B)
End of year
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m
Cash - non-interest-bearing
Savings and temporary cash investments
Pledges and grants receivable, net
Accounts receivable, net
Receivables from current and former officers, directors, trustees, key
employees, or other related parties. Complete Part II of Schedule L
Receivables from other disqualified persons (as defined under section
4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II
of Schedule L
Notes and loans receivable, net
Inventories for sales or use
Prepaid expenses and deferred charges
Land, buildings, and equipment: cost basis
Less: accumulated depreciation. Complete
Part VI of Schedule D
Investments - publicly traded securities
Investments - other securities. See Part IV, line 11
Investments - program-related. See Part IV, line 11
Intangible assets
Other assets. See Part IV, line 11
Total assets. Add lines 1 through 15 (must equal line 34)
1
2
3
4
5
6
7
8
9
1
2
3
4
5
6
7
8
9
10c
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
m m m m
m m m m m m m m m m m m m m m m
10a
10b
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
a
b
m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m
Assets
m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m
Accounts payable and accrued expenses
Grants payable
Deferred revenue
Tax-exempt bond liabilities
Escrow account liability. Complete Part IV of Schedule D
Payables to current and former officers, directors, trustees, key employees,
highest compensated employees, and disqualified persons. Complete Part II
of Schedule L
Secured mortgages and notes payable to unrelated third parties
Unsecured notes and loans payable
Other liabilities. Complete Part X of Schedule D
Total liabilities. Add lines 17 through 25
Liabilities
I and completeOrganizations that follow SFAS 117, check here
lines 27 through 29, and lines 33 and 34.
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m
m m m m m m m m
m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m
27
28
29
30
31
32
33
34
Unrestricted net assets
Temporarily restricted net assets
Permanently restricted net assets
Capital stock or trust principal, or current funds
Paid-in or capital surplus, or land, building, or equipment fund
Retained earnings, endowment, accumulated income, or other funds
Total net assets or fund balances
Total liabilities and net assets/fund balances
I andOrganizations that do not follow SFAS 117, check here
complete lines 30 through 34.
NetAssetsorFundBalances
Financial Statements and ReportingPart XI
Yes No
m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
1
2
3
Accounting method used to prepare the Form 990:
Were the organization's financial statements compiled or reviewed by an independent accountant?
Were the organization's financial statements audited by an independent accountant?
If "Yes" to lines 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the
audit, review, or compilation of its financial statements and selection of an independent accountant?
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in
the Single Audit Act and OMB Circular A-133?
If "Yes," did the organization undergo the required audit or audits?
Cash Accrual Other
a
b
c
a
b
2a
2b
2c
3a
3b
Form 990 (2008)
JSA
8E1053 1.000
89354K 3987 V08-8.3
31-0672132
13,650. 14,750.
691,738. 3,010,035.
21,282,002. 25,603,833.
8,476,438. 6,778,241.
278,756. 142,465.
1,711,005. 1,321,966.
1,121,237. 186,817.
186,804,621. 171,959,891.
175,542,528.
70,576,830. 102,657,848. 104,965,698.
6,856,066. 2,357,523.
332,394,076. 318,433,896.
21,403,959. 25,148,492.
NONE 85,988.
2,500,715. 2,092,677.
7,353,298. 16,326,560.
28,757,257. 41,561,040.
X
295,812,789. 269,552,371.
7,824,030. 7,320,485.
303,636,819. 276,872,856.
332,394,076. 318,433,896.
X
X
X
X
X
OMB No. 1545-0047SCHEDULE A
Public Charity Status and Public Support(Form 990 or 990-EZ)
To be completed by all section 501(c)(3) organizations and section 4947(a)(1)
nonexempt charitable trusts.
À¾´¼
Department of the Treasury
Open to Public
InspectionI IAttach to Form 990 or Form 990-EZ. See separate instructions.Internal Revenue Service
Name of the organization Employer identification number
Reason for Public Charity Status (All organizations must complete this part.) (see instructions)Part I
The organization is not a private foundation because it is: (Please check only one organization.)
1
2
3
4
5
6
7
8
9
10
11
A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).
A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)
A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). (Attach Schedule H.)
A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the
hospital's name, city, and state:
An organization operated for the benefit of a college or university owned or operated by a governmental unit described in
section 170(b)(1)(A)(iv). (Complete Part II.)
A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).
An organization that normally receives a substantial part of its support from a governmental unit or from the general public
described in section 170(b)(1)(A)(vi). (Complete Part II.)
A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)
An organization that normally receives: (1) more than 331/3 % of its support from contributions, membership fees, and gross
receipts from activities related to its exempt functions - subject to certain exceptions, and (2) no more than 331/3% of its
support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
An organization organized and operated exclusively to test for public safety. See section 509(a)(4). (see instructions)
An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the
purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section
509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.
a Type I b Type II c Type III - Functionally Integrated d Type III - Other
e
f
g
h
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified
persons other than foundation managers and other than one or more publicly supported organizations described in section
509(a)(1) or section 509(a)(2).
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting
organization, check this box m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mSince August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?
Yes No(i)
(ii)
(iii)
A person who directly or indirectly controls, either alone or together with persons described in (ii)
and (iii) below, the governing body of the supported organization? 11g(i)
11g(ii)
11g(iii)
m m m m m m m m m m m m m m m m m m m m mA family member of a person described in (i) above?
A 35% controlled entity of a person described in (i) or (ii) above?
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m mProvide the following information about the organizations the organization supports.
(i) Name of supported
organization
(ii) EIN (iii) Type of organization
(described on lines 1-9
above or IRC section
(see instructions))
(iv) Is the organization
in col. (i) listed in your
governing document?
(v) Did you notify
the organization in
col. (i) of your
support?
(vi) Is the
organization in col.
(i) organized in the
U.S.?
(vii) Amount of
support
Yes No Yes No Yes No
Total
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule A (Form 990 or 990-EZ) 2008
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Schedule A (Form 990 or 990-EZ) 2008 Page 2
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I.)
Part II
Section A. Public Support
(a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) TotalCalendar year (or fiscal year beginning in)
I
1 Gifts, grants, contributions, and
membership fees received. (Do not
include any "unusual grants.") m m m m m m
2 Tax revenues levied for the organization’s
benefit and either paid to or expended on
its behalf m m m m m m m m m m m m m m m m
3 The value of services or facilities
furnished by a governmental unit to the
organization without charge m m m m m m m
4 Total. Add lines 1-3 m m m m m m m m m m m
5 The portion of total contributions by each
person (other than a governmental unit or
publicly supported organization) included
on line 1 that exceeds 2% of the amount
shown on line 11, column (f) m m m m m m6 Public support. Subtract line 5 from line 4.
Section B. Total Support
(a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) TotalCalendar year (or fiscal year beginning in)
I7 Amounts from line 4m m m m m m m m m m m8 Gross income from interest, dividends,
payments received on securities loans,
rents, royalties and income from similar
sources m m m m m m m m m m m m m m m m m
9 Net income from unrelated business
activities, whether or not the business is
regularly carried on m m m m m m m m m m m
10 Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.) m m m m m m m m m m m
11 Total support. Add lines 7 through 10
Gross receipts from related activities, etc. (See instructions.)
m m 12
14
15
12 m m m m m m m m m m m m m m m m m m m m m m m m m
13 First five years. If the Form 990 is for the organization’s first, second, third, fourth, or fifth tax year as a 501(c)(3)
I
I
I
I
I
I
organization, check this box and stop here m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mSection C. Computation of Public Support Percentage
%
%
14 Public support percentage for 2008 (line 6, column (f) divided by line 11, column (f))
Public support percentage from 2007 Schedule A, Part IV-A, line 26f
33 1/3% support test - 2008. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
33 1/3% support test - 2007. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
10%-facts-and-circumstances test - 2008. If the organization did not check a box on line 13, 16a or 16b, and line 14
is 10% or more, and if the organization meets the "fact-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the “facts and circumstances” test. The organization qualifies as a publicly supported
organization
10%-facts-and-circumstances test - 2007. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the “facts and circumstances” test, check this box and stop here.
Explain in Part IV how the organzation meets the "facts-and-circumstances"” test. The organization qualifies as a publicly
supported organization
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
m m m m m m m m m m
15 m m m m m m m m m m m m m m m m m m m
16a
m m m m m m m m m m m m m m m m m m m m m m m m m
b
m m m m m m m m m m m m m m m m m m m m m m
17a
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
b
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
18
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Schedule A (Form 990 or 990-EZ) 2008
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Schedule A (Form 990 or 990-EZ) 2008 Page 3
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I.)
Part III
Section A. Public Support
(a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) Total
ICalendar year (or fiscal year beginning in)
1 Gifts, grants, contributions, and
membership fees received. (Do not include
any "unusual grants.") m m m m m m m m m m2 Gross receipts from admissions, merchandise
sold or services performed, or facilities
furnished in any activity that is related to the
organization's tax-exempt purpose m m m m m m3 Gross receipts from activities that are not an
unrelated trade or business under section 513 m4 Tax revenues levied for the organization's
benefit and either paid to or expended on
its behalf m m m m m m m m m m m m m m m m5 The value of services or facilities
furnished by a governmental unit to the
organization without charge m m m m m m m6 Total. Add lines 1-5 m m m m m m m m m m m7a Amounts included on lines 1, 2, and 3
received from disqualified persons m m m mb Amounts included on lines 2 and 3
received from other than disqualified
persons that exceed the greater of 1% of
the total of lines 9, 10c, 11, and 12 for the
year or $5,000 m m m m m m m m m m m m m
c Add lines 7a and 7b m m m m m m m m m m m8 Public support (Subtract line 7c from
line 6.) m m m m m m m m m m m m m m m m m
Section B. Total Support
(a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) TotalICalendar year (or fiscal year beginning in)
9 Amounts from line 6m m m m m m m m m m m10a Gross income from interest, dividends,
payments received on securities loans,
rents, royalties and income from similar
sources m m m m m m m m m m m m m m m m mb Unrelated business taxable income (less
section 511 taxes) from businesses
acquired after June 30, 1975 m m m m m mc Add lines 10a and 10b m m m m m m m m m11 Net income from unrelated business
activities not included in line 10b,
whether or not the business is regularly
carried on m m m m m m m m m m m m m m m12 Other income. Do not include gain or
loss from the sale of capital assets
(Explain in Part IV.) m m m m m m m m m m m13 Total support. (Add lines 9, 10c, 11,
and 12.) m m m m m m m m m m m m m m m m14 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3)
organization, check this box and stop here Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Section C. Computation of Public Support Percentage
15
16
Public support percentage for 2008 (line 8, column (f) divided by line 13, column (f))
Public support percentage from 2007 Schedule A, Part IV-A, line 27g
15
16
17
18
%
%
%
%
m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m
Section D. Computation of Investment Income Percentage
17
18
19
20
Investment income percentage for 2008 (line 10c, column (f) divided by line 13, column (f))
Investment income percentage from 2007 Schedule A, Part IV-A, line 27h
m m m m m m m m m m
m m m m m m m m m m m m m m m m m m ma
b
33 1/3 % support tests - 2008. If the organization did not check the box on line 14, and line 15 is more than 33 1/3 %, and line
17 is not more than 33 1/3 %, check this box and stop here. The organization qualifies as a publicly supported organization Im m m m m m m m33 1/3 % support tests - 2007. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3 %, and
line 18 is not more than 33 1/3 %, check this box and stop here. The organization qualifies as a publicly supported organization Im m m m m m
IPrivate foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions m m m m m m m m m mJSA Schedule A (Form 990 or 990-EZ) 2008
8E1221 1.000
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Schedule A (Form 990 or 990-EZ) 2008 Page 4
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10;
Part II, line 17a or 17b; or Part III, line 12. Provide any other additional information. (see instructions)
Part IV
Schedule A (Form 990 or 990-EZ) 2008JSA
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Schedule of Contributors OMB No. 1545-0047
Schedule B
À¾´¼Attach to Form 990, 990-EZ, and 990-PF.
(Form 990, 990-EZ,
or 990-PF) IDepartment of the Treasury
Internal Revenue Service
Name of the organization Employer identification number
Organization type (check one):
Filers of:
Form 990 or 990-EZ
Section:
501(c)( ) (enter number) organization
4947(a)(1) nonexempt charitable trust not treated as a private foundation
527 political organization
501(c)(3) exempt private foundation
4947(a)(1) nonexempt charitable trust treated as a private foundation
501(c)(3) taxable private foundation
Form 990-PF
Check if your organization is covered by the General Rule or a Special Rule. (Note. Only a section 501(c)(7), (8), or (10)
organization can check boxes for both the General Rule and a Special Rule. See instructions.)
General Rule
For organizations filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.
Special Rules
For a section 501(c)(3) organization filing Form 990, or Form 990-EZ, that met the 331/3 % support test of the regulations
under sections 509(a)(1)/170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on Form 990, Part VIII, line 1h or 2% of the amount on Form 990-EZ, line
1. Complete Parts I and II.
For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor,
during the year, aggregate contributions or bequests of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor,
during the year, some contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. (If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year.) I $m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Caution. Organizations that are not covered by the General Rule and/or the Special Rules do not file Schedule B (Form 990,
990-EZ, or 990-PF), but they must answer "No" on Part IV, line 2 of their Form 990, or check the box in the heading of their
Form 990-EZ, or on line 2 of their Form 990-PF, to certify that they do not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions
for Form 990. These instructions will be issued separately.
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)
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X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
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471,035.
X
2
5,000.
X
3
5,000.
X
4
5,000.
X
5
5,000.
X
6
5,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
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5,000.
X
8
5,000.
X
9
5,000.
X
10
5,000.
X
11
5,000.
X
12
5,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
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5,000.
X
14
5,000.
X
15
5,000.
X
16
5,025.
X
17
5,067.
X
18
5,100.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
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5,100.
X
20
5,101.
X
21
5,181.
X
22
5,297.
X
23
5,340.
X
24
5,381.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
25
5,398.
X
26
5,500.
X
27
5,600.
X
28
5,626.
X
29
5,657.
X
30
5,838.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
31
6,000.
X
32
6,000.
X
33
6,000.
X
34
6,027.
X
35
6,100.
X
36
6,208.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
37
6,236.
X
38
6,241.
X
39
6,589.
X
40
6,776.
X
41
6,779.
X
42
7,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
43
7,000.
X
44
7,028.
X
45
7,386.
X
46
7,451.
X
47
7,760.
X
48
7,935.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
49
8,000.
X
50
8,150.
X
51
8,300.
X
52
8,614.
X
53
8,783.
X
54
8,902.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
55
9,043.
X
56
9,135.
X
57
9,275.
X
58
9,363.
X
59
9,578.
X
60
9,835.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
61
9,976.
X
62
10,000.
X
63
10,000.
X
64
10,000.
X
65
10,000.
X
66
10,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
67
10,000.
X
68
10,000.
X
69
10,000.
X
70
10,000.
X
71
10,000.
X
72
10,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
73
10,000.
X
74
10,000.
X
75
10,000.
X
76
10,300.
X
77
10,350.
X
78
10,800.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
79
10,907.
X
80
11,000.
X
81
11,129.
X
82
11,507.
X
83
12,000.
X
84
12,130.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
85
12,419.
X
86
12,500.
X
87
12,500.
X
88
12,500.
X
89
12,500.
X
90
12,500.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
91
12,500.
X
92
13,160.
X
93
13,419.
X
94
14,075.
X
95
14,220.
X
96
14,469.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
97
14,666.
X
98
15,000.
X
99
15,000.
X
100
15,522.
X
101
15,870.
X
102
16,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
103
16,007.
X
104
16,404.
X
105
16,500.
X
106
16,775.
X
107
17,000.
X
108
20,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
109
20,083.
X
110
21,750.
X
111
22,279.
X
112
22,443.
X
113
22,591.
X
114
22,718.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
115
25,000.
X
116
25,000.
X
117
25,000.
X
118
25,000.
X
119
25,000.
X
120
25,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
121
25,000.
X
122
25,000.
X
123
25,000.
X
124
25,000.
X
125
25,000.
X
126
25,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
127
27,500.
X
128
27,650.
X
129
30,000.
X
130
30,000.
X
131
30,000.
X
132
30,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
133
30,000.
X
134
30,952.
X
135
45,000.
X
136
48,000.
X
137
50,000.
X
138
50,000.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
139
50,000.
X
140
50,000.
X
141
51,000.
X
142
52,000.
X
143
61,333.
X
144
84,633.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
145
100,000.
X
146
122,336.
X
147
145,735.
X
148
155,951.
X
149
170,000.
X
150
217,200.
X
Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page of of Part I
Name of organization Employer identification number
Contributors (see instructions)Part I
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Aggregate contributions
(d)
Type of contribution
Person
Payroll
Noncash$
(Complete Part II if there is
a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2008)JSA
8E1253 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER
31-0672132
151
254,655.
X
152
605,000.
X
OMB No. 1545-0047Political Campaign and Lobbying ActivitiesSCHEDULE C
I
(Form 990 or 990-EZ) For Organizations Exempt From Income Tax Under section 501(c) and section 527
I
À¾´¼To be completed by organizations described below.
Open to PublicDepartment of the Treasury Attach to Form 990 or Form 990-EZ.
Internal Revenue Service Inspection
If the organization answered "Yes," to Form 990, Part IV, line 3, or Form 990-EZ, Part VI, line 46 (Political Campaign Activities), then
%
%
%
Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes," to Form 990, Part IV, line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
%
%
Section 501(cy)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes," to Form 990, Part IV, line 5 (Proxy Tax), then
% Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of organization Employer identification number
To be completed by all organizations exempt under section 501(c) and section 527 organizations.
See the instructions for Schedule C for details.
Part I-A
I
1
2
3
Provide a description of the organization's direct and indirect political campaign activities in Part IV.
Political expenditures
Volunteer hours
$m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
To be completed by all organizations exempt under section 501(c)(3).
See the instructions for Schedule C for details.
Part I-B
I
I
$1
2
3
Enter the amount of any excise tax incurred by the organization under section 4955
Enter the amount of any excise tax incurred by organization managers under section 4955
If the organization incurred a section 4955 tax, did it file Form 4720 for this year?
m m m m m $m m
Yes
Yes
No
No
m m m m m m m m m m m m m m m m4a Was a correction made?
If "Yes," describe in Part IV.
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mb
To be completed by all organizations exempt under section 501(c), except section 501(c)(3).
See the instructions for Schedule C for details.
Part I-C
I
I
I
1
2
3
4
Enter the amount directly expended by the filing organization for section 527 exempt function
activities $m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mEnter the amount of the filing organization's funds contributed to other organizations for section
527 exempt function activities $m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mTotal of direct and indirect exempt function expenditures. Add lines 1 and 2 and enter here and
on Form 1120-POL, line 17b $m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mDid the filing organization file Form 1120-POL for this year? m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
5 State the names, addresses and employer identification number (EIN) of all section 527 political organizations to which payments
were made. Enter the amount paid and indicate if the amount was paid from the filing organization's funds or were political
contributions received and promptly and directly delivered to a separate political organization, such as a separate segregated fund
or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from
filing organization's
funds. If none, enter -0-.
(e) Amount of political
contributions received and
promptly and directly
delivered to a separate
political organization. If
none, enter -0-.
For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990. Schedule C (Form 990 or 990-EZ) 2008
JSA
8E1264 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
Schedule C (Form 990 or 990-EZ) 2008 Page 2
To be completed by organizations exempt under section 501(c)(3) that filed Form 5768
(election under section 501(h)). See the instructions for Schedule C for details.
Part II-A
I
I
A Check if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.)
(a) Filing
organization's totals
(b) Affiliated
group totals
1 a
b
c
d
e
f
Total lobbying expenditures to influence public opinion (grass roots lobbying)
Total lobbying expenditures to influence a legislative body (direct lobbying)
Total lobbying expenditures (add lines 1a and 1b)
Other exempt purpose expenditures
Total exempt purpose expenditures (add lines 1c and 1d)
Lobbying nontaxable amount. Enter the amount from the following table in both
columns.
m m m m m m
m m m m m m m
m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m
If the amount on line 1e, column (a) or (b) is:
Not over $500,000
Over $500,000 but not over $1,000,000
Over $1,000,000 but not over $1,500,000
Over $1,500,000 but not over $17,000,000
Over $17,000,000
The lobbying nontaxable amount is:
20% of the amount on line 1e.
$100,000 plus 15% of the excess over $500,000.
$175,000 plus 10% of the excess over $1,000,000.
$225,000 plus 5% of the excess over $1,500,000.
$1,000,000.
g
h
i
j
Grassroots nontaxable amount (enter 25% of line 1f)
Subtract line 1g from line 1a. Enter -0- if line g is more than line a
Subtract line 1f from line 1c. Enter -0- if line f is more than line c
If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year?
m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m
m m m m m m m m m m m m m
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
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 2a through 2f of the instructions.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in)
(a) 2005 (b) 2006 (c) 2007 (d) 2008 (e) Total
2 a Lobbying non-taxable amount
b Lobbying ceiling amount
(150% line 2a, column(e))
c Total lobbying expenditures
d Grassroots non-taxable amount
e Grassroots ceiling amount
(150% of line 2d, column (e))
f Grassroots lobbying expenditures
Schedule C (Form 990 or 990-EZ) 2008
JSA
8E1265 2.000
89354K 3987 V08-8.3
31-0672132
Schedule C (Form 990 or 990-EZ) 2008 Page 3
To be completed by organizations exempt under section 501(c)(3) that have NOT filed Form
5768 (election under section 501(h)). See the instructions for Schedule C for details.
Part II-B
(a) (b)
Yes No Amount
During the year, did the filing organization attempt to influence foreign, national, state or local
legislation, including any attempt to influence public opinion on a legislative matter or
referendum, through the use of:
1
a
b
c
d
e
f
g
h
i
j
Volunteers?
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)?
Media advertisements?
Mailings to members, legislators, or the public?
Publications, or published or broadcast statements?
Grants to other organizations for lobbying purposes?
Direct contact with legislators, their staffs, government officials, or a legislative body?
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means?
Other activities? If "Yes," describe in Part IV
Total lines 1c through 1i
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
mm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m
m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m2 a Did the activities in line 1 cause the organization to be not described in section 501(c)(3)?
If "Yes," enter the amount of any tax incurred under section 4912
If "Yes," enter the amount of any tax incurred by organization managers under section 4912
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year?
m m mb m m m m m m m m m m m m m m m mc m md m m m m m
To be completed by all organizations exempt under section 501(c)(4), section 501(c)(5), or
section 501(c)(6). See the instructions for Schedule C for details.
Part III-A
Yes No
1
2
3
Were substantially all (90% or more) dues received nondeductible by members?
Did the organization make only in-house lobbying expenditures of $2,000 or less?
Did the organization agree to carryover lobbying and political expenditures from the prior year?
1m m m m m m m m m m m m m m m m m m m 2m m m m m m m m m m m m m m m m m m 3m m m m m m m m m m
To be completed by all organizations exempt under section 501(c)(4), section 501(c)(5), or
section 501(c)(6) if BOTH Part III-A, questions 1 and 2 are answered "No" OR if Part III-A,
question 3 is answered "Yes." See Schedule C instructions for details.
Part III-B
1 Dues, assessments and similar amounts from members 1m m m m m m m m m m m m m m m m m m m m m m m m m m m m2 Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of
political expenses for which the section 527(f) tax was paid).
a
b
c
Current year
Carryover from last year
Total
2a
2b
2c
3
4
5
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m3 Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues m m m m4 If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the
excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying
and political expenditure next year? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m5 Taxable amount of lobbying and political expenditures (line 2c total minus 3 and 4) m m m m m m m m m m m m m
Supplemental InformationPart IV
Complete this part to provide the descriptions required for Part I-A, line 1; Part I-B, line 4; Part I-C, line 5 and Part II-B, line 1i.
Also, complete this part for any additional information.
JSA
8E1266 1.000
Schedule C (Form 990 or 990-EZ) 2008
89354K 3987 V08-8.3
31-0672132
X
X
X
X 64.
X 3,481.
X 116,605.
X 75.
X 59,426.
179,651.
X
X
X
SEE PAGE 4
Schedule C (Form 990 or 990-EZ) 2008 Page 4
Supplemental Information (continued)Part IV
Schedule C (Form 990 or 990-EZ) 2008
JSA
8E1267 1.000
89354K 3987 V08-8.3
31-0672132
SCHEDULE C SUPPLEMENTAL INFORMATION
SCHEDULE C, PART II-B
OHA - OHIO HOSPITAL ASSOCIATION
DUES: 43,870
% ALLOC. TO LOBBYING: 4.00%
LOBBYING EXPENSE: 1,755
OCHA - OHIO CHILDREN'S HOSPITAL ASSOCIATION
DUES: 106,524
% ALLOC. TO LOBBYING: 85.00%
LOBBYING EXPENSE: 90,545
NACH
DUES: 20,268
% ALLOC. TO LOBBYING: 16.31%
LOBBYING EXPENSE: 3,306
NACHRI - NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS AND RELATED
ORGANIZATIONS
DUES: 41,150
% ALLOC. TO LOBBYING: 0.00%
LOBBYING EXPENSE: 0
NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS
LOBBYING EXPENSE: 21,000
Schedule C (Form 990 or 990-EZ) 2008 Page 4
Supplemental Information (continued)Part IV
Schedule C (Form 990 or 990-EZ) 2008
JSA
8E1267 1.000
89354K 3987 V08-8.3
31-0672132
CONSULTING EXPENSES
LOBBYING EXPENSE: 39,791
TRAVEL EXPENSE
LOBBYING EXPENSE: 3,692
MEMBERSHIP DUES
LOBBYING EXPENSE: 0
PRINTING & SUPPLIES
LOBBYING EXPENSE: 6,444
MANAGEMENT TIME
LOBBYING EXPENSE: 13,118
TOTAL LINE 1J: 179,651
OMB No. 1545-0047SCHEDULE D
Supplemental Financial Statements(Form 990)
À¾´¼
I Attach to Form 990. To be completed by organizations that
answered “Yes,” to Form 990, Part IV, line 6, 7, 8, 9, 10, 11, or 12.
Open to PublicDepartment of the Treasury
Internal Revenue Service Inspection
Name of the organization Employer identification number
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if
the organization answered “Yes” to Form 990, Part IV, line 6.
Part I
(a) Donor advised funds (b) Funds and other accounts
1
2
3
4
5
6
1
2
3
4
5
6
7
8
9
Total number at end of year
Aggregate contributions to (during year)
Aggregate grants from (during year)
Aggregate value at end of year
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization’s property, subject to the organization’s exclusive legal control?
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
m m m m m m m m m m m
m m m m
m m m m m m
m m m m m m m m m
m m m m m m m m m m m Yes No
used only for charitable purposes and not for the benefit of the donor or donor advisor or other
impermissible private benefit? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.Part II
Purpose(s) of conservation easements held by the organization (check all that apply).
Preservation of land for public use (e.g., recreation or pleasure)
Protection of natural habitat
Preservation of open space
Preservation of an historically importantly land area
Preservation of certified historic structure
Complete lines 2a-2d if the organization held a qualified conservation contribution in the form of a conservation easement
on the last day of the tax year.
Held at the End of the Year
2a
2b
2c
2d
a
b
c
d
Total number of conservation easements
Total acreage restricted by conservation easements
Number of conservation easements on a certified historic structure included in (a)
Number of conservation easements included in (c) acquired after 8/17/06
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year
Number of states where property subject to conservation easement is located
Does the organization have a written policy regarding the periodic monitoring, inspection, violations, and
enforcement of the conservation easements it holds?
Staff or volunteer hours devoted to monitoring, inspecting, and enforcing easements during the year
Amount of expenses incurred in monitoring, inspecting, and enforcing easements during the year
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)?
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m
m m m m m m
m m m m m m m m m
I I
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
I
I $
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
the organization’s accounting for conservation easements.
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
Part III
1a If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
I(i)
(ii)
Revenues included in Form 990, Part VIII, line 1
Assets included in Form 990, Part X
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m $
$
$
$
Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:
Revenues included in Form 990, Part VIII, line 1
Assets included in Form 990, Part X
Ia m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Ib m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule D (Form 990) 2008
JSA
8E1268 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
Schedule D (Form 990) 2008 Page 2
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)Part III
Using the organization's accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
Provide a description of the organization's collections and explain how they further the organization's exempt purpose in
Part XIV.
During the year, did the organization solicit or receive donations of art, historical treasures, or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization's collection?
3
4
5
Public exhibition
Scholarly research
Preservation for future generations
Loan or exchange programs
Other
a
b
c
d
e
m m m m m m Yes No
Trust, Escrow and Custodial Arrangements. Complete if organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
Part IV
1a
b
c
d
e
f
2a
b
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X?
If "Yes," explain the arrangement in Part XIV and complete the following table:
Beginning balance
Additions during the year
Distributions during the year
Ending balance
Did the organization include an amount on Form 990, Part X, line 21?
If "Yes," explain the arrangement in Part XIV.
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
Amount
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
1c
1d
1e
1f
Yes Nom m m m m m m m m m m m m m m m m m m m m m
Endowment Funds. Complete if organization answered "Yes" to Form 990, Part IV, line 10.Part V
(a) Current Year (b) Prior year (c) Two years back (d) Three years back (e) Four years back
m m m m
m m m m m m m m m m m
m m
m m m m m m
m
m m m m m m m m m m m
m m m m m
m m m m m m m m
1a
b
c
d
e
f
g
a
b
c
3a
b
Beginning of year balance
Contributions
Investment earnings or losses
Grants or scholarships
Other expenditures for facilities
and programs
Administrative expenses
End of year balance
I
2
4
Provide the estimated percentage of the year end balance held as:
Board designated or quasi-endowment %
Permanent endowment %
Term endowment %
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:
(i) unrelated organizations
(ii) related organizations
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R?
Describe in Part XIV the intended uses of the organization's endowment funds.
I
I
Yes No
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 3a(i)
3a(ii)
3b
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m
Investments - Land, Buildings, and Equipment. See Form 990, Part X, line 10.Part VI
Description of investment (a) Cost or other basis
(investment)
(b) Cost or other
basis (other)
(d) Book value(c) Depreciation
m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m
m m m m m m m m m
m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m
Land
Buildings
Leasehold improvements
Equipment
Other
1a
b
c
d
e
m m m m m m m m m ITotal. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)
Schedule D (Form 990) 2008
JSA
8E1269 1.000
89354K 3987 V08-8.3
31-0672132
5,623,379. 5,623,379.
48,307,698. 16,810,400. 31,497,298.
NONE
115,936,794. 52,630,358. 63,306,436.
4,538,585. 4,538,585.
104,965,698.
Schedule D (Form 990) 2008 Page 3
Investments - Other Securities. See Form 990, Part X, line 12.Part VII
(a) Description of security or category
(including name of security)
(b) Book value (c) Method of valuation:
Cost or end-of-year market value
Financial derivatives and other financial products
Closely-held equity interests
Other
m m m m m m m
m m m m m m m m m m m m m m m m m
ITotal. (Column (b) should equal Form 990, Part X, col. (B) line 12.)
Investments - Program Related. See Form 990, Part X, line 13.Part VIII
(c) Method of valuation:
Cost or end-of-year market value
(b) Book value(a) Description of investment type
Total. (Column (b) should equal Form 990, Part X, col. (B) line 13.)
IOther Assets. See Form 990, Part X, line 15.Part IX
(a) Description (b) Book value
ITotal. (Column (b) should equal Form 990, Part X, col. (B) line 15.) m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mOther Liabilities. See Form 990, Part X, line 25.Part X
(a) Description of liability (b) Amount
Federal income taxes
Total. (Column (b) should equal Form 990, Part X, col. (B) line 25.)
IIn Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for
uncertain tax positions under FIN 48.
JSA Schedule D (Form 990) 2008
8E1270 1.000
89354K 3987 V08-8.3
31-0672132
16,326,560.
RESERVE FOR PROFESSIONAL LIABILITY 4,364,578.
PENSION PAYABLE 8,797,843.
DEFERRED COMPENSATION PAYABLE 1,290,254.
SERP PENSION ACCRUAL 1,873,885.
Schedule D (Form 990) 2008 Page 4
Reconciliation of Change in Net Assets from Form 990 to Financial StatementsPart XI
1
2
3
4
5
6
7
8
9
10
Total revenue (Form 990, Part VIII, column (A), line 12)
Total expenses (Form 990, Part IX, column (A), line 25)
Excess or (deficit) for the year. Subtract line 2 from line 1
Net unrealized gains (losses) on investments
Donated services and use of facilities
Investment expenses
Prior period adjustments
Other (Describe in Part XIV)
Total adjustments (net). Add lines 4-8
Excess or (deficit) for the year per financial statements. Combine lines 3 and 9
1
2
3
4
5
6
7
8
9
10
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m
Reconciliation of Revenue per Audited Financial Statements With Revenue per ReturnPart XII
1
2
3
4
5
Total revenue, gains, and other support per audited financial statements
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
Net unrealized gains on investments
Donated services and use of facilities
Recoveries of prior year grants
Other (Describe in Part XIV)
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part VIII, line 12, but not on line 1:
Investment expenses not included on Form 990, Part VIII, line 7b
Other (Describe in Part XIV)
Add lines 4a and 4b
Total revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.)
1
2e
3
4c
5
m m m m m m m m m m m m m m m m m
a
b
c
d
e
a
b
c
2a
2b
2c
2d
4a
4b
m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m
Reconciliation of Expenses per Audited Financial Statements With Expenses per ReturnPart XIII
1
2
3
4
5
1
2
3
4
5
Total expenses and losses per audited financial statements
Amounts included on line 1 but not on Form 990, Part IX, line 25:
Donated services and use of facilities
Prior year adjustments
Losses reported on Form 990, Part IX, line 25
Other (Describe in Part XIV)
Add lines 2a through 2d
Subtract line 2e from line 1
Amounts included on Form 990, Part IX, line 25, but not on line 1:
Investment expenses not included on Form 990, Part VIII, line 7b
Other (Describe in Part XIV)
Add lines 4a and 4b
Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.)
1
2e
3
4c
5
m m m m m m m m m m m m m m m m m m m m m m m m
a
b
c
d
e
a
b
c
2a
2b
2c
2d
4a
4b
m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m
Supplemental InformationPart XIV
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b
and 2b; Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b.
Schedule D (Form 990) 2008
JSA
8E1271 1.000
89354K 3987 V08-8.3
31-0672132
SEE PAGE 5
Schedule D (Form 990) 2008 Page 5
Supplemental Information (continued)Part XIV
Schedule D (Form 990) 2008
JSA
8E1272 1.000
89354K 3987 V08-8.3
31-0672132
FIN 48 DISCLOSURE
THE MEDICAL CENTER FOLLOWS THE PROVISIONS OF FASB INTERPRETATION NO. 48,
ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES - AN INTERPRETATION OF FASB
STATEMENT NO. 109 (FIN NO. 48). THE MEDICAL CENTER COMPLETED AN ANALYSIS
OF ITS TAX POSITIONS FOR ALL OPEN YEARS AND DETERMINED THAT NO MATERIAL
AMOUNTS WERE REQUIRED TO BE RECOGNIZED UNDER FIN NO. 48 IN THE
CONSOLIDATED FINANCIAL STATEMENTS AT JUNE 30, 2009 OR 2008.
Statement of Activities Outside the United States OMB No. 1545-0047
À¾´¼
Schedule F
(Form 990)
Attach to Form 990. Complete if the organization answered "Yes" to
Form 990, Part IV, line 14b line 15, or line 16.
Department of the Treasury
Internal Revenue Service
I Open to Public
Inspection
Name of the organization Employer identification number
General Information on Activities Outside the United States. Complete if the organization answered
"Yes" to Form 990, Part IV, line 14b.
Part I
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance?
1
2
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
For grantmakers. Describe in Part IV the organization's procedures for monitoring the use of grant funds outside the
United States.
3 Activities per Region. (Use Schedule F-1 (Form 990) if additional space is needed.)
(a) Region (b) Number of
offices in the
region
(c) Number of
employees or
agents in
region
(d) Activities conducted in
region (by type) (i.e.,
fundraising, program services,
grants to recipients located in
the region)
(e) If activity listed in (d) is
a program service,
describe specific type of
service(s) in region
(f) Total
expenditures in
region
ITotals m m m m m m m m m m m m
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule F (Form 990) 2008
JSA
8E1274 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
X
CENTRAL AMERICA/CARIBBEAN 1 2 PROGRAM SERVICES SELF-INSURANCE 1,258,403.
1 2 1,258,403.
Schedule F (Form 990) 2008 Page 2
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990,Part II
IPart IV, line 15, for any recipient who received more than $5,000. Check this box if no one recipient received more than $5,000 m m m m m m
(c) Region (e) Amount of
cash grant
Use Schedule F-1 (Form 990) if additional space is needed.
(d) Purpose of
grant
(b) IRS code section
and EIN (if applicable)
(f) Manner of
cash
disbursement
(h) Description
of non-cash
assistance
(g) Amount of
non-cash
assistance
(i) Method of
valuation
(book, FMV,
appraisal,
other)
(a) Name of organization1
2 Enter total number of organizations that are recognized as charities by the foreign country or for which the grantee or counsel has
provided a section 501(c)(3) equivalency letter
Enter total number of other organizations or entities
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m I
I3 m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Schedule F (Form 990) 2008
JSA
8E1275 2.000
Schedule F (Form 990) 2008 Page 3
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Use Schedule F-1 (Form 990) if additional space is needed.
Part III
(a) Type of grant or assistance (b) Region
(e) Manner of
cash
disbursement
(g) Description
of non-cash
assistance
(f) Amount of
non-cash
assistance
(c) Number of
recipients
(d) Amount of
cash grant
(h) Method of
valuation
(book, FMV,
appraisal,
other)
Schedule F (Form 990) 2008
JSA
8E1276 1.000
Schedule F (Form 990) 2008 Page 4
Supplemental Information
Complete this part to provide the information required in Part I, line 2, and any other additional information.
Part IV
Schedule F (Form 990) 2008
JSA
8E1277 1.000
89354K 3987 V08-8.3
31-0672132
SCHEDULE F SUPPLEMENTAL INFORMATION
THE TOTAL EXPENDITURES WERE DETERMINED BASED ON THE ACCRUAL ACCOUNTING
METHODOLOGY.
OMB No. 1545-0047
Supplemental Information Regarding
Fundraising or Gaming Activities
SCHEDULE G
(Form 990 or 990-EZ) À¾´¼
I Attach to Form 990 or Form 990-EZ. Must be completed by organizations that answer "Yes" to Form 990, Part IV, lines 17,
18, or 19, and by organizations that enter more than $15,000 on Form 990-EZ, line 6a.
Open To Public
Department of the Treasury
Internal Revenue Service Inspection
Name of the organization Employer identification number
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.Part I
1 Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a
b
c
d
Mail solicitations
Email solicitations
Phone solicitations
In-person solicitations
e
f
g
Solicitation of non-government grants
Solicitation of government grants
Special fundraising events
a2 Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising activities? Yes No
b If "Yes," list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name of individual
or entity (fundraiser)
(ii) Activity (iii) Did fundraiser have
custody or control of
contributions?
(iv) Gross receipts
from activity
(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i)
(vi) Amount paid to
(or retained by)
organization
Yes No
Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mTotal
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from
registration or licensing.
3
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule G (Form 990 or 990-EZ) 2008
JSA
8E1281 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
Schedule G (Form 990 or 990-EZ) 2008 Page 2
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported
more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
Part II
(a) Event #1 (b) Event #2 (c) Other Events (d) Total Events (Add col.
(a) through col. (c))
(event type) (event type) (total number)
1
2
3
Gross receipts
Less: Charitable
contributions
Gross revenue (line 1
minus line 2)
m m m m m m m m m m m m
m m m m m m m m m m m m m
m m m m m m m m m m m m m
Revenue
4
5
6
7
8
9
Cash prizes
Non-cash prizes
Rent/facility costs
Other direct expenses
Direct expense summary. Add lines 4 through 7 in column (d)
Net income summary. Combine lines 3 and 8 in column (d)
m m m m m m m m m m m m m
m m m m m m m m m m m
m m m m m m m m m m
m m m m m m m m
I ( )m m m m m m m m m m m m m m m m m m m m m m
Im m m m m m m m m m m m m m m m m m m m m m m m
DirectExpenses
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more
than $15,000 on Form 990-EZ, line 6a.
Part III
(d) Total gaming (Add
col. (a) through col. (c))
(b) Pull tabs/Instant
bingo/progressive bingo
(c) Other gaming(a) Bingo
1
2
3
Gross revenue
Cash prizes
Non-cash prizes
m m m m m m m m m m m m
Revenue
m m m m m m m m m m m m m
m m m m m m m m m m m
4
5
6
7
8
Rent/facility costs
Other direct expenses
Volunteer labor
Direct expense summary. Add lines 2 through 5 in column (d)
Net gaming income summary. Combine lines 1 and 7 in column (d)
m m m m m m m m m m
m m m m m m m m
DirectExpenses
Yes
No
Yes
No
Yes
No
% % %
m m m m m m m m m m m
( )
Im m m m m m m m m m m m m m m m m m m m m m
Im m m m m m m m m m m m m m m m m m m
NoYes
9
10
11
12
Enter the state(s) in which the organization operates gaming activities:
Is the organization licensed to operate gaming activities in each of these states?
If "No," Explain:
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year?
If "Yes," Explain:
Does the organization operate gaming activities with nonmembers?
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming?
a
b
9a
10a
11
12
m m m m m m m m m m m m m m m m m m m
a
b
m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mSchedule G (Form 990 or 990-EZ) 2008
JSA
8E1282 1.000
89354K 3987 V08-8.3
31-0672132
DINNER/DANCE GOLF OUTING 1
227,514. 106,560. 99,860. 433,934.
29,025. 10,000. 10,366. 49,391.
198,489. 96,560. 89,494. 384,543.
26,497. 4,450. 30,947.
23,616. 15,918. 15,048. 54,582.
85,529.
299,014.
Schedule G (Form 990 or 990-EZ) 2008 Page 3
Yes No
13
14
Indicate the percentage of gaming activity operated in:
The organization's facility
An outside facility
a
b
13a
13b
%
%
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Provide the name and address of the person who prepares the organization's gaming/special event books
and records:
IName
Address I
15 a
b
c
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? 15a
17a
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
IIf "Yes," enter the amount of gaming revenue received by the organization $ and the
Iamount of gaming revenue retained by the third party $ .
If "Yes," enter name and address:
IName
Address I
16 Gaming manager information:
IName
IGaming manager compensation $
IDescription of services provided
Director/officer Employee Independent contractor
17 Mandatory distributions:
a
b
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year $I Schedule G (Form 990 or 990-EZ) 2008
JSA
8E1283 1.000
89354K 3987 V08-8.3
31-0672132
OMB No. 1545-0047HospitalsSCHEDULE H
(Form 990)
ITo be completed by organizations that answer "Yes" to Form 990,
Part IV, line 20.
Attach to Form 990.
À¾´¼
Open to PublicDepartment of the Treasury
IInternal Revenue Service Inspection
Name of the organization Employer identification number
Charity Care and Certain Other Community Benefits at Cost (Optional for 2008)Part I
Yes No
1a
1b
3a
3b
4
5a
5b
5c
6a
6b
1a
b
a
b
c
5a
b
c
6a
b
a
b
Does the organization have a charity care policy? If "No," skip to question 6a
If "Yes," is it a written policy?
If the organization has multiple hospitals, indicate which of the following best describes application of the
m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
2
charity care policy to the various hospitals.
Applied uniformly to all hospitals
Generally tailored to individual hospitals
Applied uniformly to most hospitals
3 Answer the following based on the charity care eligibility criteria that applies to the largest number of the
organization's patients.
Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low income
individuals? If "Yes," indicate which of the following is the family income limit for eligibility for free care: m m m m m m m m m m m m m
100% 150% 200% Other %
Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If "Yes,"
indicate which of the following is the family income limit for eligibility for discounted care: m m m m m m m m m m m m m m m m m m m m
200% 250% 300% 350% 400% Other %
If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for
determining eligibility for free or discounted care. Include in the description whether the organization uses an
asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.
Does the organization's policy provide free or discounted care to the "medically indigent"?
Does the organization budget amounts for free or discounted care provided under its charity care policy?
If "Yes," did the organization’s charity care expenses exceed the budgeted amount?
If "Yes" to 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligible for free or discounted care?
Does the organization prepare an annual community benefit report?
If "Yes," does the organization make it available to the public?
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit
4 m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
these worksheets with the Schedule H.
(c) Total community
benefit expense
(d) Direct offsetting
revenue
(e) Net community
benefit expense
(b) Persons
served
(optional)
(f) Percent
of total
expense
(a) Number of
activities or
programs
(optional)
7 Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government
Programs
Charity care at cost (from
Worksheets 1 and 2)
Unreimbursed Medicaid (from
Worksheet 3, column a)
m m m m m
m m m mc Unreimbursed costs - other means-
tested government programs (from
Worksheet 3, column b) m m m mTotal Charity Care andd
Means-Tested Government
Programs
Other Benefits
m m m m m m m m m
e Community health improvement
services and community benefit
operations (from Worksheet 4) m
f Health professions education
(from Worksheet 5)
Subsidized health services (from
Worksheet 6)
Research (from Worksheet 7)
m m m m m
g
m m m m m m m
h m m
Cash and in-kind contributions to
community groups (from
Worksheet 8)
i
Total Other Benefits m m m m mj
k Total (line 7d and 7j) m m m m mFor Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule H (Form 990) 2008
JSA
8E1284 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
Schedule H (Form 990) 2008 Page 2
Community Building Activities Complete this table if the organization conducted any community
building activities. (Optional for 2008)
Part II
(a) Number of
activities or
programs
(optional)
(b) Persons
served
(optional)
(c) Total community
building expense
(d) Direct offsetting
revenue
(e) Net community
building expense
(f) Percent of
total expense
1
2
3
4
5
6
7
8
9
1 0
Physical improvements and housing
Economic development
Community support
Environmental improvements
Leadership development and
training for community members
Coalition building
Community health improvement
advocacy
Workforce development
Other
Total
Bad Debt, Medicare, & Collection Practices (Optional for 2008)Part III
Section A. Bad Debt Expense
Yes No
Does the organization report bad debt expense in accordance with Healthcare Financial Management
Association Statement No. 15?
1
2
3
4
1
9a
9b
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
2
3
Enter the amount of the organization's bad debt expense (at cost) m m m m m m m m m m m mEnter the estimated amount of the organization's bad debt expense (at cost)
attributable to patients eligible under the organization's charity care policy m m m m m m mProvide in Part VI the text of the footnote to the organization's financial statements that describes bad debt
expense. In addition, describe the costing methodology used in determining the amounts reported on lines
2 and 3, or rationale for including other bad debt amounts in community benefit.
Section B. Medicare
5
6
7
Enter total revenue received from Medicare (including DSH and IME)
Enter Medicare allowable costs of care relating to payments on line 5
Enter line 5 less line 6 - surplus or (shortfall)
5
6
7
8
m m m m m m m m m m
m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit
and the costing methodology or source used to determine the amount reported on line 6, and indicate which
of the following methods was used:
Cost accounting system Cost to charge ratio Other
Section C. Collection Practices
9a
b
Does the organization have a written debt collection policy? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mIf "Yes," does the organization's collection policy contain provisions on the collection practices to be followed
for patients who are known to qualify for charity care or financial assistance? Describe in Part VI m m m m m m m m m m m
Management Companies and Joint Ventures (Optional for 2008)Part IV
(b) Description of primary
activity of entity
(c) Organization's
profit % or stock
ownership %
(d) Officers, directors
trustees, or key
employees' profit %
or stock ownership %
(e) Physicians'
profit % or stock
ownership %
(a) Name of entity
1
2
3
4
5
6
7
8
9
10
11
12
13
14
JSA Schedule H (Form 990) 2008
8E1285 1.000
89354K 3987 V08-8.3
31-0672132
Schedule H (Form 990) 2008 Page 3
Facility Information (Required for 2008)Part V
Licensedhospital
Generalmedical&surgical
Children'shospital
Teachinghospital
Criticalaccesshospital
Researchfacility
ER-24hours
ER-other
Name and address Other
(Describe)
Schedule H (Form 990) 2008
JSA
8E1286 1.000
89354K 3987 V08-8.3
31-0672132
CHILDREN'S MEDICAL CENTER
1 CHILDREN'S PLAZA
DAYTON OH 45404 X X X X X
Schedule H (Form 990) 2008 Page 4
Supplemental Information (Optional for 2008)Part VI
Complete this part to provide the following information.
1 Provide the description required for Part I, line 3c; Part I, line 6a; Part I, line 7g; Part I, line 7, column (f); Part I, line 7; Part III,
line 4; Part III, line 8; Part III, line 9b, and Part V. See Instructions.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who
may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under
the organization's charity care policy.
4
5
6
7
8
Community information. Describe the community the organization serves, taking into account the geographic area and
demographic constituents it serves.
Community building activities. Describe how the organization's community building activities, as reported in Part II, promote
the health of the communities the organization serves.
Provide any other information important to describing how the organization's hospitals or other health care facilities further its exempt
purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates
in promoting the health of the communities served.
If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Schedule H (Form 990) 2008JSA
8E1287 1.000
89354K 3987 V08-8.3
31-0672132
OTHER INFORMATION:
PART V, DESCRIPTION:
3 OUTPATIENT TESTING CENTERS
1 URGENT CARE CENTER
1 OFFSITE SPECIALTY CARE CLINIC
OMB No. 1545-0047SCHEDULE I
(Form 990)
Grants and Other Assistance to Organizations,
Governments, and Individuals in the U.S. À¾´¼
IComplete if the organization answered "Yes," on Form 990, Part IV, lines 21 or 22.
Attach to Form 990.
Open to Public
Department of the Treasury
Internal Revenue Service I Inspection
Name of the organization Employer identification number
General Information on Grants and AssistancePart I
1
2
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance?
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes No
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" on
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000.
Use Part IV and Schedule I-1 (Form 990) if additional space is needed
Part II
Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m(a) Name and address of organization
or government
(f) Method of valuation
(book, FMV, appraisal,
other)
(c) IRC section
if applicable
(d) Amount of cash grant (e) Amount of non-cash
assistance
(g) Description of
non-cash assistance
(h) Purpose of grant
or assistance
(b) EIN1
I
I
2
3
Enter total number of section 501(c)(3) and government organizations
Enter total number of other organizations
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule I (Form 990) 2008
JSA
8E1288 2.000
CHILDREN'S MEDICAL CENTER 31-0672132
X
Schedule I (Form 990) 2008 Page 2
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
Part III
(f) Description of non-cash assistance(a) Type of grant or assistance (e) Method of valuation (book,
FMV, appraisal, other)
(b) Number of
recipients
(d) Amount of
non-cash assistance
(c) Amount of
cash grant
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.Part IV
Schedule I (Form 990) 2008
JSA
8E1289 1.000
31-0672132
413 12,763.TRANSPORATION
143 8,228.MEALS/FOOD
19 9,088.RENT/UTILITIES
245 43,314.PHARMACY
8 1,175.SPECIAL EQUIPMENT
27 335.OTHER
Compensation Information OMB No. 1545-0047
SCHEDULE J
(Form 990)
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
À¾´¼
Attach to Form 990. To be completed by organizations
that answered "Yes" to Form 990, Part IV, line 23.
Department of the Treasury
Internal Revenue Service
I Open to Public
Inspection
Name of the organization Employer identification number
Questions Regarding CompensationPart I
Yes No
1
2
3
4
5
6
7
8
a
b
a
b
c
a
b
a
b
Check the appropriate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Travel for companions
Tax indemnification and gross-up payments
Discretionary spending account
Housing allowance or residence for personal use
Payments for business use of personal residence
Health or social club dues or initiation fees
Personal services (e.g., maid, chauffeur, chef)
If line 1a is checked, did the organization follow a written policy regarding payment or reimbursement or
provision of all of the expenses described above? If "No," complete Part III to explain
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.
1b
2
4a
4b
4c
5a
5b
6a
6b
7
8
m m m m m m m m m m m m m m m
m m m m m m
Compensation committee
Independent compensation consultant
Form 990 of other organizations
Written employment contract
Compensation survey or study
Approval by the board or compensation committee
During the year, did any person listed in Form 990, Part VII, Section A, line 1a:
Receive a severance payment or change of control payment?
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
Participate in, or receive payment from, an equity-based compensation arrangement?
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations must complete lines 5-8.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
The organization?
Any related organization?
If "Yes" to line 5a or 5b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
The organization?
Any related organization?
If "Yes" to line 6a or 6b, describe in Part III.
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III
m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule J (Form 990) 2008
JSA
8E1290 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
X
X
X
X
X X
X X
X
X
X
X
X
X
X
X
X
X
Schedule J (Form 990) 2008 Page 2
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space is needed.Part II
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.
(B) Breakdown of W-2 and/or 1099-MISC compensation (C) Deferred
compensation
(D) Nontaxable
benefits
(E) Total of columns
(B)(i)-(D)
(F) Compensation
reported in prior
Form 990 or
Form 990-EZ
(A) Name (i) Base
compensation
(ii) Bonus & incentive
compensation
(iii) Other
reportable
compensation
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
(i)
(ii)
Schedule J (Form 990) 2008
JSA
8E1291 1.000
31-0672132
369,446.
NONE
140,137.
NONE
52,282.
NONE
NONE
NONE
768,472.
NONE
189,483. 17,124.
NONE NONEDAVID KINSAUL
188,177.
NONE
34,859.
NONE
45,767.
NONE
NONE
NONE
311,833.
NONE
27,246. 15,784.
NONE NONEDAVID T. MILLER
208,869.
NONE
41,358.
NONE
63,908.
NONE
NONE
NONE
488,753.
NONE
158,231. 16,387.
NONE NONETHOMAS MURPHY
172,917.
NONE
30,674.
NONE
3,251.
NONE
NONE
NONE
240,531.
NONE
16,988. 16,701.
NONE NONERENAE PHILLIPS
142,282.
NONE
34,116.
NONE
65,116.
NONE
NONE
NONE
287,255.
NONE
26,898. 18,843.
NONE NONEGREGORY RAMEY
134,555.
NONE
29,247.
NONE
51,351.
NONE
NONE
NONE
254,215.
NONE
24,009. 15,053.
NONE NONEVICKI GIAMBRONE
155,564.
NONE
29,238.
NONE
20,865.
NONE
NONE
NONE
240,902.
NONE
17,725. 17,510.
NONE NONEMATTHEW GRAYBILL
138,161.
NONE
23,824.
NONE
1,914.
NONE
NONE
NONE
191,776.
NONE
11,219. 16,658.
NONE NONEDUKE HADDAD
159,601.
NONE
NONE
NONE
1,076.
NONE
NONE
NONE
169,312.
NONE
7,994. 641.
NONE NONEMARGARET HEMMEN
125,753.
NONE
NONE
NONE
29,011.
NONE
NONE
NONE
187,888.
NONE
10,933. 22,191.
NONE NONEGREGORY HUFF
18,613.
NONE
NONE
NONE
336,195.
NONE
269,438.
NONE
355,992.
NONE
1,092. 92.
NONE NONEBONNIE SOMMERVILLE
Schedule J (Form 990) 2008 Page 3
Supplemental InformationPart III
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part
for any additional information.
Schedule J (Form 990) 2008
JSA
8E1292 1.000
31-0672132
SCHEDULE J SUPPLEMENTAL INFORMATION
PART I, QUESTION 4B
PARTICIPANTS IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN AND THE
INCREASE(DECREASE) IN ACTUARIAL VALUE:
DAVID KINSAUL - $156,522
DAVID MILLER - $7,810
THOMAS MURPHY - $108,849
GREGORY RAMEY - ($16,480)
VICKI GIAMBRONE - $7,201
MATTHEW GRAYBILL - $3,476
PARTICIPANT RECEIVING PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT
PLAN:
BONNIE SOMMERVILLE - $269,438
Continuation Sheet for Form 990
OMB No. 1545-0047
SCHEDULE J-2
(Form 990) À¾´¼
IAttach to Form 990 to list additional information for Form 990, Part VII, Section A, line 1a. Open to Public
Inspection
Department of the Treasury
Internal Revenue Service
Name of the Organization Employer Identification number
Continuation of Officers, Directors, Trustees, Key Employees, and Highest Compensated
Employees
Part I
(A) (B) (C) (D) (E) (F)
Name and Title Average hours
per week
Position (check all that apply) Reportable
compensation
from
the
organization
(W-2/1099-MISC)
Reportable
compensation
from related
organizations
(W-2/1099-MISC)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
Individualtrustee
ordirector
Institutionaltrustee
Officer
Keyemployee
Highestcompensated
employee
Former
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule J-2 (Form 990) 2008
JSA
8E1294 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
JEFFERY S. ADAM
TRUSTEE 1. X NONE NONE NONE
THERESA FRANKLIN
TRUSTEE 1. X NONE NONE NONE
JEAN IRELAND
TRUSTEE 1. X NONE NONE NONE
L. DAVID MIRKIN
TRUSTEE 1. X NONE NONE NONE
MICHAEL J. MATHILE
TRUSTEE 1. X NONE NONE NONE
ROBERT P. MYERS
TRUSTEE 1. X NONE NONE NONE
ARTHUR S. PICKOFF
TRUSTEE 1. X NONE NONE NONE
GREGORY SAMPLE
TRUSTEE 1. X NONE NONE NONE
COLLEEN RYAN
TRUSTEE 1. X NONE NONE NONE
ROBERT E. JOHNSON
TRUSTEE 1. X NONE NONE NONE
JERAD BARNETT
TRUSTEE 1. X NONE NONE NONE
JEFFREY CHRISTIAN
TRUSTEE 1. X NONE NONE NONE
MADONNA R. ALLREAD
CHAIRMAN 1. X 950. NONE NONE
CHARLES M. FOLEY
FIRST VICE CHAIR 1. X NONE NONE NONE
NEIL MCLACHLAN
SECOND VICE CHAIR 1. X NONE NONE NONE
VISHAL SOIN
TREASURER 1. X NONE NONE NONE
LAURENCE KLAREN
ASST. TREASURER 1. X NONE NONE NONE
DEBBIE WATTS ROBINSON
SECRETARY 1. X NONE NONE NONE
MARLA VICHICH
ASST. SECRETARY 1. X NONE NONE NONE
DAVID KINSAUL
PRESIDENT AND CEO 40. X 561,865. NONE 206,607.
DAVID T. MILLER
VICE PRESIDENT FINANCE & CFO 40. X 268,803. NONE 43,030.
Continuation Sheet for Form 990
OMB No. 1545-0047
SCHEDULE J-2
(Form 990) À¾´¼
IAttach to Form 990 to list additional information for Form 990, Part VII, Section A, line 1a. Open to Public
Inspection
Department of the Treasury
Internal Revenue Service
Name of the Organization Employer Identification number
Continuation of Officers, Directors, Trustees, Key Employees, and Highest Compensated
Employees
Part I
(A) (B) (C) (D) (E) (F)
Name and Title Average hours
per week
Position (check all that apply) Reportable
compensation
from
the
organization
(W-2/1099-MISC)
Reportable
compensation
from related
organizations
(W-2/1099-MISC)
Estimated
amount of
other
compensation
from the
organization
and related
organizations
Individualtrustee
ordirector
Institutionaltrustee
Officer
Keyemployee
Highestcompensated
employee
Former
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule J-2 (Form 990) 2008
JSA
8E1294 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
THOMAS MURPHY
VICE PRESIDENT MEDICAL AFFAIRS 40. X 314,135. NONE 174,618.
RENAE PHILLIPS
VICE PRESIDENT HOSPITAL OPS 40. X 206,842. NONE 33,689.
GREGORY RAMEY
VICE PRESIDENT OUTPATIENT SVCS 40. X 241,514. NONE 45,741.
VICKI GIAMBRONE
VP MARKETING & EXTERNAL REL. 40. X 215,153. NONE 39,062.
MATTHEW GRAYBILL
VP ALTERNATIVE SITES 40. X 205,667. NONE 35,235.
DUKE HADDAD
VP DEVELOPMENT 40. X 163,899. NONE 27,877.
MARGARET HEMMEN
CRN ANESTH. 40. X 160,677. NONE 8,635.
GREGORY HUFF
DIRECTOR OF PHARMACY 40. X 154,764. NONE 33,124.
BONNIE SOMMERVILLE
VP CORPORATE SUPPORT 20. X 354,808. NONE 1,184.
OMB No. 1545-0047SCHEDULE L
Transactions With Interested Persons(Form 990 or 990-EZ)
I Attach to Form 990 or Form 990-EZ.
To be completed by organizations that answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, lines 38b or 40b.
I À¾´¼
Department of the Treasury
Internal Revenue Service
Open To Public
Inspection
Name of the organization Employer identification number
Excess Benefit Transacations (section 501(c)(3) and section 501(c)(4) organizations only).
To be completed by organizations that answered "Yes" on Form 990, Part IV, lines 25a or 25b, or Form 990-EZ, Part V, line 40b.
Part I
(c) Corrected?
(a) Name of disqualified person1 (b) Description of transaction
Yes No
2
3
Enter the amount of tax imposed on the organization managers or disqualified persons during the year
under section 4958
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization
I
I
$
$
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m
Loans to and/or From Interested Persons.
To be completed by organizations that answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
Part II
(a) Name of interested person and purpose (b) Loan to or from
the organization?
(c) Original
principal amount
(d) Balance due (e) In default? (f) Approved
by board or
committee?
(g) Written
agreement?
To From Yes No Yes No Yes No
ITotal $m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Grants or Assistance Benefitting Interested Persons.
To be completed by organizations that answered "Yes" on Form 990, Part IV, line 27.
Part III
(a) Name of interested person (b) Relationship between interested person and the
organization
(c) Amount of grant or type of assistance
Business Transactions Involving Interested Persons.
To be completed by organizations that answered "Yes" on Form 990, Part IV, lines 28a, 28b, or 28c.
Part IV
(a) Name of interested person (b) Relationship between
interested person and the
organization
(c) Amount of
transaction
(d) Description of transaction (e) Sharing of
organization's
revenues?
Yes No
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule L (Form 990 or 990-EZ) 2008
JSA
8E1297 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
L. DAVID MIRKIN, M.D. 120,979. EMPLOYMENT XTRUSTEE
ARTHUR S. PICKOFF, M.D. 197,495. EMPLOYMENT XTRUSTEE
JEFFREY CHRISTIAN, M.D. 450,004. EMPLOYMENT XTRUSTEE
NEIL FREUND 96,017. LEGAL SERVICES XSPOUSE OF FORMER KEY EMP
CARRELL PICKOFF 25,136. EMPLOYMENT XSPOUSE OF TRUSTEE
Supplemental Information to Form 990
OMB No. 1545-0047
SCHEDULE O
(Form 990)
Attach to Form 990. To be completed by organizations to provide
additional information for responses to specific questions for the
Form 990 or to provide any additional information.
I À¾´¼
Department of the Treasury
Internal Revenue Service
Open to Public
Inspection
Name of the organization Employer identification number
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule O (Form 990) 2008
JSA
8E1300 1.000
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
FORM 990, SUPPLEMENTAL INFORMATION
PART VI, LINE 10
THE CFO REVIEWS KEY DISCLOSURES WITH APPROPRIATE COMMITTEES OF THE BOARD
OF TRUSTEES. THEN PRIOR TO FILING, THE FORM 990 IS ELECTRONICALLY LOADED
TO A SECURE HOSPITAL WEBSITE FOR THE ENTIRE BOARD OF TRUSTEES TO REVIEW.
AN EMAIL IS SENT TO ALL MEMBERS NOTIFYING THEM THAT THE FORM IS AVAILABLE
FOR THEIR REVIEW AND THAT IT WILL BE FILED ON OR BEFORE 05/15/10.
PART VI, LINES 15A AND 15B
COMPENSATION FOR THE HOSPITAL'S CHIEF EXECUTIVE OFFICER (CEO) IS SET BY
AN EXECUTIVE COMPENSATION COMMITTEE (THE COMMITTEE) MADE UP OF THREE
INDEPENDENT TRUSTEES WHO ARE ALSO OFFICERS OF THE BOARD. THIS COMMITTEE
ALSO APPROVES COMPENSATION LEVELS, INCENTIVE PLAN PAYOUTS AND EXECUTIVE
BENEFITS FOR EACH EXECUTIVE EMPLOYED BY THE HOSPITAL. THE COMMITTEE
OPERATES UNDER A FORMAL CHARTER AND KEEPS CONTEMPORANEOUS MINUTES OF ITS
PROCEEDINGS. THE COMMITTEE USES A TOTAL COMPENSATION PHILOSOPHY TO GUIDE
ALL DECISIONS RELATED TO EXECUTIVE COMPENSATION AT DAYTON CHILDREN'S
MEDICAL CENTER (DCMC), AND AS SUCH DETERMINES AND APPROVES ALL ASPECTS OF
THE CEO'S TOTAL COMPENSATION PACKAGE, INCLUDING BENEFITS AND EXPENSE
ALLOWANCES. THESE ARE DETAILED IN A WRITTEN EMPLOYMENT AGREEMENT FOR THE
CEO. THE COMMITTEE USES AN OUTSIDE CONSULTANT TO CONDUCT PERIODIC
Supplemental Information to Form 990
OMB No. 1545-0047
SCHEDULE O
(Form 990)
Attach to Form 990. To be completed by organizations to provide
additional information for responses to specific questions for the
Form 990 or to provide any additional information.
I À¾´¼
Department of the Treasury
Internal Revenue Service
Open to Public
Inspection
Name of the organization Employer identification number
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule O (Form 990) 2008
JSA
8E1300 1.000
89354K 3987 V08-8.3
REVIEWS OF THE EXECUTIVE COMPENSATION LEVELS OF THE ORGANIZATION VERSUS
THOSE OF SIMILARLY SIZED AND SITUATED ORGANIZATIONS USING PUBLISHED
SURVEYS. THESE SURVEY RESULTS ARE USED BY THE COMMITTEE IN SETTING
EXECUTIVE LEVELS AND THE CEO'S COMPENSATION IN PARTICULAR. THE COMMITTEE
FOLLOWS A FORMAL CALENDAR OF MEETINGS AND THE CHAIRMAN OF THE COMMITTEE
REPORTS TO THE BOARD OF TRUSTEES AT LEAST ANNUALLY ON THE COMMITTEE'S
ACTIVITIES AND ON DETAILS OF THE CEO'S COMPENSATION AND BENEFITS PACKAGE.
THE COMMITTEE ALSO REVIEWS AND APPROVES DISCLOSURES RELATED TO EXECUTIVE
COMPENSATION MADE AS PART OF IRS FORM 990.
PART VI, LINE 19
**OPEN ITEM - NEED CLIENT RESPONSE**
PART IX, LINES 2A & 2B
THE ORGANIZATION'S FINANCIAL STATEMENTS WERE COMPILED AND REVIEWED ON A
CONSOLIDATED BASIS.
SCHEDULE R, PART II, COLUMN B
CHILDREN'S HOMECARE OF DAYTON - TO PROVIDE PEDIATRIC HEALTHCARE IN THE
Supplemental Information to Form 990
OMB No. 1545-0047
SCHEDULE O
(Form 990)
Attach to Form 990. To be completed by organizations to provide
additional information for responses to specific questions for the
Form 990 or to provide any additional information.
I À¾´¼
Department of the Treasury
Internal Revenue Service
Open to Public
Inspection
Name of the organization Employer identification number
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule O (Form 990) 2008
JSA
8E1300 1.000
89354K 3987 V08-8.3
HOME.
CHILDREN'S MEDICAL CENTER FOUNDATION - TO ACCUMULATE FUNDS TO BENEFIT FOR
AND TO ASSIST IN ITS CHARITABLE MISSIONS.
OMB No. 1545-0047
SCHEDULE R
(Form 990)
Related Organizations and Unrelated Partnerships
À¾´¼
I Attach to Form 990. To be completed by organizations that answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
See separate instructions.
Department of the Treasury
Internal Revenue Service
Open to Public
InspectionIName of the organization Employer identification number
Identification of Disregarded EntitiesPart I
(A)
Name, address, and EIN of disregarded entity
(B)
Primary activity
(C)
Legal domicile (state
or foreign country)
(D)
Total income
(E)
End-of-year assets
(F)
Direct controlling
entity
Identification of Related Tax-Exempt OrganizationsPart II
(A)
Name, address, and EIN of related organization
(B)
Primary activity
(C)
Legal domicile (state
or foreign country)
(D)
Exempt Code section
(E)
Public charity status
(if section 501(c)(3))
(F)
Direct controlling
entity
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule R (Form 990) 2008
JSA
8E1307 1.000
CHILDREN'S MEDICAL CENTER 31-0672132
CHILDREN'S HOMECARE OF DAYTON 31-1356037
ONE CHILDREN'S PLAZA DAYTON, OH 45404 SEE SCHED O OH 501(C)(3) 9 N/A
CHILDREN'S MEDICAL CENTER FOUNDATION 31-1045247
ONE CHILDREN'S PLAZA DAYTON, OH 45404 SEE SCHED O OH 501(C)(3) 11A N/A
Schedule R (Form 990) 2008 Page 2
Identification of Related Organizations Taxable as a PartnershipPart III
(A)
Name, address, and EIN of
related organization
(B)
Primary activity
(C)
Legal
domicile
(state or
foreign
country)
(D)
Direct controlling
entity
(E)
Predominant
income (related,
investment,
unrelated)
(F)
Share of total income
(G)
Share of end-of-year
assets
(H)
Disproportionate
allocations?
(I)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
(J)
General or
managing
partner?
Yes No Yes No
Identification of Related Organizations Taxable as a Corporation or TrustPart IV
(A)
Name, address, and EIN of related organization
(B)
Primary activity
(C)
Legal domicile
(state or
foreign country)
(D)
Direct controlling
entity
(E)
Type of entity
(C corp, S corp,
or trust)
(F)
Share of total income
(G)
Share of
end-of-year assets
(H)
Percentage
ownership
Schedule R (Form 990) 2008
JSA
8E1308 1.000
31-0672132
AMCH COMPANY, LLC 31-1610708
MILFORD, OH 45150 URGENT CARE CTR OH N/A UNRELATED 119,539. 354,766. X NONE X
MDDLTWN SURG CTR, 20-5160579
MIDDLETOWN, OH 45005 SURGERY CENTER OH N/A UNRELATED -200,707. NONE X NONE X
CHILDREN'S CARE GROUP 31-1411364
ONE CHILDREN'S PLAZA DAYTON, OH 45404 SPEC PHYS GROUP OH N/A 10,870,293. 4,262,178. 100.0000C-CORP
CHILDREN'S ANESTHESIA GROUP 26-0887231
ONE CHILDREN'S PLAZA DAYTON, OH 45404 ANESTHESIA SVCS OH N/A 4,042,559. 717,342. 100.0000C-CORP
PEDIATRIC ASSURANCE COMPANY, LTD. 98-0478183
BUTTERFIELD BANK BLDG, 6TH FLOOR HM12 HAMILTON, BERMUDA SELF-INSURANCE BD N/A 1,533,822. 26,585,360. 100.0000N/A
Schedule R (Form 990) 2009 Page 3
Transactions With Related OrganizationsPart V
Yes No
Note. Complete line 1 if any entity is listed in Parts II, III, or IV.
1 During the tax year did the organization engage in any of the following transactions with one or more related organizations listed in Parts II–IV?
Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity
Gift, grant, or capital contribution to other organization(s)
Gift, grant, or capital contribution from other organization(s)
Loans or loan guarantees to or for other organization(s)
Loans or loan guarantees by other organization(s)
Sale of assets to other organization(s)
Purchase of assets from other organization(s)
Exchange of assets
Lease of facilities, equipment, or other assets to other organization(s)
Lease of facilities, equipment, or other assets from other organization(s)
Performance of services or membership or fundraising solicitations for other organization(s)
Performance of services or membership or fundraising solicitations by other organization(s)
Sharing of facilities, equipment, mailing lists, or other assets
Sharing of paid employees
Reimbursement paid to other organization for expenses
Reimbursement paid by other organization for expenses
Other transfer of cash or property to other organization(s)
1a
1b
1c
1d
1e
1f
1g
1h
1i
1j
1k
1l
1 m
1n
1o
1p
1q
1r
a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mr Other transfer of cash or property from other organization(s) m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
(C)
Amount involved
2 If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(A)
Name of other organization(s)
(B)
Transaction
type (a–r)
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2008
JSA
8E1309 1.000
31-0672132
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
SEE SCHEDULE R-1
Schedule R (Form 990) 2008 Page 4
Unrelated Organizations Taxable as a PartnershipPart VI
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets
or gross revenue) that was not a related organization. See Instructions regarding exclusion for certain investment partnerships.
(A)
Name, address, and EIN of entity
(B)
Primary activity
(F)
Disproportionate
allocations?
(C)
Legal domicile
(state or foreign
country)
(D)
Are all partners
section
501(c)(3)
organizations?
(E)
Share of
end-of-year
assets
(G)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065)
(H)
General or
managing
partner?
Yes No Yes No Yes No
Schedule R (Form 990) 2008
JSA
8E1310 1.000
31-0672132
Schedule R-1 (Form 990) 2008 Page 2
Continuation of Identification of Related Tax-Exempt OrganizationsPart II
(D)
Exempt Code section
(A)
Name, address, and EIN of related organization
(B)
Primary activity
(C)
Legal domicile (state
or foreign country)
(E)
Public charity status
(if section 501(c)(3))
(F)
Direct controlling
entity
Schedule R-1 (Form 990) 2008
JSA
8E1312 1.000
Page 3Schedule R-1 (Form 990) 2008
Part III Continuation of Identification of Related Organizations Taxable as a Partnership
(A)
Name, address, and EIN of
related organization
(B)
Primary activity
(C)
Legal
domicile
(state or
foreign
country)
(D)
Direct controlling
entity
(E)
Predominant
income (related,
investment,
unrelated)
(F)
Share of total income
(G)
Share of end-of-year
assets
(H)
Disproportionate
allocations?
(I)
Code V-UBI amount on
box 20 of K-1
(J)
General or
managing
partner?
Yes No Yes No
Schedule R-1 (Form 990) 2008
JSA
8E1313 1.000
Page 4Schedule R-1 (Form 990) 2008
Part IV Continuation of Identification of Related Organizations Taxable as a Corporation or Trust
(B) (C) (D) (E) (F) (G) (H)(A)
Legal domicile
(state or
foreign country)
Share of
end-of-year
assets
Primary activity Direct controlling
entity
Type of entity
(C corp, S corp,
or trust)
Share of total income Percentage
ownership
Name, address, and EIN of related organization
Schedule R-1 (Form 990) 2008
8E1314 2.000
Schedule R-1 (Form 990) 2008 Page 5
Continuation of Transactions With Related Organizations (Schedule R (Form 990), Part V, line 2)Part V
(A)
Name of other organization
(B)
Transaction
type (a-r)
(C)
Amount involved
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
Schedule R-1 (Form 990) 2008
JSA
8E1315 1.000
31-0672132
CHILDREN'S HOMECARE OF DAYTON A 39,648.
CHILDREN'S MEDICAL CENTER FOUNDATION B 133,158.
CHILDREN'S MEDICAL CENTER FOUNDATION C 3,292,309.
CHILDREN'S CARE GROUP L 8,102,071.
CHILDREN'S HOMECARE OF DAYTON L 412,857.
CHILDREN'S MEDICAL CENTER FOUNDATION L 71,548.
CHILDREN'S CARE GROUP N 114,755.
CHILDREN'S HOMECARE OF DAYTON N 22,622.
CHILDREN'S CARE GROUP P 2,130,282.
CHILDREN'S HOMECARE OF DAYTON P 7,513,606.
CHILDREN'S CARE GROUP Q 3,115,000.
CHILDREN'S HOMECARE OF DAYTON Q 629,889.
CHILDREN'S CARE GROUP R 3,425,000.
CHILDREN'S HOMECARE OF DAYTON R 1,750,000.
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT
FORM 990, PART III - PROGRAM SERVICES
=====================================
1
4A PROGRAM SERVICE
-------------------
THE CHILDREN'S MEDICAL CENTER IS A PEDIATRIC HOSPITAL LOCATED IN
DOWNTOWN DAYTON, OHIO. THE MEDICAL CENTER AND ITS STAFF ARE
COMMITTED TO SERVING AS AN ADVOCATE FOR THE CHILDREN AND THEIR
FAMILIES IN THE MIAMI VALLEY THROUGH A VARIETY OF DIFFERENT
PROGRAMS. IT OFFERS INPATIENT, OUTPATIENT AND ANCILLARY SERVICES
TO THE CHILDREN IN THE SURROUNDING 20 COUNTIES. SERVICES ARE
PROVIDED TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. FOR
THE FISCAL YEAR ENDING JUNE 30, 2009, THE HOSPITAL'S MIX OF
PATIENTS WAS 47% MEDICAID, 46% COMMERCIAL, 5% OTHER GOVERNMENT
PROGRAMS AND 2% SELF PAY. THE HOSPITAL PROVIDES A LEVEL III
NEONATAL NURSERY FOR PREMATURE NEWBORNS AS WELL AS CRITICAL CARE
AND GENERAL PEDIATRIC INPATIENT BEDS. A 24 HOUR EMERGENCY
DEPARTMENT IS AVAILABLE TO ALL CHILDREN IN THE AREA. SOME OF THE
SPECIALTIES OFFERED AT THE HOSPITAL ARE NEUROSURGERY,
HEMATOLOGY/ONCOLOGY, PULMONARY, GASTROENTEROLOGY, NEUROLOGY,
DEVELOPMENTAL DISORDERS, PSYCHOLOGY, ENDOCRINOLOGY, GENETICS,
CARDIOLOGY AND GENERAL SURGERY. WITHOUT CHILDREN'S MEDICAL
CENTER, MANY CHILDREN IN THE AREA WOULD HAVE TO TRAVEL A GOOD
DISTANCE TO RECEIVE THESE SERVICES. THE MEDICAL CENTER ALSO
OFFERS A PEDIATRIC RESIDENCY PROGRAM THAT TRAINS NEW PEDIATRICIANS
WHO WILL CARE FOR THE NEXT GENERATION OF CHILDREN. CHILDREN'S
ALSO SPONSORS MANY COMMUNITY EVENTS WHERE CHILDREN'S HEALTH AND
SAFETY ARE PROMOTED. SOME STATISTICS FOR THE FISCAL YEAR ENDING
JUNE 30, 2009 ARE AS FOLLOWS:
# OF BEDS : 155 INPATIENT DAYS: 29,410 ADMISSIONS: 6,008
AVERAGE LENGTH OF STAY: 4.90 DAYS AVERAGE DAILY CENSUS: 80.6
OCCUPANCY RATE: 52% SURGERIES PERFORMED: 12,342 X-RAY STUDIES:
65796 LAB TESTS: 783,877 RESPIRATORY THERAPY PROCEDURES: 188,234
PHARMACY DOSES DISPENSED: 2,253,689 CARDIOLOGY PROCEDURES:
36,233 NEUROLOGY PROCEDURES: 3,417 URGENT CARE VISITS: 25,944
EMERGENCY DEPARTMENT VISITS: 57,613 OUTPATIENT CLINICS: 58,427.
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT
990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS
=====================================================================
NAME AND ADDRESS
----------------
DESCRIPTION OF SERVICES
-----------------------
COMPENSATION
------------
2
CHILDREN'S CARE GROUP PHYSICIAN SERVICES 7,091,912.
1 CHILDREN'S PLAZA
DAYTON, OH 45404
WRIGHT STATE PHYSICIANS PHYSICIAN SERVICES 2,101,152.
P.O. BOX 1144
DAYTON, OH 45401
DAYTON CHILDREN'S CARDIOLOGY PHYSICIAN SERVICES 1,693,345.
1 CHILDREN'S PLAZA
DAYTON, OH 45404
CHILDREN'S EMERGENCY SERVICES PHYSICIAN SERVICES 1,291,716.
1 CHILDREN'S PLAZA
DAYTON, OH 45404
COMMUNITY BLOOD CENTER BLOOD SERVICES 653,361.
349 S. MAIN ST.
DAYTON, OH 45402
TOTAL COMPENSATION 12,831,486.
------------
============
OMB No. 1545-0704Information Return of U.S. Persons With
Respect To Certain Foreign CorporationsForm 5471
(Rev. December 2007)
ISee separate instructions.
Information furnished for the foreign corporation's annual accounting period (tax year required byDepartment of the Treasury Attachment
Sequence No. 121Internal Revenue Service section 898) (see instructions) beginning , and ending
Name of person filing this return A Identifying number
Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address) B Category of filer (See instructions. Check applicable box(es)):
1 (repealed) 2 3 4 5
City or town, state, and ZIP code C Enter the total percentage of the foreign corporation's voting stock
you owned at the end of its annual accounting period %
Filer's tax year beginning , and ending
D Person(s) on whose behalf this information return is filed:
(4) Check applicable box(es)
(1) Name (2) Address (3) Identifying number
Shareholder Officer Director
Important: Fill in all applicable lines and schedules. All information must be in English. All amounts must be stated
in U.S. dollars unless otherwise indicated.
1a Name and address of foreign corporation b Employer identification number, if any
c Country under whose laws incorporated
e Principal place of business fd Date of incorporation Principal business activity g h Functional currencyPrincipal business activity
code number
2 Provide the following information for the foreign corporation's accounting period stated above.
a Name, address, and identifying number of branch office or agent (if any) b If a U.S. income tax return was filed, enter:
in the United States
(ii) U.S. income tax paid
(i) Taxable income or (loss) (after all credits)
Name and address (including corporate department, if applicable) ofc Name and address of foreign corporation's statutory or resident agent in d
person (or persons) with custody of the books and records of the foreigncountry of incorporation
corporation, and the location of such books and records, if different
Stock of the Foreign CorporationSchedule A
(b) Number of shares issued and outstanding
(ii) End of annual(i) Beginning of annual(a) Description of each class of stock
accounting periodaccounting period
For Paperwork Reduction Act Notice, see instructions. Form 5471 (Rev. 12-2007)
JSA
8X1660 1.000
89354K 3987 V08-8.3
07/01/2008 06/30/2009
07/01/2008 06/30/2009
CHILDREN'S MEDICAL CENTER
ONE CHILDREN'S PLAZA
DAYTON
31-0672132
X X X
OH 45404
INSURANCE
100.0000
INDEPENDENT MANAGEMENT GROUP, LTD
P.O. BOX HM 2087 HMHX
HAMILTON BD
PEDIATRIC ASSURANCE COMPANY, LTD
BUTTERFIELD BANK BLDG, 6TH FLOOR, 65 FRONT STREET
FOREIGN
BERMUDA
07/29/1992 BD 524140
HAMITLTON, HM12 BD
USD
COMMON 120,000. 120,000.
Form 5471 (Rev. 12-2007) Page 2
U.S. Shareholders of Foreign Corporation (see instructions)Schedule B
(c) Number of (d) Number of(b) Description of each class of stock held by (e) Pro rata share
shares held at shares held atshareholder. Note: This description should match the of subpart F(a) Name, address, and identifying
end of annualbeginning of
corresponding description entered in Schedule A, income (enter asnumber of shareholder accountingannual
column (a). a percentage)accounting period period
Income Statement (see instructions)Schedule C
Important: Report all information in functional currency in accordance with U.S. GAAP. Also, report each amount in
U.S. dollars translated from functional currency (using GAAP translation rules). However, if the functional currency is
the U.S. dollar, complete only the U.S. Dollars column. See instructions for special rules for DASTM corporations.
Functional Currency U.S. Dollars
1 a 1aGross receipts or sales m m m m m m m m m m m m m m m m m m m m m m mb 1bReturns and allowances m m m m m m m m m m m m m m m m m m m m m m mc 1cSubtract line 1b from line 1a m m m m m m m m m m m m m m m m m m m m2 2Cost of goods sold m m m m m m m m m m m m m m m m m m m m m m m m m3 3Gross profit (subtract line 2 from line 1c) m m m m m m m m m m m m m m m4 4Dividends m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Income
5 5Interest m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mGross rents6 a 6am m m m m m m m m m m m m m m m m m m m m m m m m m m m m 6bGross royalties and license feesb m m m m m m m m m m m m m m m m m m m7 7Net gain or (loss) on sale of capital assets m m m m m m m m m m m m m m8 8Other income (attach schedule) m m m m m m m m m m m m m m m m m m mTotal income (add lines 3 through 8)9 9m m m m m m m m m m m m m m m m m10 10Compensation not deducted elsewhere m m m m m m m m m m m m m m mRents 11a11a m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 11bRoyalties and license feesb m m m m m m m m m m m m m m m m m m m m m m12 12Interest m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m13 13Depreciation not deducted elsewhere m m m m m m m m m m m m m m m m14 14Depletion m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m15 15Taxes (exclude provision for income, war profits, and excess profits taxes) m m m
Deductions
16 Other deductions (attach schedule - exclude provision for income, war
16profits, and excess profits taxes) m m m m m m m m m m m m m m m m m m m17 m m m m m m m m m m m m m m 17Total deductions (add lines 10 through 16)
18 Net income or (loss) before extraordinary items, prior period
adjustments, and the provision for income, war profits, and excess
18profits taxes (subtract line 17 from line 9) m m m m m m m m m m m m m m19 19Extraordinary items and prior period adjustments (see instructions) m m20 20Provision for income, war profits, and excess profits taxes (see instructions) m m m
NetIncome
Current year net income or (loss) per books (combine lines 18 through 20)21 21m m m Form 5471 (Rev. 12-2007)
JSA
8X1661 2.000
89354K 3987 V08-8.3
THE CHILDREN'S MEDICAL CENTER
ONE CHILDREN'S PLAZA
DAYTON OH 45404
COMMON 119,992. 119,992.
1.0000031-0672132
898,188.
-2,813,808.
-1,915,620.
205,485.
205,485.
-2,121,105.
-2,121,105.
SEE STATEMENT 1
Page 3Form 5471 (Rev. 12-2007)
Income, War Profits, and Excess Profits Taxes Paid or Accrued (see instructions)Schedule E
(a) Amount of tax
Name of country or U.S. possession
(b) (c) (d)
In foreign currency Conversion rate In U.S. dollars
U.S.1
2
3
4
5
6
7
Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mTotal8
Balance SheetSchedule F
Important: Report all amounts in U.S. dollars prepared and translated in accordance with U.S. GAAP. See instructions
for an exception for DASTM corporations.
(a) (b)Assets
Beginning of annual End of annual
accounting period accounting period
1 Cash 1m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m2a Trade notes and accounts receivable 2am m m m m m m m m m m m m m m m m m m m m m m m mb Less allowance for bad debts 2b ( ) ( )m m m m m m m m m m m m m m m m m m m m m m m m m m m m3 Inventories 3m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m4 Other current assets (attach schedule) 4m m m m m m m m m m m m m m m m m m m m m m m m5 Loans to shareholders and other related persons 5m m m m m m m m m m m m m m m m m m m6 Investment in subsidiaries (attach schedule) 6m m m m m m m m m m m m m m m m m m m m m7
8
9
Other investments (attach schedule) 7m m m m m m m m m m m m m m m m m m m m m m m m mBuildings and other depreciable assets 8aa m m m m m m m m m m m m m m m m m m m m m m mb Less accumulated depreciation 8b ( ) ( )m m m m m m m m m m m m m m m m m m m m m m m m m m ma Depletable assets 9am m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mb Less accumulated depletion 9b ( ) ( )m m m m m m m m m m m m m m m m m m m m m m m m m m m m m10 Land (net of any amortization) 10m m m m m m m m m m m m m m m m m m m m m m m m m m m m11 Intangible assets:
a Goodwill 11am m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mb Organization costs 11bm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mc Patents, trademarks, and other intangible assets 11cm m m m m m m m m m m m m m m m m m md Less accumulated amortization for lines 11a, b, and c 11d ( ) ( )m m m m m m m m m m m m m m m m m12 Other assets (attach schedule) 12m m m m m m m m m m m m m m m m m m m m m m m m m m m m
13 Total assets m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 13
Liabilities and Shareholders' Equity
14 Accounts payable 14m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m15 Other current liabilities (attach schedule) 15m m m m m m m m m m m m m m m m m m m m m m m16 Loans from shareholders and other related persons 16m m m m m m m m m m m m m m m m m m17 Other liabilities (attach schedule) 17m m m m m m m m m m m m m m m m m m m m m m m m m m m18 Capital stock:
a Preferred stock 18am m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m mb Common stock 18bm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m19 Paid-in or capital surplus (attach reconciliation) 19m m m m m m m m m m m m m m m m m m m m20 Retained earnings 20m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m21 Less cost of treasury stock ( ) ( )21m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
22 Total liabilities and shareholders' equity m m m m m m m m m m m m m m m m m m m m m m m 22
Form 5471 (Rev. 12-2007)
JSA
8X1662 1.000
89354K 3987 V08-8.3
1,134,194.
2,584,000.
24,386,583.
833,715.
3,091,313.
22,654,219.
5,989.
28,110,766.
6,113.
26,585,360.
7,726,643.
120,000.
834,453.
19,429,670.
28,110,766.
8,955,408.
120,000.
834,453.
16,675,499.
26,585,360.
SEE STATEMENT 2
SEE STATEMENT 2
SEE STATEMENT 2
SEE STATEMENT 2
SEE STATEMENT 3
Form 5471 (Rev. 12-2007) Page 4
Other InformationSchedule G
Yes No
1 During the tax year, did the foreign corporation own at least a 10% interest, directly or indirectly, in any foreign
partnership?
If "Yes," see the instructions for required attachment.
During the tax year, did the foreign corporation own an interest in any trust?
During the tax year, did the foreign corporation own any foreign entities that were disregarded as entities separate
from their owners under Regulations sections 301.7701-2 and 301.7701-3 (see instructions)?
If "Yes," you are generally required to attach Form 8858 for each entity (see instructions).
During the tax year, was the foreign corporation a participant in any cost sharing arrangement?
During the course of the tax year, did the foreign corporation become a participant in any cost sharing arrangement?
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
2 m m m m m m m m m m m m m m m m m m m m m m m m m m m3
m m m m m m m m m m m m m m m m m m
4 m m m m m m m m m m m m m m m m m m5 m m m m m m m m
Current Earnings and Profits (see instructions)Schedule H
Important: Enter the amounts on lines 1 through 5c in functional currency.
1 Current year net income or (loss) per foreign books of account 1m m m m m m m m m m m m m m m m m m m m m m m
Net
Additions
Net
Subtractions
2 Net adjustments made to line 1 to
determine current earnings and profits
according to U.S. financial and tax
accounting standards (see instructions):
a Capital gains or losses m m m m m m m m m mb Depreciation and amortization m m m m m mc Depletion m m m m m m m m m m m m m m m md Investment or incentive allowance m m m me Charges to statutory reserves m m m m m m mf Inventory adjustments m m m m m m m m m mg Taxes m m m m m m m m m m m m m m m m m mh Other (attach schedule) m m m m m m m m m m3 Total net additions m m m m m m m m m m m m4 Total net subtractions m m m m m m m m m m m m m m m m m m m m m m m m m m5 a 5aCurrent earnings and profits (line 1 plus line 3 minus line 4) m m m m m m m m m m m m m m m m m m m m m m m mb 5bDASTM gain or (loss) for foreign corporations that use DASTM (see instructions) m m m m m m m m m m m m m mc 5cCombine lines 5a and 5b m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m md Current earnings and profits in U.S. dollars (line 5c translated at the appropriate exchange rate as
defined in section 989(b) and the related regulations (see instructions)) 5dm m m m m m m m m m m m m m m m m m
IEnter exchange rate used for line 5d
Summary of Shareholder's Income From Foreign Corporation (see instructions)Schedule I
1 Subpart F income (line 38b, Worksheet A in the instructions) 1
2
3
4
5
6
7
8
m m m m m m m m m m m m m m m m m m m m m m m
2 Earnings invested in U.S. property (line 17, Worksheet B in the instructions) m m m m m m m m m m m m m m m m3 Previously excluded subpart F income withdrawn from qualified investments (line 6b, Worksheet C
in the instructions) m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m4 Previously excluded export trade income withdrawn from investment in export trade assets (line 7b,
Worksheet D in the instructions) m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
5 Factoring income m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
6 Total of lines 1 through 5. Enter here and on your income tax return. See instructions m m m m m m m m m m m m
7 Dividends received (translated at spot rate on payment date under section 989(b)(1)) m m m m m m m m m m m m
8 Exchange gain or (loss) on a distribution of previously taxed income m m m m m m m m m m m m m m m m m m m m
Yes No
m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m m m m m m m m m m m%
%
Was any income of the foreign corporation blocked?
Did any such income become unblocked during the tax year (see section 964(b))?
If the answer to either question is "Yes," attach an explanation.
Form 5471 (Rev. 12-2007)
JSA
8X1663 1.000
89354K 3987 V08-8.3
X
X
X
X
X
-2,121,105.
-2,121,105.
-2,121,105.
-2,121,105.
NONE
NONE
NONE
NONE
-2,121,105.
NONE
NONE
X
SCHEDULE J
(Form 5471)
Accumulated Earnings and Profits (E&P)
OMB No. 1545-0704of Controlled Foreign Corporation(Rev. December 2005)
Department of the Treasury
Internal Revenue Service IAttach to Form 5471. See Instructions for Form 5471.
Name of person filing Form 5471 Identifying number
Name of foreign corporation
(b) Pre-1987 E&P (c) Previously Taxed E&P (see instructions)(a) Post-1986 (d) Total Section
(sections 959(c)(1) and (2) balances)Undistributed Earnings Not Previously Taxed 964(a) E&PImportant. Enter amounts in
functional currency. (ii) Earnings Invested
in Excess Passive
Assets
(post-86 section (pre-87 section (i) Earnings Invested (combine columns
(iii) Subpart F Income
in U.S. Property959(c)(3) balance) 959(c)(3) balance) (a), (b), and (c))
1 Balance at beginning of year
2a Current year E&P
b Current year deficit in E&P
3 Total current and accumulated
E&P not previously taxed (line 1
plus line 2a or line 1 minus line 2b)
4 Amounts included under section
951(a) or reclassified under
section 959(c) in current year
5a Actual distributions or
reclassifications of
previously taxed E&P
b Actual distributions of
nonpreviously taxed E&P
6a Balance of previously taxed
E&P at end of year (line 1 plus
line 4, minus line 5a)
b Balance of E&P not previously
taxed at end of year (line 3
minus line 4, minus line 5b)
7 Balance at end of year. (Enter
amount from line 6a or line 6b,
whichever is applicable.)
For Paperwork Reduction Act Notice, see the Instructions for Form 5471. Schedule J (Form 5471) (Rev. 12-2005)
JSA
8X1665 3.000
89354K 3987 V08-8.3
31-0672132
CHILDREN'S MEDICAL CENTER 31-0672132
PEDIATRIC ASSURANCE COMPANY, LTD
8,444,715.
2,121,105.
6,323,610.
-2,121,105.
8,444,715.
8,444,715.
5,180,749. 13,625,464.
-2,121,105.
3,059,644.
3,059,644. 11,504,359.
SCHEDULE M Transactions Between Controlled Foreign Corporation(Form 5471) OMB No. 1545-0704
(Rev. December 2007)
Department of the Treasury
Internal Revenue Service
and Shareholders or Other Related Persons
I Attach to Form 5471. See Instructions for Form 5471.
Name of person filing Form 5471 Identifying number
Name of foreign corporation
Important: Complete a separate Schedule M for each controlled foreign corporation. Enter the totals for each type of transaction that occurred during
the annual accounting period between the foreign corporation and the persons listed in columns (b) through (f). All amounts must be stated in U.S.
dollars translated from functional currency at the average exchange rate for the foreign corporation's tax year. See instructions.
Enter the relevant functional currency and the exchange rate used throughout this schedule I(c) Any domestic
corporation or
partnership controlled
by U.S. person filing
this return
(d) Any other foreign
corporation or
partnership controlled
by U.S. person filing
this return
(e) 10% or more U.S.
shareholder of controlled
foreign corporation
(other than the U.S.
person filing this return)
(f) 10% or more U.S.
shareholder of any
corporation
controlling the
foreign corporation
(a) Transactions
(b) U.S. personof
filing this returnforeign corporation
1 Sales of stock in trade (inventory)
2 Sales of tangible property other
than stock in trade m m m m m m
3 Sales of property rights
(patents, trademarks, etc.) m m m
4 Buy-in payments received m m m
5 Cost sharing payments received
6 Compensation received for tech-
nical, managerial, engineering,
construction, or like services m m
7 Commissions received m m m m m
8 Rents, royalties, and license
fees received m m m m m m m m m
9 Dividends received (exclude
deemed distributions under
subpart F and distributions of
previously taxed income)m m m m
10 Interest receivedm m m m m m m m
11 Premiums received for insurance
or reinsurance m m m m m m m m m
12 Add lines 1 through 11 m m m m
13 Purchases of stock in trade
(inventory) m m m m m m m m m m
14 Purchases of tangible property
other than stock in trade m m m m
15 Purchases of property rights
(patents, trademarks, etc.) m m m
16 Buy-in payments paid m m m m m
17 Cost sharing payments paid m m
18 Compensation paid for tech-
nical, managerial, engineering,
construction, or like services m m
19 Commissions paid m m m m m m m
20 Rents, royalties, and license
fees paid m m m m m m m m m m m
21 Dividends paid m m m m m m m m
22 Interest paid m m m m m m m m m
23 Premiums paid for insurance or
reinsurance m m m m m m m m m m
24 Add lines 13 through 23 m m m m
25 Amounts borrowed (enter the
maximum loan balance during
the year) - see instructions m m m
26 Amounts loaned (enter the
maximum loan balance during
the year) - see instructions m m mFor Paperwork Reduction Act Notice, see the Instructions for Form 5471. Schedule M (Form 5471) (Rev. 12-2007)
JSA
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CHILDREN'S MEDICAL CENTER 31-0672132
PEDIATRIC ASSURANCE COMPANY, LTD
USD
Organization or Reorganization of Foreign
Corporation, and Acquisitions and
Dispositions of its Stock
SCHEDULE O
(Form 5471)
OMB No. 1545-0704
(Rev. December 2005)
Department of the Treasury
IAttach to Form 5471. See Instructions for Form 5471.Internal Revenue Service
Name of person filing Form 5471 Identifying number
Name of foreign corporation
Important: Complete a separate Schedule O for each foreign corporation for which information must be reported.
To Be Completed by U.S. Officers and DirectorsPart I
(e)(a) (c) (d)(b)
Date of original
10% acquisition
Date of additional
10% acquisition
Name of shareholder for whom Identifying numberAddress of shareholder
acquisition information is reported of shareholder
Part II To Be Completed by U.S. Shareholders
Note: If this return is required because one or more shareholders became U.S. persons, attach a list showing the
names of such persons and the date each became a U.S. person.
Section A General Shareholder Information
(c)
(b)
Date (if any) shareholder
For shareholder's latest U.S. income tax return filed, indicate:(a) last filed information
(1) Type of
return
(enter form
number)
(2) return under section(3)Name, address, and identifying number of
Date return filed 6046 for the foreignInternal Revenue Service Centershareholder(s) filing this schedule
corporationwhere filed
Section B U.S. Persons Who Are Officers or Directors of the Foreign Corporation
(d) Check
(a) (b) (c) appro-
priate
Name of U.S. officer or director Address Social security number box(es)
Ofcr Dir
Section C Acquisition of Stock
(e)
(d)(b) (c) Number of shares acquired(a)
Method ofClass of stock Date of
Name of shareholder(s) filing this schedule (1) (2) (3)
acquisitionacquired acquisition Directly Indirectly Constructively
For Paperwork Reduction Act Notice, see the Instructions for Form 5471. Schedule O (Form 5471) (12-2005)
JSA
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CHILDREN'S MEDICAL CENTER 31-0672132
PEDIATRIC ASSURANCE COMPANY, LTD
CHILDREN'S MEDICAL CENTER
990 05/17/2010
1 CHILDREN'S PLAZA
DAYTON, OH 45404-1815 OGDEN
Schedule O (Form 5471) (Rev. 12-2005) Page 2
(f) (g)
Amount paid or value given Name and address of person from whom shares were acquired
Section D Disposition of Stock
(e)
(a) (d)
Number of shares disposed of(b) (c)Name of shareholder disposing of Method of
disposition (1) (2) (3)stock Class of stock Date of disposition
Directly Indirectly Constructively
(f) (g)
Amount received Name and address of person to whom disposition of stock was made
Section E Organization or Reorganization of Foreign Corporation
(a) (b) (c)
Name and address of transferor Identifying number (if any) Date of transfer
(d) (e)
Assets transferred to foreign corporation Description of assets transferred by, or notes or
securities issued by, foreign corporation
(3)(2)(1)
Adjusted basis (if transferor
was U.S. person)
Fair market valueDescription of assets
Section F Additional Information
(a) If the foreign corporation or a predecessor U.S. corporation filed (or joined with a consolidated group in filing) a U.S. income tax return
for any of the last 3 years, attach a statement indicating the year for which a return was filed (and, if applicable, the name of the corporation
filing the consolidated return), the taxable income or loss, and the U.S. income tax paid (after all credits).
(b) List the date of any reorganization of the foreign corporation that occurred during the last 4 years while any U.S. person held 10% or
more in value or vote (directly or indirectly) of the corporation's stock I(c) If the foreign corporation is a member of a group constituting a chain of ownership, attach a chart, for each unit of which a shareholder
owns 10% or more in value or voting power of the outstanding stock. The chart must indicate the corporation's position in the chain of
ownership and the percentages of stock ownership (see instructions for an example).
Schedule O (Form 5471) (Rev. 12-2005)
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89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT
PEDIATRIC ASSURANCE COMPANY, LTD
FORM 5471, PAGE 2 DETAIL
1
SCH C, LINE 16 - OTHER DEDUCTIONS
---------------------------------
MANAGEMENT FEES 45,000.
LEGAL AND SECRETARIAL FEES 9,513.
AUDIT FEES 20,652.
ACTUARIAL FEES 21,483.
BERMUDA COMPANY TAX 3,945.
BERMUDA REGISTRATION FEES 1,042.
COMMUNICATIONS 2,958.
BANK CHARGES 326.
INVESTMENT MANAGEMENT FEES 102,738.
TRAVEL -2,172.
TOTAL
---------------
===============
205,485.
---------------
===============
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT
PEDIATRIC ASSURANCE COMPANY, LTD
FORM 5471, PAGE 3 DETAIL
BEGINNING ENDING
--------------- ---------------
US CURRENCY US CURRENCY
--------------- ---------------
2
SCH F, LINE 4 - OTHER CURRENT ASSETS
------------------------------------
REINSURANCE RECEIVABLE 2,584,000. 3,091,313.
TOTALS 2,584,000.
---------------
===============
3,091,313.
---------------
===============
SCH F, LINE 7 - OTHER INVESTMENTS
---------------------------------
US GOVERNMENT DEBT SECURITIES 8,092,924. 7,808,500.
CORPORATE DEBT SECURITIES 2,094,831. 2,548,091.
MUTUAL FUND 213,493. 217,493.
INTEREST RECEIVABLE 81,397. 75,286.
U.S. EQUITIES 13,903,938. 12,004,849.
TOTALS 24,386,583.
---------------
===============
22,654,219.
---------------
===============
SCH F, LINE 12 - OTHER ASSETS
-----------------------------
PREPAID EXPENSE 5,989. 6,113.
TOTALS 5,989.
---------------
===============
6,113.
---------------
===============
SCH F, LINE 17 - OTHER LIABILITIES
----------------------------------
LOSSES AND LOSS EXPENSE 7,639,111. 8,891,623.
ACCRUED EXPENSES 87,532. 63,785.
TOTALS 7,726,643.
---------------
===============
8,955,408.
---------------
===============
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT
PEDIATRIC ASSURANCE COMPANY, LTD
FORM 5471, PAGE 3 DETAIL
BEGINNING ENDING
--------------- ---------------
US CURRENCY US CURRENCY
--------------- ---------------
3
SCH F, LINE 19 - PAID-IN OR CAP SURPLUS
---------------------------------------
ADDITIONAL PAID IN CAPITAL 834,453. 834,453.
TOTALS 834,453.
---------------
===============
834,453.
---------------
===============
Return by a U.S. Transferor of Property
to a Foreign Corporation
926Form OMB No. 1545-0026
(Rev. December 2008)
Attachment
Sequence No. 128
Department of the Treasury
Internal Revenue Service IAttach to your income tax return for the year of the transfer or distribution.
U.S. Transferor Information (see instructions)Part I
Name of transferor Identifying number (see instructions)
If the transferor was a corporation, complete questions 1a through 1d.
If the transfer was a section 361(a) or (b) transfer, was the transferor controlled (under section 368(c)) by
5 or fewer domestic corporations?
Did the transferor remain in existence after the transfer?
1
a
b
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m
If not, list the controlling shareholder(s) and their identifying number(s):
Controlling shareholder Identifying number
c If the transferor was a member of an affiliated group filing a consolidated return, was it the parent
corporation?
If not, list the name and employer identification number (EIN) of the parent corporation:
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Name of parent corporation EIN of parent corporation
d Have basis adjustments under section 367(a)(5) been made? Yes Nom m m m m m m m m m m m m m m m m m m m m m m m
If the transferor was a partner in a partnership that was the actual transferor (but is not treated as such under section 367),
complete questions 2a through 2d.
2
a List the name and EIN of the transferor's partnership:
Name of partnership EIN of partnership
b
c
d
Did the partner pick up its pro rata share of gain on the transfer of partnership assets?
Is the partner disposing of its entire interest in the partnership?
Yes Nom m m m m m m m m m m
Yesm m m m m m m m m m m m m m m m m m m m m m m No
Is the partner disposing of an interest in a limited partnership that is regularly traded on an established
securities market? Yesm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m No
Transferee Foreign Corporation Information (see instructions)Part II
3 4 Identifying number, if anyName of transferee (foreign corporation)
5 Address (including country)
6 Country code of country of incorporation or organization (see instructions)
7 Foreign law characterization (see instructions)
8 Is the transferee foreign corporation a controlled foreign corporation? m m m m m m m m m m m m m m m m m Yes No
For Paperwork Reduction Act Notice, see separate instructions. Form 926 (Rev. 12-2008)
JSA
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THE CHILDREN'S MEDICAL CENTER 31-0672132
X
X
PEDIATRIC ASSURANCE COMPANY, LTD
BUTTERFIELD BANK BLDG, 6TH FLOOR 65 FRONT STREET
BD
CORPORATION
X
HAMILTON BERMUDA BD HM12
Page 2Form 926 (Rev. 12-2008)
Information Regarding Transfer of Property (see instructions)Part III
Type of
property
(a)
Date of
transfer
(b)
Description of
property
(c)
Fair market value on
date of transfer
(d)
Cost or other
basis
(e)
Gain recognized on
transfer
Cash
Stock and
securities
Installment
obligations,
account
receivables or
similar property
Foreign currency
or other property
denominated in
foreign currency
Inventory
Assets subject to
depreciation
recapture (see
Temp. Regs. sec.
1.367(a)-4T(b))
Tangible property
used in trade or
business not listed
under another
category
Intangible
property
Property to be
leased (as
described in
Temp. Regs. sec.
1.367(a)-4T(c))
Property to be
sold (as
described in
Temp. Regs. sec.
1.367(a)-4T(d))
Transfers of oil and
gas working interests
(as described in
Temp. Regs. sec.
1.367(a)-4T(e))
Other property
Supplemental Information Required To Be Reported (see instructions):
Form 926 (Rev. 12-2008)
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VAR 1,908,822.
Form 926 (Rev. 12-2008) Page 3
Additional Information Regarding Transfer of Property (see instructions)Part IV
9
10
11
12
13
14
15
16
17
Enter the transferor's interest in the foreign transferee corporation before and after the transfer:
(a) Before % (b) After %
IType of nonrecognition transaction (see instructions)
Indicate whether any transfer reported in Part III is subject to any of the following:
Gain recognition under section 904(f)(3)
Gain recognition under section 904(f)(5)(F)
Recapture under section 1503(d)
Exchange gain under section 987
a
b
c
d
a
b
c
d
a
b
a
b
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Did this transfer result from a change in the classification of the transferee to that of a foreign corporation? Yes No
Indicate whether the transferor was required to recognize income under Temporary Regulations sections
1.367(a)-4T through 1.367(a)-6T for any of the following:
Tainted property
Depreciation recapture
Branch loss recapture
Any other income recognition provision contained in the above-referenced regulations
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Yes Nom m m m m m m m m m m m m
Did the transferor transfer assets which qualify for the trade or business exception under section 367(a)(3)? Yes No
Did the transferor transfer foreign goodwill or going concern value as defined in Temporary Regulations
section 1.367(a)-1T(d)(5)(iii)? Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
If the answer to line 15a is "Yes," enter the amount of foreign goodwill or going concern value
transferred
Was cash the only property transferred?
I $
Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
Was intangible property (within the meaning of section 936(h)(3)(B)) transferred as a result of the
transaction? Yes Nom m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m
If "Yes," describe the nature of the rights to the intangible property that was transferred as a result of the
transaction:
Form 926 (Rev. 12-2008)
JSA
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IRC SEC 351
X
X
X
X
X
X
X
X
X
X
X
X
X
89354K 3987 V08-8.3
CHILDREN'S MEDICAL CENTER 31-0672132
STATEMENT 1
FEDERAL ELECTIONS
REGULATION REFERENCE: SECTION 1.6038B-1(C)
FEDERAL FOOTNOTE #1
INFORMATION REQUIRED PURSUANT TO REGULATION SECTION 1.6038B-1(C)
1) TRANSFEROR: CHILDREN'S MEDICAL CENTER
EIN: 31-0672132
ONE CHILDREN'S PLAZA DAYTON, OH 45404-1815
2) TRANSFER: (I) TRANSFEREE FOREIGN CORPORATION
PEDIATRIC ASSURANCE COMPANY, LTD
BUTTERFIELD BANK BUILDING, 6TH FLOOR
65 FRONT STREET, HAMILTON HM12 BERMUDA
EIN: N/A
COUNTRY OF INCORPORATION: BERMUDA
(II) CHILDREN'S MEDICAL CENTER
CONTRIBUTED CASH TOTALING $1,908,822 USD
TO PEDIATRIC ASSURANCE COMPANY, LTD
3) CONSIDERATION RECEIVED: COMMON STOCK SHARES
4) PROPERTY TRANSFERRED:
(I) ACTIVE BUSINESS PROPERTY CASH OF $1,908,822 USD
(II) STOCK AND SECURITIES: NOT APPLICABLE
(III) DEPRECIATED PROPERTY: NOT APPLICABLE
(IV) PROPERTY TO BE LEASED: NOT APPLICABLE
(V) PROPERTY TO BE SOLD: NOT APPLICABLE
(VI) TRANSFERS TO FSC: NOT APPLICABLE
(VII) TAINTED PROPERTY: NOT APPLICABLE
(VIII) FOREIGN LOSS BRANCH: NOT APPLICABLE
(IX) OTHER INTANGIBLES: NOT APPLICABLE
5) TRANSFER TO FOREIGN BRANCH LOSS WITH PREVIOUSLY DEDUCTED LOSSES: N/A
6) APPLICATION OF SECTION 367(A)(5): N/A
9. ENTER THE TRANSFEROR'S INTEREST IN THE FOREIGN TRANSFEREE
CORPORATION BEFORE AND AFTER THE TRANSFER:
(A) BEFORE: UNKNOWN BUT IS THOUGHT TO BE LESS THAN 10%
(B) AFTER: UNKNOWN BUT IS THOUGHT TO BE LESS THAN 10%