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Form 9 9 0 Return of Organization Exempt From Income Tax I OMB

° 154 5-0047 O

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung Department or me Treasury benefit trust or private foundation) Internal Revenue Service " The organization may have to use a copy of this return to satisfy state reporting requirements ."

A For the 2003 calendar ear or tax ear be innin 2003 and endin 09/30/ 2004 B Check if applicable pivse C Name of organization D Employer identification number

Address -'RS DEACONESS HOSPITAL INC . 35-0593390 change

label or Name change print o, Number and street (or P O. box if mad is not delivered to street address) Room/suite E Telephone number Ind .iii,itturn type

Final return see 600 MARY STREET (812 ) 450-2370

Amended g~ITC

Accou nting c- City or town, state or country, and ZIP + 4 �,.mod Cash X Accrual return

1 I I Other (specify)

H and I are not applicable to section 527 organizations

H(a) Is this a group return for afihates? F-l Yes Fx-]No H(b) If "Yes," enter number of affiliates 1

H(c) Are all affiliates included? N/A Yes =No (Ii "No," attach a list See instructions

H(d) Is this a separate realm filed by an organization covered by a group ruling? ~ Yes n NO

I Group Exemption Number

M Check 11~ d the organization is not required

G Websits~ " . DEACONESS . COM J Organization type (check only one) 1 }[ 501(c) ( 3 ) ~ (insert no ) 1 4947(a)(1 ) or 527

K Check here 1 if the organization's gross receipts are normally not more than $25,000 me

organization need not file a return with the IRS, but if the organization received a Forth 990 Package

in the mail, it should file a return without financial data Some states require a complete return

L Gross receipts Add lines Bb, Bb, 9b, and 10b to line 12 1 385 722 932 . to attach Sch B (Form 990 . 990-EZ . or 99o-PF)

Revenue, Expenses, and Changes in Net Assets or Fund Balances See page 18 of the rostra 1 Contributions, gifts, grants, and similar amounts received a Direct public support , , , , , , , , , , , , , , , , , , , , , , , 1 a 1 , 137 , 386 . b Indirect public support , , , , , , , , , , , , , , , , , , , , , , 1 b 50,054 .

n ~~~..G.q~y~ fe~, p~m.t contra utions (grants) , , , , , , , , , , , , , , , , , 1 c 318 , 991 . ~solalqa~GJ 1amrw tc) (cash $ 1,119,082 . noncasn 8 387,349o )

2 Program serve enue including government fees and contracts (from Part VII, line 93) , , , , , , ,

d 1,506,4 8,901,5

623,8 1,312,0

3,794,1 -in o

N CAD A (t Lr Ti ip

d ~ nd assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 I to t o sa ~ and temporary cash investments , , , , , , , , , , , , , , , , , , , , , , , , 4

est from securities 5

. . . . . . . . . . . . . . . . . . . . . . . . ga . . . . .

.3 970 .684 . 0 D`14~

rt;,7ST. " S . . . . . . . . . . . . . . . . . . . . . . . 6b 176 571 .

C Net rental income or (loss) (subtract line 6b from line 6a) , , , , , , , , , , , , , , , , , , , , , , 6C 7 Other investment income (describe " STMT 1 7 8 a Gross amount from sales of assets other (A) securities (s) Other m

than inventory , , , , , , , , . . 7=, 4, , 75 , 076 710 . 8a 366 023 . b Less . cost or other basis and sales expenses , 73 , 927 , 318 . 8b 561 , 805 . C Gain or (loss) (attach schedule) , , , , , , , 1 1 149 , 392 . 8c -195 , 782 . d Net gain or (loss) (combine line 8c, columns (A) and (B)) . . . . , . , , , , , , , , , , , ,

"

8d 9 Special events and activities (attach schedule) If any amount is from gaming, check here " El a Gross revenue (not including $ of

contributions reported on line 1a), , , , , , , , , , , , , , , , , 9a b Less direct expenses other than fundraising expenses , , , , , , , , 9b c Net income or (loss) from special events (subtract line 9b from line 9a) " " " " " " . . . . . . . . 9c

10 a Gross sales of inventory, less returns and allowances , , , , , , , oa b Less cost of goods sold , . � � � � � � � � � � ob C Gross profit or (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) , , 1 oc

11 Other revenue (from Part VII, line 103) � � � � � � � � � � � � � � � , 11 12 Total revenue add lines 1d 2 3, 4 5 tic, 7 Sd 9c 10c, and 11 12 13 Program services (from line 44, column (B)) , , , , , , , , . , , , , , , , , , , . , , , , , , , , .

. 13

y 14 Management and general (from line 44, column (C)) , , , , , , , , , , , , , , , , , , , , , . , , , 14 a 15 Fundraising (from line 44, column (D)) , , , , , , , , , , , , , . , , , , , , , , , , _ , , , , , , 15

16 Payments to affiliates (attach schedule) , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , . 16 17 Total expenses add lines 16 and 44, column A

12 18 Excess or (deficit) for the year (subtract line 17 from line 12) , , " 18

19 Net assets or fund balances at beginning of year (from line 73, column (A)) , , , , , , , , , , , , , , 19 20 Other changes in net assets or fund balances (attach explanation) , , , , , ,S~I~ ,z , , $~T, ,~ , 20 21 Net assets or fund balances at end of ear combine lines 18 19 and 20 . 21

For Paperwork Reduction Act Notice, see the separate instructions .

3,976,586 . 311,057,238 . 275,844,270 . 21,753,829 .

453,142 .

298,051,241 . 13,005,997 .

232,966,436 . 9,290,657 .

255,263,090 . Forth 990 (2003)

W Z

Q

JSA 3E1010 2 000

5DF42T 1274 V03-8 002-01850448

Application bon"

fif Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A (Form 990 or 890-EZ).

Q

22 Grants and allocations (attach schedule) -` (cash 3 53,500 . nonwshE ) 22 53 , 500 . 53,500 . STMT 4

23 Specific assistance to individuals (attach schedule) 23 , ,

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

25 Compensation of officers, directors, etc 25 2 , 255 , 744 . 2 , 255 , 744 . . 26 Other salaries and wages , , . , , , , 26 111 , 192 , 394 . 105 , 739 , 987 . 5 ,273 , 235 . 179 , 172

27 Pension plan contributions , , 27 5 , 925 , 720 . 4 , 797 , 045 . 1 , 128 , 675 . 28 Other employee benefits , , , , , , , 28 16 , 318 , 287 . 13 , 215 , 712 . 3 , 102 , 575 . 29 Payroll taxes , , , , , , , , , , , , , , L9_ 7 , 857 , 008 . 857 008 . 6 , 362 , 957 . 1 , 494 , 051 . 30 Professional fundraising fees , , , , , 30 31 Accounting fees � � � � � � 31 32 Legal fees � � � � � . . � , 32 1 , 463 , 356 . 1 , 454 , 800 . 8 , 556 . 33 Supplies , , , , , , , , , , , , . , , . 33 54 222 558 . 53 876 745 . 320 884 . 24 , 929 .

. 34 Telephone , , , , , , , , , , , . , . . 34 1 , 070 , 932 . 891 711 . 177 848 . 1 , 373

. 35 Postage and shipping , , , , , , , , , 35 487 390 . 318 221 . 157 453 . 11 , 716 36 Occupancy , , , , , , , , , , . . , , 36 8 , 218 , 087 . 7 , 646 , 025 . 572 062 . 37 Equipment rental and maintenance, , 37 13 , 188 , 960 . 12 , 317 , 822 . 871 , 138 . 38 Printing and publications , , , , , , , 38

. 39 Travel� � � � � � � � � 39 1 , 074 , 671 . 814 636 . 258 935 . 1 , 100 40 Conferences, conventions, and meetings , 40 41 Interest � � � � � � , . . . . 41 3 , 480 , 598 . 3 , 480 , 598 .

. 42 Depreciation, depleton,etc (attacM&lR,-~, 42 16 897 070 . 15 654 284 . 1 , 239 , 609 . 3 , 177

. 43 Other evensesnotco%eredabove (itemae)sTMT_6 43a 54 344 966 . 49 220 227 . 4 , 893 , 064 . 231 , 675 b 3b c 43c d 3d

3e

44 Total functional expenses (add lines 22 through 43) OrganrraUons completing columns (B)-(D), carry

. Utesetotals Mlines 13-15 , , , 44 298 , 051 , 241 . 1 275 844 270 . 21 753 829 . 453 , 142 Joint Costs . Check " if you are following SOP 98-2 Are any point costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? , , , , , " E] Yes aX No

If "Yes," enter (i) the aggregate amount of these point costs $ , (ii) the amount allocated to Program services $

(ill) the amount allocated to Management and general $ , and (iv) the amount allocated to Fundraising $ Statement of Program Service Accomplishments (Seepage 25 of the instructions .)

What is the organization's exempt " PROVIDE HOSPITAL CARE _____________________ ~~m service primary purpose? ------------------- Expenses

All organizations must describe their exempt purpose achievements in a clear and concise manner State the number (Required for so1(c)(s) and

of clients served, publications issued, etc Discuss achievements that are not measurable (Section 501(c)(3) and (4) (a) ores , and asa7(a)(1)

organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allocations to others ) trusts, butoptionalfw others )

a SEE-STATEMENT-6A ________ --------------------------------------------------------------------------- ---------------------------------------------------------------------------

(Grants and allocations $ ) b

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

(Grants and allocations $ ) c

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

(Grants and allocations $ ) d

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

(Grants and allocations $ )

275

e Other program services (attach schedule) (Grants and allocations $ ) f Total of Program Service Expenses (should equal line 44, column (B), Program services) . . . . " 275,844,270 .

JSA Form 990 (2003) 3E 1020 1 000

5DF42T 1274 V03-8 002-01850448

Form 990 (2003) 35-0593390 Page

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

Do not include amounts reported. . on line IA1 ToWI (B) Program (C) Mana~,

gement (D) Fundraising �,~ __ ,~ _~ ~_ ~o~~~ ~e,. ..b~ ~.,

66 Total liabilities (add lines 60 through 65) . . . . . . . . . . . . . . . . . . . . 133 , 309 , 321 . 66 206 , 017 , 402 . Organizations that follow SFAS 117, check here " U and complete lines

67 through 69 and lines 73 and 74 . 67 Unrestricted �� , 224 031 209 . 67 246 , 084 , 763 .

c 68 Temporarily restricted , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , 4 , 277 , 301 . 68 4 , 227 , 574m 69 Permanently restricted . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 , 657 , 926 . 69 4 , 950 , 753 .

o Organizations that do not follow SFAS 117, check here ~ ~ and complete lines 70 through 74 . ILL

0 70 Capital stock, trust principal, or current funds , , , , , , , , , . , , , , , , , , 70 71 Paid-in or capital surplus, or land, building, and equipment fund , , , , , , . 71

m 72 Retained earnings, endowment, accumulated income, or other funds 72 Q 73 Total net assets or fund balances (add lines 67 through 69 or fines

70 through 72, column (A) must equal line 19 ; column (B) must equal line 21) , , , , , , , , 232 , 966 , 436 . 73 255 , 263 , 090m

74 Total liabilities and net assets / fund balances add lines 66 and 73 . 366 275 757 . 74 461 280 492 . Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about a

particular organization. How the public perceives an organization in such cases may be determined by the information presented on its return Therefore, please make sure the return is complete and accurate and fully describes, in Part III, the organization's programs and accomplishments

JSA 3E1030 2 000

5DF42T 1274 V03-8 002-01850998

Y

35-0593390 Form 990 (2003)

Balance Sheets (See page 25 of the instructions .)

Note : Where required, attached schedules and amounts within the description (A) (a) Column should be for end-0f-year amounts only Beginning of year End of year

45 Cash - non-interest-bearing . . . . . . . . . . . . . . . . . . . . . . . . . . 11 579 343 . 45 13 , 564 , 630 : 46 Savings and temporary cash investments . . . . . . . . , . . . . . . . , . . . 46

47a Accounts receivable , , , , , , , , , , , , , , , , 47a 102 205 316 . b Less : allowance for doubtful accounts , , , , , , 47b 46 62 , 780 . 57 , 481 , 794 . 47c 56 042 536 .

48a Pledges receivable � � � � � � � � , 48a

b less' allowance for doubtful accounts , , , , , , 48b 48c 49 Grants receivable �� , 49

50 Receivables from officers, directors, trustees, and key employees

(attach schedule)�� , 50 51a Other notes and loans receivable (attach

schedule) , , , , , , , , , , , , , , , , , , , , , 1 51a

b less : allowance for doubtful accounts , , , , , , 51 b 51 c 52 Inventories for sale or use , , , , , , , , , , , , , , , , , , , , , , , , , , , 1 , 564 , 069 . 52 1 , 545 , 527 . 53 Prepaid expenses and deferred charges . . . . . . . . . . . . . . . . . . . . . 2 , 224 , 506 . 53 2 , 278 , 862 . 54 Investments - securities (attach schedule) $Tt~T ,7, " [:] Cost x~ FMV 127 258 253. 54 190 952 769 . 55a Investments - land, buildings, and

equipment: bass � � � � � � � � � 55a b Less . accumulated depreciation (attach

schedule) , , , , , , , , , , , , , , , , , , , , , , 56b 55c ~ 56 Investments - other (attach schedule) . . . . . . . . . . , . . . . . . 56 57a Land, buildings, and equipment: bass , , , , , , 57a 337 552 928 .

b Less' accumulated depreciation (attach

schedule) , , , , , , , , , , , , , , , , STMT . 5A 57b 172 500 789 . 149 , 165 , 334 . 57c 165 052 139 . 58 Other assets (describe " STMT B - ) 17 , 00 2 458 . 58 31 844 029 .

59 Total assets (add lines 45 through 58) (must equal line 74) . . . . . . . . . . 366 275 757 . 59 461 280 492 . 60 Accounts payable and accrued expenses , , , , , , , , , , , , , , , , , , , , 10 , 719 , 148 . 60 10 057 909 . 61 Grants payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

62 Deferred revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 d 63 Loans from officers, directors, trustees, and key employees (attach

schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

R 64a Tax-exempt bond liabilities (attach schedule) , . . . , , . , . . $~? SA , , No 64a 166 , 683 , 076 . J b Mortgages and other notes payable (attach schedule) , , , , , , , , , , , , , 106 499 190 . 64b NONE

65 Other liabilities (describe " STMT 9 _ ) 16 , 09 0 983 . 65 29 , 276 , 417 .

4

per

2

Add amounts on lines (1) through (4) , , 1 c Line aminus line b 10 d Amounts included on line 17,

Form 990 but not on line a: (1) Investment expenses

not included on line 6b, Form 990 , , , s

(2) Other (specify)

c Line a minus line b " c d Amounts included on line 12,

Form 990 but not on line a:

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

(2) Other (specify)

STMT 11 $ 1,636,734 . STMT 12 $ 1,486,180 . Add amounts on lines (1) and (2) . , " d 1 , 636 , 734 . . Add amounts on lines (1) and (2) , , " d 1 , 486 , 180 .

e Total revenue per line 12, Form 990 e Total expenses per line 17, Form 990 ( line c plus line d . . " e 311 , 057 , 238 . line c plus line d ~ ~ ~ ~ " e 298 051 241 .

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

75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your organization and all related organizations, of which more than $10,000 was provided by the related organizations? " E~ Yes El No If "Yes," attach schedule - see page 28 of the instructions SEE STATEMENT 14

Form 990 (2003)

JSA 3E 1040 2 000

5DF42T 1274 V03-8 002-01850448

Form 990 (2003)

Financial Statements with A Return See page 27 of the ii

a Total revenue, gains, and other support per audited financial statements , , " a

b Amounts included on line a but not on line 12, Form 990

(1) Net unrealized gains on investments , , $

(2) Donated seances and use of facilities $

(3) Recoveries of prior

year grants , , , , $ (4) Other (specify)

STMT 10 $ 6,325,829 . Add amounts on lines (1) through (4)

35-0593390

ea ~ rceconcuiation or txpenses~ per Financial Statements with E; ns Return

a Total expenses and losses per 746 333 . audited financial statements , , , , " a

b Amounts included on line a but not on line 17, Form 990

(1) Donated services

and use of facilities $ (2) Prior year adjustments

reported on line 20, Form 990 , , , , , $

(3) Losses reported on line 20, Form 990 $

(4) Other (specify)

5DF42T 1274 V03-8 002-01850448

Form 990 2003 35-0593390 Pace 5 " Other Information See page 28 of the instructions Yes No

76 Did the organization engage in any activity not previously reported to the IRS If "Yes," attach a detailed description of each activity , , 76 X 77 Were any changes made in the organizing or governing documents but not reported to the IRS , , , , , , , , , , , , , , , . . . . 77 X

If "Yes," attach a conformed copy of the changes 78a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this returns , , , , , , , , , 78a X b If "Yes," has it filed a tax return on Form 990-T for this yeah , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 78b X

79 Was there a liquidation, dissolution, termination, or substantial contraction during the year's If "Yes," attach a statement , , , , , , , , 79 X 80a Is the organization related (other than by association with a statewide or nationwide organization) through common

membership, governing bodies, trustees, officers, etc , to any other exempt or nonexempt organization? . . . . . . . . _ . . . . . . . BOa X b If "Yes," enter the name of the orgarnzationjp~ STMT 15

and check whether it is X exempt or I 1~ nonexempt 81 a Enter direct and indirect political expenditures See line 81 instructions, , , , , , , , , , , , , , , , 81a NO

b Did the organization file Form 1120-POL for this yeart . . . . . . . . . . . . . , . , . . . . . . . . _ . . . . . . . . . . . . . . 81b X

82a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge

or at substantially less than fair rental values , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , . . . . . . . . B2a X b If "Yes," you may indicate the value of these items here Do not include this amount

as revenue in Part I or as an expense m Part II (See instructions in Part III ) , , , . , , , , , , , , , , 82b 232 , 752 . 83a Did the organization comply with the public inspection requirements for returns and exemption applications , , , , , , , , , . . . . 83a X b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? , , , , , , , , , , , , , . , , . 83b X

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

85 501(c)(4), (5), or (6) organizations a Were substantially all dues nondeductible by members , , , . . . . . . . . . . . . . . . . . . 85a N b Did the organization make only in-house lobbying expenditures of $2,000 or less . . . . . . . . . . . . . . . . . . . . . . . . . , ? 85b NI AL

If "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization

received a waiver for proxy tax owed for the prior year

c Dues, assessments, and similar amounts from members 85c N/A d Section 162(e) lobbying and political expenditures , , , , , , , , , , , , , , , , , , , , , , , , , 85d N/A e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices , , , , , , , , , , , , , , , 85e N/A f Taxable amount of lobbying and political expenditures (line 85d less 85e) , , , , , , , , . . . . . . 85f N/A g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f? , , , , , , , . . . . . . . . . . . . . . . . . 85 N h If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount on line 85f to its reasonable

estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax yeah, , , . . . . . , . , , , , 85h N 86 501(c)(7) orgs Enter a Initiation fees and capital contributions included on line 12 . . . . . . . . . . 86a N/A

b Gross receipts, included on line 12, for public use of club facilities . , , . . , , , , , . . . . . . . . 86b N/A 87 501(c)(12) orgs Enter a Gross income from members or shareholders . . . . . . . . . . . _ . . . . 87a N/A

b Gross income from other sources (Do not net amounts due or paid to other

sources against amounts due or received from them ) , , , , , . , , , . , , , . . , , , , , . . . . 87b N/A 88 At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or

partnership, or an entity disregarded as separate from the organization under Regulations sections 301 7701-2 and 301 7701-3? If "Yes," complete Part IX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 g

89a 501(c)(3) organizations Enter Amount of tax imposed on the organization during the year under'

section 4911 1 NONE , section 4912 " NONE , section 4955 " NONE b 501(c)(3) and 501(c)(4) orgs Did the organization engage in any section 4958 excess benefit transaction

during the year or did it become aware of an excess benefit transaction from a prior yeah If "Yes," attach

a statement explaining each transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89b X c Enter Amount of tax imposed on the organization managers or disqualified persons during the year under

sections 4912, 4955, and 4958 . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . 1 NONE d Enter Amount of tax on line 89c, above, reimbursed by the organization . . . . . . . . . . . . . . . . . . , . . . . . . . . . 1 NONE

90a List the states with which a copy of this return is filed 1 INDIANA

b Number of employees employed m the pay period that includes March 12, 2003 (See instructions) , , , , , , , . , , , , , . . . , , 190b 2777 91 The books are in care of 1 MRS. CHERYL WATHEN Telephone no " ( 812) 450-2370

Located at, 600 MARY STREET, EVANSVILLE, IN ZAP+q 1 47747 92 Section 4947(a)(1) nonexempt charitable (rusts filing Form 990 in lieu of Form 1041 -Check here . . . . . . . . . . . .

and enter the amount of tax-exempt interest received or accrued during the tax year . " 192 1 N/A . "

Form 990 (2003)

JSA 3E 1041 2 000

105 Total (add line 104, columns (B), (D), and (E)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . jl~ 309 , 550 , 807 . Note : Line 105 plus line 1d, Part l, should equal the amount on line 12, Part I

Relationship of Activities to the Accom plishment of Exempt Purposes See page 34 of the instructions .) Line No. Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the accomplishment

of the organization's exempt purposes (other than by providing funds for such purposes)

93A STATEMENT 16A

Information Regarding Taxable Subsidiaries and Disregarded Entities See page 34 of the instructions.

Name, address, and1EIN of corporation, Percentage of Nature of activities Total n come EndoEfyear oartnershio. or disregarded en4tv ~ ownership interest assets

47 TMT 17 70,033,8

Information Regarding Transfers Associated with Personal Benefit Contracts (See page 34 of the instructions ) (8) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? . , , . , , , Yes )( NO (b) Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contracts Yes g No Note : If "Yes" to (b). file Form 8870 and Form 4720 (see instructions)

JSA 3E1050 1 000

5DF42T 1274

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

93 Program service revenue Business code Amount Exclusion code Amount exempt lion

a NET PATIENT b REVENUE 298 , 901 , c d

e f Medicare/Medicaid payments , . , , , . g Fees and contracts from government agencies .

94 Membership dues and assessments . .

95 interest on saangs and temporary cash investments 14 623 , 841 . 96 Dividends and interest from securities 14 1 , 312 , 017 .

97 Net rental income or (loss) from real estate

a debt-financed property . . . . . . . .

b not debt-financed property . . . . . . 16 3 ,794 ,113 . 9 8 Net rental income or (loss) from personal properly

99 Other investment income . . . . . . . 623990 -10 , 929 .

100 Gain or (joss) from saes of assets other man inventory 18 953 , 610 . 101 Net income or (loss) from special events .

102 Gross profit or (loss) from sales of inventory ,

103 Other revenue a

b STMT 16 1 1 968 , 504 . 2 , 008 , 082 . c d e

104 Subtotal (add columns (B), (D), and (E)) . . 1 , 957 , 575 .1 8 , 691.663 . 298 , 901 ,

JAMES _ SPILLIgRz_ MD ................... . ...... . ....

Schedule A (Form 990 or 990-EZ) 2003

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

(Form 990 Or 990-EZ) (Except Private Foundation) and Section 501(e), 501(n, 501(k),

501(n), or Section 4947(a)(1) Nonexempt Charitable Trust G~OO~ Department of the Treasury Supplementary Information - (See separate instructions .) Internal Revenue Service " MUST be completed b the above organizations and attached to their Form 990 or 990"EZ Name of the organization Employer identification number

DEACONESS HOSPITAL INC . 35-0593390 Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (See page 1 of the instructions. List each one. If there are none, enter "None")

(a) Name and address of each employee paid more (b) Title and average (d) Contributions to (a) Expense

than $50,000 hours per week (c) Compensation employee benefit plans & account and other

devoted to position deferred com pensation allowances

FRANCIS J. MCDONNELL ANESTHESIOLOGIST 600 MARY STREET EVANSVILLE IN 47747 40 HOURS 1 , 250 , 302 . 24 , 214 . NON

SUSAN M. DOUGLAS ANESTHESIOLOGIST 600 MARY STREET

EVANSVILLE IN 47747 40 HOURS 771 701 . 16 , 255. NON

PALLAVI-K_-BFIATT------------------ - ANESTHESIOLOGIST 600

ANSVILLETRINT47747 40 HOURS f 733 .475 .1 28 .168 .1 NON EV

RAJESH-J-_PATEL------------------- ANESTHESIOLOGIST

600 MARY STREET 1

EVANSVILLE . IN 47747 140 HOURS I 621 .097

EVAN-SPECK ------------------------ ANESTHESIOLOGIST

600 MARY STREET i

Total number of other employees paid over

Compensation of the Five Highest Paid Independent Contractors for Professional Services (See page 2 of the instructions . List each one (whether individuals or firms) . If there are none, enter "None.

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

L DONOVAN & KAHN -------------------------------------

ARUP-LABS ---------------------------------------

EVANSVILLE-SURGICAL-ASSOCIATES,-INC -------------

77

Total number of others receiving over $50,000 for professional services jl~ gg

For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Form 990-EZ. JSA

3E1210 2 000

5DF42T 1274 V03-8 002-01850448

4 Did you maintain any separate account for participating donors where donors have the right to provide advice on the use or distribution of funds? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The or anization is not a private foundation because it is (Please check only ONE applicable box)

5 A church, convention of churches, or association of churches Section 170(b)(1)(A)(i) 6 A school Section 170(b)(1)(A)(u) (Also complete Part V )

7 X A hospital or a cooperative hospital service organization Section 170(b)(1)(A)(m)

8 u A Federal, state, or local government or governmental and Section 170(b)(1)(A)(v) 9 ~ A medical research organization operated in conjunction with a hospital Section 170(b)(1)(A)(uQ Enter the hospital's name, city,

and state 1__

10 F_~ An organization operated for the benefit of a college or university owned or operated by a governmental unit Section 170(b)(1)(A)(iv) (Also complete the Support Schedule in Part IV-A )

11 a E_1 An organization that normally receives a substantial part of its support from a governmental unit or from the general public

Section 170(b)(1)(A)(vi) (Also complete the Support Schedule in Part IV-A )

11 b B A community trust Section 170(b)(1)(A)(w) (Also complete the Support Schedule in Part IV-A 12 An organization that normally receives (1) more than 33 113% of its support from contributions, membership fees, and gross

receipts from activities related to its charitable, etc , functions - subject to certain exceptions, and (2) no more than 33 1/3"/. 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) (Also complete the Support Schedule in Part IV-A )

13

F_] An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations

described m (1) lines 5 through 12 above, or (2) section 501(c)(4), (5), or (6), if they meet the test of section 509(a)(2) (See section 509(a)(3) )

(a) Name(s) of supported organization(s) I (b) Line number from above

5DF92T 1274 V03-8 002-01850448

Schedule A (Form sso a 990-EZ) 2003 35-0593390 Page 2 ORM Statements About Activities See page 2 of the instructions . Yes No 1 During the year, has the organization attempted to influence national, state, or local legislation, including any

attempt to influence public opinion on a legislative matter or referendums If "Yes," enter the total expenses paid or incurred in connection with the lobbying activities " $ (Must equal amounts on line 38, Part VI-A, or line I of Part VI-B ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 X Organizations that made an election under section 501(h) by fling Form 5768 must complete Part VI-A Other organizations checking "Yes," must complete Part VI-B AND attach a statement giving a detailed description of

the lobbying activities . 2 During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any

substantial contributors, trustees, directors, officers, creators, key employees, or members of their families, or with any taxable organization with which any such person is affiliated as an officer, director, trustee, majority owner, or principal beneficiary? (If the answer to any question is "Yes," attach a detailed statement explaining

the transactions ) a Sale, exchange, or leasing of property , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 2a X

b Lending of money or other extension of credit? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

c Furnishing of goods, services, or facilities? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)7 , ,FQFU.4, 9,9p, , RAFQT. V . . .

e Transfer of any part of its income or assets? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 3a Do you make grants for scholarships, fellowships, student loans, etc? (If "Yes," attach an explanation of how

you determine that recipients qualify to receive payments ) , , , , , , , , , , , , , , , , , , , , , , , , , , , , . %TjytT , 19,

b Do you have a section 403(b) annuity plan for your employees , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

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

14 F-] An organization organized and operated to test for public safety Section 509(a)(4) (See page 6 of the instructions )

3Ei22o 2 000 Schedule A (Form 990 or 980-EZ) 2003

5DF42T 1274 V03-8 002-01850448

Schedule A Form 990 or 990-EZ 2003 35-0593390 Page 3 K~, Support Schedule (Complete only if you checked a box online 10, 11, or 12 .) Use cash method of accounting. Note : You ma use the worksheet in the instructions for converting from the accrual to the cash method of accounting NOT APPLICABLE

Calendar year (or fiscal year beginning in) . a 2002 b 2001 c 2000 d 1999 e Total

15 Gifts, grants, and contributions received (Do

not include unusual rants See line 28

18 Membership fees received . . 17 Gross receipts from admissions, merchandise

sold or services performed, or furnishing of

facilities in any activity that is related to the

18 Gross income from interest, dividends,

amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable income (less

section 511 taxes) from businesses acquired

b the or anization after June 30 1975 19 Net income from unrelated business

activities not included in line 18 20 Tax revenues levied for the organization's

benefit and either paid to it or expended on

its behalf

21 The value of services or facilities furnished to

the organization by a governmental unit

without charge Do not include the value of

seances or facilities generally furnished to the

public without charge 22 Other income Attach a schedule Do not

include gam or (loss) from sale of capital assets

23 Total of lines 15 through 22 . 24 Line 23 minus line 17

25 Enter 1% of line 23 26 Organizations described on lines 10 or 11 : a Enter 2% of amount in column (e), line 24 t4QT, jWLDIr;Cj%P" 26a

b Prepare a list for your records to show the name of and amount contributed by each person (other than a governmental unit or publicly supported organization) whose total gifts for 1999 through 2002 exceeded the

amount shown in line 26a Do not file this list with your return . Enter the total of all these excess amounts " 26b c Total support for section 509(a)(1) test Enter line 24, column (e) . . . . . . . . . . . . . . . , . . . . . . . . . . . . . jo~ 26c d Add Amounts from column (e) for lines 18 19

22 26b � � � � � � " 26d

e Public support (line 26c minus line 26d total) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , " 26e f Public support percentage (line 26e (numerator) divided by line 26c (denominator)) . . " 26f 1 0/6

27 Organizations described on line 12 : a For amounts included in lines 15, 16, and 17 that were received from a "disqualified person," prepare a list for your records to show the name of, and total amounts received m each year from, each "disqualified person " Do not file this list with your return . Enter the sum of such amounts for each year.

(2002) -------_________ (2001) --____________----- (2000) ---NOT APPLICABLE _ (1999) _____-__-_____

b For any amount included in line 17 that was received from each person (other than "disqualified persons"), prepare a list for your records to show the name of, and amount received for each year, that was more than the larger of (1) the amount on line 25 for the year or (2) $5,000 (Include m the list organizations described in lines 5 through 11, as well as individuals) Do not file this list with your return After computing the difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year (2002) ---------------- (2001) ------------------- (2000) ------------------- (1999)---------------

c Add Amounts from column (e) for lines 15 16

17 20 21 . . . . . . . . . . . . 1 27c

d Add Line 27a total and line 27b total , , . . . . . . . . . . . . " 27d

e Public support (line 27c total minus line 27d total) " " " " " " " " " " " " " " " " " " " " " " " " - " - " " - 27e

f Total support for section 509(a)(2) test Enter amount from line 23, column (e) . . . . . . . . . . 11~27f g Public support percentage (line 27e (numerator) divided by line 27f (denominator) . , . . . , . . . . . . . . . . . . " 27

h Investment income percentage line 18 column e numerator divided b line 27f denominator . 27h 28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any. unusual grants .during 1999 through 2002,

prepare a list for your records to show, for each year, the name of the contributor, the date and amount of the grant, and a brief description of the nature of the grant Do not file this list with your return . Do not include these grants m line 15

JSA Schedule A (Form 990 or 990-EZ) 2003 3E1221 2 000

If you answered "No" to any of the above, please explain (If you need more space, attach a separate statement.)

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

-- --------------------------------------------------------------------------33 Does the organization discriminate by race m any way with respect to:

a Students'rights orpnvdeges? �� , 33a

b Admissions policies? 33b

c Employment of faculty or administrative staff? . , . , , . . , , , , , . . , , , , . . . . , . . . . . . . . . . . , . 33c

d Scholarships or other financial assistance? 33d

e Educational policies? 33e

f Use of facilities? 33f

g Athletic programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

h Other extracurricular activities? 33h

If you answered "Yes" to any of the above, please explain. (If you need more space, attach a separate statement )

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

34a Does the organization receive any financial aid or assistance from a governmental agency . , 34a

b Has the organization's right to such aid ever been revoked or suspended . . . . . . . . . . . . . . . . . . . . 34b If you answered "Yes" to either 34a or b, please explain using an attached statement

35 Does the organization certify that it has complied with the applicable requirements of sections 4 01 through 4.05 of Rev Proc 75-50 1975-2 C B 587 covering racial nondiscnmination7 If "No , " attach an explanation .

" " 35

3Ei23o 2 000 Schedule A(Form 990 or 990-EZ) 2003

5DF42T 1274 V03-8 002-01850448

schedule A (Form sso or 990-ez) zoos 35-0593390 Page 4

Private School Questionnaire (See page 7 of the instructions .) (To be completed ONLY by schools that checked the box on line 6 in Part IV)

NOT APPLICABLE

29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, Yes No

other governing instrument, or in a resolution of its governing body . . . . , . . . . 29 30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its

brochures, catalogues, and other written communications with the public dealing with student admissions, programs, and scholarships? . . . . . . . . . . . . . . . . . . . . . , . . 30

31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during the period of solicitation for students, or during the registration period if it has no solicitation program, in a way that makes the policy known to all parts of the general community it serves . . . . , . . . . . . . . . . . . . 37 If "Yes," please describe, if "No," please explain. (If you need more space, attach a separate statement.)

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

32 Does the organization maintain the following: ----------------------------------------------------------------------------- a Records indicating the racial composition of the student body, faculty, and administrative staff? . . . . . . . . . . 32a b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory

bas's? 32b c Copies of all catalogues, brochures, announcements, and other written commurncations to the public dealing

with student admissions, programs, and scholarships . . . . . . . . . . . . . . . . 32c d Copies of all material used by the organization or on its behalf to solicit contributions? . . . . , . . . . . , . . . . 32d ~

Schedule A Form 990 or 990-EZ 2003 Page 5 Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions.) (To be completed ONLY by an eligible organization that filed Form 5768) NOT APPLICABLE

Check lip. a if the organization belongs to an affiliated group Check 1 b if you checked "a" and "limited control" provisions aDDlv.

Limits on Lobbying Expenditures

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

36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 37 Total lobbying expenditures to influence a legislative body (direct lobbying) 38 Total lobbying expenditures (add lines 36 and 37) . . . , . . . . 39 Other exempt purpose expenditures � � � � � � � � � � � �

40 Total exempt purpose expenditures (add lines 38 and 39) 41 Lobbying nontaxable amount . Enter the amount from the following table-

If the amount on line 40 is - The lobbying nontaxable amount is - Not over $500,000 , , , , , , , , , , , , 20°h of the amount on line 40 Over $500,000 but not over $1,000,000 , , , $100,000 plus 15% of the excess over $500,000 Over $1,000,000 but not over $1,500,000 $175,000 plus 10% of the excess over $1,000,000 Over $1,500,000 but not over $17,000,000 , , $225,000 plus 5% of the excess over $1,500,000

J Over $17,000,000

. .

, $1,000,000 42 Grassroots nontaxable amount (enter 25% of line 41) . . . . . . . . . . . , 43 Subtract line 42 from line 36 . Enter -0- if line 42 is more than line 36 44 Subtract line 41 from line 38 Enter -0- if line 41 is more than line 38 .

Affiliated group To be completed totals for ALL electing

organizations

41

Lobbying Expenditures During 4-Year Averaging Period

1b1 I (c) I (d) I (e) 2002 2001 2000 Total

Grassroots ceding amount

(150% of line 48(e))

Grassroots lobbying

5DF42T 1274 V03-8 002-01850448

38

on : If there is an amount on either line 43 or hne 44, you must file Form 4 720 1 1 4-Year Averaging Period Under Section 501(h)

(Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 45 through 50 on page 11 of the instructions )

Calendar year (or fiscal (a) ear beginning in " 2003 Lobbying nontaxable amount

Lobbying ceiling amount (150% of line 451e)1 . .

Grassroots nontaxable

Lobbying Activity by Nonelecting Public Charities For reportin g only b organizations that did not complete Part VI-A) See page 12 of the instructions .

During the year, did the organization attempt to influence national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of

Yes No Amount

a Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b Paid staff or management (Include compensation m expenses reported on lines c through h ) . . , x c Media advertisements X d Mailings to members, legislators, or the public, g e Publications, or published or broadcast statements , , , , , , , , , , , . , , , , , , , , . . . . . . g f Grants to other organizations for lobbying purposes , , , , , , , , , , , , , , , , , , , , , , , , , g g Direct contact with legislators, their staffs, government officials, or a legislative body . . . . . , . . X h Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means , , , , , , x i Total lobbying expenditures (Add lines c through h.), , , , , , , , , , , , , , , , , ,

If "Yes" to any of the above, also attach a statement giving a detailed description of the lobbying activities JSA Schedule A (Form 990 or 990-EZ)2003 3E 1240 2 000

Schedule A Form 990 or 990-EZ 2003 35-0593390 Page 6 Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations (See page 12 of the instructions .)

51 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section 501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations

a Transfers from the reporting organization to a nonchantable exempt organization of. Yes No (i) Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51a ( i) X (ii) Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a ( !!) x

b Other transactions : (i) Sales or exchanges of assets with a nonchantable exempt organization . . . . . . . . . . . . . , , . . . . , b il l) x (ii) Purchases of assets from a nonchantable exempt organization . . . . . . . , , , . . . . . . . . . . . . . . . b ii X (iii) Rental of facilities, equipment, or other assets . , , , , , , , , . , . , . , , , , , , . . . . , , . . . . . . . . b (iii) X (iv) Reimbursement arrangements , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , b( iv) X (v) Loans or loan guarantees , , . , , , , , , , , , , , , , , . , , , , , , , , . , , , , , . b ( v ) X (vi) Performance of services or membership or fundraising solicitations , , , , , , , , , , , , , , , , , , , , , , vi X

c Sharing of facilities, equipment, mailing lists, other assets, or paid employees , , , . , , , , . , , . , , , , . . , , c x d If the answer to any of the above is "Yes," complete the following schedule Column (b) should always show the fair market value of the

goods, other assets, or services given by the reporting organization . If the organization received less than fair market value m any

52a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? , , , , , , , , , , " E]Yes a No

JSA Schedule A (Form 990 or 990-EZ) 2003

3E1250 2 000

5DF42T 1274 V03-8 002-01850448

DEACONESS HOSPITAL, INC .

FORM 990, PART II - GRANTS AND ALLOCATIONS PAID DURING THE YEAR

RELATIONSHIP TO SUBSTANTIAL CONTRIBUTOR AND

RECIPIENT NAME AND ADDRESS FOUNDATION STATUS OF RECIPIENT

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

GRANTS PAID

AMY WILLIS NONE

INDIVIDUAL

DENISE SPINDLER NONE

INDIVIDUAL

CORA JARRETT NONE INDIVIDUAL

CASSANDRA KERN NONE

INDIVIDUAL

ERIKA AHSHIRE NONE

INDIVIDUAL

JESSICA MCGOLDEN NONE INDIVIDUAL

BRIELLE SITZMAN NONE

INDIVIDUAL

ERIN SUTER NONE INDIVIDUAL

CONNIE STONE NONE INDIVIDUAL

5DF42T 1274 V03-8 002-01850448 STATIINENT 4

35-0593390

PURPOSE OF GRANT OR CONTRIBUTION AMOUNT -------------------------------- ------

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500 .

SCHOLARSHIP 3,500

5DF42T 1274 V03-8 002-01850448 STATEMENT 5


FORM 990, PART II - GRANTS AND ALLOCATIONS PAID DURING THE YEAR ---- - - ----------------------

RELATIONSHIP TO SUBSTANTIAL CONTRIBUTOR

AND RECIPIENT NAME AND ADDRESS FOUNDATION STATUS OF RECIPIENT -------------------------- ------------------------------

MAUREEN VAN HOOK NONE INDIVIDUAL

SARA SAMMET NONE INDIVIDUAL

LARA JAQiIEMXI NONE

INDIVIDUAL

BRITTNEY DOER NER NONE

INDIVIDUAL

LAURA REEDER NONE

INDIVIDUAL

JUSTINE MOBLAN NONE INDIVIDUAL

35-0593390

PURPOSE OF GRANT OR CONTRIBUTION AMOUNT -------------------------------- ------

SCHOLARSHIP 3,500 .

SCHOLARSHIP 7,000 .

SCHOLARSHIP 7,000

SCHOLARSHIP 2,500 .

SCHOLARSHIP 1,000

SCHOLARSHIP 1,000 .

TOTAL CONTRIBUTIONS PAID 53,500 .

35-0593390

$73,927,318 $75,076,710 $1,149,392

$74,489,123 $75,442,733 $953,610 Grand Total

STATEMENT A

(A) Securities

Foundation Various

(B) Other

Property, Plant, & Equipment

Deaconess Hospital, Inc. Part I - Line 8(c) - Net Gain/Loss on Sale of Assets

Period Ending September 30, 2004

NeU Acquisition Sales Gain/

Value Pace (Loss)

$1,147,315 $1,131,142 (S "' 6. 173) $72,780,003 $73,945,568 $1,165,565

$561,805 $366,023 (S1 95,782)

$561,805 $366,023 (S9 95 .782;

TOTAL

STATEMENT 1

5DF42T 1274 V03-8 002-01850448

Deaconess Hospital, Inc .

FORM 990, PART I - OTHER INVESTMENT INCOME

DESCRIPTION

THE HEALTHCARE GROUP, LLC

35-0593390

AMOUNT

-10,929 . ------------

-10,929 .

35-0593390

TOTAL

002-01850448 V03-8 5DF42T 1274


FORM 990, PART I - OTHER INCREASES IN FUND BALANCES

DESCRIPTION

CHANGE IN UNREALIZED GAIN/LOSS ON INV. INCOME FROM AFFILIATES

AMOUNT

4,707,154 . 6,336,758 .

------------11,043,912 .

STATEMENT 2

35-0593390

TOTAL

002-01850448 V03-8 5DF92T 1274


FORM 990, PART I - OTHER DECREASES IN FUND BALANCES

DESCRIPTION -----------

CHANGE IN PENSION LIABILITY ELIMINATION OF STUDENT NURSE FUND ADJUSTMENT FOR DONATED PROPERTY

AMOUNT

1,337,022 . 66,233 .

350,000 . ------------1,753,255 .

STATEMENT 3

Balance Balance Net September 30,

October 1, 2003 Additions Disposals 2004

9,564,876 299,088 0 9,863,964 189,787,216 6,992,008 (544,300) 196,234,923 89,926,406 12,467,115 (1,607,282) 100,786,239 2,472,603 202,959 0 2,675,562

14,548,264 13,443,976 0 27,992,240 306,299,364 33,405,146 (2,151,583) 337,552,928

Accumulated Depreciation

Building 92,689,020 8,941,133 (68,398) 101,561,756 Equipment 62,363,099 7,976,915 (1,552,736) 68,787,277 Parking 2,081,911 69,844 0 2,151,755

Totals 157,134,030 16,987,892 (1,621,134) 172,500,788

Net Property 8 Equipment 149,165,333 165,052,140

Part II - Depreciation Expense - Line 42

Depreciation - Property, Plant and Equipment Depreciation Included in Rent Expense Depreciation - Deaconess Hospital Foundation

Total Depreciation

STATEMENT 5A

Assets

Land Building Equipment Parking CIP

Totals

Deaconess Hospital, Inc.

Part IV - Balance Sheet - Line 57

FYE September 30, 2004

16,987,892 (94,000) 3,177

16,897,069

(1) INCLUDES CONTRACT SERVICES, PHYSICIAN ACTIVITIES, CONSULTING FEES AND MISCELLANEOUS FEES . DOES NOT INCLUDE LEGAL FEES . TOTAL LEGAL FEES ARE ON PART II, LINE 32 .

V03-8 002-01850448 STATEMENT 6 5DF42T 1274

DEACONESS HOSPITAL, INC . 35-0593390

FORM 990, PART II - OTHER EXPENSES

PROGRAM MANAGEMENT DESCRIPTION TOTAL SERVICES AND GENERAL FUNDRAISING ----------- ----- -------- ----------- -----------

BAD DEBTS 27655691 . 27655691 . PROFESSIONAL FEES (1) 8,100,497 . 4,949,330 . 3,133,845 . 17,322 . INSURANCE 1,502,876 . 1,499,447 . 3,429 . ADVERTISING 1,667,320 . 360,416 . 1,306,904 . COLLECTION FEES-OUTSIDE AGENCY 3,317,140 . 3,303,650 . 13,490 . PROFESSIONAL FEES - PHYSICIAN 14336136 . 14324567 . 11,569 . MISCELLANEOUS -3390800 . -4028980 . 423,827 . 214,353 . LAUNDRY EXPENSE 97,648 . 97,648 . INTERN RESIDENCY PROGRAM 200,870 . 200,870 . HOSPICE PROGRAM 125,000 . 125,000 . HOSPICE CARE CENTER 97,877 . 97,877 . CHILD CARE CENTER EXPANSION 63,229 . 63,229 . FAMILY PRACTICE GRANT 54,593 . 54,593 . MAMMOGRAMS & PELVIC SCREENING

FOR INDIGENT 88,046 . 88,046 . STAFF EDUCATION 199,221 . 199,221 . MISCELLANEOUS PROGRAMS 229,622 . 229,622 .

---------- ---------- ---------- ---------- TOTALS 54344966 . 49220227 . 4,893,064 . 231,675 .

35-0593390

STATEMENT 6A


Pan III - Line (a)

September 30, 2004

Deaconess Hospital is a general acute care facility operating 358 beds and associated ancillary services, searing Evansville and surrounding communities. Deaconess Hospital provides quality medical health care to all people regardless of race, creed, sex, national origin, handicap, age, or the ability to pay.

Deaconess Hospital provided healthcare to 262,473 patients on both an inpatient 8 outpatient basis.

Deaconess Hospital provides care to persons covered by governmental programs at below cost . Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. To the extent reimbursement is below cost, Deaconess Hospital absorbs these costs in meeting its mission to the entire community.

The Hospital's commitment to serve the Tri-State community is demonstrated by the attached report .

In support of its mission, Deaconess Hospital provided $4.3 million of indigent/charity care, $39.4 million of subsidized services to the Medicare and Medicaid programs and $5.1 million in community benefit activities (all on a cost basis) . These activities served a minimum of 378,784 people within the Tri-State community.

SEE ATTACHED COMMUNITY BENEFIT REPORT

Net Funding Cost

1,350,717 4,297,009

Descriptions Served Cost

Traditional Charity Care - 6,337 5,647,726

Government-Funded Programs Medicare Medicaid Illinois & Kentucky Medicaid Programs

Community Benefit Activities Consisting of the Following (See Attached Detail) : - Medical Eduation and Training Programs - Medical and Health Services Research - Community Health Education - Community Programs/Services - Community Health Assessment - Support to Local Colleges and Universities - Donations of Money and Time - Provision for Taxes - Bad Debts

Total Community Benefit 506,075 176,225,750 127,430,464 48,795,286

NOTE' The above information is reflected on a cost versus charge basis.

Deaconess Hospital Summary of Community Benefit Report For the Year Ended September 30, 2004

Persons

87,514 134,925,182 104,399,923 30,525,259 32,236 22,254,995 14,547,503 7,707,492 1,204 2,886,228 1,727,106 1,159,122

378,784 10,511,619 5,405,215 5,106,404

Subsidized . I

Subsidized Medical Services to all I com L

ncome L=els

Beacon Group

Black Lung Clinic 82 12,939 7,048 5,891 Blood Pressure Screenings Cancer Program 872 12,723 0 12,723 Employed Primary Care Physicians Serving Rural Areas 55,090 648,887 648,887 Family Practice Center 19,736 3,380,642 2,126,748 1,253,894

Flu Shots HeartCare Health System Satellite Clinics 138,119 138,119 Hospice Care 50 3,046,125 2,994,187 51,938 Mammograms for Indigent 88,046 88,046

Neonatal Clinic

No Names Anonymous, Inc . Deaconess Riley Pediatric Clinic 2,417 291,434 118,253 173,181

Prenatal Clinic

Physician Finder 6,665 7,095 0 7,095

Resource Center: 72,032 350,792 118,375 232,417 Blood Pressure Screenings

Blood Sugars Cholesterol Testing

Companion Service

Flu Shots Glaucoma Testing

Helping Hand Program Holistic Healthcare Program

Lipid Screenings Medicare Supplement Enrollees

Phone Counseling Physician Referrals

Processing of Insurance Claims Resource Center Lectures Skin Cancer Screenings

Stroke Screenings Telecare Program

Rural Specialty Clinics 149,442 149,442

Services to Indigent 21,000 21,000 School Physicals Wound Care Center

Total Subsidized Services 156,944 8,147,244 5,364,611 2,782,633

2 . Medical Services Not Duplicated By Other Agencies

Hyperbaric Services

Cystic Fibrosis Clinic & Pediatric Pulmonary Care Clinic 0 2,359 0 2,359 Poison Control Center 50 332 332

Total Services Not Duplicated By Other Agencies 50 2,691 0 2,691

3. Donations to Various Health Related & Other Organizations Including:

American Cancer Society 340 14,117 40 14,077 Boy Scouts of America 300 2,463 2,463 Center City Corporation Deaconess/Ohio Valley Hospice Easter Seals 58 58 ECHO Health Clinic Girl Scouts of America 44,000 1,690 1,690 National Multiple Sclerosis Society Ohio Valley Heart Care Other Rural Health Facilities Rescue Mission YWCA 520 0 520 YMCA 2,500 7,298 7,298

Total donations to Various Health Related & Other Organizations 47,140 26,146 40 26,106

4. Services/In-Kind Donations

Advisory to College Students 1,252 0 1,252 Adopt-A-Family Program 65 507 0 507 AIDS Resource Group 2 0 Albion Center 600 600 ALS American Diabetes Association 196 196 American Heart Association 3,600 6,223 6,223 American Heart 8c Stroke Association ARK Crisis Nursery Arthritis Foundation Annotto Bay Hospital, Jamaica 88,662 88,662 Boys and Girls Club 86 324 0 324 Community Benefit Committee 200 6,472 6,472 Deaconess Volunteer Services Program 57,791 57,791 Dietary In-Kind Services for Community Organizations and Support Groups 5,624 96,075 96,075 Equipment Donation for Philippines Evansville Association of Retarded Citizens 25 6,365 0 6,365 Evansville Chamber of Commerce 0 r 3,750 0 ~ 3,750

Weed & Seed 182 182 Total

S West S!ide Nut Club Total

Services/In-Kind Donations 117,079 1,077,804 30,811 1,046,993 Services/In-Kind Donations

5 . Education for Health Care Professionals And Students

Continuing Education for Professional Staff 137 597,076 0 597,076 CPR Courses-Adult Graduate Medical Education Programs

Indiana University Student Education 18 11,001 11,001 Pharmacy Student Education

Various University Student Rotations and Affiliations 1,011 104,721 0 104,721

Total Education for Health Care Professionals & Students 1,166 712,798 0 712,798

. Health Care Related Programs

Chaplain Residency Program 50,946 9,753 41,193 Clinical Pastoral Education Programs 21,457 21,457 Physician/Clergy Conference 225 4,562 4,562

Total Health Care Related Educational Programs 225 76,965 9,753 67,212

7. Prevention, Wellness and Community Health Education

a . Accidents :

Bike Safety Programs

Brain Injury Task Force 274 274 Companion Service

Disaster Recovery Business Alliance Earthquake Preparedness Presentation

Emergency Department Community Presentations Health Education Programs in Schools

Poison Prevention Training in Schools and for Public Regional Poison Control Center

Think First Prevention Program in Schools 5,083 4,805 4,805

Trauma Presentations 9,718 9,718

b. Alcohol & Drugs

dR Deaconess ~a 1 th System

2004 Community Benefit Report Includes financial information from Fiscal Year 2004

1 Deaconess Health System

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..2

A Heritage of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

" Mission " Values " Goals

The Community Benefit Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Caring for the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Compassion with a Plan .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 " Evaluating the plan's effectiveness " Soliciting the views of the community " Establishing measurable objectives " Budgeting for community benefit activities

Making a Difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 " Well Aware Delaware " Jacobsville Family Fun & Health Fair " SWIRCA Spring Health Festival " Community Stroke Screening " Buddy Walk " Spiritual Care Program " Yellow Ribbon Adolescent Suicide Prevention

Program

Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

The Path Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Deaconess Health System

Executive Summary

Deaconess-Health System is a premiere provider of health care

services in southwestern Indiana, western Kentucky and

southeastern Illinois. For more than a century, Deaconess has

remained a steady caregiver, embracing the community's needs

with expertise and compassion . As a not-for-profit health care

provider, Deaconess has enjoyed many accomplishments,

including being named one of the nation's Top 100 Hospitals by

HCIA Sachs and one of America's Best Hospitals by U.S. News

& World Report.

In acting to fulfill our mission and public trust, Deaconess strives

to benefit the communities we serve . These "community benefit"

activities relate to accessibility and affordability of the

_ - community's health system . Community benefit activities pay

_ specific attention to community collaboration, community

capacity building, and people in the community with unmet health needs.

' Some examples of the many types of community benefit programming include :

" Improving access to primary care, especially for the medically indigent

" Managing some aspects of the uncompensated care

problem to improve access to charity care

" Facilitating enrollment in health care coverage for vulnerable

populations

" Providing direct assistance to community services " Supporting, providing and advocating for health education,

health promotion and disease prevention

" Collaborating with other community organizations in quality

of life or healthy communities initiatives that create the

conditions in which people can be healthy

Last year, nearly 400,000 people were served through

community benefit activities at a cost of more than $86 million .

This amount has grown 58 .7 percent since 2001 .

" Nearly $12 million was spent on traditional charity care

2


" More than $5 .1 million was donated through community activities and services

" More than $69 million was spent on unreimbursed care

Following are some community activities in which Deaconess

employees have been heavily involved . While some of these

activities occurred solely in 2004, many are ongoing:

" Well Aware Delaware

" Jacobsville Family Fun & Health Fair

" SWIRCA Spring Health Festival

" Community Stroke Screening

" Buddy Walk

" Spiritual Care Program " Yellow Ribbon Adolescent Suicide Prevention Program

_ - Additionally, Deaconess is involved in many community initiatives, including health education, medical and health

_ research and training, and various programs and services .

Dozens of organizations benefited from Deaconess community benefit activities and sponsorships in 2004 .

After a thorough review of available research, and in

consideration of the health system's strengths and resources,

the Community Benefit Committee selected the following four

needs as priorities or areas of emphasis during 2005 :

" Dental Care

" Medication Assistance

" Mental Health

" Nutrition/Food Assistance

We look forward in the coming year to providing quality programs

and services that benefit the community .


A Heritage of Service

Deaconess Health System is a premiere provider of health care

services in southwestern Indiana, western Kentucky and

southeastern Illinois . The system includes four hospitals, located

in southern Indiana : Deaconess Hospital, an acute care facility ;

The Women's Hospital, serving the needs of women and infants ;

Deaconess Cross Pointe, a behavioral health hospital ; and

HeaIthSouth Deaconess Rehabilitation Hospital, specializing in

comprehensive medical rehabilitation . Also included in the

system are a freestanding cancer center, a health system and

physician owned managed care network of preferred hospitals

and doctors, two ambulatory surgery centers, 14 ambulatory

care sites, two urgent care facilities and multiple partnerships

L

with other health care providers .

OWU _ For more than a century, Deaconess has remained a steady

caregiver, embracing the community's needs with expertise and

compassion . As a not-for-profit health care provider, Deaconess

has enjoyed many accomplishments, including being named one

of the nation's Top 100 Hospitals by HCIA Sachs and one of

America's Best Hospitals by U.S . News & World Report.

Mission . In keeping with its Christian heritage and tradition of service, the mission of Deaconess is to provide quality health

care services with a compassionate and caring spirit to persons, families and communities of the Tri-State .

Values . At Deaconess, our values are based on our commitment to quality . We define quality as the continuous improvement of services to meet the needs and exceed the expectations of the

customers we serve . Following are our values :

" Quality in everything we do

" Respect for all people

" Efficiency and effectiveness in the use of resources

" Innovation toward continuous systems improvement

" Partnership with those we serve and with suppliers

" Education for continuous growth and knowledge

" Pride in workmanship

4


Goals. To accomplish its mission, Deaconess is committed to

improving the quality of life for the people of the Tri-State by :

" Demonstrating excellence in health care services

" Providing access to health care

" Providing charity care to those in need

" Promoting healthy lifestyles

" Offering spiritual and psychological support

" Supporting health related education

" Advancing health knowledge through research

The Community Benefit Commitment

In acting to fulfill our mission and public trust, Deaconess strives

_ - to benefit the communities we serve . These "community benefit"

_ activities relate to accessibility and affordability of the community's health system . Community benefit activities pay

specific attention to community collaboration, community

capacity building and people in the community with unmet health

needs .

Deaconess organizes and manages its community benefit

programs that include measurable goals and involve the

coordination of all health system components - including the

medical staff. Community benefit programs build on and work to

expand and align our ongoing health improvement and

community service initiatives into our strategic plan and budget .

Collaboration with health services and other community

organizations is an important characteristic of community benefit

efforts . These initiatives can target physical, mental, emotional or

spiritual health, as well as community well being. Their activities

may involve funding and/or in-kind contributions including

personnel, time, space or other resources .

Some examples of the many types of community benefit

programming include :

5


" Improving access to primary care, especially for the medically indigent

" Managing some aspects of the uncompensated care problem to improve access to charity care

" Facilitating enrollment in health care coverage for vulnerable

populations " Providing direct assistance to community services " Supporting, providing and advocating for health education,

health promotion and disease prevention

" Collaborating with other community organizations in quality

of life or healthy communities initiatives that create the conditions in which people can be healthy

Caring for the Community

=q6, 'PAM The state of Indiana's definition of "community benefit" lays out _ what is legally meant by community benefit activities :

Community Benefrt.The unreimbursed cost to a hospital of providing charity care, government-sponsored indigent

health care, donations, education, government sponsored services, research and subsidized health services.

Although the state of Indiana gives a good guideline for what is

meant, it does not truly convey all that community benefit

represents to Deaconess . Community benefit activities

demonstrate how the health system has expanded the depth of its services that are available to the community . Our neighbors,

our families, our friends - all are affected by the dollars

dedicated by Deaconess to community benefit activities .

Since Deaconess is a not-for-profit health system, our

community benefit activities support that not-for-profit privilege

by sharing our resources to help people in the Tri-State

community .


Compassion with a Plan

When developing our community benefit plan, several steps are

taken :

1 . We assess the needs of the community .

2 . We set goals to address specific needs .

3 . We develop programs and services to meet those needs .

4 . We evaluate our effectiveness .

To complete the needs assessment, information was reviewed

from numerous studies that assessed the community's health

status . Among these reports were the Needs and Capacity Study

produced by the United Way of Southwestern Indiana ; Healthy

Hoosiers 2000, provided by the Indiana State Department of

Health ; Indiana Public Health Priorities, compiled by the Indiana

_ - State Department of Health ; summary reports for Business &

_ Industry clients, completed by the Deaconess Hospital Wellness

Department; community surveys distributed and compiled by the

Deaconess Hospital Family Practice Center; and research

conducted by the Community Benefit Committee through one-

on-one contact with local agencies .

After a thorough review of all these studies, and in consideration

of the health system's strengths and resources, the Community

Benefit Committee selected the following four needs as priorities

or areas of emphasis during 2005 :

" Dental Care


" Mental Health


Evaluating the plan's effectiveness . Deaconess measures the

effectiveness of the plan by evaluating the accomplishment of

goals and timetables, conducting pre- and post-activity health

screenings and analyzing improvements and deficiencies .

Soliciting the views of the community . Deaconess uses its

Community Benefit Committee to prioritize the many needs of

the community and to focus the health system's resources where

they can have the greatest impact . This committee is comprised

of community and health system leaders .

Establishing measurable objectives . Following are Deaconess

community benefit goals for 2004 and examples of how we met

those goals :

1 . Lifestyle-related health and wellness

" Resource Center for Healthy Living

" Health system-sponsored education programs

2 . Provide programs and services aimed at reducing infant

mortality and morbidity rates of the community

" Deaconess Family Practice Center's Mentor Mom

program " Health system-sponsored education programs

3 . Affordable and accessible health care

_ FA

Deaconess Family Practice Center

" University of Southern Indiana Health Clinic

_ " Deaconess Riley Children's Specialty Clinic

4 . Support and foster community initiatives and citizen

involvement in improving health care

" Deaconess Family Practice Center's Community

Advisory Board

" Community Benefit Committee

" Donation of automated electronic defibrillators to

community organizations and venues " Well Aware Delaware

Budgeting for community benefit activities . When the health

system tracks community benefit dollars, we follow our fiscal

year, and we base these dollars on three categories :

" Traditional charity care, where the health system directly

pays for a patient's care because of inability to pay

" The unreimbursed cost of providing care to Medicare and

Medicaid patients ; also included in this category are

uncollected care costs, where costs have been charged but

not collected from patients able to pay (or bad debts)

" The health system sponsored programs and services

provided in the community at no or nominal cost


percent since 2001 .

Community Benefit Expenditures

$1oo,ooo,ooo $90,000,000 $80,000,000 $70,000,000 $60,000,000 $50,000,000 $40,000,000 $30,000,000 $20,000,000

$10,000,000 $0

Fiscal Year : 2001 2002 2003 2004

=q6, Pim

activities and services

Charity $11,919,660

Communit Activities $5,167,327

Unreimbursed Care,

$69,231,309


Making a Difference

Last year, nearly 400,000 people were served through

community benefit activities at a cost of more than $86 million .

As shown in the chart below, this amount has grown 58 .7

You can see how these dollars for 2004 were distributed in the

pie chart below:

" Nearly $12 million was spent on traditional charity care " More than $69 million was spent on unreimbursed care

" More than $5.1 million was donated through community

Deaconess continues to expand its community benefit resources as indicated by the following charts .

Charity Care

$14,000,000

$12,000,000

$10,000,000

$8,000,000

$6,000,000

$4,000,000

$2,000,000

$0 Fiscal Year: 2001 2002 2003 2004

=q,k L Traditional charity care involves providing free or reduced health care to those who meet certain income guidelines . Deaconess continually monitors economic factors and

adjusts the guidelines to ensure the health care needs of low income families are met.

Unreimbursed Care

$70,000,000 $60,000,000 $50,000,000

$40,000,000

$30,000,000

$20,000,000

$10,000,000

$0 Fiscal Year: 2001 2002 2003 2004


Unreimbursed care involves charges incurred for which Deaconess receives no reimbursement. The biggest driver

is a shortfall in reimbursements from government-funded programs (Medicare and Medicaid) . Also included in this category is uncollected debt .

$6,000,000

$5,000,000

$4,000,000

$3,000,000

$2,000,000

$1,000,000

$0

Fiscal Year: 2001 2002 2003 2004

FY01-02 Deaconess Hosortal Onlv FY03 Deaconess Hosititall and


Community Activities

Cross POIMB only FYUO tI1LIWM 811 U28COf12S5 Me81f11 bysiern entities

Following are summaries of various community activities in

which Deaconess employees have been heavily involved . While

some of these activities occurred solely in 2004, many are

_ PAM ongoing .

Well Aware Delaware. Deaconess Health system joined with

Delaware Elementary School, located in the Jacobsville

neighborhood, in initiating and promoting the Well Aware

Delaware program for one reason : to improve the health of

families in our own neighborhood by increasing knowledge of

nutrition and physical activity . Some examples of the Well Aware

Delaware collaboration to date include the following :

" Delaware leaders were invited to serve as ad-hoc members

of the Deaconess Community Benefit Committee . This

allowed for better communication of needs and better

planning .

" Deaconess donated transportation vouchers for Delaware

families to use for health-related appointments .

" Deaconess employees conducted after-school programs for

students that featured nutrition and exercise .

" The Indy 1000 contest was implemented to encourage

Delaware families to exercise . The more exercise, the better

the prizes, which are donated by Deaconess .

" Deaconess employees helped assess student health to

establish a baseline . Students will be reevaluated at the end

of the school year to determine progress .


" Deaconess donated pencils, sharpeners, rulers and pencil

cases for all Delaware students .

" Deaconess is providing health education to parents at

monthly PTA meetings .

Jacobsville Family Fun & Health Fair . More than 200

Jacobsville neighborhood residents attended this annual event .

A variety of free screenings were provided to participants from

elementary school age students to grandparents, including

cholesterol, blood pressure and osteoporosis screenings . Other

health and safety information included :

" Attaining reliable health information

" Lice prevention " Drug and alcohol education

" Bicycle safety

_ PAW

" Information on the boys & girls club

_ Heart health, including smoking cessation

" Cancer education, including breast cancer awareness

" End-of-life care

" Mouth care " Adult day care " Pedestrian safety " Injury prevention

SWIRCA Spring Health Festival . In collaboration with the

Southwestern Indiana Regional Council on Aging (SWIRCA),

Deaconess sponsored this April 2004 event at the SWIRCA

Activity Center . More than 400 seniors accessed a variety of

screenings and assessments, including gait and balance

assessments, depression screening, stroke risk assessment,

diabetes risk assessment, foot assessment, vision/glaucoma

screening, cancer screening, osteoporosis screening, blood

pressure and blood sugar screenings, online health risk

assessment, and hearing screenings .

Community Stroke Screening. The purpose of this screening -

held at Evansville's Memorial Baptist Church in May 2004 - was

to provide education on early recognition and intervention

regarding the signs and symptoms of stroke . More than 260


people participated in the free screening, which checked for

elevated cholesterol/HDL, high blood sugar, elevated blood

pressure, irregular heartbeat, carotid artery disease, and body

mass index . One-on-one counseling was provided by healthcare

professionals, including dietitians, pharmacists, physicians,

social workers and nurses . Overall, nearly 50 Deaconess

employees participated in conducting this screening . Deaconess

extends appreciation for collaboration and support from our

community partners : The American Stroke Association (a

division of the American Heart Association), The Heart Group,

Welborn Clinic, Heartcare LLC, ECHO Community Health

Center, HeaIthSouth Deaconess Rehabilitation Hospital, and

Memorial Baptist Church .

Buddy Walk. The Buddy Walk promotes acceptance and

_ - inclusion of people with Down syndrome . It is the premier

advocacy event for Down syndrome and has become a major

_ platform for inclusion in communities across the country . The

Women's Hospital is a major sponsor of the local Buddy Walk,

providing funds for printing Buddy Walk materials and event

preparation . The Women's Hospital also hosts SMILE, a local

parent-to-parent group that exists to help educate and

encourage each other in matters regarding Down syndrome . The

group meets at The Women's Hospital . The Women's Hospital

takes pride in spending community benefit dollars to help with

this family-based event and organization .

Spiritual Care Program. Hopelessness is thought to be one of

the reasons for non-compliance in chronically ill patients . The

Spiritual Care Program uses spirituality to address this issue

through the use of individual patient education, group education

sessions, one-on-one counseling, chronic disease support

group, and referrals to the chaplain's office . While Deaconess

received a grant to help support the program, Deaconess also contributes financially for medications .

Yellow Ribbon Adolescent Suicide Prevention Program .

Deaconess Cross Pointe has offered the Yellow Ribbon

Adolescent Suicide Prevention Program for the last 3 years .

13

43 ~q EMA L

1

Deaconess is involved in many community initiatives, including

health education, medical and health research and training, and

various programs and services . Following is a partial list of

organizations benefiting from Deaconess community benefit

activities and sponsorships in 2004 : Albion Fellows Bacon Center Alzheimer's Association American Cancer Society American Diabetes Association American Heart Association American Red Cross ARK Crisis Nursery Arthritis Foundation Beacon Group Big Brothers Big Sisters Boy Scouts of America Boys & Girls Club of Evansvdle Children's Fit-for-Life Foundation Cystic Fibrosis Foundation Downtown Evansvdle, Inc Easter Seals ECHO Community Health Care Evansvdle African-American Museum Evansvdle ARC Evansvdle-Vanderburgh School Corporation First District Medical Society Fraternal Order of Police Gibson General Health Foundation Girls Scouts of Ramtree Council Goodwill Industries Habitat for Humanity Hands On Discovery Homeward Bound

IMPACT Ministries Indiana University Medical School (Evansvdle campus) Ivy Tech Foundation Jacobswlle Neighborhood Association Leadership Evansvdle Meals on Wheels Multiple Sclerosis Society Muscular Dystrophy Association National Down Syndrome Society National Kidney Foundation Ozanam Family Shelter Patchwork Central Potter's Wheel Riley Hospital for Children Special Olympics Susan G Komen Breast Cancer Foundation The Arts Council Thunder on the Ohio United Family Care Services United Way University of Evansville University of Southern Indiana West Sector Neighborhood YMCA Youth First, Inc . YWCA


During that time, the training has been offered in the Tri-State to

more than 7,500 adolescents and 500 educators, parents and

other interested adults . The program is a non-threatening suicide

prevention training program rooted in education and awareness

of depression and suicide among adolescents . It teaches

children, youth and adults to ask for help in times of crisis . It also

teaches how to respond to a crisis to help prevent suicide . The

program is geared primarily to teens ; however, it can be tailored

to be presented to educators, parents and other adults interested

in the welfare of teens . Deaconess Cross Pointe has offered the

program at Tri-State middle schools and high schools and to

educators, PTA/PTSA groups, church groups and health care

professionals .

Beneficiaries


The Path Forward

After a thorough review of community studies, and in

consideration of the health system's strengths and resources,

the Community Benefit Committee selected the following four

needs as priorities or areas of emphasis during 2005:

" Dental Care


" Mental Health


Deaconess is dedicated to embracing the community's needs

with expertise and compassion and fulfilling its mission of

providing quality health care services with a compassionate and

caring spirit to persons, families and communities of the Tri-

_ - State.

Questions about Deaconess community benefit activities? Contact the Public Relations Department

Deaconess Health System 600 Mary Street, Evansville, IN 47747

812-450-3199


FORM 990, PART IV - INVESTMENTS - SECURITIES

369,695 . 3,625,345 . 4,706,852 . 233,385 .

7,425,829 .

3,491,958 . 20,056,980 . 33,679,856 . 53,369,589 .

298,814 . ---------------

127,258,253 .

STATEMENT 7

5DF42T 1274 V03-8 002-01850448

DESCRIPTION

RESTRICTED FUNDS : CASH & SHORT-TERM US GOVERNMENT OBLIGATIONS MARKETABLE SECURITIES ACRUED INTEREST & OTHER

FUNDS HELD BY TRUSTEE : CASH & SHORT-TERM

BOARD DESIGNATED FUNDS : CASH & SHORT-TERM US GOVERNMENT OBLIGATIONS CORPORATE OBLIGATIONS MARKETABLE SECURITIES ACCRUED INTEREST

TOTALS

BEGINNING BOOK VALUE

35-0593390

ENDING BOOK VALUE

476,659 . 3,418,768 . 5,286,294 .

-3,394 .

81,531,576 .

5,575,269 . 14,654,967 . 30,323,753 . 49,481,437 .

207,440 . ---------------

190,952,769 .

12,907,799 . 3,213,846 .

880,813 . ---------------

17,002,458 .

STATEMENT 8

V03-8 002-01850448 5DF42T 1274



FORM 990, PART IV - OTHER ASSETS

DESCRIPTION

INVESTMENT IN SUBSIDIARY SUNDRY DEFERRED FINANCING COSTS

TOTALS

35-0593390

ENDING BOOK VALUE

23,802,074 . 4,668,218 . 3,373,737 .

---------------31,844,029 .

166,683,076

STATEMENT 8A


Part N - Line 64(a) -Tax Exempt Bond Liabilities

September 30, 2004

9/30/2004

Adjustable Convertible Extendible Securities Hospital Revenue Bonds, Serves 1992 : Serial bonds, payable annually from January 2002 through January 2022 in amounts ranging from $500,000 to $1,700,000 plus interest at variable rates 18,500,000 (1.04% and 142% at September 30, 2003 and 2002)

Hospital Revenue Refunding Bonds, Series 1993 Serial bonds, payable annually through March 2004 in amounts ranging from $1,825,000 to $1,920,000; interest ranging from 2.0% to 5.3% -

Term bonds, payable from March 2005 through March 2015(through operation of a mandatory sinking fund) ; interest ranging from 5.65% to 5.75% -

Original issue discount and premiums, net 548,076 548,076

Hospital Revenue Refunding Bonds, Serves 1999A: Sepal Bonds, payable annually March 2003, through March 2009 in amounts ranging from $445,000 to $580,000, interest ranging from 4.25% to 4 8% 2,650,000

Term bonds, payable from March 2010 through March 2029 (through operation of a mandatory sinking fund) ; interest ranging from 5 5% to 5.75% 21,515,000

Hospital Revenue Bonds, Series 19998 : Sepal bonds, payable annually from January 2003 through January 2019 in amounts ranging from $600,000 to $1,600,000 plus interest at variable rates (1 .24% and 1 72%) 15,800,000

Variable Rate Certificates with maturities beginning in 2004 and ending in 2024 ; interest rate at BMA plus 40 basis points (1 .91 % at September 30, 2004) 27,905,000

Hospital Revenue Bonds, Serves 2004A : Term bonds, payable from March 2020 through March 2034 (through operation of a mandatory sinking fund), interest rates ranging from 5 00% to 5.375% 54,765,000

Hospital Revenue Bonds, Series 2004B Sepal bonds, payable annually from January 2010 through January 2029 in amounts ranging from $870,000 to $1,720,000 plus interest at a variable rate of 1 51 % at September 30, 2004 25,000,000

DESCRIPTION

10,195,449 . 5,895,534 .

NONE ---------------

16,090,983 .

STATEMENT 9

V03-8 002-01850448 5DF42T 1274


FORM 990, PART IV - OTHER LIABILITIES

SALARIES AND WAGES EST . THIRD-PARTY SETTLEMENTS ACCRUED PENSION/ACCRUED SICK

TOTALS


35-0593390

ENDING BOOK VALUE

10,544,818 . 4,590,476 . 14,141,123 .

---------------29,276,417 .

5De42T 1274 v03-8 002-01850448


FORM 990, PART IV-A - OTHER REVENUE ON HOOKS BUT NOT ON RETURN

DESCRIPTION AMOUNT ----------- ------

INCOME FROM AFFILIATES 6,325,829 . ---------------

TOTAL 6,325,829 .

STATEMENT 10

35-0593390

FORM 990, PART IV-A - OTHER REVENUE ON RETURN BUT NOT ON BOOKS

5DE42T 1274 V03-8 002-01850448

DEACONESS HOSPITAL, INC.

DESCRIPTION

INTERN RESIDENCY PROGRAM FOUNDATION INCOME EXPENSE REIMBURSEMENT FOR

LAUNDRY SERVICES RENTAL EXPENSES HEALTHCARE GROUP, LLC

TOTAL

AMOUNT

200,870 . 1,525,716 .

97,648 . -176,571 . -10,929 .

---------------1,636,734 .

STATEMENT 11

35-0593390

FORM 990, PART IV-B - OTHER EXPENSES ON RETURN BUT NOT ON BOORS

V03-8 002-01850448 5DF42T 1274


DESCRIPTION

INTERN RESIDENCY PROGRAM FOUNDATION EXPENSES LAUNDRY EXPENSES OFFSET BY EXPENSE RECOVERY ON BOOKS

RENTAL EXPENSES SCHOLARSHIPS MISC . PROGRAM EXPENSES

TOTAL

AMOUNT

200,870 . 453,145 .

97,648 . -176,571 .

53,500 . 857,588 .

---------------1,486,180 .

STATEMENT 12

'* See Statement 14a Statement 13

Deaconess Hospital, Inc 35-0593390

Part V - List of Officers, Directors, 8 Trustees - 9/30/2004

Time Devoted Employee

To Benefit Other Name Address Title Position Comp. Plan Allowance

Thomas H. Kramer 600 Mary Street Director 40+ $1,066,841 $ 24,910 $ 2,899 EvansvdIe,IN 47747

James H. Muehlbauer 14 S Eleventh Avenue Chairman Part - -Evansvdte,IN 47744

Robert B. Wright 4500 Division Secretary 8 Part - - -Evansville, IN 47715 Treasurer

Richard M. Slivers 600 Mary Street Chief Financial 40t 410,934 24,143 9,004 Evansville, IN 47747 Officer

Linda E. White 600 Mary Street President & 40+ 550,924 29,276 8,100 EvansvdIe,IN 47747 C.E.O .

Howard S Abrams 501 Scenic Dr Director Part - - -EvansvdIe,IN 47715

Jerome A. Benkert, Jr . P.O . Box 209 Director Part - -Evansville, IN 47702

David D. Chnsteson 421 Chestnut Street Director Part - - -EvansvdIe,IN 47713

H . Lee Cooper 539 Pfeiffer Road Director Part - - -Evansville, IN 47711

Jean G . Dremstedt 600 S . Cullen Ave . #501 Director Part - - -EvansvdIe,IN 47715

William Hardesty, MD 2010 Center Drive Director 40+ 227,045 31,518 -Evansville, IN 47711

Michael H Head 2200 West Franklin Street Director Part - - -Evansville, IN 47712

H. Ray Hoops 8600 University Blvd . Director Part - - -Evansville, IN 47712

Michael B. Hoover, MD 520 Mary St., Ste . 520 Director Part - - -Evansville, IN 47710

William C. Houser, MD 611 Harriet St , Ste 504 Director Part - - -Evansville, IN 47710

Matthew R . Lee, MD P O Box 717 Director Part - -Mt. Vernon, IN 47620

Marilyn Morns 53 Park Ridge Drive Director Part - - -Mt Vernon, IN 47620

William R. Penland, MD 1020 W Buena Vista Rd Vice-Chairman Part - -EvansvdIe,IN 47710

Ronald G. Reherman 10881 Watershore Drive Director Part -Evansville, IN 47710

Richard W Shymanski 20 NW Third Street Director Part - -Evansville, IN 47705

Bruce Stallings P O Box 4129 Director Part - - -Evansville, IN 47724

Jaleigh J. White P O Box 719 Director Part - - -EvansvdIe,IN 47705

2,255,744 109,847 20,003

**

.*

35-0593390 Deaconess Hospital, Inc .

Part V - Compensation and Benefits by Related Corporations

Period Ending September 30, 2004

Other Name Title Compensation Benefits Allowance

Thomas H. Kramer Director 8 President

10+ hours/week

Richard M . Stivers Asst Treasurer/Asst Secretary/ CFO

10+ hours/week Deaconess Health System, Inc. $73,457 $8,048 $0(1) 35-1532289

Statement 14

Deaconess Health System, Inc. $134,591 $8,303 $0(1) 35-1532289

(1) Mr . Kramer and Mr. Stivers had no reportable expense accounts or other allowance accounts for Deaconess Health System, Inc.

Statement 14a

Part V - List of Officers, Directors & Trustees 9/30/04

Note 1 :

Report of the Compensation/Benefits/Pension & Insurance Committee

The Compensation/Benefits/Pension & Insurance Committee ("the Committee") is providing this report to explain the Committee's responsibilities, the Company's compensation policies and practices with respect to its executives, and the 2004 compensation of the Company's top three executive officers . The Committee membership consists solely of seven (7) non-employee "independent" directors .

Consistent with resolutions adopted by the Company's Board of Directors and acting under a written charter, the principal functions of the Committee are to :

1 . Determine the compensation of executive officers ; (executive officers are the President and CEO, Deaconess Health System, Inc . ; the President and CEO, Deaconess Hospital, Inc . ; and the Chief Financial Officer, Deaconess Health System, Inc.) ;

2 . Determine the compensation payable to employed physicians and contracts for services between Deaconess entities and independent physicians ;

3 . Determine executive benefits and other employee benefits of a material nature ;

4 . Approve any administrative changes to employee pension programs; and 5. Approve the annual comprehensive insurance program .

The Company's pay philosophy is that the compensation of the Company's executives and key employees should :

1 . Be reasonable and designed to promote the achievement of the Company's mission, financial operations, community benefit and charitable objectives ;

2 . Provide pay that is externally competitive and internally equitable ; 3 . Allow the Company to attract, retain, and motivate executives and key

employees necessary to accomplish its objectives ; and 4. Reward exceptional performance .

During 2001, the Committee retained Clark Consulting, an independent consulting firm, to conduct a comprehensive executive compensation study for the Company. The Committee commissioned the study to obtain an up-to-date competitive pay analysis and evaluation of the Company's executive compensation policies and practices .

Based on the 2001 study, the Committee implemented various changes in the Company's executive compensation policies during 2001, 2002 and 2003 . In 2004, the Committee considered the recommendations and relied on information provided by Clark Consulting for base salary increases and incentive awards based on goal achievement.

Statement 14a

The Committee retains William M. Mercer Company, an independent consulting firm, to provide pension plan consulting and actuary services . Based upon recommendations of the consultant, a supplemental executive retirement plan was adopted by the Committee in 1996 for the executive officers of the Company. The supplemental executive retirement plan represents benefits that are earned over the career of the executive in order to provide retirement benefits as determined by the independent consultant to be competitive within the industry . In fiscal year 2002, based upon recommendations of the consultant, the Committee approved a pro rata payment to each executive officer based upon his or her prior years of service. Annual payments were made in 2003 and 2004 based upon calculations provided by William M . Mercer Company. These amounts are contained in "Supplemental Retirement Benefit."

Statement 14a

Compensation of Executive Officers Summary Compensation Table

Name and Principal Fiscal Base Incentive Supplemental Other Other Position Year Salary' Award' Retirement BenefitsZ Compensation

Benefit' Allowance 3 Thomas H . Kramer, 2004 $557,837 $205,800 $437,795 $33,213 $2,899 President and CEO, Deaconess Health System, Inc. and 2003 $488,942 $177,444 $315,198 $5,820 $3,018 Chairman, Deaconess Hospital, Inc.

2002 $461,923 $169,831 $1,715,501 $5,812 $3,769 Linda E. White, 2004 $353,745 $92,625 $104,554 $29,276 $8,100 President and CEO, Deaconess Hospital, Inc.

2003 $323,943 $92,923 $90,287 $6,499 $6,600

2002 $281,999 $89,092 $591,875 $5,812 $5,575 Richard M. Stivers, 2004 $304,778 $90,300 $89,313 $32,190 $9,004 Senior Vice President and Chief Financial Officer, Deaconess Health 2003 $279,365 $96,215 $82,460 $9,272 $7,927 System, Inc. and Deaconess Hospital, Inc.

2002 $263,954 $86,352 $497,180 $6,777 $7,182

'Base salary, incentive award and supplemental retirement benefit equal total cash compensation .

20ther benefits include health insurance, dental insurance, life insurance, long-term disability, employee 401 k matching contribution, and pension.

30ther compensation allowances include reimbursement to the employee for financial planning and tax services, and taxable portion of personal use of a company owned vehicle .

DEACONESS HEALTH SYSTEM, INC . TRI-STATE MEDICAL MANAGEMENT DEACONESS BREAST CENTER, LLC DEACONESS WOMEN'S HOSPITAL OF SOUTHERN INDIANA, LLC UNITED HEARTCARE INSTITUTE, LLC HEARTCARE HEALTH SYSTEM, LLC DEACONESS HEALTH PLANS GATEWAY RADIOLOGICAL IMAGING INC . EVANSVILLE SURGERY CENTER ASSOCIATES, LLP DEACONESS CROSS POINT DEACONESS HEALTH CONNECTION

STATEMENT 15

V03-8 002-01850448 5DF42T 1274


FORM 990, PART VI - NAMES OF RELATED ORGANIZATIONS

35-0593390

EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT NON-EXEMPT


FORM 990, PART VII - OTHER REVENUE

EXCLUSION CODE

03

03

AMOUNT

1,142,253 .

44,208 .

812300

03 821,621 .

------------ 2,008,082 .

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

1,968,504 .

5DF42T 1274 V03-8 002-01850448 STATEMENT 16

DESCRIPTION

CAFETERIA COMM VENDING & BARBER

ROUTINE/ANCILLARY SERVICES

LAUNDRY SALES TO OTHER ENTITIES

OTHER HOSPITAL SERVICES

TOTALS

BUSINESS CODE AMOUNT

1,870,856 .

97,648 .

35-0593390

RELATED OR EXEMPT FUNCTION INCOME ---------------

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

35-0593390

STATEMENT 16A

1


Part VIII - Relationship of Activities to the Accomplishment of Exempt Purposes

September 30, 2004

Deaconess Hospital generates the patient service revenue through the operation of a 394 bed acute care facility . This mission of the Hospital is to serve the community with respect to providing health care services and health care education . Quality health care is provided regardless of race, creed, sex, national origin, age or ability to pay . Although reimbursement for services rendered is critical to the operation and stability of the Hospital, it is recognized that not all individuals possess the ability to purchase essential medical services . Therefore, the Hospital is committed to serve all members of its community through:

" Free care and/or subsidized care . " Care to persons covered by governmental programs at below cost . " Health activities and programs to support the community .

The Hospital also operates an emergency room which is open 24 hours a day, 365 days a year.

Part III of Form 990 lists various medical and non-medical services provided to the community.


FORM 990, PART IX - INFORMATION REGARDING TAXABLE SUBSIDIARIES

PERCENTAGE NATURE OF NAME AND ADDRESS OWNERSHIP BUSINESS TOTAL EMPLOYER IDENTIFICATION NUMBER INTEREST ACTIVITIES INCOME ------------------------------ -------- ---------- ------

DEACONESS HEALTH PLANS 92 .729432 PREF PROV ORG 1,484,565 .

100 .000000 MGMT SVCS

50 .000000 PREF PROV ORG

50 .000000 OUTPATIENT

50 .000000 SHELL CORP

10,458,903 .

V03-8 002-01850448 5DF42T 1274 STATEMENT 17

600 MARY STREET EVANSVILLE, IN 47710 38-3492529 TRI-STATE MEDICAL

NIANAGMENT EVANSVILLE, IN 47710 35-1875888 DEACONESS HEALTH CONNECTION 617 WEST DELAWARE EVANSVILLE, IN 47710 35-1942931 DEACONESS WOMENS' HOSPITAL OF

SOUTHERN INDIANA, LLC EVANSVILLE, IN 47710 35-2062016 DEACONESS BREAST CENTER, LLC

EVANSVILLE, IN 47710 35-2056384 UNITED HEART CARE INSTITUTE 415 WEST COLUMBIA EVANSVILLE, IN 47710 35-1967194 HEARTCARE HEALTH SYSTEMS, LLC 415 WEST COLUMBIA EVANSVILLE, IN 47710 35-2038344 DEACONESS CROSS POINTE 7200 EAST INDIANA STREET EVANSVILLE, IN 47715 35-2060259

50 .000000 HOSPITAL

50 .000000 HEALTHCARE

100 .000000 HEALTHCARE

3,061,300 .

NONE

30,463,910 .

1,947,704 .

NONE

1,036,350 .

ENDING ASSETS

1,106,343 .

809,281 .

NONE

8,373,171 .

1,023,110 .

NONE

135,200 .

6,153,317 .

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

70,033,836 . TOTAL INCOME

STATEMENT 18 5DF42T 1274 V03-8 002-01850448


FORM 990, PART IX - INFORMATION REGARDING TAXABLE SUBSIDIARIES

PERCENTAGE NATURE OF NAME AND ADDRESS OWNERSHIP BUSINESS EMPLOYER IDENTIFICATION NUMBER INTEREST ACTIVITIES ------------------------------ -------- ----------

EVANSVILLE SURGERY CENTER 51 .841439 OUTPATIENT ASSOCIATES, LLP

EVANSVILLE, IN 47728 35-1622992 GATEWAY RADIOLOGICAL 80 .000000 RADIOLOGY

IMAGING, LLC EVANSVILLE, IN 47710 83-0375577

35-0593390

TOTAL INCOME

17,932,223 .

3,648,881 .

ENDING ASSETS

10,376,522 .

3,613,527 .

------------31,590,471 .


SCHEDULE A, PART III - EXPLANATION FOR LINE 3A

5DF42T 1274 V03-8 002-01850448

GRANTS OR SCHOLARSHIPS ARE AWARDED TO FURTHERANCE OF THEIR EDUCATION BASED MERIT .

STUDENT NURSES TO AID IN THE ON FINANCIAL NEED AND ACADEMIC

STATEMENT 19

Form 8868 Application for Extension of Time To File an (December 2000) Exempt Organization Return OMB No 1545-1709 Department of the Treasury Internal Revenue Service 0- File a separate application for each return .

" If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box . . . . . . . . . . . . . . . . 1, - 27L F " If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part 11 (on page 2 of this form) N ote: Do not complete Part R unless you have already been granted an automatic 3-month extension on a previously riled

Form 8868. [M Automatic 3-Month Extension of Time - Only submit original (no copies needed)

Note : Form 990-T corporations requesting an automatic 6-month extension - check this box and complete Part I only . . . . . . . 10. El All other corporations (including Form 990-C hlers) must use Form 7004 to request an extension of time to hle income tax

returns Partnerships, REMICs and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041

Type or Name of Exempt Organization Employer identification number

print DEACONESS HOSPITAL, INC. 35-0593390

File by the due Number, street, and room or suite no If a P 0 box, see instructions.

date for filing 600 MARY STREET your return See -E-ity-, town or post office, state, and ZIP code For a foreign address, see instructions instructions

3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits See instructions $

b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments made Include any prior year overpayment allowed as a credit

* * . " . . . . . . . . . . .

. * . * * " $

c Balance Due. Subtract line 3b from line 3a Include your payment with this form, or, if required, deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System) See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 0

Signature and Verification Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, corkect, and complete, and that I am authorized to prepare this form

211, - lii~ Title 00, -A Date Illo-

ce, see Instruction Form 8868 (12-2000)

5DF42T 1274 V03-8 002-01850448

Check type of return to be filed (file se arate app ication for each retum) X Form 990 Form 990-T (corporation) Form 4720

Form 990-BL Form 990-T(sec 401 (a) or 408(a) trust) Form 5227 Form 990-EZ Form 990-T (trust other than above) Form 6069 Form 990-PF Form 1041-A Form 8870

" If the organization does not have an office or place of business in the United States, check this box . . . . . . . . . . . .

. . No- 1:1 " If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) if this is for the whole group, check this box Do- F~ If it is for part of the group, check this box lip. and attach a list with the names and EINs of all members the extension will cover 1 1 request an automatic 3-month (6-month, for 990-T corporation) extension of time until 05/16 2005

to file the exempt organization return for the organization named above The extension is for the organization's return for 11111. calendar year or 111i RX tax year beginning - 10/01 2003 , and ending 09/30 2004

2 If this tax year is for less than 12 months, check reason 0 Initial return 0 Final return 1:1 Change in accounting period

Signature 111i \ I For PaperworkRe

JSA 3F8054 1 000

9 9 0 i990s.foundationcenter.org/990_pdf_archive/350/350593390/... · 2017. 6. 22. · t form 9 9 0...

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