CLEVELAND, OH Phone no May the IRS discuss this return with the preparer shown above? (see instructions)...

Transcription

1 Form Under setion 501(), 527, or 97(a)(1) of the Internal Revenue Code (exept private foundations) Department of the Treasury u Do not enter Soial Seurity numers on this form as it may e made puli. Internal Revenue Servie u Information aout Form 990 and its instrutions is at A For the 201 alendar year, or tax year eginning, and ending B I J K Chek if appliale: Address hange Name hange Initial return Terminated /1/201 10: AM Ativities & Governane Revenue Expenses Net Assets or Fund Balanes Amended return Appliation pending Tax-exempt status: Wesite: u Form of organization: Part I 1 2 C Name of organization F Doing Business As Return of Organization Exempt From Inome Tax Numer and street (or P.O. ox if mail is not delivered to street address) City or town, state or provine, ountry, and ZIP or foreign postal ode Name and address of prinipal offier: Summary 501() ( ) t (insert no.) 97(a)(1) or Grants and similar amounts paid (Part I, olumn (A), lines 1 ) Benefits paid to or for memers (Part I, olumn (A), line ) Salaries, other ompensation, employee enefits (Part I, olumn (A), lines 5 10) a Professional fundraising fees (Part I, olumn (A), line 11e) Total fundraising expenses (Part I, olumn (D), line 25) u , Other expenses (Part I, olumn (A), lines 11a 11d, 11f 2e) Total expenses. Add lines 1 17 (must equal Part I, olumn (A), line 25) Room/suite D E Telephone numer G Gross reeipts $ OMB No Open to Puli Inspetion Employer identifiation numer H(a) Is this a group return for suordinates? H() Are all suordinates inluded? If "No," attah a list. (see instrutions) H() Group exemption numer u Corporation Trust Assoiation Other u L Year of formation: M State of legal domiile: Briefly desrie the organization's mission or most signifiant ativities: Chek this ox u if the organization disontinued its operations or disposed of more than 25% of its net assets. Numer of voting memers of the governing ody (Part VI, line 1a) Numer of independent voting memers of the governing ody (Part VI, line 1) Total numer of individuals employed in alendar year 201 (Part V, line 2a) Total numer of volunteers (estimate if neessary) a Total unrelated usiness revenue from Part VIII, olumn (C), line Net unrelated usiness taxale inome from Form 990-T, line Prior Year DETROIT AVENUE NORTH COAST HEALTH LAKEWOOD OH ()() SEE SCHEDULE O Contriutions and grants (Part VIII, line 1h) Program servie revenue (Part VIII, line 2g) Investment inome (Part VIII, olumn (A), lines,, and 7d) Other revenue (Part VIII, olumn (A), lines 5, 6d, 8, 9, 10, and 11e) Total revenue add lines 8 through 11 (must equal Part VIII, olumn (A), line 12) Revenue less expenses. Sutrat line 18 from line Total assets (Part, line 16) Total liailities (Part, line 26) Net assets or fund alanes. Sutrat line 21 from line Part II Signature Blok 5 6 7a 7 Beginning of Current Year Yes Yes Current Year End of Year Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Delaration of preparer (other than offier) is ased on all information of whih preparer has any knowledge ,067,51 No No 0 0,58,22 6,065,558,021 1,1 1, ,5,59 6,067, ,00,289 1,001,716 0,79,19,758,50,7,28 5,760, ,889 07,22 915,78 1,251,885 25,72 28,77 661, ,508 Sign Here Paid Preparer Use Only Signature of offier LEE ELMORE Type or print name and title Print/Type preparer's name For Paperwork Redution At Notie, see the separate instrutions. Preparer's signature Date Chek if PTIN LAWRENCE E. YUNASKA CPA LAWRENCE E. YUNASKA CPA 10/1/1 self-employed P } Firm's name Firm's EIN } CLEVELAND, OH 115 Phone no Firm's address } May the IRS disuss this return with the preparer shown aove? (see instrutions).... Date EECUTIVE DIRECTOR BAUMGARTEN & COMPANY LLP EUCLID AVE STE 110 Yes No Form 990 (201)

2 Form 990 (201) Page 2 Part III Statement of Program Servie Aomplishments 1 Briefly desrie the organization's mission: Did the organization undertake any signifiant program servies during the year whih were not listed on the 2 prior Form 990 or 990-EZ? If "Yes," desrie these new servies on Shedule O. Did the organization ease onduting, or make signifiant hanges in how it onduts, any program servies? If "Yes," desrie these hanges on Shedule O. Desrie the organization's program servie aomplishments for eah of its three largest program servies, as measured y expenses. Setion 501()() and 501()() organizations are required to report the amount of grants and alloations to others, the total expenses, and revenue, if any, for eah program servie reported. a (Code: ) (Expenses $ inluding grants of $ ) (Revenue $ ) ) $ (Revenue ) $ inluding grants of $ ) (Expenses (Code: (Code: $ inluding grants of $ ) ) (Expenses $ ) (Revenue. d Other program servies. (Desrie in Shedule O.) (Revenue ) $ (Expenses ) $ inluding grants of $ e Total program servie expenses u Form 990 (201) No Yes Yes No Chek if Shedule O ontains a response or note to any line in this Part III SEE SCHEDULE O 8,898 NORTH COAST HEALTH EISTS TO STRENGTHEN THE QUALITY OF COMMUNITY LIFE THROUGH THE PROVISION OF HEALTH CARE SERVICES TO THOSE THAT DO NOT QUALIFY FOR GOVERNMENTAL MEDICAL AID. THIS COMMITTMENT IS FULFILLED BY PROVIDING MEDICAL SERVICES, INCLUDING DIAGNOSIS, TREATMENT AND REFERRAL; COOPERATING WITH SOCIAL SERVICES AND HEALTH AGENCIES, AND SEEKING ADDITIONAL OPPORTUNITIES TO SERVE THOSE PERSONS IN NEED. 5,68,585 5,52, /1/201 10: AM

3 Form 990 (201) Part IV Cheklist of Required Shedules a 1 1a a d e f 20a Is the organization desried in setion 501()() or 97(a)(1) (other than a private foundation)? If Yes, omplete Shedule A Is the organization required to omplete Shedule B, Shedule of Contriutors (see instrutions)? Did the organization engage in diret or indiret politial ampaign ativities on ehalf of or in opposition to andidates for puli offie? If Yes, omplete Shedule C, Part I Setion 501()() organizations. Did the organization engage in loying ativities, or have a setion 501(h) eletion in effet during the tax year? If "Yes," omplete Shedule C, Part II.... Is the organization a setion 501()(), 501()(5), or 501()(6) organization that reeives memership dues, assessments, or similar amounts as defined in Revenue Proedure 98-19? If "Yes," omplete Shedule C, Part III Did the organization maintain any donor advised funds or any similar funds or aounts for whih donors have the right to provide advie on the distriution or investment of amounts in suh funds or aounts? If Yes, omplete Shedule D, Part I Did the organization reeive or hold a onservation easement, inluding easements to preserve open spae, the environment, histori land areas, or histori strutures? If Yes, omplete Shedule D, Part II Did the organization maintain olletions of works of art, historial treasures, or other similar assets? If Yes, omplete Shedule D, Part III Did the organization report an amount in Part, line 21, for esrow or ustodial aount liaility; serve as a ustodian for amounts not listed in Part ; or provide redit ounseling, det management, redit repair, or det negotiation servies? If Yes, omplete Shedule D, Part IV Did the organization, diretly or through a related organization, hold assets in temporarily restrited endowments, permanent endowments, or quasi-endowments? If Yes, omplete Shedule D, Part V If the organization's answer to any of the following questions is Yes, then omplete Shedule D, Parts VI, VII, VIII, I, or as appliale. Did the organization report an amount for land, uildings, and equipment in Part, line 10? If "Yes," omplete Shedule D, Part VI Did the organization report an amount for investments other seurities in Part, line 12 that is 5% or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part VII Did the organization report an amount for investments program related in Part, line 1 that is 5% or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part VIII Did the organization report an amount for other assets in Part, line 15 that is 5% or more of its total assets reported in Part, line 16? If "Yes," omplete Shedule D, Part I Did the organization report an amount for other liailities in Part, line 25? If "Yes," omplete Shedule D, Part Did the organization's separate or onsolidated finanial statements for the tax year inlude a footnote that addresses the organization's liaility for unertain tax positions under FIN 8 (ASC 70)? If "Yes," omplete Shedule D, Part Did the organization otain separate, independent audited finanial statements for the tax year? If Yes, omplete Shedule D, Parts I and II Was the organization inluded in onsolidated, independent audited finanial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then ompleting Shedule D, Parts I and II is optional Is the organization a shool desried in setion 170()(1)(A)(ii)? If Yes, omplete Shedule E Did the organization maintain an offie, employees, or agents outside of the United States? Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, usiness, investment, and program servie ativities outside the United States, or aggregate foreign investments valued at $100,000 or more? If Yes, omplete Shedule F, Parts I and IV Did the organization report on Part I, olumn (A), line, more than $5,000 of grants or other assistane to or for any foreign organization? If Yes, omplete Shedule F, Parts II and IV.... Did the organization report on Part I, olumn (A), line, more than $5,000 of aggregate grants or other assistane to or for foreign individuals? If Yes, omplete Shedule F, Parts III and IV Did the organization report a total of more than $15,000 of expenses for professional fundraising servies on Part I, olumn (A), lines 6 and 11e? If Yes, omplete Shedule G, Part I (see instrutions) Did the organization report more than $15,000 total of fundraising event gross inome and ontriutions on Part VIII, lines 1 and 8a? If "Yes," omplete Shedule G, Part II Did the organization report more than $15,000 of gross inome from gaming ativities on Part VIII, line 9a? If "Yes," omplete Shedule G, Part III Did the organization operate one or more hospital failities? If Yes, omplete Shedule H If Yes to line 20a, did the organization attah a opy of its audited finanial statements to this return? a d 11e 11f 12a a a 20 Yes Page No Form 990 (201)

4 Form 990 (201) Page Part IV Cheklist of Required Shedules (ontinued) Yes No a a 5a 6 7 d 25a Did the organization report more than $5,000 of grants or other assistane to any domesti organization or government on Part I, olumn (A), line 1? If Yes, omplete Shedule I, Parts I and II Did the organization report more than $5,000 of grants or other assistane to individuals in the United States on Part I, olumn (A), line 2? If "Yes," omplete Shedule I, Parts I and III.... Did the organization answer Yes to Part VII, Setion A, line,, or 5 aout ompensation of the organization's urrent and former offiers, diretors, trustees, key employees, and highest ompensated employees? If "Yes," omplete Shedule J Did the organization have a tax-exempt ond issue with an outstanding prinipal amount of more than $100,000 as of the last day of the year, that was issued after Deemer 1, 2002? If Yes, answer lines 2 through 2d and omplete Shedule K. If No, go to line 25a Did the organization invest any proeeds of tax-exempt onds eyond a temporary period exeption? Did the organization maintain an esrow aount other than a refunding esrow at any time during the year to defease any tax-exempt onds? Did the organization at as an on ehalf of issuer for onds outstanding at any time during the year? Setion 501()() and 501()() organizations. Did the organization engage in an exess enefit transation with a disqualified person during the year? If Yes, omplete Shedule L, Part I Is the organization aware that it engaged in an exess enefit transation with a disqualified person in a prior year, and that the transation has not een reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes," omplete Shedule L, Part I Did the organization report any amount on Part, line 5, 6, or 22 for reeivales from or payales to any urrent or former offiers, diretors, trustees, key employees, highest ompensated employees, or disqualified persons? If so, omplete Shedule L, Part II Did the organization provide a grant or other assistane to an offier, diretor, trustee, key employee, sustantial ontriutor or employee thereof, a grant seletion ommittee memer, or to a 5% ontrolled entity or family memer of any of these persons? If Yes, omplete Shedule L, Part III Was the organization a party to a usiness transation with one of the following parties (see Shedule L, Part IV instrutions for appliale filing thresholds, onditions, and exeptions): A urrent or former offier, diretor, trustee, or key employee? If "Yes," omplete Shedule L, Part IV A family memer of a urrent or former offier, diretor, trustee, or key employee? If "Yes," omplete Shedule L, Part IV An entity of whih a urrent or former offier, diretor, trustee, or key employee (or a family memer thereof) was an offier, diretor, trustee, or diret or indiret owner? If Yes, omplete Shedule L, Part IV Did the organization reeive more than $25,000 in non-ash ontriutions? If Yes, omplete Shedule M Did the organization reeive ontriutions of art, historial treasures, or other similar assets, or qualified onservation ontriutions? If Yes, omplete Shedule M Did the organization liquidate, terminate, or dissolve and ease operations? If Yes, omplete Shedule N, Part I Did the organization sell, exhange, dispose of, or transfer more than 25% of its net assets? If "Yes," omplete Shedule N, Part II Did the organization own 100% of an entity disregarded as separate from the organization under Regulations setions and ? If Yes, omplete Shedule R, Part I.... Was the organization related to any tax-exempt or taxale entity? If Yes, omplete Shedule R, Parts II, III, or IV, and Part V, line Did the organization have a ontrolled entity within the meaning of setion 512()(1)? If "Yes" to line 5a, did the organization reeive any payment from or engage in any transation with a ontrolled entity within the meaning of setion 512()(1)? If Yes, omplete Shedule R, Part V, line Setion 501()() organizations. Did the organization make any transfers to an exempt non-haritale related organization? If Yes, omplete Shedule R, Part V, line Did the organization ondut more than 5% of its ativities through an entity that is not a related organization and that is treated as a partnership for federal inome tax purposes? If Yes, omplete Shedule R, Part VI Did the organization omplete Shedule O and provide explanations in Shedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to omplete Shedule O a 2 2 2d 25a a a Form 990 (201)

5 Form 990 (201) Page 5 Part V Statements Regarding Other IRS Filings and Tax Compliane Chek if Shedule O ontains a response or note to any line in this Part V a 2a a a 5a 6a a d e f g h a a a Enter the numer reported in Box of Form Enter -0- if not appliale Enter the numer of Forms W-2G inluded in line 1a. Enter -0- if not appliale Did the organization omply with akup withholding rules for reportale payments to vendors and reportale gaming (gamling) winnings to prize winners? Enter the numer of employees reported on Form W-, Transmittal of Wage and Tax Statements, filed for the alendar year ending with or within the year overed y this return If at least one is reported on line 2a, did the organization file all required federal employment tax returns? Note. If the sum of lines 1a and 2a is greater than 250, you may e required to e-file (see instrutions) Did the organization have unrelated usiness gross inome of $1,000 or more during the year? If Yes, has it filed a Form 990-T for this year? If No to line, provide an explanation in Shedule O At any time during the alendar year, did the organization have an interest in, or a signature or other authority over, a finanial aount in a foreign ountry (suh as a ank aount, seurities aount, or other finanial aount)? If Yes, enter the name of the foreign ountry: u See instrutions for filing requirements for Form TD F , Report of Foreign Bank and Finanial Aounts. Was the organization a party to a prohiited tax shelter transation at any time during the tax year? Did any taxale party notify the organization that it was or is a party to a prohiited tax shelter transation? If Yes to line 5a or 5, did the organization file Form 8886-T? Does the organization have annual gross reeipts that are normally greater than $100,000, and did the organization soliit any ontriutions that were not tax dedutile as haritale ontriutions? If Yes, did the organization inlude with every soliitation an express statement that suh ontriutions or gifts were not tax dedutile? Organizations that may reeive dedutile ontriutions under setion 170(). Did the organization reeive a payment in exess of $75 made partly as a ontriution and partly for goods If Yes, did the organization notify the donor of the value of the goods or servies provided? Did the organization sell, exhange, or otherwise dispose of tangile personal property for whih it was required to file Form 8282? If Yes, indiate the numer of Forms 8282 filed during the year d Did the organization reeive any funds, diretly or indiretly, to pay premiums on a personal enefit ontrat? Did the organization, during the year, pay premiums, diretly or indiretly, on a personal enefit ontrat? If the organization reeived a ontriution of qualified intelletual property, did the organization file Form 8899 as required? If the organization reeived a ontriution of ars, oats, airplanes, or other vehiles, did the organization file a Form 1098-C? Sponsoring organizations maintaining donor advised funds and setion 509(a)() supporting organizations. Did the supporting organization, or a donor advised fund maintained y a sponsoring organization, have exess usiness holdings at any time during the year? Sponsoring organizations maintaining donor advised funds. Did the organization make any taxale distriutions under setion 966? Did the organization make a distriution to a donor, donor advisor, or related person? Setion 501()(7) organizations. Enter: Initiation fees and apital ontriutions inluded on Part VIII, line Gross reeipts, inluded on Form 990, Part VIII, line 12, for puli use of lu failities Setion 501()(12) organizations. Enter: Gross inome from memers or shareholders. Gross inome from other soures (Do not net amounts due or paid to other soures against amounts due or reeived from them.) a Setion 97(a)(1) non-exempt haritale trusts. Is the organization filing Form 990 in lieu of Form 101? If Yes, enter the amount of tax-exempt interest reeived or arued during the year Setion 501()(29) qualified nonprofit health insurane issuers. a and servies provided to the payor? Is the organization liensed to issue qualified health plans in more than one state? Note. See the instrutions for additional information the organization must report on Shedule O. Enter the amount of reserves the organization is required to maintain y the states in whih the organization is liensed to issue qualified health plans Enter the amount of reserves on hand a Did the organization reeive any payments for indoor tanning servies during the tax year? If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Shedule O Form 990 (201) 1a 1 2a 10a 10 11a a a 5a 5 5 6a 6 7a 7 7 7e 7f 7g 7h 8 9a 9 12a 1a 1a 1 Yes No

6 Form 990 (201) Page 6 Part VI Governane, Management, and Dislosure For eah "Yes" response to lines 2 through 7 elow, and for a "No" response to line 8a, 8, or 10 elow, desrie the irumstanes, proesses, or hanges in Shedule O. See instrutions. Chek if Shedule O ontains a response or note to any line in this Part VI Setion A. Governing Body and Management Yes No 1a a 8 9 a 10a organization s exempt status with respet to suh arrangements? Setion C. Dislosure 17 List the states with whih a opy of this Form 990 is required to e filed u OH Setion 610 requires an organization to make its Forms 102 (or 102 if appliale), 990, and 990-T (Setion 501()()s only) Enter the numer of voting memers of the governing ody at the end of the tax year If there are material differenes in voting rights among memers of the governing ody, or Enter the numer of voting memers inluded in line 1a, aove, who are independent Did any offier, diretor, trustee, or key employee have a family relationship or a usiness relationship with any other offier, diretor, trustee, or key employee? Did the organization delegate ontrol over management duties ustomarily performed y or under the diret supervision of offiers, diretors, or trustees, or key employees to a management ompany or other person? Did the organization make any signifiant hanges to its governing douments sine the prior Form 990 was filed? Did the organization eome aware during the year of a signifiant diversion of the organization s assets? Did the organization have memers or stokholders? Did the organization have memers, stokholders, or other persons who had the power to elet or appoint one or more memers of the governing ody? Are any governane deisions of the organization reserved to (or sujet to approval y) memers, stokholders, or persons other than the governing ody? Did the organization ontemporaneously doument the meetings held or written ations undertaken during the year y the following: The governing ody? Eah ommittee with authority to at on ehalf of the governing ody? Is there any offier, diretor, trustee, or key employee listed in Part VII, Setion A, who annot e reahed at the organization s mailing address? If Yes, provide the names and addresses in Shedule O Setion B. Poliies (This Setion B requests information aout poliies not required y the Internal Revenue Code.) Did the organization have loal hapters, ranhes, or affiliates? If Yes, did the organization have written poliies and proedures governing the ativities of suh hapters, affiliates, and ranhes to ensure their operations are onsistent with the organization's exempt purposes? a Has the organization provided a omplete opy of this Form 990 to all memers of its governing ody efore filing the form? Desrie in Shedule O the proess, if any, used y the organization to review this Form a a 16a if the governing ody delegated road authority to an exeutive ommittee or similar ommittee, explain in Shedule O. Did the organization have a written onflit of interest poliy? If No, go to line Were offiers, diretors, or trustees, and key employees required to dislose annually interests that ould give rise to onflits?.... Did the organization regularly and onsistently monitor and enfore ompliane with the poliy? If Yes, desrie in Shedule O how this was done Did the organization have a written whistlelower poliy? Did the organization have a written doument retention and destrution poliy? Did the proess for determining ompensation of the following persons inlude a review and approval y independent persons, omparaility data, and ontemporaneous sustantiation of the delieration and deision? The organization s CEO, Exeutive Diretor, or top management offiial Other offiers or key employees of the organization If Yes to line 15a or 15, desrie the proess in Shedule O (see instrutions). Did the organization invest in, ontriute assets to, or partiipate in a joint venture or similar arrangement with a taxale entity during the year? If Yes, did the organization follow a written poliy or proedure requiring the organization to evaluate its partiipation in joint venture arrangements under appliale federal tax law, and take steps to safeguard the availale for puli inspetion. Indiate how you made these availale. Chek all that apply. Own wesite Another's wesite Upon request Desrie in Shedule O whether (and if so, how) the organization made its governing douments, onflit of interest poliy, and finanial statements availale to the puli during the tax year. Other (explain in Shedule O) State the name, physial address, and telephone numer of the person who possesses the ooks and reords of the organization: u LEE ELMORE DETROIT AVENUE LAKEWOOD OH a a 7 8a 8 10a 10 11a 12a a 15 16a Yes No Form 990 (201)

7 Form 990 (201) Page 7 Part VII Compensation of Offiers, Diretors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contrators Chek if Shedule O ontains a response or note to any line in this Part VII Setion A. Offiers, Diretors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this tale for all persons required to e listed. Report ompensation for the alendar year ending with or within the organization's tax year. List all of the organization's urrent offiers, diretors, trustees (whether individuals or organizations), regardless of amount of ompensation. Enter -0- in olumns (D), (E), and (F) if no ompensation was paid. List all of the organization's urrent key employees, if any. See instrutions for definition of "key employee." List the organization's five urrent highest ompensated employees (other than an offier, diretor, trustee, or key employee) who reeived reportale ompensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. List all of the organization's former offiers, key employees, and highest ompensated employees who reeived more than $100,000 of reportale ompensation from the organization and any related organizations. List all of the organization s former diretors or trustees that reeived, in the apaity as a former diretor or trustee of the organization, more than $10,000 of reportale ompensation from the organization and any related organizations. List persons in the following order: individual trustees or diretors; institutional trustees; offiers; key employees; highest ompensated employees; and former suh persons. (1) (2) () () (5) (6) (7) (8) (9) (10) (11) Chek this ox if neither the organization nor any related organizations ompensated any urrent offier, diretor, or trustee. (A) (B) (C) (D) (E) (F) Name and Title Average hours per week (list any hours for related organizations elow dotted line) Position (do not hek more than one ox, unless person is oth an offier and a diretor/trustee) Individual trustee or diretor Institutional trustee Offier Key employee Highest ompensated employee Former Reportale ompensation from the organization (W-2/1099-MISC) Reportale ompensation from related organizations (W-2/1099-MISC) Estimated amount of other ompensation from the organization and related organizations THOMAS GABLE LINDA STOKES, PH D TOM FRASER BRYAN GILLETTE MICHAEL MITCHELL GEORGE W. QUIL WENDY KIEDING BRIAN M. KING FRED DE GRANDIS MARK GETSAY JULIUS SKERLAN DIRECTOR EMERITUS DIRECTOR EMERITUS Form 990 (201)

8 Form 990 (201) Page 8 Part VII Setion A. Offiers, Diretors, Trustees, Key Employees, and Highest Compensated Employees (ontinued) (12) (1) (1) (15) (16) (17) (18) (19) 1 Su-total.... u Total from ontinuation sheets to Part VII, Setion A u 78,600 d Total (add lines 1 and 1) u 78,600 2 Total numer of individuals (inluding ut not limited to those listed aove) who reeived more than $100,000 in reportale ompensation from the organization u 5 (A) Name and title Did the organization list any former offier, diretor, or trustee, key employee, or highest ompensated employee on line 1a? If Yes, omplete Shedule J for suh individual For any individual listed on line 1a, is the sum of reportale ompensation and other ompensation from the organization and related organizations greater than $150,000? If Yes, omplete Shedule J for suh individual Did any person listed on line 1a reeive or arue ompensation from any unrelated organization or individual for servies rendered to the organization? If Yes, omplete Shedule J for suh person Setion B. Independent Contrators (B) Average hours per week (list any hours for related organizations elow dotted line) Individual trustee or diretor Institutional trustee Offier (C) Position (do not hek more than one ox, unless person is oth an offier and a diretor/trustee) Key employee 1 Complete this tale for your five highest ompensated independent ontrators that reeived more than $100,000 of ompensation from the organization. Report ompensation for the alendar year ending with or within the organization's tax year. (A) (B) Name and usiness address Desription of servies Highest ompensated employee Former (D) Reportale ompensation from the organization (W-2/1099-MISC) (E) Reportale ompensation from related organizations (W-2/1099-MISC) Estimated amount of other ompensation from the organization and related organizations NEIL P SMITH, D.O CAROL STERBA MILIJANA SUCEVIC, B.S.N., R.N WARREN VODAK PHILIP E. TOMSIK, M.D C.J. NOCK, M.D BILL BACKUS JOHN MEYERHOFFER CLINICAL DIRECTOR DIRECTOR EMERITUS MEDICAL DIRECTOR 0 5 (F) Yes (C) Compensation No 2 Total numer of independent ontrators (inluding ut not limited to those listed aove) who reeived more than $100,000 of ompensation from the organization u 0 Form 990 (201)

9 Form 990 (201) Page 8 Part VII Setion A. Offiers, Diretors, Trustees, Key Employees, and Highest Compensated Employees (ontinued) (12) (1) (1) (15) (16) (17) (A) Name and title (B) Average hours per week (list any hours for related organizations elow dotted line) Individual trustee or diretor Institutional trustee Offier (C) Position (do not hek more than one ox, unless person is oth an offier and a diretor/trustee) Key employee Highest ompensated employee Former (D) Reportale ompensation from the organization (W-2/1099-MISC) (E) Reportale ompensation from related organizations (W-2/1099-MISC) (F) Estimated amount of other ompensation from the organization and related organizations LEE ELMORE 5 78, JOHN GRIFFITHS KEITH VANDERBURG JAY R. CARSON, ESQ LAWRENCE E. YUNASKA EECUTIVE DIRECTOR CHAIR VICE CHAIR SECRETARY TREASURER (18) (19) 1 Su-total.... u Total from ontinuation sheets to Part VII, Setion A u d Total (add lines 1 and 1) u 2 Total numer of individuals (inluding ut not limited to those listed aove) who reeived more than $100,000 in reportale ompensation from the organization u 5 Did the organization list any former offier, diretor, or trustee, key employee, or highest ompensated employee on line 1a? If Yes, omplete Shedule J for suh individual For any individual listed on line 1a, is the sum of reportale ompensation and other ompensation from the organization and related organizations greater than $150,000? If Yes, omplete Shedule J for suh individual Did any person listed on line 1a reeive or arue ompensation from any unrelated organization or individual for servies rendered to the organization? If Yes, omplete Shedule J for suh person Setion B. Independent Contrators 78,600 1 Complete this tale for your five highest ompensated independent ontrators that reeived more than $100,000 of ompensation from the organization. Report ompensation for the alendar year ending with or within the organization's tax year. (A) (B) Name and usiness address Desription of servies 5 Yes (C) Compensation No 2 Total numer of independent ontrators (inluding ut not limited to those listed aove) who reeived more than $100,000 of ompensation from the organization u Form 990 (201)

10 Form 990 (201) Page 9 Part VIII Statement of Revenue Chek if Shedule O ontains a response or note to any line in this Part VIII Contriutions, Gifts, Grants and Other Similar Amounts Program Servie Revenue Other Revenue 1a d e f g h 2a 5 d e f g 6a Federated ampaigns Memership dues Fundraising events Related organizations Government grants (ontriutions)... All other ontriutions, gifts, grants, and similar amounts not inluded aove 1f 5,99,76 Nonash ontriutions inluded in lines 1a-1f: $,96, Total. Add lines 1a 1f u 1a 1 1 1d 1e All other program servie revenue Total. Add lines 2a 2f Investment inome (inluding dividends, interest, and other similar amounts) u Inome from investment of tax-exempt ond proeedsu Royalties u Gross rents Less: rental exps. Rental in. or (loss) (i) Real (ii) Personal Busn. Code d Net rental inome or (loss) a Gross amount from (i) Seurities (ii) Other sales of assets other than inventory Less: ost or other 10a 11a d e asis & sales exps. Gain or (loss) d Net gain or (loss) u 8a Gross inome from fundraising events (not inluding $ of ontriutions reported on line 1). See Part IV, line a Less: diret expenses Net inome or (loss) from fundraising events u 9a Gross inome from gaming ativities. See Part IV, line a Less: diret expenses Net inome or (loss) from gaming ativities u 12 Gross sales of inventory, less returns and allowanes a Less: ost of goods sold Net inome or (loss) from sales of inventory Misellaneous Revenue All other revenue ,79 Total. Add lines 11a 11d Total revenue. See instrutions u u u Busn. Code u u (A) (B) (C) (D) Total revenue Related or Unrelated Revenue exempt funtion revenue usiness revenue exluded from tax under setions ,065,558 PATIENT DONATIONS 1,1 1,1 1, ,067,51 1, Form 990 (201)

11 Form 990 (201) Page 10 Part I Statement of Funtional Expenses Setion 501()() and 501()() organizations must omplete all olumns. All other organizations must omplete olumn (A). Chek if Shedule O ontains a response or note to any line in this Part I Do not inlude amounts reported on lines 6, 7, 8, 9, and 10 of Part VIII. 1 2 Grants and other assistane to governments and organizations in the U.S. See Part IV, line Grants and other assistane to individuals in (A) (B) (C) (D) Total expenses Program servie Management and Fundraising expenses general expenses expenses 5 the U.S. See Part IV, line Grants and other assistane to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and Benefits paid to or for memers Compensation of urrent offiers, diretors, a d e f g a d e trustees, and key employees Compensation not inluded aove, to disqualified persons (as defined under setion 958(f)(1)) and persons desried in setion 958()()(B) Other salaries and wages Pension plan aruals and ontriutions (inlude setion 01(k) and 0() employer ontriutions) Other employee enefits Payroll taxes Fees for servies (non-employees): Management Legal Aounting Loying Professional fundraising servies. See Part IV, line 17 Investment management fees Other. (If line 11g amount exeeds 10% of line 25, olumn (A) amount, list line 11g expenses on Shedule O.) Advertising and promotion Offie expenses Information tehnology Royalties Oupany Travel Payments of travel or entertainment expenses for any federal, state, or loal puli offiials Conferenes, onventions, and meetings... Interest Payments to affiliates Depreiation, depletion, and amortization... Insurane Other expenses. Itemize expenses not overed aove (List misellaneous expenses in line 2e. If line 2e amount exeeds 10% of line 25, olumn (A) amount, list line 2e expenses on Shedule O.) All other expenses Total funtional expenses. Add lines 1 through 2e..... Joint osts. Complete this line only if the organization reported in olumn (B) joint osts from a omined eduational ampaign and fundraising soliitation. Chek here u if following SOP 98-2 (ASC ) ,9 79,29 1,680 85,565 10,66 8,898 5,1 1,25 1,558,6 2,11 5,78 15,626 15,626 9,000 9,000 9,76 9,76,626,626,85 26,686 7,168 51,98 7, ,616 7,2 7,2,2,2 1,169 1,169 27,102 27,102 PRESCRIPTIONS & PHYSICIAN,55,990,55,990 MISCELLANEOUS 1,06 26,65,29 CLINIC SUPPLIES 18,552 18,552 FEES AND DUES 11,770 11,770 6,275 2,989 7,15,151 5,760,219 5,52,8 17,97 169,76 Form 990 (201)

12 Form 990 (201) Page 11 Part Balane Sheet Chek if Shedule O ontains a response or note to any line in this Part (A) (B) Beginning of year End of year Assets Liailities Net Assets or Fund Balanes a other asis. Complete Part VI of Shedule D a Less: aumulated depreiation ,911 6,26 10, Investments pulily traded seurities Investments other seurities. See Part IV, line Investments program-related. See Part IV, line Intangile assets Other assets. See Part IV, line 11 1, , Total assets. Add lines 1 through 15 (must equal line ) , ,251, Aounts payale and arued expenses , ,92 18 Grants payale Deferred revenue , , Tax-exempt ond liailities Esrow or ustodial aount liaility. Complete Part IV of Shedule D Loans and other payales to urrent and former offiers, diretors, Cash non-interest earing Savings and temporary ash investments Pledges and grants reeivale, net Aounts reeivale, net Loans and other reeivales from urrent and former offiers, diretors, trustees, key employees, and highest ompensated employees. Complete Part II of Shedule L... Loans and other reeivales from other disqualified persons (as defined under setion 958(f)(1)), persons desried in setion 958()()(B), and ontriuting employers and sponsoring organizations of setion 501()(9) voluntary employees' enefiiary organizations (see instrutions). Complete Part II of Shedule L Notes and loans reeivale, net... Inventories for sale or use Prepaid expenses and deferred harges Land, uildings, and equipment: ost or trustees, key employees, highest ompensated employees, and disqualified persons. Complete Part II of Shedule L Seured mortgages and notes payale to unrelated third parties Unseured notes and loans payale to unrelated third parties Other liailities (inluding federal inome tax, payales to related third parties, and other liailities not inluded on lines 17-2). Complete Part of Shedule D Total liailities. Add lines 17 through Organizations that follow SFAS 117 (ASC 958), hek here u and omplete lines 27 through 29, and lines and. Unrestrited net assets Temporarily restrited net assets. Permanently restrited net assets Organizations that do not follow SFAS 117 (ASC 958), hek here u and omplete lines 0 through. Capital stok or trust prinipal, or urrent funds Paid-in or apital surplus, or land, uilding, or equipment fund Retained earnings, endowment, aumulated inome, or other funds Total net assets or fund alanes. Total liailities and net assets/fund alanes ,906 12,915 2, 1 227, , ,08 9 2, , ,77 661, , , ,61 508,08 0,000 6,92 661, , ,78 1,251,885 Form 990 (201)

13 Form 990 (201) Page 12 Part I Reoniliation of Net Assets Chek if Shedule O ontains a response or note to any line in this Part I Total revenue (must equal Part VIII, olumn (A), line 12) Total expenses (must equal Part I, olumn (A), line 25) Revenue less expenses. Sutrat line 2 from line Net assets or fund alanes at eginning of year (must equal Part, line, olumn (A)) Net unrealized gains (losses) on investments Donated servies and use of failities Investment expenses Prior period adjustments Other hanges in net assets or fund alanes (explain in Shedule O) Net assets or fund alanes at end of year. Comine lines through 9 (must equal Part, line, olumn (B)) Part II Finanial Statements and Reporting Chek if Shedule O ontains a response or note to any line in this Part II a Aounting method used to prepare the Form 990: Cash Arual 2a Were the organization's finanial statements ompiled or reviewed y an independent aountant? If "Yes," hek a ox elow to indiate whether the finanial statements for the year were ompiled or Were the organization's finanial statements audited y an independent aountant? If "Yes," hek a ox elow to indiate whether the finanial statements for the year were audited on a of the audit, review, or ompilation of its finanial statements and seletion of an independent aountant? If the organization hanged either its oversight proess or seletion proess during the tax year, explain in the Single Audit At and OMB Cirular A-1? If Yes, did the organization undergo the required audit or audits? If the organization did not undergo the Other If the organization hanged its method of aounting from a prior year or heked Other, explain in Shedule O. reviewed on a separate asis, onsolidated asis, or oth: Separate asis Consolidated asis Both onsolidated and separate asis Separate asis If Yes to line 2a or 2, does the organization have a ommittee that assumes responsiility for oversight Shedule O. separate asis, onsolidated asis, or oth: Consolidated asis As a result of a federal award, was the organization required to undergo an audit or audits as set forth in required audit or audits, explain why in Shedule O and desrie any steps taken to undergo suh audits Both onsolidated and separate asis 6,067,51 5,760,219 07,22 661,276 2a 2 2 a 968,508 Yes No Form 990 (201)

14 SCHEDULE A (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Servie Name of the organization Part I (i) Name of supported organization Puli Charity Status and Puli Support Complete if the organization is a setion 501()() organization or a setion 97(a)(1) nonexempt haritale trust. u Attah to Form 990 or Form 990-EZ. u Information aout Shedule A (Form 990 or 990-EZ) and its instrutions is at Employer identifiation numer Reason for Puli Charity Status (All organizations must omplete this part.) See instrutions. The organization is not a private foundation eause it is: (For lines 1 through 11, hek only one ox.) A hurh, onvention of hurhes, or assoiation of hurhes desried in setion 170()(1)(A)(i). A shool desried in setion 170()(1)(A)(ii). (Attah Shedule E.) A hospital or a ooperative hospital servie organization desried in setion 170()(1)(A)(iii). OMB No A medial researh organization operated in onjuntion with a hospital desried in setion 170()(1)(A)(iii). Enter the hospital's name, 201 Open to Puli Inspetion ity, and state: An organization operated for the enefit of a ollege or university owned or operated y a governmental unit desried in setion 170()(1)(A)(iv). (Complete Part II.) A federal, state, or loal government or governmental unit desried in setion 170()(1)(A)(v). An organization that normally reeives a sustantial part of its support from a governmental unit or from the general puli desried in setion 170()(1)(A)(vi). (Complete Part II.) A ommunity trust desried in setion 170()(1)(A)(vi). (Complete Part II.) 9 An organization that normally reeives: (1) more than 1/% of its support from ontriutions, memership fees, and gross e f g h (A) reeipts from ativities related to its exempt funtions sujet to ertain exeptions, and (2) no more than 1/% of its support from gross investment inome and unrelated usiness taxale inome (less setion 511 tax) from usinesses aquired y the organization after June 0, See setion 509(a)(2). (Complete Part III.) An organization organized and operated exlusively to test for puli safety. See setion 509(a)(). An organization organized and operated exlusively for the enefit of, to perform the funtions of, or to arry out the purposes of one or more pulily supported organizations desried in setion 509(a)(1) or setion 509(a)(2). See setion 509(a)(). Chek the ox that desries the type of supporting organization and omplete lines 11e through 11h. a Type I Type II Type III Funtionally integrated d Type III Non-funtionally integrated By heking this ox, I ertify that the organization is not ontrolled diretly or indiretly y one or more disqualified persons other than foundation managers and other than one or more pulily supported organizations desried in setion 509(a)(1) or setion 509(a)(2). If the organization reeived a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, hek this ox Sine August 17, 2006, has the organization aepted any gift or ontriution from any of the following persons? (i) A person who diretly or indiretly ontrols, either alone or together with persons desried in (ii) and (iii) elow, the governing ody of the supported organization? (ii) A family memer of a person desried in (i) aove? (iii) A 5% ontrolled entity of a person desried in (i) or (ii) aove? Provide the following information aout the supported organization(s). (ii) EIN (iii) Type of organization (desried on lines 1 9 aove or IRC setion (see instrutions)) (iv) Is the organization in ol. (i) listed in your governing doument? (v) Did you notify the organization in ol. (i) of your support? (vi) Is the organization in ol. (i) organized in the U.S.? Yes No Yes No Yes No 11g(i) 11g(ii) 11g(iii) Yes (vii) Amount of monetary support No (B) (C) (D) (E) Total For Paperwork Redution At Notie, see the Instrutions for Form 990 or 990-EZ. Shedule A (Form 990 or 990-EZ) 201