Form
990
Return of Organization Exempt From Income Tax
•
Under section 501 (c), 527, or 4947(a)(1) of the Internal Revenue Code ( except black lung
benefit trust or private foundation)
^ The organiza tion may have to use a copy of this return to satis fy state reporting requirements.
Department of the Treasury
Internal Revenue Service
A For the 2004 calendar y ear , or tax y ear be g innin g
B Check ifapplicable
Address
change
Please
C
4 , and endin
2
07 / 01
Name of organization
06/30/ 2005
D Employer identification number
usellt s ALLE-KISKI
MEDICAL CENTER
25-1875178
label or
Name change
Initial return
Number and street (or P 0 box if mail is not delivered to street address)
print or
type- C/O TAX DEPARTMENT
see
Final return
Specific
Amended
return
Application
Instructions
pending
PITTSBURGH ,
G
Website:
J
Organization type (check only one) ^ X
K
Check here
412 ) 330-6083
Accounting
method
PA 15212
H(a) Is this a group return for affiliates
^ N/A
501(c) (3
) 4 (Insertno)
1 4947(a)(1) or
527
If the organization's gross receipts are normally not more than $25,000 The
d
, , , , , , , , , , , , , , , , ,
Total ( add lines 1a through 1c ) (cash $
H(c) Are all affiliates included?
(If "No," attach a list See Instructions
Yes T:] No
H(d) Is this a separate return filed by an
org anization covered b y a g rou p rulin '
Yes
X
I
Group Exemption Number
M
Check ^70 if the organization is not required
to attach Sch B (Form 990, 99 0-EZ, or 990-PF)
No
^
1c
noncash $
183,263.
)
1 d
2
Program service revenue including government fees and contracts ( from Part VII, line 93) , , , ,
2
3
Membership dues and assessments
3
4
Interest on savings and temporary cash investments
, , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
, , , , , , , , , , , , , , , , , , , , , , , , ,
5
Dividends and interest from securities , , , , , , , , , , , , ,
6 a Gross rents , , , , , , , , , , , , , , , , , , , , , , , , , ,
b Less rental expenses
7
, , , , , , , , , , , ,
16
Other investment income ( describe
5
it)cl ti d e d r'r,
c
671.
625 , 825.
it
, , , , , , , , , , , , , , , , , , , ,
6c
^
73 , 695 .
7
Gross revenue ( not including $
-339 , 575.
of
contributions reported on line 1a) . . . . . . . . . . . . . . . .
b Less direct expenses other than fundraising expenses , , , , , , ,
10a
438
4
8 a Gross amount from sales of assets other
( B) Other
(A) Securities
than inventory . . .. . . . . . . . . . .
42 342 703 . 8a
3 , 205.
b Less cost or other basis and sales expenses .
42 685 483. 8b
c Gain or (loss) (attach schedule )
-342 , 780 . 8c
3 , 205.
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 ^ ❑
a
183 263 .
106
73 695.
6b
c Net rental income or (loss) (subtract line 6b from line 6a)
w
Yes I-XI No
Revenue , Ex p enses, and Chan g es in Net Assets or Fund Balances ( See p a g e 18 of the instructions
Contributions , gifts, grants , and similar amounts received
a Direct public support . . . . . . . . . . . . . . . . . . . . . .
1a
183 , 263.
b Indirect public support . . . . . . . . . . . . . . . . . . . . .
1b
c Government contributions ( grants )
9a
9b
Net income or (loss ) from special events (subtract line 9b from line 9a )
Gross sales of inventory , less returns and allowances
b Less cost of goods sold , , , , , , , , , ,
C Gross profit or (loss ) from sales of inventory
11
Other revenue (from Part VII, line 103) , , ,
12
Total revenue (add lines 1d 2 , 3 , 4 , 5 , 6c ,
13
Program services (from line 44, column ( B)) ,
0
0
Accrual
H(b) If "Yes ," enter number of affiliates ^
Gross receipts Add lines 6 b, 8b, 9b, and 1Ob to line 12 ^
W
X
H and I are not applicable to section 527 organizations
in the mail, it should file a return without financial data Some states require a complete return.
1
Cash
Other (specify) ^
organization need not file a return with the IRS, but if the organization received a Form 990 Package
L
E Telephone number
320 EAST NORTH AVENUE
City or town, state or country, and ZIP + 4
• Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable
trusts must attach a completed Schedule A (Form 990 or 990-EZ).
^
Room /suite
, , , , , , , ,
. . •
.
0a
9c
J
, , , , , , , , , ,
Ob
(attach schedule ) (subtract
, , , , , , , , , ,
7 , sd 9c , 10c and
, , , , , , , ,
m line 1Q^
%
10c
11
• 12
13
1 , 620 , 455z
108 , 602 , 334.
85 , 691 , 038.
W
14
Management and general (from line 44, column (C)) , ,
14
17 143 305 .
a
W
15
16
Fundraising ( from line 44, column (D)) , , , , , , , , , , , ,
OV
15
Payments to affiliates (attach schedule) ,
.......... 16
Total ex p enses ( add lines 16 and 44, column (A)) . . . .
17
Excess or (deficit ) for the year ( subtract line 17 from line 12) . . . . . . . . . . . . . . . . . . . . .
18
102 , 834 , 343.
5 , 767 , 991.
Z
17
18
Z
19
Net assets or fund balances at beginning of year (from line 73, column (A)) . . . . . . . . . . . . . .
19
-1 , 754 , 993.
Z
20
Other changes in net assets or fund balances (attach explanation ) , , , ,
20
-3 , 642 , 3670
21
Net assets or fund balances at end of year ( combine lines 18 , 19 , and 20 )
Q
Z
For Privacy Act and Paperwork Reduction Act Notice , see the separate instructions .
STVT ,1, . . $T14T. 2 .
•
• • • • •
21
370 , 631 .
Form 990 (2004)
4E1010 1 000
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Page2
25-1875178
column
Columns
(B),
(C),
and
(D)
are
required
for
section
501(c)(3)
and
(4)
organizations
organizations
must
complete
(A)
All
Statement of
and section 4947(a)(1) nonexempt charitable trusts but optional for others (See page 22 of the instructions )
Functional Expenses
(C) Management
(B) Program
Do not include amounts reported on line
(A) Total
(D) Fundraising
and eneral
services
66 86 96 10b or 16 of Part I
Form 990 (2004)
3Tmt 15
22 Grants and allocations (attach schedule)
(cash $
22
5,624. noncash$
23
Specific assistance to individuals (attach schedule)
23
24
Benefits paid to or for members (attach schedule)
24
5 , 624.
5 , 624.
780.
35 843 463.
1 , 902 , 854.
6 , 325 , 317.
335 798.
3 , 962 , 260.
2 , 930 , 418.
517 , 133.
25 Compensation of officers, directors, etc 25
26
26
27
Other salaries and wages , , , , ,
Pension plan contributions , , , ,
28
Other employee benefits , , , ,
Payroll taxes , , , , , , , , , , , , , ,
29
30
Professional fundraising fees , ,
30
31
32
33
Accounting fees , , , , , . . . . . .
Legal fees . . . . . . . . .. . . . .
29
Postage and shipping , . . . . . . ,
Occupancy . . . . . . . . . . . . .
Equipment rental and maintenance. .
35
36
37
38
39
40
Printing and publications , . . . . .
Travel . . . . . . . . . . . . . . . . . .
Conferences, conventions, and meetings
^
Interest .
Depreciation , depletion , etc (attach fi'edu e^ .
Other expenses not covered above ( ftemize ) 9TMT _ 3_
41
42
43
2 , 238 , 652.
4 , 661 , 482.
3 , 447 , 551.
31
. . .
Supplies . . . . .
Telephone . . . . . . . . . . . . . .
34
42 168
27
28
104 452.
6 , 176.
32
33
34
35
18
168 612.
149 433.
163 782.
36
2 , 532 , 954.
3 , 995 , 603.
87 , 420.
86 , 039.
33 , 023.
3 , 503 , 023.
5 , 072 , 357.
16 409 380.
37
38
39
40
41
42
43a
17
623 554.
134 490.
158 869.
2 , 279 ,
3 1 596 ,
78 .
77 ,
29 ,
3 , 152 ,
659.
043.
678.
435.
721.
721.
4 1 565 , 121.
9 , 350 , 128.
699 , 222.
104 , 452.
6 , 176.
545 058.
14
4
253
399
, 943.
8
8
3
350
507
7 1 059
, 742.
, 604.
, 302.
, 302.
, 236.
, 252.
1 913.
295.
560.
3b
b
43c
C
d -------------------------3d
-------------------------e
3e
44
Total functional expenses (add lines 22 through 43)
Organizations completing columns (B)-(D), carry
these totals to lines f3-15.
Joint Costs . Check
^
44
102 834 343.
85 691 038.
17 143 305.
if you are following SOP 98-2
Are any j oint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? , , , , , ^ ❑ Yes
N Pr
, (n) the amount allocated to Program services $
NIA
If "Yes," enter ( i) the aggregate amount of these j oint costs $
(iii) the amount allocated to Management and general $
Ill I P'
, and (iv) the amount allocated to Fundraising $
No
NA
OMM Statement of Program Service Accomplishments (See page 25 of the instructions.)
What is the organization's primary exempt purpose? ^ PROVISION OF HEALTHCARE
SERVICES _____-----
All organizations must describe their exempt purpose achievements in a clear and concise manner State the number
of clients served , publications issued , etc Discuss achievements that are not measurable ( Section 501(c )(3) and (4)
organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allocations to others )
a
( Required for 501 (c)(3) and
(4) orgs , and 4947(a)(1)
trusts, but optional for
others )
SEE _ STMT -J9-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Grants and allocations $
5 , 624 .)
b
P rogram Service
F-xpenses
85 , 691 , 038.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------(Grants and allocations $
C
---------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------(Grants and allocations $
d
( Grants and allo cations $
e
Other program services ( attach schedule )
f
Total of Program Service Expenses (should equal line 44, column (B), Program services).
JSA
4E1020
4E1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Grants and allocations $
. ^
85,691,038.
Form 990 (2004)
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Page 3
Form 990 (2004)
,
Balance Sheets (See page 25 of the instructions)
Note: Where required, attached schedules and amounts within the description
column should be for end-of-year amounts only
. . . . . . . . . . . . . . . . . . . . . . . . . . .
45
Cash - non-interest-bearing
46
Savings and temporary cash investments ... . . . . . . . . . . . . . . . . .
47a Accounts receivable . . . . . . . . . . . . . . .
b Less allowance for doubtful accounts , , ,
48a Pledges receivable . . . . . . . . . . . . .. . .
b Less allowance for doubtful accounts
49
Grants receivable
. ..
47a
47b
14 , 239 , 992 .
1 , 786 , 179.
(A)
Beginning of year
3 137
140. 45
6 , 903 , 718.
46
13 578
621. 47c
12
453
813.
48a
48c
48b
,,,,,,,,,,,,,,,, ,,,,,,,
49
.......
50 Receivables from officers, directors, trustees, and key employees
(attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51a Other notes and loans receivable (attach
51a
schedule)
1
51b
d
b Less. allowance for doubtful accounts , , , , ,
u)
(B)
End of year
Inventories for sale or use . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
. . . STMT. 4.
Prepaid expenses and deferred charges . . . . . . .
53
FMV
Investments - securities (attach schedule) ATIA .5. ^ ❑ Cost
54
55a Investments - land, buildings, and
50
51 c
1 087 899. 52
815 361. 53
14 033 699. 54
1 , 808 , 007.
889 326.
16 , 462 855 .
equipment basis . . . . . . . . . . . . . .. . . . 55a
b Less accumulated depreciation (attach
55c
schedule) . .. . . . . . . . . . . . . . . . .. . . 55b
Investments - other (attach schedule) . . . . . . . . . . . . . . . STMT. 6.
56
57a
107 922 234.
57a Land, buildings, and equipment basis . . . . . .
443 901. 56
306 , 612.
b Less: accumulated depreciation (attach
58
59
60
61
62
63
schedule) . . . . . . . . . . . . . . .S1
Other assets (describe ^
?1 ' .
Total assets (add lines 45 through 58) (must equal
Accounts payable and accrued expenses , , , , , ,
Grants payable . . . .. . . . . . . . . . . . . . . .
Deferred revenue . . . . . . . . . . . . . . . . . . .
57b
89 441 862.
STMT 7 )
line 74) . . . . . . . . . .
, , , , , , , , , , , , ,
. . . . . . .. . . . . . .
. . . . . . . . . . . . . .
19 594 138. 57c
4 , 293 , 604. 58
18
56 984 363. 59
7 108 117. 60
63 706 949.
8 , 058 , 302.
61
NO
Loans from officers, directors, trustees, and key employees (attach
schedule)
64a Tax-exempt bond liabilities (attach schedule)
b Mortgages and other notes payable (attach schedule) , , , , , . $T14T. P. .
STMT 9 _ )
Other liabilities (describe ^
65
. . . . . . . .
Total liabilities (add lines 60 through 65) . . . . . . . . . . .
lines
complete
and
Organizations that follow SFAS 117, check here ^ X
66
480 372.
6 , 402 , 246.
62
85 , 398.
63
33 860 892. 64a
3 , 440 , 001. 64b
33 , 537 , 074 .
3 , 680 , 801.
14 , 330 , 346. 65
17 , 974 , 743.
58 739 356. 66
63 , 336 , 318.
172 325. 67
417 332. 68
69
9 175.
361 456.
67 through 69 and lines 73 and 74
Unrestricted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Temporarily restricted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . .
Permanently restricted . . . . . . . . . . . . . . . .
Organizations that do not follow S FAS 117 , c h ec k h ere ^ ❑ and
in 67
68
R 69
U_
0 70
u) 71
y 72
V)
73
-2
complete lines 70 through 74
. . . . . .
Capital stock , trust principal , or current funds ,
Paid-in or capital surplus , or land, building, and equipment fund . . . . . . .
Retained earnings , endowment , accumulated income, or other funds . . , , .
Total net assets or fund balances (add lines 67 through 69 or lines
70
71
72
70 through 72,
370 , 631 .
-1 754 993. 73
column (A) must equal line 19 , column (B) must equal line 21) . . . . . . .
949.
706
63
363.
74
,
984
56
lines
66
and
73
)
balances
(
add
Total liabilities and net assets i fund
74
about
a
information
source
of
or
sole
the
primary
serves
as
people,
some
and,
for
Form 990 is available for public inspection
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
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Page 4
Form 990 (2004)
a
b
R econci l iation of evenue per Audited
Financial Statements with Revenue per
0n*rnrn (ma nano 77 of tha instrimtinns )
Total revenue, gains, and other support
per audited financial statements , , ^ a 108 481 314.
Amounts included on line a but not on
a
Total
audited financial statements
b
Amounts included on line a but not
on line 17, Form 990
line 12, Form 990•
year grants
_ , , , ^ a
102,934,343.
(1) Donated services
and use of facilities $
(2) Prior year adjustments
(1) Net unrealized gains
$
on investments
(2) Donated services
and use of facilities
(3) Recoveries of prior
Reconciliation OT Expenses p er iauaitea
Financial Statements with Expenses per
Return
expenses and losses per
reported on line 20,
Form 990 . . . . . $
(3) Losses reported on
$
. . . . $
line 20, Form 990
(4) Other (specify)
$
(4) Other (specify)
STMT
10
$
8,521.
Add amounts on lines (1) through (4) ^ b
Line a minus line b , , , . . . . . .
Amounts included on line 12,
Form 990 but not on line a:
(1) Investment expenses
not included on line
c
d
^ c
8 , 521.
108
472 793.
6b, Form 990 .
.$
(2) Other (specify)-
129,541.
$
STMT 11
Add amounts on lines (1) and (2) . . ^ d
$
Add amounts on lines (1) and (2)
129 541.
e
Total revenue per line 12, Form 990
(line c p lus lined
102 834 343.
Form 990 but not on line a:
(1) Investment expenses
not included on line
6b, Form 990 , . . $
(2) Other (specify)
e
c
d
$
^ b
Add amounts on lines (1) through (4) ,
Line a minus line b . , , , , , . , . ^ c
Amounts included on line 17,
. • • • • • • • • • ^ e
108
602 334.
^ d
Total expenses per line 17, Form 990
( line c p lus lined
• • • • • • • • • • ^ e
102 , 834 , 343.
List of Officers, Directors , Trustees, and Key Employees (List each one even IT not compensatea, see page z
(B) Title and average
hours per week
devoted to position
(A) Name and address
STATEMENT
(C) Compensation
( if not paid , enter
.0-. )
(D) contributions to
employee benefit plans &
deferred compensation
(E) Expense
account and other
allowances
ICI
NONE
75
or
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?
If "Yes," attach schedule - see page 28 of the instructions
5'+Q it m e n)1'
NONE
NONE
^
Yes
❑ No
/ 9
Form 990 (2004)
JSA
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-1875178
Paae 5
Other Information (See p a g e 28 of the instructions. )
Yes No
Did the organization engage in any activity not previously reported to the IRS's If "Yes," attach a detailed description of each
Were any changes made in the organizing or governing documents but not reported to the IRS? , , , , , , , , , , , , ,
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 return? . . .
b If "Yes," has it filed a tax return on Form 990-T for this year's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79 Was there a liquidation, dissolution, termination, or substantial contraction during the year's If "Yes," attach a statement , ,
76
77
activity
76
, , , , , , . 77
X
X
. . . . . .
8a
X
. . . . .
, , , , , ,
8b
79
X
80a
X
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?
b If "Yes," enter the name of the organization. SEE
STMT
-O
and check whether it is
exempt or
nonexempt
81 a Enter direct and indirect political expenditures See line 81 instructions. . . . . . . . . . . . . . .
b Did the organization file Form 1120-POL for this year?
81a
NONE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .-
82 a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge
or at substantially less than fair rental value?
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 in Part II (See instructions in Part III ) . . . . . . . . . . . . .
82b
83a Did the organization comply with the public inspection requirements for returns and exemption applications? , , ,
b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? , , , , , , ,
84 a Did the organization solicit any contributions or gifts that were not tax deductible? , , , , , , , , , ,
, , , ,
b If "Yes," did the organization include with every solicitation an express statement that such contributions
or gifts were not tax deductible? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
85
501(c)(4), (5), or (6) organizations
X
691 , 987.
, , , , , , , , , , 83a
, , , , , , , , , , 83b
84a
, , , , , ,
, , , , , , , , , ,
84b
a Were substantially all dues nondeductible by members? , , , , , , , , , , , , , , , , , , , , ,
85a
b Did the organization make only in-house lobbying expenditures of $2,000 or less
If "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization
85b
X
X
X
NI L
N1 A
N1 K
85c
N/ A
. . .
85d
N/A
e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices . . . . . . . . . . . . . .
f Taxable amount of lobbying and political expenditures (line 85d less 85e) , . . . , , . . , , .
85e
85f
N/ A
N /A
d Section 162(e) lobbying and political expenditures
. . .
g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f? , , , , , , , , , , , ,
, , , , , , . ,
.
received a waiver for proxy tax owed for the prior year
c Dues, assessments, and similar amounts from members
!!
N
85h
N 1 P,
88
X
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
86
estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year?,
86a
501(c)(7) orgs. Enter. a Initiation fees and capital contributions included on line 12 . , . . . , .
b Gross receipts, included on line 12, for public use of club facilities
87
501(c)(12) orgs. Enter a Gross income from members or shareholders . .
b Gross income from other sources (Do not net amounts due or paid to other
N A
86b
N /A
87a
N/A
87b
N/A
. . _ . . . . .
sources against amounts due or received from them) . . . . . . . . . . . . . . . . . . . . . . . .
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
89a 501(c)(3) organizations Enter. Amount of tax imposed on the organization during the year under
section 4911 ^
N/A
, section 4912 ^
N/A
, section 4955 ^
N/A
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 year? 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
d Enter Amount of tax on line 89c, above, reimbursed by the organization
. .
^
N/A
lip-
N/A
90a List the states with which a copy of this return is filed .PENNSYLVANIA
b Number of employees employed in the pay period that includes March 12, 2004 (See instructions) , , , , , , , , , , , , , , , , , ,
91
The books are in care of
Located at ^ 320
92
^ MANAGEMENT
EAST NORTH AVENUE,
PITTSBURGH
PA
1 90b 1 120 1
Telephone no
^ 412-33 0-60 83
ZIP+4
15212
^
Section 4947(a)(1) nonexempt charitable trusts 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
I
N/A
Form 990 (2004)
JSA
4E1041 1 000
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7
Pag e 6
25-1875178
Form 990 2004
• ..
Analysis of Income - Producinq Activities (See page 33 of the instructions.)
Unre lated business income
Note: Enter gross amounts unless otherwise
93
Related or
exempt function
Income
C
Amount
Business code
Program service revenue:
621500
a INPATIENT/OUTPATNT
(E)
Excluded by section 512, 513, or 514
indicated
Exclusion code
Amount
3 , 072 , 847.
103 365 824.
b
c
d
e
f Medicare/Medicaid payments . . . . . . .
g Fees and contracts from government agencies ,
94
Membership dues and assessments . . •
95
Interest on savings and temporary cash investments
96
97
Dividends and interest from securities .
Net rental income or (loss) from real estate
a debt-financed property . . . . . . . . .
b not debt-financed property . . . . . . .
98
Net rental Income or (loss) from personal property
99
Other investment income . . . . . . . .
Gain or (loss) from sales of assets other than inventory
101
Net income or (loss) from special events
Gross profit or (loss) from sales of inventory
103
Other revenue: a
b
625 , 825.
16
73 , 695.
18
-339 , 575.
.
100
102
14
764 789.
855 666.
STMT 12
c
d
e
104
1 215
3 , 072 , 847. 1
Subtotal (add columns (B), (D), and (E)) .
105 Total ( add line 104 , columns ( B), (D), and ( E)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note : Line 105 plus line I d, Part 1, should equal the amount on line 12, Part L
611.
.
104
130
613.
108 , 419,071.
Relationship of Activities to the Accomplishment of Exempt Purposes (See page 34 of the instructions.)
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)
Line No.
y
FROM SERVICES
93A
INCOME
103B
MISCELLANEOUS
PROVIDED
HEALTHCARE
OVERALL HEALTHCARE
TO PATIENTS
SERVICES
OF THE
WHICH
COMMUNITY-SEE
OF THE HOSPITAL
CONTRIBUTE
PART
TO THE
III
MoM Information Reg ardin g Taxable Subsidiaries and Disreg arded Entities (See page 34 of the instructions. )
(A)
Name, address, and EIN of corporation,
p artnershi p, or disre g arded entity
STMT
(B)
Percentage of
ownershi p interest
%
13
(C)
Nature of activities
(D)
Total income
NONE
(E)
End-OT-year
assets
NONE
o^
o^
%
Information Regarding Transfers Associated with Personal Benefit Contracts (See page 34 of the instructions )
Yes
X No
(a) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? . . , , , , ,
X No
(b) Did the organization, during the year, pay premiums, directly or Indirect) on a personal benefit contract?
H Yes
Note : If "Yes" to (b), file Form 8870 and Form 4720 (see instructions)
Under penalties of perjury, I declare that I have examined this return
and belief it is true, correct, and complete Declaration of preparer
Please
Sign
Here
`5'
SI nature o f officer
'
s
Type or print name and title
Preparers
Paid
Preparer's
signature'
Use Only
if self-employed),
address, and ZIP + 4
Firm's name (or yours
Cc/Ti4
3,f'
e C
rw.
JSA
4E1050 1 000
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Organization Exempt Under Section 501(c)(3)
SCHEDULE A
OMB No 1545-0047
(Form 990 or 990-EZ)
(Except Private Foundation) and Section 501(e), 501(f), 501(k),
501(n), or Section 4947(a)(1) Nonexempt Charitable Trust
Department of the Treasury
Internal Revenue Service
^ MUST be completed by the above organizations and attached to their Form 990 or 990-EZ
2004
Supplementary Information - (See separate instructions.)
Name of the organization
En
KISKI MEDICAL CENTER
entification number
25-1875178
Compensation of the Five Highest Paid Employees Other Than Officers , Directors , and Trustees
(See Daae 1 of the instructions. List each one. If there are none, enter "None.")
hours per week
than $50,000
CARLISLE
(c) Compensation
devoted to p osition
BRAD_WOLK_________________________
1301
(d) Contributions to
(e) Expense
employee benefit plans &
account and other
deferred com p ensation
allowances
(b) Title and average
(a) Name and address of each employee paid more
PHYSICIAN
STREET
NATRONA HEIGHTS ,
40
PA 15065
210 002.
35 , 531.
NONE
132
856.
19 , 185.
NONE
132
658.
26 , 107.
NONE
130 856.
30 , 160.
NONE
128
28 , 631.
NONE
VICE PRESIDENT
HARLOVIC
1301 CARLISLE STREET
NATRONA HEIGHTS ,
40
PA 15065
GEORGE_SANDORA-------------------- - VICE PRESIDENT
1301 CARLISLE STREET
NATRONA HEIGHTS , PA 15065
40
WILLIAM-ENGLERT
---------------------------------
1301 CARLISLE STREET
NATRONA HEIGHTS , PA 15065
VICE PRESIDENT
40
LORRI_WILDI----------------------- - VICE PRESIDENT
1301 CARLISLE STREET
NATRONA HEIGHTS ,
Total
number
of
other
40
PA 15065
employees
paid
$50,000
460.
over
^
231
Compensation of the Five Highest Paid Independent Contractors for Professional Services
(See naae 2 of the instructions. List each one (whether individuals or firms). If there are none, enter "None.")
UOMM
(a) Name and address of each independent contractor paid more than $50,000
(b) Type of service
(c) Compensation
CLEAN CARE-------------------------------------PO BOX 40330 ,
PGH PA 15201
LINEN SERVICE
532
006.
ANESTHESIA SVC
725
350.
SVC
387
723.
INC
PA ANESTHESIA PROVIDERS -----------------------1301
CARLISLE
ST
MAYO-COLLABORATIVE_SVS__INC
------------------------------PO BOX
9146 MINNEAPOLIS
CROTHALL
-------
LABORATORY
MN
HEALTHCARE-INC.
------------------------------
13028 COLLECTIONS CTR CHICAGO ,
IL 60693
MANAGEMENT SERVICES
479 827.
E-ME-RGENCY-MEDICAL-PHY-OF-ALLE-KISKI
-----------------------------------------4535
DRESSLER RD NW CANTON OH
44718-4500
Total number of others receiving over $50,000 for
professional services
. ^
MEDICAL
SERVICES
300
17
For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Form 990-EZ.
Schedule A (Form 990 or 990-EZ) 2004
JSA
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9
Schedule A (Form 990 or990-EZ) 2004
Page 2
25-1875178
Yes No
Statements About Activities ( See p a g e 2 of the instructions. )
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 referendum? If "Yes," enter the total expenses paid
(Must equal amounts on line 38,
32,893.
or incurred in connection with the lobbying activities ^ $
Part VI-A, or line i of Part VI-B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Organizations that made an election under section 501(h) by filing 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
I
1
X
the lobbying activities
During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any
2
substantial
contributors,
trustees,
directors,
officers,
creators,
key employees,
or members
with any taxable organization with which any such person is affiliated as an officer,
owner,
or principal
of their families,
director, trustee,
or
majority
beneficiary? (If the answer to any question is "Yes," attach a detailed statement explaining
the transactions )
a
Sale, exchange, or leasing of property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b
Lending of money or other extension of credit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 b I
c
Furnishing of goods, services, or facilities ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d
Payment of compensation ( or payment or reimbursement of expenses if more than $1,000 ) ' ,
e
Transfer of any part of its income or assets '
3a
b
4a
. . . . . . . . . . . . . . . . . . . . .
Do you make grants for scholarships , fellowships , student loans , etc
( If "Yes
,".
FOFZ .9. 9.0. -PART. y. . . .
^m T 2- I
. . . . .
....
attach an explanation of how
you determine that recipients qualify to receive payments ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you have a section 403 ( b) annuity plan for your employees ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
2a
I X
2d
X
2e
X
X
3a
X
3b
Did you maintain any separate account for participating donors where donors have the right to provide advice
on the use or distribution of funds' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Do you p rovide credit counseling , debt management , credit repair, or debt negotiation services?
X
4a
4b
X
Reason for Non -Private Foundation Status ( See pages 3 through 6 of the instructions.)
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)(1)
A school Section 170(b)(1)(A)(u). (Also complete Part V)
6
7
X
A hospital or a cooperative hospital service organization Section 170(b)(1)(A)(ui)
8
A Federal, state, or local government or governmental unit. Section 170(b)(1)(A)(v)
9
A medical research organization operated in conjunction with a hospital. Section 170(b)(1)(A)(u) Enter the hospital's name, city,
and state
10
❑
-----------------------------------------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 ❑ 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 )
11b
12
13
H
❑
A community trust Section 170(b)(1)(A)(vi). (Also complete the Support Schedule in Part IV-A )
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 )
An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizations
described in, (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).)
Provide the following information abou t the supported organizations (See page 5 of the instructions )
(b) Line number
from
m above
(a) Name (s) of supported organization (s)
14
❑ An organization organized and operated to test for public safety Section 509(a)(4) (See page 5 of the instructions )
Schedule A (Form 990 or 990 -EZ) 2004
JSA
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Page 3
25-1875178
Schedule A (Form 990 or 990-EZ) 2004
Support Schedule (Complete only if you checked a box on line 10, 11, or 12) Use cash method of accounting.
KI-4--. V,,,, m
,,on tha ieinrli
haAt in fho incfn,rhnn.c for cnnverfrnn from the accrual to the cash method of accountino
Calendar year ( or fiscal year beginning in )
15 Gifts, grants , and contributions received (Do
not include unusual grants See line 28) .
16 Membership fees received . ,
17
1111.
( c) 2001
(b) 2002
( a) 2003
unm
(d ) 2000
APPT .TCART.R
( e) Total
Gross receipts from admissions, merchandise
sold or services performed, or furnishing of
facilities in any activity that is related to the
organization's charitable, etc , purpose .
18
Gross
income
from
interest,
dividends,
amounts received from payments on securities
loans (section 512(a)(5)), rents, royalties, and
19
20
unrelated business taxable income (less
section 511 taxes) from businesses acquired
by the organization after June 30, 1975
business
Net income from unrelated
activities not included in line 18 . . . . . . . . .
Tax revenues levied for the organization's
benefit and either paid to it or expended on
21
its behalf ....................
The value of services or facilities furnished to
the organization by a governmental unit
without charge Do not include the value of
22
services or facilities generally furnished to the
public without charge .
Other income. Attach a schedule. Do not
include gain 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 ! QT AF1?"CA$74 . . . ^ 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 2000 through 2003 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)
d Add: Amounts from column (e) for lines 18
. . , . . . . . . . .
. , , , , , , ^ 26c
19
26b
.
22
e Public support (line 26c minus line 26d total) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f Public su ooort percentage ( line He ( numerator ) divided by line 26c (denominator )) . . .
27 Organizations described on line 12 : a For amounts included in lines 15, 16, and
person," prepare a list for your records to show the name of, and total amounts received
Do not file this list with your return . Enter the sum of such amounts for each year
(2003) ________________ (2002) ___________________
(2001 )
. . . . . . , , . , . ^ 26d
. . . . . . . . . . . ^ 26e
%
. ^ 26f
aisquallnea
17 that were received from a
in each year from, each "disqualified person"
___ NOT APPLICABLE _ (2000) ______________
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 in the list organizations described in lines 5 through 11 , as well as individuals ) Do not file this list with your return . After computing
excess
the difference between the amount received and the larger amount described in (1) or ( 2), enter the sum of these differences ( the
amounts ) for each year
(2002) ------------------- (2001) ------------------- (2000)--------------(2003)
----------------
c Add Amounts from column (e) for lines 15
20
17
d Add : Line 27a total
e Public support (line 27c total minus line 27d total )
16
........ ••••
21
. . . . . . . . . . . .
and line 27b total .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . • • • • • • •
^ 27c
^ 27d
^ 27e
Total support for section 509(a )( 2) test Enter amount from line 23, column ( e) . . . . . . . . . . ^ 27f
%
g Public support percentage (line 27e ( numerator) divided by line 27f (denominator)) . . . . . . . . . . . . . . . . . . ^ 27
27h
denominator
))
line
27f
(
divided
b
y
numerator
)
column
(
e
)
(
line
18
,
g
e
(
h Investment income p ercenta
unusual grants during 2000 through 2003,
28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any
brief
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
description of the nature of the grant Do not file this list with your return . Do not include these grants in line 15
f
Schedule A ( Form 990 or 990-EZ) 2004
JSA
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11
25-1875178
Page 4
Schedule A (Form 990 or 990-EZ) 2004
29
NOT APPLICABLE
Private School Questionnaire (See page 7 of the instructions.)
( To be com p leted ONLY b y schools that checked the box on line 6 in Part IV)
Yes
Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws,
30
. .
. . . . . .
other governing instrument , or in a resolution of its governing body?
Does the organization include a statement of its racially nondiscriminatory policy toward students in all its
31
29
brochures, catalogues, and other written communications with the public dealing with student admissions,
. .
. .
. . . . . . . . . , .
_ . . . . . . . .
programs , and scholarships
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
statement )
separate
space,
attach
a
more
need
(If
you
please
explain
"No,"
describe,
if
please
If "Yes,"
30
31
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------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
basis ?
. . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . . . . .
. .
c Copies of all catalogues , brochures, announcements, and other written communications to the public dealing
. . . . . . . . . . . . . . . . .
with student admissions , programs , and scholarships
. . . . . . . , . ,
32b
32c
.
d Copies of all material used by the organization or on its behalf to solicit contributions'
No
32d
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 in any way with respect to
a Students' rights or privileges? . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . ,
b Admissions policies'
c Employment of faculty or administrative staff?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33b
33c
. . . . . . . . . . .
33d
. . . . . . . . . . . . . . . . . . . . . . . . . . .
33e
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33f
d Scholarships or other financial assistance'
e Educational policies?
f Use of facilities?
33a
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 )
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------34 a Does the organization receive any financial aid or assistance from a governmental agency?
, . . . . . . . . . . .
. . . . . . . . . . . . . . . .
b Has the organization's right to such aid ever been revoked or suspended
statement
attached
using
an
please
explain
b,
either
34a
or
"Yes"
to
If you answered
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 nondiscrimination ? If "No," attach an explanation
35
Schedule A (Form 990 or 990-EZ) 2004
JSA
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Schedule A ( Form 990 or 990-EZ 2004
25-1875178
Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions)
Pa g e 5
(To be completed ONLY by an eligible organization that filed Form 5768)
If the organi z ation b elong s to an affiliated group
Check ^ a
Check ^ b
if you checked "a" and "limited control" provisions apply
Limits on Lobbying Expenditures
(a)
(b)
Affiliated group
totals
To be completed
for ALL electing
organizations
(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). . . . . . . .
36
NONE
NONE
37
38
286 077.
286 077.
32 893.
32 , 893.
39
Other exempt purpose expenditures , • • , • • . • • • , • • . , • . . • • _ , • . .
39
40
Total exempt purpose expenditures (add lines 38 and 39)
40
405 549 524.
405 835 601.
102 , 834 , 343.
41
1 , 000 , 000.
1 , 000 , 000.
41
801
450.
Lobbying nontaxable amount Enter the amount from the following table The lobbying nontaxable amount is -
If the amount on line 40 is Not over $500,000
,
,
,
,
.
.
.
.
. .
Over $500,000 but not over $1,000,000
42
43
102
.
.
.
. 20% of the amount on line 40 .
.
.
.
.
.
. .
.
$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
Over$17,000,000
$1,000,000
, , , • , , , , ,
. . . . . . . .
. . 250 , 000.
Grassroots nontaxable amount (enter 25% of line 41)
Subtract line 42 from line 36 Enter -0- If line 42 Is more than line 36
250
000 .
44 Subtract line 41 from line 38. Enter -0- if line 41 is more than line 38
Caution : If there is an amount on either line 43 or line 44, you must file Form 4720.
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 throu g h 50 on page 11 of the instructions )
SYm-r as
Calendar year (or fiscal
year beginning in) ^
( a)
2004
Lobbying Expenditures During 4-Year Averaging Period
(c)
2002
(b)
2003
(d)
2001
(e)
Total
Lobbying nontaxable
45
46
amount
Lobbying ceiling amount
( 150% of line 45 (e))
1 , 000 , 000.
1 , 000 , 000.
2 , 000 , 000.
3 , 000 , 000.
47
Total lobbyin g expenditures
Grassroots nontaxable
286 077.
170 594.
456
671.
48
amount • • • • • • • •
250 000.
250 000.
500 000.
Grassroots ceiling amount
49
( 150% of line 48 (e))
Grassroots lobbying
50
ex penditures .
750 , 000.
NO
NONE
NONE
Lobbying Activity by Nonelecting Public Charities
NOT APPLICABLE
(For reporting only by organizations that did not complete P a rt VI-A) (Se e page 1 1 of the in stru cti on s.)
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
a Volunteers . . . . .
. . . . . . . . . . . . . . . . . .
. . . .. . . . . . . .. . . . . . .
b Paid staff or management (Include compensation in expenses reported on lines c through h )
c Media advertisements
d
e
f
g
h
i
Mailings to members, legislators, or the public, , • , • • . • • . • • . • • . • , , • • , ,
Publications, or published or broadcast statements , • • • , • , , , • , _ , , , • , , , ,
Grants to other organizations for lobbying purposes • • • , , , , , • , • , • , , , , , ,
Direct contact with legislators, their staffs, government officials, or a legislative body
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means
Total lobbying expenditures (Add lines c through h ) . . . . . . . . . . . . . . . . . . . .
Yes
No
Amount
.
, . • , • ,
, , , , , •
, , , , , ,
, , , , , ,
. . . . . .
If "Yes" to any of the above, also attach a statement giving a detailed description of the lobbying activities
JSA
4E1240 1 000
18120B
Schedule A (Form 990 or 990 - EZ) 2004
633M 01/23/2006
12:18:14 V04-8
13
Pa g e 6
25-1875178
Schedule A ( Form 990 or 990-EZ) 2004
Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations (See page 11 of the instructions.)
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 noncharitable exempt organization of
(i) Cash .......................................................
(ii) Other assets .
.
. .. . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
b Other transactions
(i) Sales or exchanges of assets with a noncharitable exempt organization . . .. . . . . . . . . . . . . . . .
(ii) Purchases of assets from a noncharitable exempt organization , ,, , , , , , , , , , , , , , , , , , , , , ,
(iii) Rental of facilities, equipment, or other assets , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(iv) Reimbursement arrangements , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
(v) Loans or loan guarantees . . . . . . . . . . . . . . . .
Yes
a(ii)
No
X
-
.
51
(vi) Performance of services or membership or fundraising solicitations , , , , , , , , , , , , , , , , , , , , ,
c Sharing of facilities, equipment, mailing lists, other assets, or paid employees , , , , , , , , , , , , , , , , , , ,
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 in 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? . , , , . , . . . .
Yes
No
Schedule A (Form 990 or 990-EZ) 2004
JSA
4E1250 1 000
18120B
633M 01/23/2006
10:23:57
V04-8
14
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
I
- OTHER INCREASES
IN FUND BALANCES
AMOUNT
------
DESCRIPTION
-----------
129,541.
136,979.
761.
CHANGE IN UNREALIZED GAIN
TRANSFER VDMC NET ASSETS
OTHER
TOTAL
-----------267,281.
STATEMENT
18120B 633M 01/23/2006 10:23:57 V04-8
18
1
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
I
- OTHER DECREASES
IN FUND BALANCES
DESCRIPTION
-----------
AMOUNT
------
TRANSFER TO AFFILIATES
ADDITIONAL MINIMUM PENSION LIABILITY
ELIMINATE VDMC INVESTMENT
1,735,822.
2,015,562.
158,264.
TOTAL
-----------3,909,648.
STATEMENT
18120B
633M 01/23/2006
10:23:57 V04-8
19
2
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
II
- OTHER EXPENSES
DESCRIPTION
PURCHASED SERVICES
BAD DEBT EXPENSE
PROFESSIONAL FEES
MISCELLANEOUS TRANSFERS
CORE LABORATORY
CORPORATE ALLOCATION
BANK BOND FEES
RECRUITMENT FEES
OUTPLACEMENT FEES
OTHER PROFESSIONAL FEES
MEDICAL SERVICES
PATIENT TRANSPORT SERVICES
RECORD STORAGE
DUES
NON-DEPRECIABLE FIXED ASSETS
NON-DEPRECIABLE FURNITURE
EMPLOYEE RECOGNITION
TAXES
MALPRACTICE INSURANCE
OTHER INSURANCE
GIFTS AND FLOWERS
PATIENT REIMBURSABLES
MEMBERSHIP FEES
LICENSES/FEES
MEDIA ADVERTISING
MISC ADMIN
OTHER REBATES
MISCELLANEOUS
TOTALS
25-1875178
TOTAL
3,455,301.
3,491,308.
444,761.
1,200.
177,299.
5,963,602.
47,647.
117,912.
6,000.
4,548.
452,666.
66,693.
213,712.
92,756.
117,481.
316.
84,664.
12,469.
1,193,896.
205,794.
6,452.
8,473.
7,030.
35,450.
152,478.
60,950.
-18,834.
7,356.
16,409,380.
18120B 633M 01/23/2006 10:23:57 V04-8
PROGRAM
SERVICES
MANAGEMENT
AND GENERAL
3,109,771.
3,491,308.
1,164.
159,569.
42,882.
106,120.
5,400.
4,093.
407,399.
60,024.
192,341.
83,480.
105,733.
284.
76,198.
11,222.
1,074,506.
185,215.
5,807.
7,626.
6,327.
31,905.
137,230.
54,855.
-16,951.
6,620.
9,350,128.
---------------
345,530.
444,761.
36.
17,730.
5,963,602.
4,765.
11,792.
600.
455.
45,267.
6,669.
21,371.
9,276.
11,748.
32.
8,466.
1,247.
119,390.
20,579.
645.
847.
703.
3,545.
15,248.
6,095.
-1,883.
736.
--------------7,059,252.
---------------
20
STATEMENT
3
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IV - PREPAID EXPENSES AND DEFERRED CHARGES
ENDING
BOOK VALUE
----------
DESCRIPTION
-----------
337,582.
114,749.
NONE
436,995.
MALPRACTICE & OTHER INSURANCE
BLUE CROSS BENEFIT RESERVE
US HEALTHCARE BENEFIT RESERVE
OTHER
TOTALS
889,326.
STATEMENT
18120B 633M 01/23/2006
10:23:57 V04-8
21
4
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990, PART IV - INVESTMENTS
---------------
-
SECURITIES
ENDING
BOOK VALUE
----------
DESCRIPTION
-----------
15,536,433.
240,429.
325,000.
360,993.
FUNDED DEPRECIATION
WORKERS COMP ESCROW FUND
LETTER OF CREDIT ESCROW
DUE TO/FROM OPERATING SPF
TOTALS
16,462,855.
STATEMENT
18120B 633M 01/23/2006 10:23:57 V04-8
22
5
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IV -
25-1875178
INVESTMENTS
- OTHER
ENDING
BOOK VALUE
----------
DESCRIPTION
----------INVESTMENT
INVESTMENT
INVESTMENT
INVESTMENT
IN
IN
IN
IN
CANCERCO LLC
VHA
RRG
VALLEY DEVELOPMT
TOTALS
NONE
167,172.
139,440.
NONE
306,612.
STATEMENT
18120B
633M 01/23/2006
10:23:57 V04-8
23
6
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
25-1875178
IV - OTHER ASSETS
ENDING
BOOK VALUE
----------
DESCRIPTION
----------RIGHTS OF FIRST REFUSAL
INTANGIBLE - CITIZENS
LONG TERM RECEIVABLE - AHS RES
CRA MEDICARE
OTHER A/R
SCHOOL OF NURSING
INTERCOMPANY A/R
INTANGIBLE PENSION ASSET
OTHER
TOTALS
122,224.
5,525,875.
17,556.
NONE
30,715.
605,201.
NONE
99,454.
1,221.
6,402,246.
STATEMENT
18120B 633M 01/23/2006 10:23:57 V04-8
24
7
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IV - MORTGAGES AND OTHER NOTES
--------
--------
PAYABLE
--------
CITIZENS GENERAL HOSPITAL
LENDER:
3,004,630.
ORIGINAL AMOUNT:
7.000000
INTEREST RATE:
04/16/2002
DATE OF NOTE :
04/16/2017
MATURITY DATE:
ANNUAL PAYMENTS OVER 16 YEARS
REPAYMENT TERMS :
ASSET PURCHASE FROM CITIZEN'S HOSPITAL
PURPOSE OF LOAN:
BEGINNING BALANCE DUE .....................................
ENDING BALANCE DUE ........................................
TOTAL BEGINNING MORTGAGES AND OTHER NOTES
PAYABLE
TOTAL ENDING MORTGAGES AND OTHER NOTES PAYABLE
3,440,001.
3,680,801.
---------------
3,440,001.
----------------------------3,680,801.
STATEMENT
18120B
633M 01/23/2006
10:23:57 V04-8
25
8
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IV - OTHER LIABILITIES
ENDING
BOOK VALUE
----------
DESCRIPTION
----------CURB PORT OF SELF-INSUR LIAB
SELF INSURANCE LIABILITIES
ACCRUED PENSION COST
306,449.
754,407.
12,155,308.
595,182.
LT CORP SVCS ACCRUAL
NONE
64,725.
1,783,826.
2,314,846.
CURRENT PORTION - CIP
RETIREE LIFE INSURANCE
3RD PARTY LIABILITY
INTERCOMPANY PAYABLES
TOTALS
17,974,743.
STATEMENT
181203 633M 01/23/2006 10:23:57 V04-8
26
9
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IV-A - OTHER REVENUE
ON BOOKS BUT NOT ON RETURN
AMOUNT
DESCRIPTION
8,521.
---------------
NET ASSETS RELEASED
TOTAL
8,521.
STATEMENT
18120B 633M 01/23/2006
10:23:57 V04-8
27
10
25-1875178
ALLE-KISKI MEDICAL CENTER
FORM 99.0,
PART
IV-A - OTHER REVENUE ON RETURN BUT NOT ON BOOKS
AMOUNT
DESCRIPTION
RESTRICTED CONTRIBUTIONS
TOTAL
129,541--------------129,541.
STATEMENT
18120B 633M 01/23/2006 10:23:57 V04-8
28
11
25-1875178
ALLE- KISKI MEDICAL CENTER
FORM 990,
PART VII
DESCRIPTION
- OTHER REVENUE
BUSINESS
CODE
AMOUNT
PARKING REVENUE
TRANSCRIPTS
ATHLETE HEALTH COV
LIFELINE PAYMENTS
MEDNET
PHYSICIAN APP REV
TUITION
CAFETERIA
TELEPHONE
DRUG SALES
INSURANCE CLAIM
MEDICAL
MISCELLANEOUS
EXCLUSION
CODE
03
RELATED OR EXEMPT
FUNCTION INCOME
---------------
AMOUNT
278,395.
41,245.
58,194.
126,587.
650.
18,100.
448,799.
03
03
577,262.
9.
10,005.
47,470.
400.
13,339.
-------------
TOTALS
18120B 633M 01/23/2006 10:23:57 V04-8
855,666.
29
764,789.
STATEMENT
12
ALLE-KISKI MEDICAL CENTER
FORM 990,
PART
IX -
25-1875178
INFORMATION REGARDING TAXABLE
PERCENTAGE
NAME AND ADDRESS
EMPLOYER IDENTIFICATION NUMBER
------------------------------
OWNERSHIP
INTEREST
--------
VALLEY DEVELOPMENT MGMT CORP
1301 CARLISLE STREET
NATRONA HEIGHTS PA 15065
25-1494317
100.000000
SUBSIDIARIES
NATURE OF
BUSINESS
TOTAL
i
ENDING
ACTIVITIES
----------
INCOME
------
ASSETS
------
PROP MGMT
NONE
NONE
-------------
------------
NONE
NONE
TOTAL INCOME
18120B 633M 01/23/2006
10:23:57 V04-8
30
STATEMENT
13
Statement 14
Form 990
Part I, Line 8
Gain/(Loss) from Sale of Assets
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Period Ended June 30, 2005
Gain/(Loss ) From Sale of Assets - Column A (Securities)
Description
Gain/(Loss) from sale of publicly
traded securities
Dates
Various
Gross
Proceeds
Cost or
Gain/(Loss)
Other Basis
on Sale
42,342,703
42,685,483
Gross
Proceeds
Gain/(Loss)
Cost or
Other Basis
on Sale
(342,780)
Gain/(Loss) From Sale of Assets - Column B (Other Assets)
Description
Provis Pedestal
Sold To: Diny, Inc.
no address available
other small equipment sales
general ledger error
May-05
Various
2,800
405
1,935
0
865
405
1,935
Gain/(Loss) from sale of equipment
TOTAL Line 8d:
$ (339,575)
Statement 15
Form 990
Part II Functional Expenses
Line 22 Grants and Allocations
Alle-Kiski Medical Center
EIN 25-1875178For Tax Period Ended June 30, 2005
Recipients Name
Amount
Purpose
poromt
Healthcare Program
... Service S ipr
99
American Cancer Society
PO Box 57
Apollo, PA 15616
Healthcare Program Service Support
100
Bible Way Church
c/o Shirley Sharpe
Community Program Service Support
250
Healthcare Program Service Support
1,000
Community Program Service Support
1,000
Scholarship
1,500
American Cancer Society
320 Bilmar Drive
Pittsburgh, PA 15205
109 Wood Street
Tarentum, PA 15084
American Cancer Society
Highlands Relay for Life
320 Bilmar Drive
Pittsburgh, PA 15205
Highlands Little League
PO Box 136
Natrona Heights, PA 15065
Hightower Scholars, Inc.
2614 Anne Street
Lower Burrell, PA 15068
Community Program Service Support
250
Community Program Service Support
100
Community Program Service Support
1,000
Allegheny Chamber of Commerce
1030 Broadview Boulevard
Brackenridge, PA 15014
Community Program Service Support
75
American Cancer Society
Healthcare Program Service Support
250
Strongland Chamber Foundation
1129 Industrial Park Road
Box 10, Suite 108
Vandergrift, PA 15690-9646
Strongland Chamber of Commerce
1129 Industrial Part Road
Box 10, Suite 108
Vandergnft, PA 15690
Allegheny Chamber of Commerce
1030 Broadview Boulevard
Brackenridge, PA 15014
320 Bilmar Drive
Pittsburgh, PA 15205
$
5,624
Alle-Kiski Medical Center
EIN 25-1875178
For Tax Period Ended June 30, 2005
Statement 16
Form 990
Part II, Line 42 & Part IV, Line 57
Land, Buildings , and Equipment
Land, Buildings, & Equipment
Land
Land Improvements
Building
Building Improvements
Leasehold Improvements
Major Moveable Equipment
Major Moveable Equipment - Current Additions
Capitalized Interest
Contruction in Process
PP&E Receipt Accrual
27,912
1,822,769
57,217,274
7,974,104
394,701
39,830,671
24,593
225,115
507,988
(102,893)
107,922,234
Less: Accumulated Depreciation
Net Land , Buildings , and Equipment
Depreciation expense of $5,072, 357 is calculated using the straight line method.
(89,441,862)
18,480,372
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
INTRODUCTION ^'O AU v-MSIU MEDICAL CENTER (AlCMC
^Al
The Alle-Kiski Medical Center has been dedicated to providing exceptional health care since its
beginnings in 1909 when Allegheny Valley Hospital opened an 18-bed facility inside a house on
Second Avenue in Tarentum, Pennsylvania. Today, that hospital has evolved into a 250-bed
inpatient facility and has joined hands with Citizens Ambulatory Care Center and its outpatient
programs. Alle-Kiski Medical Center is part of the West Penn Allegheny Health System
(www.wpahs.org). Organized in 2000, WPAHS is comprised of Allegheny General Hospital
(AGH), The Western Pennsylvania Hospital (WPH), Forbes Regional Hospital (FRH), AlleKiski Medical Center (AKMC), Canonsburg General Hospital (CGH), Allegheny Medical
Practice Network (AMPN), Allegheny Specialty Practice Network (ASPN) and Allegheny-Singer
Research Institute (ASR").
AKMC offers advanced technologies in the caring atmosphere of a community hospital. It also
serves as a health-care provider and community resource to nearly 200,000 people in portions of
Allegheny, Butler, Westmoreland and Armstrong counties.
Alle-Kiski Medical Center is a 250 bed community hospital, comprised of Allegheny Valley
Hospital located in Allegheny County, Natrona Heights, PA and the Citizens Ambulatory Care
Center, located in Westmoreland County, New Kensington, PA.
AKMC provides a wide array or programs and services, including the Alle-Kiski Cancer Center
which offers both chemotherapy and radiation as treatments for cancer. A state-of-the-art linear
accelerator provides Intensity Modulated Radiation Therapy, the newest cancer treatment
modality. Other services include cardiac care, emergency medical care, neurodiagnostics,
obstetrics, psychiatry, pulmonary medicine, radiology, diagnosis and treatment of sleep related
disorders, rehabilitation services including sports medicine, and general and orthopaedic surgery.
Citizens Ambulatory Care Center functions as the medical center's outpatient facility, while
inpatient services are consolidated at the main hospital. Citizens offers a number of outpatient
programs, including ambulatory surgery and endoscopy, laboratory studies, and both diagnostic
radiology and cardiology.
Other components of AKMC include an urgent care center, a special services anticoagulant
clinic, home-health services, hospice care and a nutrition clinic.
As acknowledged by readers of the hospital's local newspaper, AKMC was selected as the No. I
Best Hospital for the 3`d year in a row, as well as the No.l Best Physical Therapy Facility.
Page 1
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
For the 12 months ended June 30, 2005, AKMC admitted 11,974 inpatients , registered 218,427
outpatients , treated 32 , 625 emergency department patients , delivered 416 newborns, and
performed 8,235 inpatient and outpatient surgeries . AKMC has an employed work force of
1,302 employees, with 274 physicians on its medical staff. 13.6% of AKMC 's patients receive
medical assistance.
Major projects undertaken by AKMC during the year were emergency department bedside
registration , a CT waiting room , restoration of the parking garage , an obstetrics patient
monitoring system , and bed replacement on several floors.
MISSION, VISION, & VALUES
Mission
The mission of Alle-Kiski Medical Center is to be the:
Alle-Kiski region's
Knowledgeable and trusted provider of quality
Medical services and education, in a
Comprehensive and caring environment
Vision
Alle-Kiski Medical Center will be recognized as the premier provider of healthcare services and
education to the residents of the Alle-Kiski region and the gateway to world-class medical care.
AKMC will achieve its vision by providing efficient and excellent service that exceeds the
expectations of its patients, medical staff, employees and volunteers.
Values
Alle-Kiski Medical Center provides an environment of integrity, accountability, consideration,
initiative and adaptability in fulfilling its mission, achieving its vision and implementing strategic
objectives as an organization.
UNCOMPENSATED CARE
To enhance the health status of the community in which it operates and consistent with its taxexempt status, AKMC provides needed health care services to individuals regardless of their
ability to pay for all or part of the services rendered. These services include both inpatient and
outpatient services as well as an emergency room that is available 24 hours a day. Components
of uncompensated care include charity care, uninsured discounts, and bad debt. Because patients
are often reluctant to complete the required charity care paperwork, an unquantifiable amount of
charity care results in bad debt expense.
Page 2
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
Exclusive of bad debt of $3,492,000, Alle-Kiski Medical Center provided free care of
approximately $1,938,000 in fiscal 2005 as follows:
Uninsured Discount
Charity Care
Total
$ 958,000
980,000
$ 1,938,000
Services are also provided to beneficiaries of government sponsored programs, including state
Medical Assistance and indigent care programs. Reimbursement from these programs is often
less than the cost of providing these services, and is as follows:
MA Payments
MA Costs
Total
$6,649,000
9,413,000
($2,764,000)
In summary, Alle-Kiski Medical Center provided a total of $8,194,000 of uncompensated care to
its patients in fiscal year 2005.
COMMUNITY ASSESSMENT
Community Health Services
Community health services include activities carried out to improve community health. They extend
beyond patient care activities and are subsidized by the hospital. The programs ranged from
community health education to free clinics and screenings. Alle-Kiski Medical Center provided the
following community health services during fiscal year 2005 at an estimated cost of $397,000.
PriorityCare Senior Membership Proms- More than 27,000 area residents who are 55 or older
belong to the PriorityCare senior membership program, which provides access to educational
programs, health screenings and answers to health-related questions. Members receive a
personal membership card and a tri-annual newsletter, which includes a calendar of events.
Members also benefit from having a PriorityCare coordinator available to answer their healthcare questions and help them navigate the health care system. The PriorityCare program
administered over 1,900 flu immunizations to those at risk and over 100 pneumonia vaccinations
through a series of outreach events and at local senior centers.
AARP' s 55 Alive Mature Driving Program - AKMC co-sponsors this two-day driver refresher
course , approximately 18 times each year . In fiscal 2005 approximately 200 drivers participated
at a program offered at Allegheny Valley Hospital or Citizens Ambulatory Care Center. Free
Page 3
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
meeting -space , parking, refreshments , and publicity are provided through the hospital.
Adopt-A-School, Community Oriented Schools Initiative - AKMC representatives serve on the
Advisory Board of this community partnership developed by the Federal Bureau of Investigation.
The initiative strives to encourage students to become responsible, accountable citizens and to
choose a lifestyle free from crime, drugs, gangs and violence.
Alle-Kiski HOPE Center - The hospital worked closely with agency representatives to develop
ri sk
policiPS and procedures for staff to assess all pffor
a
for ris'K o f domesti c violence .
1111
A
k If f"
1A1Tlr
1Vll 1
representative also serves on a HOPE center advisory board . AKMC co-sponsors the area's
largest community information event, the Families First 2005 GALA . Each year the "GALA"
(Growing Awareness of Local Agencies) provides over 2,000 participants with the opportunity to
learn about the many community services available to serve all types of family and individual
needs.
Allegheny County Bar Association - VIP (Very Important Papers) program - Through a
partnership with the Priority Care program, the Bar Association's Young Lawyers section offers
a series of legal information workshops targeting the interests and needs of older adults.
American Cancer Society (ACS) Four Corners Unit - AKMC staff works closely with the ACS to
provide many services and educational programs to cancer patients. Additionally, AKMC is an
avid supporter of ACS services and fund raisers.
Look Good - Feel Better! - AKMC provides free space at the hospital for the American
Cancer Society to host the program Look Good - Feel Better, a program directed toward helping
cancer patients feel good about their appearance.
Relay for Life - Alle-Kiski Medical Center sponsored two teams of walkers for the American
Cancer Society's Relay for Life (Apollo-Ridge and Highlands)
Medicare/Medig_ap Workshop - AKMC provides seniors with information about Medicare and
supplemental insurance and HMOs and helps with decision making.
Childbirth Education Classes - The hospital provided 10 classes covering breast feeding,
newborn care and sibling classes.
Safe Sitter Classes - AKMC conducted classes which focused on safe-sitting practices.
Page 4
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
A 'Series of "Doc" Talks" - The hospital provided the following classcs icad by physicians:
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Knee Surgery
Procedure for Healing Enlarged Prostate
Medicare Drug Discount Card: Is It Right For You
Women and Breast Cancer: An Update
TMJ and Jaw Disorders
Obesity: Risk Reduction
Treatment Options for I-lip and Knee Arth.riiis
Diabetes and Dieting: Understanding Facts and Fads About Weight Management
The Eyes Have It: Annual Vision Screening
Stroke Prevention Screening (8`h annual)
Colorectal Cancer Awareness and Screening
American Diabetes Alert Day
PA Society of Radiation Technologists
Breast Cancer Awareness
New Procedures for Women with Menorrhagia
Various School Tours - Every year, AKMC provides free hospital tours to nursery schools, scout
troops, career clubs and other groups as requested. Approximately 125 visitors toured AKMC
during the year.
Nutrition Clinic - This clinic teaches individuals how to change their eating habits through meal
planning and behavior modification. Staffed by registered nutritionists, the clinic focuses on
several different types of diets, including diabetic, cardiac rehabilitation, weight control,
digestive disorders, food allergies, high blood pressure, healthy meal plans for children, and food
and drug interaction.
Manunogram Voucher Program - AKMC is a participant in two programs (i.e. the Family Health
Council and the American Cancer Society) that provided mammograms and follow-up diagnostic
services to medically under-insured and uninsured women in western Pennsylvania.
Influenza and Pneumonia Immunization - In fiscal 2005 flu shots were administered to the public
for a minimal fee during October and November. A total of 2,170 immunizations were provided
at several sites including Allegheny Valley Hospital, Citizens Ambulatory Care Center, the AlleKiski Senior Center, the Avonmore Senior Center, and the East Vandergrift Senior Center.
AKMC has offered a community immunization program through the Priority Care program for
fifteen years. Expenses attributable to this program are vaccine and supplies. There are no
Page 5
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
salaries associated with this program. Shots are administered by retired RN volunteers and
senior School of Nursing students.
Health Fairs and Screenings - Throughout the year, AKMC participates in several health fairs
that provide free screenings and information to the residents of the Alle-Kiski Valley.
Health Professions Education
Alle_
su, Medical Center provided th e following e ducation for health professionals during the
fiscal year at an estimated cost of $297,000.
Nurses/Nursing Students - Since 1913, the Citizens School of Nursing has provided more than
1,700 graduates with a strong foundation on which to build their future nursing careers. The
school earned its first National League on Nursing accreditation in 1960 and continues to enjoy
the privilege of full accreditation, due in part to a constantly evolving curriculum that
consistently meets the needs of its students and reflects the changes of the nursing profession.
Committed to its original tradition of intent, the school prepares each student with the knowledge
and skills necessary to exceed the challenges of providing quality nursing in the 21st century.
Operated in conjunction with La Roche College , the School of Nurse Anesthesia at AKMC offers
a master's degree with a concentration in anesthesia . The students fulfill their academic
requirement through classes at La Roche, while their clinical experience is obtained at AKMC.
Other Health Professions Education - AKMC provides students from various health-related fields
(including medical technology, nursing, physical therapy, occupational therapy and pharmacy)
with the vital clinical training and experience they need to prepare for their future careers.
Students pursuing degrees in hospital administration and medical records administration also find
internships at AKMC extremely beneficial. In addition, the AKMC affiliation with the Center
for Health Careers enables area high school students to participate in job fairs, hospital tours and
classroom presentations by healthcare professionals to assist them in deciding whether a career in
healthcare might be right for them.
Subsidized Health Services
Subsidized health services represent those programs provided to the community by Alle-Kiski
Medical Center despite the fact the hospital operates them at a financial loss. AKMC recognizes
the needs of its community and voluntarily subsidizes these programs in support of its charitable
mission. The following information is reflective of the full cost of-these programs as well as
uncompensated care as previously described.
Page 6
Alle-Kiski Medical Center
EIN: 25-1875178
For Tax Year Ended June 30, 2005
Statement 17
Form 990, Part III
Program Service Accomplishments
Among the subsidized health services provided by AKMC at a combined loss of$3,251,000 are
the treatment of patients afflicted with cancer , mental health, and eye disease . Alle-Kiski Medical
Center also incurs significant losses associated with the treatment of women , children and
newborns.
Another subsidized health service is a paramedic program known as the Alle-Kiski Paramedic
Unit for Life Support Emergency Response (A-K Pulser), a not-for-profit venture of AKMC and
13 area ambulance services. A-K Pulser is staffed by paramedics taking call 24 hours a day and
is fully cquipped with specialized emergency equipment. The A-K Puiser ensures that
community residents receive quality pre-hospital care quickly and efficiently. A-K Pulser
responded to 1,545 calls during fiscal year 2005.
Page 7
Alle-Kiski Medical Center
E1N:25-1875178
For Year Ended June 30, 2005
Statement 18
Form 990, Part IV
Line 64a Bond Liabilities
The members of the Obligated group are jointly and severally liable for the satisfaction of
WPAHS bond debt. The debt has been allocated to each of the members of the Obligated
bolup for financial reporting purposes.
Alle-Kiski Medical Center's share of long-term debt is $33 ,537,074. See Page 2 of this
statement for long-term debt detail.
The total long-term debt of the Obligated group is reported on West Penn Allegheny
Health System's Form 990. West Penn Allegheny Health System is the sole member of
Alle-Kiski Medical Center.
Statement 18
Form 990, Part IV Line 64a
Alle-Kiski Medical Center
EIN 25-1875178
Year End Date: June 30, 2005
TAX-EXEMPT BOND LIABILITIES
Name of Bond:
Allegheny County Hospital Development Authority Hospital Revenue Bonds,
Series 2000 A & B
Issue Date:
August 9, 2000
Purpose of Issue:
To acquire identified assets of the Obligated Group through a substitution
of interests, establish debt service reserve funds for the Series 2000 Bonds,
reimburse certain members of West Penn Allegheny Health System for,
or finance, capital expenditures, and pay the costs of issuing the Series 2000
Bonds.
Original Amount of Issue:
$465,065,000
Forms filed at Issue (if applicable):
(i.e. 8038, 8038-G, or 8038-GC)
Form 8038
If the Issue was retired during the year.
Date of Retirement:
N/A
Maturity Date:
November 15, 2030
Amount of Issue outstanding at end of tax year:
$33,537,074
Amount of unexpended bond proceeds at
end of tax year:
If any part of the bond financed facility was
used by a third party other than a charitable
exempt organization or governmental unit,
the percentage of use by that third party:
Page 0
(total of all entities)
(this entity only)
$0
All property financed with the proceeds of tax-exempt bonds is owned
by a Section 501 (c)(3) organization or used by a private party as private
use permitted under the Internal Revenue Code or pursuant to a safe harbor
under Rev. Proc 97-15.
Alle-Kiski Medical Center
Statement 19
EIN 25-1875178.
Form 990
For Tax Period Ended June 30, 2005
Part V
Officers, Directors, Trustees, and Key Employees
OFFICERS. DIRECTORS. TRUSTEES. AND KEY EMPLOYEE S
(A)
(B)
NAME
TITLE
AND ADDRESS
HOURS/WEEK
COMPENSATION
CHAIRMAN
6 HOURS
$0
HOSPITAL
$357,866
SECRETARY
40 HOURS
ASSISTANT
M STEPHEN HEILMAN MD
VASCOR AND LIFECOR
566 ALPHA DRIVE
(Di
(E)
CONTRIBUTIONS TO
EXPENSES AND
BENEFIT PLANS
OTHER ALLOWANCES
$0
$0
Note 1
$35,177
$0
$329,585
Note 1
$26,917
$0
$88,458
Note 2
$16,462
$0
$569,368
Note 1
$49,581
$0
ASSISTANT
TREASURER
40 HOURS
$284,338
Note 1
$33,590
$0
SYSTEM
$834,413
Note 1
$55,001
$0
$634,127
Note 1& 3
$22,028
$0
$0
$0
$0
$0
$0
$0
(C;
NOTE
PITTSBURGH PA 15238
CINDY K. SCHAMP
1301 CARLISLE STREET
NATRONA HEIGHTS PA 15065
JUDY HLAFCSAK
320 EAST NORTH AVENUE
PITTSBURGH PA 15212
SHARON LOFTUS
320 EAST NORTH AVENUE
PITTSBURGH PA 15212
DAVID A SAMUEL
4800 FRIENDSHIP AVENUE
PRESIDENT/CEO
40 HOURS
SECRETARY
40 HOURS
TREASURER
40 HOURS
PITTSBURGH, PA 15224
DAWN JAVERSACK
320 EAST NORTH AVENUE
PITTSBURGH, PA 15212
JERRY J. FEDELE ESQ
4800 FRIENDSHIP AVENUE
PITTSBURGH, PA 15224
CHARLES O'BRIEN JR
4800 FRIENDSHIP AVENUE
PITTSBURGH PA 15224
PRESIDENT/CEO
40 HOURS
SYSTEM
PRESIDENT/CEO
40 HOURS
(Involvement terminated 10/13/03)
FRANKA BORGIAM D
HIGHLAND SURGICAL ASSOCIATES
1629 UNION AVENUE
NATRONA HEIGHTS PA 15065
M K BARNHART
1232 MINNESOTA AVENUE
NATRONA HEIGHTS, PA 15065
(INVOLVEMENT TERMINATED 12131/04)
DIRECTOR
4 HOURS
DIRECTOR
2 HOURS
Alle-Kiski Medical Center
Statement 19
EIN 25-1875178,
Form 990
For Tax Period Ended June 30, 2005
Part V
Officers, Directors, Trustees, and Key Employees
OFFICERS. DIRECTORS. TRUSTEES. AND KEY EMPLOYEES
(A)
NAME
(B)
TITLE
(C)
AND ADDRESS
HOURS/WEEK
COMPENSATION
DIRECTOR
BENEDICT DEMARIA
MINE SAFETY APPLIANCES COMPANY
121 GAMMA DRIVE
PITTSBURGH PA 15238
(D)
CONTRIBUTIONS TO
(E)
EXPENSES AND
BENEFIT PLANS
OTHER ALLOWANCES
$0
$0
$0
$0
$0
$0
NOTE
2 HOURS
(Involvement terminated Feb 2005)
RUSSELL EVANS
MEDRAD
DIRECTOR
6 HOURS
ONE MEDRAD DRIVE
INDIANOLA PA 15051
JOAN FERLAN
1301 CARLISLE STREET
NATRONA HEIGHTS PA 15065
DIRECTOR
4 HOURS
$0
$0
$0
BART FRIEDMAN MD
DEPARTMENT OF MEDICINE
ALLE-KISKI MEDICAL CENTER
DEPARTMENT OF M I R 0
DIRECTOR
6 HOURS
$0
$0
$0
DIRECTOR
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1301 CARLISLE STREET
NATRONA HEIGHTS PA 15065
DAVID L MCCLENAHAN
KIRKPATRICK & LOCKHART
1500 OLIVER BUILDING
PITTSBURGH PA 15222
MARGARET E MEALS MD
ASSOCIATES IN INTERNAL MEDICINE
4 HOURS
DIRECTOR
4 HOURS
320 THIRD AVENUE
TARENTUM PA 15084
CAROL RUSH PH D
9301 PANNIER ROAD
DIRECTOR
4 HOURS
PITTSBURGH PA 15237
LAURIE STERN SINGER
ALLEGHENY VALLEY DEVELOPMENT CORP
DIRECTOR
4 HOURS
1030 BROADVIEW BLVD
BRACKENRIDGE PA 15014
DARIUS SAGHAFI, M D
251 7TH STREET, SUITE C-204
DIRECTOR
4 HOURS
NEW KENSINGTON PA 15068
WALTER L. WILLIAMSON (Retired)
1301 CARLISLE STREET
NATRONA HEIGHTS PA 15065
EMERITUS
4 HOURS
Alle-Kiski Medical Center
Statement 19
EIN 25-1875178
Form 990
For Tax Period Ended June 30, 2005
Part V
Officers, Directors, Trustees, and Key Employees
OFFICERS . DIRECTORS , TRUSTEES , AND KEY EMPLOYEE S
(A)
(B)
NAME
TITLE
AND ADDRESS
HOURS /WEEK
COMPENSATION
EXECUTIVE VICE PRES
OF OPERATIONS
40 HOURS
$665,113
JAMES L . ROSENBERG
320 EAST NORTH AVENUE
PITTSBURGH PA 15212
(C)
(D)
(E)
CONTRIBUTIONS TO
EXPENSES AND
NOTE
BENEFIT PLANS
OTHER ALLOWANCES
Note 1
$51,858
$0
DIRECTORS AND TRUSTEES SERVE ON THE ALLE-KISKI MEDICAL CENTER
BOARD WITHOUT COMPENSATION
NOTE 1
THIS INDIVIDUAL DOES NOT RECEIVE COMPENSATION FORHIS /HER DUTIES AS AN
OFFICER / DIRECTOR, BUT IS PAID AS AN EMPLOYEE OF THE WESTERN
PENNSYLVANIA HOSPITAL , A RELATED IRC 501 (C)(3) TAX EXEMPT ORGANIZATION.
NOTE 2-
THIS INDIVIDUAL DOES NOT RECEIVE COMPENSATION FORHIS / HER DUTIES AS AN
OFFICER /DIRECTOR , BUT IS PAID AS AN EMPLOYEE OF ALLEGHENY GENERAL
HOSPITAL , A RELATED IRC 501(C)(3) TAX EXEMPT ORGANIZATION
NOTE 3
THIS AMOUNT REPRESENTS SEVERANCE PAYMENTS PAID DURING THE YEAR
ALLE-KISKI MEDICAL CENTER
EIN: 25-1875178
FOR YEAR ENDED JUNE 30, 2005
RELATED PARTIES AS OF JUNE 30 , 2005
Allegheny General Hospital ("AGH")
Allegheny Si nger Research Institute ("ASRI')
Forbes Regional Hospital (" FRH")
Canonsburg General Hospital
Canonsburg General Hospital Ambulance Service Inc.
Valley Development and Management Corporation
Alle-Kiski Paramedic Unit for Life Support Emergency Response (AKPULSER)
Allegheny Medical Practice Network ("AMPN ")
Allegheny Specialty Practice Network ("ASPN ")
Canonsburg Health and Hospital Foundation
The Western Pennsylvania Hospital ("WPH")
The Western Pennsylvania Hospital Foundation
West Penn Allegheny Oncology Network
Suburban General Hospital (" SGH")
Suburban Health Foundation
Friendship Insurance Company , Ltd.
West Penn Corporate Medical Services , Inc.
West Penn Comprehensive Health Care , PC
West Penn Specialty MSO, Inc.
Medical Center Clinic, PC
Burn Care Associates , Ltd.
Liberty Physicians , PC
Western Pennsylvania Obstetrical and Gynecological Multispecialists , PC
West Penn Neurosurgery, PC
West Penn Allegheny Health System , Inc. ("WPAHS")
West Penn Allegheny Foundation , LLC
Greater Canonsburg Health System
West Allegheny Hospital
West Penn Medical Associates
STATEMENT 20
Form 990
PART VI Question 80b
Exempt or
Non-Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Non-Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Exempt
Foreign Corp
Non - Exempt
Non- Exempt
Non-Exempt
Non-Exempt
Non-Exempt
Non-Exempt
Non - Exempt
Non- Exempt
Exempt
Exempt
Exempt
Exempt
Non-Exempt
Alle-Kiski Medical Center
EIN. 25-1875178
For Year Ended June 30, 2005
Statement 21
Form 990, Schedule A
Part III, Statement about Activities Ques 2e
Russell Evans, a member of the Alle-Kiski Medical Center Board of Directors, is
employed by Medrad, Inc. Medrad Inc provides products and services to West Penn
---Allegheny Health System member hospitals.
M. Stephen Heilman, Chairman of the Alle-Kiski Medical Center Board of Directors and
a member of the West Penn Allegheny Health System Board of Directors, is employed by
Vascor, Inc. and Lifecor. Mr. Heilman is also the Director of Medrad,Inc. Medrad Inc.
supplies minimal medical products and services to the hospitals of the West Penn
Allegheny Health System. Mr. Heilman is also the owner and director of SkyMark,
which sells software to healthcare organizations.
Bart Friedman,
M.D., a member of the Alle-
Kiskl
Medical Center Board of Directors, is
employed by Allegheny Valley Medical Imaging . Allegheny Valley Medical Imaging
has an exclusive imaging contract with Alle-Kiski Medical Center to provide imaging
services at fair market value.
David McClenahan, Esq., an attorney with Kirkpatrick & Lockhart, is the Chairman of
the Board for Allegheny Medical Practice Network and West Penn Allegheny Health
System. Mr. McClenahan also serves on the Board of Directors for Allegheny General
Hospital, Forbes Regional Hospital, Canonsburg General Hospital, Canonsburg General
Hospital Ambulance Service, Allegheny Singer Research Institute, Suburban General
Hospital, Alle-Kiski Medical Center, Allegheny Specialty Practice Network, The
Western Pennsylvania Hospital and The Western Pennsylvania Hospital Foundation.
During the fiscal year, Kirkpatrick & Lockhart provided legal services at fair market
value to members of the West Penn Allegheny Health System affiliated group.
Darius Saghafi, M.D., a member of the Alle-Kiski Medical Centers Board of Directors
receives Medical Renal Director and President of Medical Staff fees from Alle-Kiski
Medical Centers.
ALLE- KISKI MEDICAL CENTER
EIN: 25-1875178
FOR YEAR ENDED JUNE 30, 2005
STATEMENT 22
Form 990
SCHEDULE A, PART VI-A
Alle-Kiski Medical Center is not required to complete all columns as the 5768 election was
made for the year ended 6/30/04.
Name
Address
On
1 Allegheny General Hospital
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Ein: 25-1322626
2 Allegheny Singer Research Institute
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Tax Year
Graduated
( Return
Type)
Jun-05
(990)
(990T)
Jun-05
(990)
(9901)
Ein: 25-1320493
Rates
Tax Rate
AMT
AMT
Section
Structure
Exemption
Phase-Out
179
15 %
25%
34%
$50,000
$25,000
$25,000
39%
34%
$235,000
$9 , 665,000
15%
$0
$22 , 163
$150,000
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
_
$102,000
25%
34%
39%
34%
3 Allegheny Medical Practice Network
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Eln: 25-1838457
Jun-05
(990)
(990T)
15%
25%
34%
$0
39%
34%
4 Allegheny Specialty Practice Network
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Eln: 25-1838458
Jun-05
(990)
(990T)
15%
$0
25%
34%
39%
34%
5 Alle-KiskI Medical Center
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
EIN: 25-1875178
Jun-05
(990)
(990T)
15%
25%
34%
$o
39%
34%
6 Alle-Kiskl Paramedic Unit for Life Support
Jun-05
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
( 990)
(990T)
EIN: 25-1604818
15%
25%
$0
34%
39%
34%
Name
Address
Eln
7 Canonsburg Health and Hospital Foundation
C/O Tax Department
Tax Year
(Return
Type )
Jun-05
( 990)
Graduated
Rates
15%
320 East North Avenue, Pgh, PA 15212
25%
EIN: 25-1818505
34%
Tax Rate
Structure
AMT
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Section
179
$0
39%
34%
8 Canonsburg General Hospital Ambulance Service , Inc.
AMT
Phase -Out
Exemption
$0
$0
$0
$0
$0
$0
s0
s0
so
$0
$0
$0
$0
$0
$0
$0
$0
Jun-05
(990)
15%
(990T)
25%
Ein: 23-2939715
34%
39%
34%
9 Canonsburg General Hospital
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
EIN:25-1737079
Jun-05
(990)
(990T)
15%
25%
34%
$0
39%
34%
10 Forbes Regional Hospital
c/o Tax Department
320 East North Avenue, Pgh, PA 15212
Ein. 25-1798379
11 Friendship Insurance Company, Ltd.
Go Tax Department
320 East North Avenue, Pgh, PA 15212
Ein 98-0116952
Jun-05
(990)
(990T)
15%
25%
34%
39%
34%
$0
15%
$0
Jun-05
(5471)
25%
34%
39%
34%
12 Suburban General Hospital
Go Tax Department
320 East North Avenue, Pgh, PA 15212
Ein• 25-0965574
Jun-05
(990)
(990T)
15%
25%
$0
34%
39%
34%
_
$o
Name
Address
Ein
13 Suburban Health Foundation
cto Tax Department
320 East North Avenue, Pgh, PA 15212
Ein: 25-1472073
Tax Year
Graduated
( Return
Type)
Jun-05
(990)
(990T)
Rates
15%
25%
34%
Tax Rate
Structure
AMT
Exemption
AMT
Phase-Out
Section
179
$0
39%
34%
14 The Western Pennsylvania Hospital
do Tax Department
320 East North Avenue, Pgh, PA 15212
Ein• 25-0969492
Jun-05
(990)
(990T)
15%
25%
34%
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
39%
34%
15 The Western Pennsylvania Hospital Foundation
do Tax Department
320 East North Avenue, Pgh, PA 15212
Eln: 25-1470766
Jun-05
(990)
(990T)
15%
$0
25%
34%
39%
34%
16 Valley Development and Management
Corporation
Jun-05
(1120)
15%
C/O Tax Department
25%
320 East North Avenue, Pgh, PA 15212
34%
Eln, 25-1494317
39%
$0
34%
17 West Penn Allegheny Health System, Inc.
C/O Tax Department
320 East North Avenue, Pgh, PA 15212
Ein- 25-1848306
Jun-05
(990)
(990T)
15%
25%
34%
$0
39%
34%
18 West Penn Corporate Medical Services, Inc
do Tax Department
Jun-05
(1120)
15%
4800 Friendship Avenue
25%
Pittsburgh, PA 15224
Ein, 25-1437405
34%
39%
34%
$0
Name
Address
Eln
19 West Penn Specialty MSO, Inc.
c/o Tax Department
Tax Year
( Return
Type)
Dec-04
( 1120)
Graduated
Tax Rate
Rates
15%
320 East North Avenue, Pgh, PA 15212
25%
Ein: 23-2894932
34%
AMT
Exemption
Structure
AMT
Phase -Out
Section
179
$0
39%
34%
20 West Penn Allegheny Oncology Network
c/a Tax Department
320 East North Avenue, Pgh, PA 15212
EIN. 11-3683376
Jun-05
(990)
15%
25%
34%
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
39%
34%
21 Greater Canonsburg Health System
do Tax Department
320 East North Avenue, Pgh, PA 15212
Jun-05
( 990)
15%
25%
$0
34%
Ein: 25-1488089
39%
34%
22 West Allegheny Hospital
do Tax Department
Jun-05
(990)
320 East North Avenue, Pgh, PA 15212
Em 25-1054206
15%
$0
25%
34%
39%
34%
23 West Penn OB-GYN Multispecialists, PC
do Tax Department
320 East North Avenue, Pgh, PA 15212
EIN 25-1619226
15%
25%
34%
Dec-04
39%
34%
15%
24 West Penn Neurosurgery
do Tax Department
320 East North Avenue, Pgh, PA 15212
EIN 25-1630719
$0
_
$0
$0
25%
34%
Dec-04
39%
34%
$0
Name
Address
Tax Year
Type )
On
Dec-04
EIN 25 - 1637318
Tax Rate
AMT
AMT
Section
Structure
Exemption
Phase-Out
179
$0
34%
39%
34%
15%
25%
26 MCC, PC
clo Tax Department
320 East North Avenue, Pgh, PA 15212
Rates
15%
25%
25 Liberty Physicians, PC
c/o Tax Department
320 East North Avenue, Pgh, PA 15212
Graduated
(Return
Dec-04
EIN 23-2894939
Daily Bldg, 3rd Fl, Pittsburgh, PA 15224
EIN 25-1732745
$0
$0
$7,354
$0
$0
$0
$0
$0
$0
$0
$0
$ 40,000
$150 , 000
$102,000
$0
39%
34%
15%
25%
$0
34%
do Tax Department
320 East North Avenue, Pgh, PA 15212
29 Burn Care Associates, Ltd
Go Tax Department
320 East North Avenue, Pgh, PA 15212
EIN 23-2899534
$5,825
34%
Jun-05
28 West Penn Medical Associates, PC
EIN 25 -1666783
$0
34%
39%
15%
25%
4800 Friendship Avenue
$0
$0
34%
27 West Penn Comprehensive Health Care, PC
$4,658
39%
Dec-04
34%
15%
25%
$0
34%
Dec-04
39%
34%
Total
Signature of authorized person for all group members:
Title
/sa-cam
Form 8868
(Rev December2004)
Application for Extension of Time To File an
Exempt Organization Return
Department of the Treasury I
Internal Revenue Service
-
It- File a separate application for each return
OMB No. 1545-1709
I
• If you are filing for an Automatic 3-Month Extension , complete only Part I and check this box . . . . . . . . ^ ❑✓
• If you are filing for an Additional (not automatic) 3-Month Extension , complete only Part II (on page 2 of this form).
Do-not complete Part 11 unless you have alread y been g ranted an automatic 3-month extension on a p reviousl y filed Form 8868.
Automatic 3-Month Extension of Time-Only submit original (no copies needed)
Fg-WH
Form 990 -T corporations requesting an automatic 6-month extension-check this box and complete Part I only . . . ^ ❑
All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to file income tax returns
Partnerships, REMICs, and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041.
Electronic Filing (e -file). Form 8868 can be filed electronically if you want a 3-month automatic extension of time to file one of the
returns noted below (6 months for corporate Form 990-T filers). However, you cannot file it electronically if you want the additional
(not automatic) 3-month extension, instead you must submit the fully completed signed page 2 (Part II) of Form 8868. For more
details on the electronic filing of this form, visit www.lrs.gov/efile.
Employer identification number
Type or
print
Name of Exempt Organization
File by the
fiingdyouror
Number, street, and room or suite no. If a P.O. box, see instructions.
c/o Tax Department, 320 East North Avenue
return . See
instructions.
City, town or post office, state , and ZIP code. For a foreign address, see instructions.
25 : 18 75178
Alle - Kiski Medical Center
Pittsburgh , PA 15212
Check type of return to be filed (file a separate application for each return):
✓❑ Form 990
❑ Form 990-T (corporation)
❑ Form 990-T (sec. 401(a) or 408(a) trust)
❑ Form 990-BL
❑ Form 990-T (trust other than above)
❑ Form 990-EZ
❑ Form 1041-A
❑ Form 990-PF
❑
❑
❑
❑
Form
Form
Form
Form
4720
5227
6069
8870
• The books are in the care of ^ WP AHS Tax Department
FAX No. ^ ___412 ) 330-6060
Telephone No. ^ (__412 ) 330-4962
. . . . . . ^ ❑
• If the organization does not have an office or place of business in the United States, check this box
. If this
• If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN)
. If it is for part of the group, check this box ^ ❑ and attach a list with the
is for the whole group, check this box
names and EINs of all members the extension will cover.
20 .061
I request an automatic 3-month (6-months for a Form 990-T corporation) extension of time until -February 15 I
to file the exempt organization return for the organization named above. The extension is for the organization's return for:
^ ❑ calendar year 20... or
June 30-_------___- 20 -5.
20 04, and ending
tax year beginning ............ July 1
^
2
If this tax year is for less than 12 months, check reason: ❑ Initial return
❑ Final return ❑ Change in accounting period
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative
nonrefundable credits. See instructions . . . . . . . . . . . . . . . . .
b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated
.
. . . . . . .
made. Include any prior year overpayment allowed as a credit
tax, less any
. . . . .
tax payments
. . . . .
$
$
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
. . . . . . . . . . . .
with this Form 8868, see Form 8453-EO and Form 8879-EO
withdrawal
electronic
fund
Caution . If you are going to make an
for payment instructions.
For Privacy Act and Paperwork Reduction Act Notice , see Instructions .
Cat No 27916D
Form 8868 (Rev 12-2004)
Form 8868 (Rev. 12 -2004)
Page 2
• If you are filing for an Additional (not automatic) 3-Month Extension , complete only Part II and check this box . . ^ ✓❑
Note . Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868.
• If you are filing for an Automatic 3-Month Extension , complete only Part I (on page 1).
Additional (not automatic ) 3-Month Extension of Time-Must File Ori g in I and One Co py,
Name of Exempt Organization
Type or
Employer identification number
Alle Kiskl Medical Center
print
25 : 1875178
Number, street , and room or suite no . If a P.O. box , see instructions.
File by the
exte nded
due date
ate for
filing the
For IRS use only
c/o Tax Department, 320 East North Avenue
City, town or post office , state, and ZIP code. For a foreign address , see instructions .
Pittsburgh , PA 15212
structions .
Check type of return to be filed (File a separate application for each return):
a
-.s
0 Form 990
❑ Form 990-T (sec. 401(a) or 408(a) trust)
❑ Form 5227
❑ Form 990-BL
❑ Form 990-T (trust other than above)
❑ Form 6069
❑ Form 8870
❑ Form 990-EZ
❑ Form 1041-A
❑ Form 990-PF
❑ Form 4720
STOP: Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868.
• The books are in the care of ^ WP AHS Tax Department. ...... . ....... . .......................................
330-4962
FAX No. ^ (AR .) _________ 330-6060
Telephone No. ^ (__412 )
• If the organization does not have an office or place of business in the United States, check this box
. . . . . . ^ ❑
• If this is for a Group Return , enter the organization's four digit Group Exemption Number (GEN)
If this is
❑ . If it is for part of the group, check this box ^ ❑ and attach a list with the
for the whole group, check this box ^
names and EINs of all members the extension is for.
20 06
4
I request an additional 3-month extension of time until ........:.......
-....-__..._
July-1
, 20. M ., and endin
June 30
For calendar year - _ _ _ - . - , or other tax year beginning
.20055
6
7
If this tax year is for less than 12 months, check reason: ❑ Initial return ❑ Final return ❑ Change in accounting period
^5__n•?e
Stat in detail why you need the extension
.............
in prma-fion -FO ^rr^ar2---and
st
n
a^t --V v r-Oubn .
this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
8a If---------------------------------------------------------------------------------------------------------------------------------------------
.
$
0
b If this application is for Form 990-PF, 990-T, 4720, or 6069 , enter any refundable credits and estimated
tax payments made . Include any prior year overpayment allowed as a credit and any amount paid
previously with Form 8868
. . . . . . . . . . . . . . . . . . . . . . . . . .
c Balance Due. Subtract line 8b from line 8a. 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
$
0
nonrefundable credits. See instructions
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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,
ed to prepare this form.
mplete . and
it is true , co
Signature
I
- S
i tis
7:77
-
Tice to Appiicaint-To Be Co nplet
"
Date ^
by the -RS
We have approved this application . Please attach this form to the organization ' s return.
❑
❑
We have not approved this application . However , we have granted a 10-day grace period from the later of the date shown below or the due
date of the organization ' s return (i ncluding any prior extensions). This grace period is considered to be a valid extension of time for elections
otherwise required to be made on a timely return . Please attach this form to the organization ' s return.
We have not approved this application . After considering the reasons stated in item 7, we cannot grant your request for an extension of time
C
to file . We are not granting a 10-day grace period.
>^
We cannot consider this application because it was filed after the extended due date of the return for which an extensiorl^ 8 ENiG&JAPPROVED
❑
Other ......................................................................................................................................
❑
JAN 2 0 2005
By.
Date
Director
Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-m
returned to an address different than the one entered above.
Name
Type or
print
r RFr..-
DIRECTOR,
EN
MgMs
ED
I Number and street ( include suite , room, or apt no.) or a P.O. box number
City or town, province or state, and country [i ncluding postal or ZIP code)
OGDE ^ A
12-2004)