Professional Documents
Culture Documents
OMB No 1545-0047
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung 1(0)11
benefit trust or private foundation) O p e n t o Public
Department of the Treasury
Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements Inspection
A For the 2011 calendar year, or tax year beginning 2011. and ending ,20
B Check if applicable C Name of organization D E A C O N E S S ASSOCIATIONS, INC. D Employer identification number
>
o 2 Check this box ► D if the organization discontinued its operations or disposed of more than 25% of its net assets.
3 Number of voting members of the governing body (Part VI, line 1a)
CNJ.8 4 Number of independent voting members of the governing body (Part VI, line 1b) . . . .
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a)
6 Total number of volunteers (estimate if necessary)
<
C_> 7a Total unrelated business revenue from Part VIII, column (C), line 12 7a
O - b Net unrelated business taxable income from Form 990-T, line 34 7b
Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h)
9 Program service revenue (Part VIII, line 2g) 1,361,854 1,190,344
If 10
11
Investment income (Part VIII, column (A), lines 3, 4, and 7d)
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) . . .
14,698,506
19,119
16,802,969
167
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 16,079,479 17,993,480
13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) . 100,000
O *
OGDEN; UT J Beginning of Current Year End of Year
■J3C 375,493,140
20
W CO
Total assets (Part X, line 16) 375,126,823
9. 21 Total liabilities (Part X, line 26) 23,851,632 24,558.095
22 Net assets or fund balances. Subtract line 21 from line 20 351,275,191 350,935,045
Signature Block
Under penalties of perjury, I declare that I have examined this retura including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and compteJB DeelaratiotiJ* preparer (other/than officer) is based on all information of which preparer has any knowledge
I WHIP-
Sign Signature of officer Date? I
Here
Type or pnnt name and title
Pnnt/Type preparer's name
*f Preparer's signature Date PTIN
Paid Check □ if
self-employed
Preparer
Firm's name Firm's EIN ►
Use Only
Firm's address ► Phone no
May the IRS discuss this return with the preparer shown above? (see instructions) □ Yes Q No
For Paperwork Reduction Act Notice, see t h e separate instructions. Cat No 11282Y Form 9 9 0 (2011)
qo-tf
Form 990 (2011) Page 2
S t a t e m e n t of P r o g r a m Service A c c o m p l i s h m e n t s
C h e c k if S c h e d u l e O c o n t a i n s a r e s p o n s e t o any q u e s t i o n in this Part III [7J
'1 Briefly describe the organization's mission:
Deaconess Associations, Inc. serves as a holding company to coordinate the activities of its non-profit subsidiaries including
Deaconess Health Association Fund, Inc. and Deaconess Long Term Care Inc. The primary purpose of the Deaconess organization
is to advance health care solutions by providing viable health care services and products, and releasing proceeds to support
charitable initiatives.
2 Did the organization undertake any significant program services during the year which were not listed on the
prior Form 990 or 990-EZ? [7] Yes DNo
If "Yes," describe these new services on Schedule O.
3 Did the organization cease conducting, or make significant changes in how it conducts, any program
services? DYes 0No
If "Yes," describe these changes on Schedule O.
4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by
expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of
grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
5
4b (Code: ) (Expenses $ J??j?'.??.1. including grants of $ 0 ) (Revenue $ _!7.:_V!3 )
Deaconess Associations, Inc. serves as the sole owner of Deaconess Diagnostic LLC, making it a disregarded entity. Deaconess
Diagnostic provides Radiology services to the community and the tenants located in the Deaconess Hospital. In 2011, Deaconess
Diagnostic served 524 patients from the community.
i i ij
R 5" -n
(describe o the organizations compensation
hours for *t
ro a
3 organization (W-2/1099-MISC) from the
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related (W-2/1099-MISC) organization
o SL
organizations and related
in Schedule
O)
c
W
CD
CD
i organizations
(8)
(9)
(10)
(11)
(12)
(13)
(14) t
Form 9 9 0 (2011)
Form 990 (2011) Page 8
I J H S y j r i Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(C)
Position
(A) (B) (D) (E) (F)
(do not c h e c k more than one
Name and title Average box, unless person is both an Reportable Reportable Estimated
hours per officer a n d a director/trustee) compensation compensation from amount of
week from related
"n
3 1
1!]
(describe
Z3
CO o the organizations compensation
o
hours for ca ca.
Q-
c CD i organization (W-2/1099-MISC) from the
related 5 CD (W-2/1099-MISC) organization
EJSL
organizations and related
in Schedule "?
w organizations
O) CD
CD
GO
CD
CD
(15)
(16)
(17)
(18)
(19)
(20)
(21)
(22)
(23)
(24)
(25)
2 Total number of independent contractors (including but not limited to those listed above) who ■ - . . .
6a Gross rents . .
b Less: rental expenses
c Rental income or (loss) 0 0
d Net rental income or loss) ► 0
7a Gross amount from sales of (i) Securities (u) Other
assets other than inventory 71,078,137
b Less: cost or other basis
and sales expenses . 63,536,797
- c Gain or (loss) . . 7,541,340
d Net gain or (loss) . ► 7,541,340 7,541,340
0)
3 8a Gross income from fundraising
C
0) events (not including $ o
>
CC of contributions reported on line 1 c).
See Part IV, line 18 a 0
o b Less: direct expenses . . . . b 0
Net income or (loss) from fundraising events ► 0
9a Gross income from gaming activities.
See Part IV, line 19 a 0
b Less: direct expenses . . . . b 0
c Net income or (loss) from gaming activities . . ► 0
10a Gross sales of inventory, less
returns and allowances . . . a 0
b Less: cost of goods sold . . . b 0
c Net income or (loss) from sales of invejntory . . ► 0
Miscellaneous Revenue Business Code
11a Other receipts 561000 167 167
b 0
c 0
d All other revenue 0
e Total. A d d lines 1 1 a - 11d . . . . . . . . ► 167
12 Total revenue. See iristructions ► 17,993,480 1,190,511 0 16,802,969
Form 9 9 0 (2011)
Form 990 (2011) Page 10
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are no
required to complete columns (B), (C), and (D).
C h e c k if S c h e d u l e O c o n t a i n s a r e s p o n s e t o any q u e s t i o n in t h i s Part IX . .
Do not include amounts reported on lines 6b, 7b, (A) (B)
Program service
(C)
Management and
(D)
Fundraising
□
8b, 9b, and 10b of Part VIII. Total expenses
expenses general expenses expenses
1 Grants and other assistance to governments and
organizations in the United States. See Part IV, line 21 0 j
2 Grants and other assistance to individuals in
the United States. See Part IV, line 22 . . . 0
3 Grants and other assistance to governments,
organizations, and individuals outside the
United States. See Part IV, lines 15 and 16 . . 0
4 Benefits paid t o or for members . . . . 0 i
-i 23 Secured mortgages and notes payable to unrelated third parties . . 22,105,005 23 23,705,005
24 Unsecured notes and loans payable to unrelated third parties . . . 0 24 0
25 Other liabilities (including federal income tax, payables to related third
parties, and other liabilities not included on lines 17-24). Complete Part X 0 0
of Schedule D 25
26 Total liabilities. Add lines 17 through 25 23,851,632 26 24,558,095
Organizations that follow SFAS 117, check here ► □ and complete
1 27
lines 27 through 29, and lines 33 and 34.
Unrestricted net assets 351,275,191 27 350,935,045
28 Temporarily restricted net assets 28
■g 29 Permanently restricted net assets 29
o
30 Capital stock or trust principal, or current funds 30
J2
1
<
31
32
Paid-in or capital surplus, or land, building, or ecjuipment fund . . .
Retained earnings, endowment, accumulated income, or other funds .
31
32
i£\ Deaconess
Healthcare Services 31-1365388 3 / / / 52,053
ia\ Deaconess Long
Term Care 31-1391195 11b / / • 0
IQ\ Deaconess Hospital
ofCinti. OH 31-0537109 11b / / / 2,241,752
in\ Deaconess Health
Assoc. Fund 31-1209378 11b / / / 368,479
(E)
Total
For Paperwork Reduction Act Notice, see the Instructions for Cat No 11285F Schedule A (Form 990 or 990-EZ) 2011
Form 990 or 990-EZ.
Version A, cycle 1
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
►$
8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)
(i) and section 170(h)(4)(B)(ii)? D Yes D No
9 In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the
organization's accounting for conservation easements
I2QDD Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet
works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of
public service, provide the following amounts relating to these items:
(i) Revenues included in Form 990, Part VIII, line 1 ► $
(ii) Assets included in Form 990, Part X ► $
2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a Revenues included in Form 990, Part VIII, line 1 ► $
b Assets included in Form 990, Part X ► $
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 52283D Schedule D (Form 990) 2011
Schedule D (Form 990) 2011 Page 2
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3 Using the organization's acquisition, accession, and other records, check any of the following that are a significant use of its
collection items (check all that apply):
a □ Public exhibition d □ Loan or exchange programs
b □ Scholarly research e □ Other
c □ Preservation for future generations
* Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part
XIV.
5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization's collection? . . r j Yes □ No
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990, Part IV,
line 9, or reported an amount on Form 990, Part X, line 2 1 .
1a Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? r j Yes □ No
b If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance 1c
d Additions during the year 1d
e Distributions during the year 1e
f Ending balance . . . . 1f
2a Did the organization include an amount on Form 990, Part X, line 21? □ Yes 0 No
b If "Yes," explain the arrangement in Part XIV.
P M Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back
(D
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col (B) line 13) ►
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) Due From Affiliates 29.816,586
(2)
(3)
(4)
(5)
(6)
(7)-
(8)
(9)
(10)
Total. (Column (b) must eaual Form 990, Part X, col. (B) line 15.) ►
Other Liabilities. See Form 990, Part X, line 25.
1. (a) Descnption of liability (b) Book value
(1) Federal income taxes 0
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
Total. (Column (b) must equal Form 990, Part X, col (B) line 25.) ► 0
2. FIN 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the
organization's liability for uncertain tax positions under FIN 48 (ASC 740).
Schedule D (Form 990) 2011
Schedule D (Form 990) 2011 Page 4
Reconciliation of Change in Net Assets from Form 990 to Audited Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) 17,993,480
2' Total expenses (Form 990, Part IX, column (A), line 25) 4,761,834
3 Excess or (deficit) for the year. Subtract line 2 from line 1 13,231,646
4 Net unrealized gains (losses) on investments
5 Donated services and use of facilities
6 Investment expenses
7 Prior period adjustments
8 Other (Describe in Part XIV.)
9 Total adjustments (net). Add lines 4 through 8 . . . . . .
10 Excess or (deficit) for the year per audited financial statements. Combine lines 3 and 9 10 13,231,646
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
Total revenue, gains, and other support per audited financial statements 1 17,993,480
Amounts included on line 1 but not on Form 990, Part VIII, line 12:
Net unrealized gains on investments 2a
Donated services and use of facilities 2b
Recoveries of prior year grants 2c
Other (Describe in Part XIV.) 2d
Add lines 2a through 2d . . . . 2e
3 Subtract line 2e from line 1 . . . .
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1 :
a Investment expenses not included on Form 990, Part VIII, line 7b . . 4a
b Other (Describe in Part XIV.) 4b
c Add lines 4a and 4b 4c
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) 17,993,834
Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements . . 4,761,834
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
Donated services and use of facilities 2a
Prior year adjustments 2b
Other losses 2c
Other (Describe in Part XIV.) 2d
Add lines 2a through 2d 2e
3 Subtract line 2e from line 1
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
Investment expenses not included on Form 990, Part VIII, line 7b 4a
Other (Describe in Part XIV.) 4b
Add lines 4a and 4b 4c
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) 4,761,834
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide
anv additional information.
b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment
or reimbursement or provision of all of the expenses described above? If "No," complete Part III to
explain 1b
2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
3 Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a
related organization to establish compensation of the CEO/Executive Director Explain in Part III.
0 Compensation committee □ Written employment contract
0 Independent compensation consultant 0 Compensation survey or study
□ Form 990 of other organizations 0 Approval by the board or compensation committee
4' During the year, did any person listed in Form 990, Part VII, Section A, line 1a, with respect to the filing
organization or a related organization:
a Receive a severance payment or change-of-control payment? 4a /
b Participate in, or receive payment from, a supplemental nonqualified retirement plan? 4b /
c Participate in, or receive payment from, an equity-based compensation arrangement? 4c /
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only section 501(c)(3) and 501(c)(4) organizations must complete lines 5-9.
5 For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a The organization? 5a /
b Any related organization? 5b /
If "Yes" to line 5a or 5b, describe in Part III.
6 For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a The organization? 6a /
b Any related organization? 6b /
If "Yes" to line 6a or 6b, describe in Part III.
7 For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III /
8 Were any amounts reported in Form 990, Part VII, paid or accrued pursuant to a contract that was subject
to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III /
9 If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in
Regulations section 53.4958-6(c)?
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50053T Schedule J (Form 990) 2011
Schedule J (Form 990) 2011 page 2
■amill Officers, Directors, TrusteesTKey Employees, and Highest-Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part Vll.
Note. The sum of columns (B)(iH"i) for each listed individual must equal the total amount of Form 990, Part Vll, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation
(C) Retirement and (D) Nontaxable (E) Total of columns (F) Compensation
(i) Base (ii) Bonus & incentive (iii) Other other deferred benefits (B)(iMD)
(A) Name reported as deferred in
compensation compensation re portable compensation
prior Form 990
compensation
Part I Line 4b - E. Anthony Woods, Chairman and CEO of Deaconess Associations, participates in a nonqualified supplemental executive retirement plan. He received
distributions of $321,853 from the plan during 2011 that were reported on Form 1099-R.
Part II Line 18(i) and F - E. Anthony Woods was paid out $1,762,000 in 2011 for compensation that was deferred from years 2008, 2009, and 2010.
Form 990 Part III Line 1 Deaconess Associations, Inc. became the sole owner of Deaconess Diagnostic, LLC, which provides Radiology
services. These services were provided by another subsidiary in prior years, however in 2011 Deaconess Diagnostic was formed and
Form 990 Part VI Section A Line 9 - Directors and officers not at the organizations' address can be reached as follows:
William Bahl, 6475 Given Rd, Cincinnati, OH 45243; A.J. McPhie, 10801 Fallsington Ct., Cincinnati, OH 45242; Rodger Reed,
8461 Calumet Way, Cincinnati, OH 45241; Lee Scroggins, 7905 Graves Rd., Cincinnati, OH 45243; William Zimmer,
Form 990 Part VI Section B Line 11 - Copies of the 990's are provided to the Chairman for presentation to the Board
Form 990 Part VI Section B Line 12c - Each manager, officer, and director are given a copy of the Conflict of Interest Policy to
review and are required to fill out certification forms, which are reviewed and updated on an annual basis
Form 990 Part VI Section B Line 15 - Compensation for the Chairman/CEO is reviewed and approved by the Board
and the Compensation Committee, which established compensation after reviewing comparability data.
Form 990 Part IV Section C Line 19 - No copies of the governing documents, etc., are available to the public, other than those
publicly available through the Secretary of State's website, or other similar reporting agencies.
Form 990 Part XI Line 5 - Other changes in the fund balance were: unrealized losses of $13,571,792
Form 990 Part Vll Section A Line 1a - E. Anthony Woods - Average hours per week (estimate only for standard 40 hour week) on behalf of all
Deaconess related organizations: Deaconess Associations (25); Deaconess Hospital (5); Deaconess Long Term Care and Subsidiaries (5);
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Cat No 51056K Schedule O (Form 990 or 990-EZ) (2011)
Schedule O (Form 990 or 990-EZ) (2011) Page 2
Name of the organization Employer identification number
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(3)
(4)
(5)
(6)
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had
one or more related tax-exempt organizations during the tax year.)
(a) (b) (c) (d) (e) (t) (9)
Name, address, and EIN of related organization Primary activity Legal domicile (state Exempt Code section Public charity status Direct controlling Section 512(b)(13)
or foreign country) (if section 501(c)(3)) entity controlled
entity?
Yes No
(1) Deaconess Hospital of Cincinnati, OH 31-0537109
311 Straight St., Cincinnati OH 45219 health care services OH 501(c)(3) 11b Deaconess Assoc /
(2) Deaconess Health Association Fund, Inc. 31-1209378
311 Straight St., Cincinnati, OH 45219 fundraising OH 501(c)(3) 11b Deaconess Assoc /
(3) Tnstate Health Systems Inc. 31-1385584
311 Straight St., Cincinnati, OH 45219 medical services OH 501(c)(3) 3 Deaconess Hospi /
(4) Deaconess Health Care Services 31-1365388
311 Straight St., Cincinnati, OH 45219 medical services OH 501(c)(3) 3 Deaconess Hospi /
(5) Cottingham Retirement Community 31-1338449
c/o DLTC 330 Straight St., Suite 330, Cincinnati, OH 45219 health care services OH 501(c)(3) 11b Deaconess Long /
(6) Deaconess Long Term Care Inc. 31-1391195
330 Straight St, Suite 330, Cincinnati, OH 45219 parent co-managament OH 501(c)(3) 11b Deaconess Assoc /
(7) Deaconess Long Term Care of Missouri Inc. 43-1693036
330 Straight St., Suite 330, Cincinnat, OH 45219 health care services OH 501(c)(3) 3 Deaconess Long /
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50135Y Schedule R (Form 990) 2011
OMB No 1545-0047
SCHEDULE R
- Related Organizations and Unrelated Partnerships
(Form 990)
1011.
► Complete rf the organization answered "Yes" to Form 990, Part IV, line 33, 34,35, 36, or 37.
Department of the Treasury
Open to Public
► Attach to Form 990. ► See separate instructions.
Internal Revenue Service Inspection
Name of the organization Employer identification number
DEACONESS ASSOCIATIONS, INC. 31-1209377
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(2)
(3)
(4)
(5)
(6)
Identification of Related Tax-E:xempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had
one or more related tax-exempt organizations during the tax year.)
(a) (b) (c) (d) (e) (f) (9)
Name, address, and EIN of related organization Primary activity Legal domicile (state Exempt Code section Public charity status Direct controlling Section 512(b)(13)
or foreign country) (if section 501(c)(3)) entity controlled
entity?
Yes No
(1) Deaconess Hospital of Cincinnati, OH 31-0537109
311 Straight St., Cincinnati OH 45219 health care services OH 501(c)(3) 11b Deaconess Assoc /
(2) Deaconess Health Association Fund, Inc. 31-1209378
311 Straight St., Cincinnati, OH 45219 fundraising OH 501(c)(3) 11b Deaconess Assoc /
(3) Tristate Health Systems Inc. 31-1385584
311 Straight St., Cincinnati, OH 45219 medical services OH 501(c)(3) 3 Deaconess Hospi /
(4) Deaconess Health Care Services 31-1365388
311 Straight St., Cincinnati, OH 45219 medical services OH 501(c)(3) 3 Deaconess Hospi /
(5) Cottingham Retirement Community 31-1338449
c/o DLTC 330 Straight St., Suite 330, Cincinnati, OH 45219 health care services OH 501(c)(3) 11b Deaconess Long /
(6) Deaconess Long Term Care Inc. 31-1391195
330 Straight St, Suite 330, Cincinnati, O H 45219 parent co-managament OH 501(c)(3) 11b Deaconess Assoc /
(7) Deaconess Long Term Care of Missouri Inc. 43-1693036
330 Straight St., Suite 330, Cmcinnat, OH 45219 health care services OH 501(c)(3) 3 Deaconess Long /
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50135Y Schedule R (Form 990) 2011
OMB No 1545-0047
SCHEDULE R
Related Organizations and Unrelated Partnerships
(Form 990)
► Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
son.
Department of the Treasury
Open to Public
► Attach to Form 990. ► See separate instructions.
Internal Revenue Service Inspection
Name of the organization Employer identification number
DEACONESS ASSOCIATIONS, INC. 31-1209377
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(D
(2)
(3)
(4)
(5)
(6)
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had
one or more related tax-exempt organizations during the tax year.)
(a) (b) (c) (d) (e) (g)
Name, address, and EIN of related organization Primary activity Legal domicile (state Exempt Code section Public charity status Direct controlling Section 512(b)(13)
or foreign country) (if section 501 (c)(3)) entity controlled
entity?
Yes No
(1) Deaconess Long term Care of Ohio Inc. 31-1394484
330 Straight St., Suite 330, Cincinnati, OH 45219 health care services OH 501(c)(3) 3 Deaconess Long /
(2) Ottawa Retirement Village, Inc. 48-0955654
c/o DLTC 330 Straight St., Suite 330, Cincinnati, OH 45219 health care services KS 501(c)(3) 3 Deaconess Long /
(3) Ottawa Retirement Plaza, Inc. 48-1101021
c/o DLTC 330 Straight St., Suite 330, Cincinnati, OH 45219 health care services KS 501(c)(3) 11b Deaconess Long /
(4) Ottawa Medical Services, Inc. 48-1114608
c/o DLTC 330 Straight St., Suite 330, Cincinnati, OH 45219 health care services KS 501(c)(3) 11b Deaconess Long /
(5)
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For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat No 50135Y Schedule R (Form 990) 2011
Schedule R (Form 990) 2011 Page 2
IJjffllll Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes " to Form 990, Part IV, line 34
■«-M*U because it had one or more related organizations treated as a partnership during the tax year.)
(a) (b) (c) (d) (e) (f) (g) <h) 0) 0) (k)
Name, address, and EIN Primary activity Legal Direct controlling Predominant Share of total Share of end-of- Disproportionate CodeV-UBI General or Percentage
of domicile entity income (related, income year assets allocations? amount in box 20 of managing ownership
related organization (state or unrelated, Schedule K-1 partner?
foreign excluded from
(Form 1065)
country) tax under
sections 512-514)
Yes No Yes No
(1) Ottawa Services
c7o DLTC 330 Straigh Owns building used KS Ottawa Medica Related 0 0 • 0 /
(2)
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(5)
(6)
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liffllW Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV,
******* line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a) (b) (c) (d) (e) (f) (g) (h)
Name, address, and EIN of related organization Primary activity Legal domicile Direct controlling Type of entity Share of total Share of Percentage
(state or entity (C corp, S corp, income end-of-year assets ownership
foreign country) or trust)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35, 35a, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. Yes No
1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts ll-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity 1a /
b Gift, grant, or capital contribution to related organizations) 1b /
c Gift, grant, or capital contribution from related organization(s) 1c /
d Loans or loan guarantees to or for related organization(s) 1d /
e Loans or loan guarantees by related organization(s) 1e /
tee.
f Sale of assets to related organization(s) 1f /
g Purchase of assets from related organization(s) 19 /
h Exchange of assets with related organization(s) 1h /
i Lease of facilities, equipment, or other assets to related organization(s) 1i /
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35, 35a, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. Yes No
1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts ll-IV?
Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity 1a
Gift, grant, or capital contribution to related organization(s) 1b
Gift, grant, or capital contribution from related organization(s) 1c
Loans or loan guarantees to or for related organization(s) 1d
Loans or loan guarantees by related organization(s) 1e
I^QQI Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets
or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a) (b) (c) (d) (e) (9) (h) (0 (j) 00
Name, address, and EIN of entity Primary activity Legal domicile Predominant Are all partners Share of Share of Disproportionate CodeV-UBI General or Percentage
(state or foreign income (related, section total income end-of-year allocations? amount in box 20 managing ownership
country) unrelated, excluded S01(cP assets of Schedule K-1 partner?
from tax under organizations'' (Form 1065)
section 512-514)
Yes No Yes No Yes No
(D
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