Ancilla Domini Hospital Self Ins Tr in Hobart, Indiana (IN)

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Ancilla Domini Hospital Self Ins Tr
Employer Identification Number (EIN)362967603
Name of OrganizationAncilla Domini Hospital Self Ins Tr
Address1419 S Lake Park Ave, Hobart, IN 46342-6635
ActivitiesChurch, synagogue, etc, Hospital, Publishing activities
SubsectionCharitable Organization
Ruling Date03/1946
DeductibilityContributions are deductible
FoundationOrganizations operated solely for the benefit of and in conjunction with organizations described in 10 through 16 above
OrganizationAssociation
Exempt Organization StatusUnconditional Exemption
Tax Period12/2011
Assets$1,000,000 to $4,999,999
Income$25,000 to $99,999
Filing Requirement990 (all other) or 990EZ return
Asset Amount$2,058,305
Amount of Income$72,718
Form 990 Revenue Amount$72,718
National Taxonomy of Exempt Entities (NTEE)Mutual/Membership Benefit Organizations, Other: Insurance Providers, Services


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Amount of income in 2011: $72,718
This organization: 

 $72,718
Other organizations performing similar types of work: 

 $5,508,185

Assets in 2011: $2,058,305
Ancilla Domini Hospital Self Ins Tr: 

 $2,058,305
Other organizations performing similar types of work: 

 $22,382,791

Expenses in 2007: $-170,007
This organization: 

 $-170,007
Other organizations performing similar types of work: 

 $4,814,604

Income to expenses ratio in 2007: -1.5
Ancilla Domini Hospital Self Ins Tr: 

 -1.5
Other organizations performing similar types of work: 

 1.2

Financial snapshot ($)

Assets at end of 2007

Functional Expenses for 2007 ($)

Revenue, Expenses, and Changes in Net Assets or Fund Balances
20002001200220032004200520062007
Total revenue$4,422,695$4,166,219$1,514,468$1,556,528$1,251,599$450,899$332,837$258,207
Contributions, gifts, grants, and similar amounts received$0$0$0$0$0$0$0$0
Contributions to donor advised funds$0$0
Direct public support$0$0$0$0$0$0$0$0
Indirect public support$0$0$0$0$0$0$0$0
Government contributions (grants)$0$0$0$0$0$0$0$0
Program service revenue including government fees and contracts$3,509,516$3,155,803$541,936$710,719$192,036$0$0$0
Membership dues and assessments$0$0$0$0$0$0$0$0
Interest on savings and temporary cash investments$0$0$0$0$0$0$0$0
Dividends and interest from securities$913,179$1,010,416$972,532$845,809$1,059,563$450,899$332,837$258,207
Net rental income or (loss)$0$0$0$0$0$0$0$0
Gross rents$0$0$0$0$0$0$0$0
Less: rental expenses$0$0$0$0$0$0$0$0
Other investment income$0$0$0$0$0$0$0$0
Gain or (loss) from sales of assets other than inventory$0$0$0$0$0$0$0$0
Gross amount from sales of assets other than inventory$0$0$0$0$0$0$0$0
Less: cost or other basis and sales expenses$0$0$0$0$0$0$0$0
Net income or (loss) from special events and activities$0$0$0$0$0$0$0$0
Gross revenue$0$0$0$0$0$0$0$0
Less: direct expenses other than fundraising expenses$0$0$0$0$0$0$0$0
Gross profit or (loss) from sales of inventory$0$0$0$0$0$0$0$0
Gross sales of inventory, less returns and allowances$0$0$0$0$0$0$0$0
Less: cost of goods sold$0$0$0$0$0$0$0$0
Other revenue$0$0$0$0$0$0$0$0
Total expenses$3,392,689$7,046,760$2,578,034$4,242,063$3,034,978$2,402,575$-1,274,392$-170,007
Program services$3,266,677$6,930,900$2,513,181$4,112,095$2,875,015$2,243,632$-1,448,220$-329,614
Management and general$126,012$115,860$64,853$129,968$159,963$158,943$173,828$159,607
Fundraising$0$0$0$0$0$0$0$0
Payments to affiliates$0$0$0$0$0$0$0$0
Net assets or fund balances at end of year$9,521,959$6,750,044$6,322,006$3,128,647$806,459$-1,379,432$207,713$724,438
Excess or (deficit) for the year$1,030,006$-2,880,541$-1,063,566$-2,685,535$-1,783,379$-1,951,676$1,607,229$428,214
Net assets or fund balances at beginning of year$7,909,842$9,521,960$6,750,044$6,322,006$3,128,647$806,459$-1,379,432$207,715
Other changes in net assets or fund balances$582,111$108,625$635,528$-507,824$-538,809$-234,215$-20,084$88,509
Statement of Functional Expenses (for 2007)
TotalProgram servicesManagement and generalFundraising
Total functional expenses$-170,007$-329,614$159,607$0
Grants paid from donor advised funds$0
Other grants and allocations$0
Specific assistance to individuals$0
Benefits paid to or for members$0
Compensation of current officers, directors, key employees, etc.$0$0$0$0
Compensation of former officers, directors, key employees, etc.$0$0$0$0
Compensation and other distributions, not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)$0$0$0$0
Salaries and wages of employees not included above$0$0$0$0
Pension plan contributions not included above$0$0$0$0
Employee benefits not included above$0$0$0$0
Payroll taxes$0$0$0$0
Professional fundraising fees$0$0$0$0
Accounting fees$6,000$0$6,000$0
Legal fees$0$0$0$0
Supplies$0$0$0$0
Telephone$0$0$0$0
Postage and shipping$0$0$0$0
Occupancy$0$0$0$0
Equipment rental and maintenance$0$0$0$0
Printing and publications$0$0$0$0
Travel$0$0$0$0
Conferences, conventions, and meetings$0$0$0$0
Interest$70,000$0$70,000$0
Depreciation, depletion, etc.$0$0$0$0
Other expenses not covered above$-246,007$-329,614$83,607$0
Balance Sheets
20002001200220032004200520062007
Total assets$17,220,438$20,069,416$18,373,477$17,602,788$14,183,747$6,817,033$6,638,215$4,259,022
Cash - non-interest-bearing$0$0$0$0$0$0$0$0
Savings and temporary cash investments$6,101,336$3,868,302$256,121$517,220$900,976$400,059$881,783$337,268
Accounts receivable less allowance for doubtful accounts$448,311$11,250$9,577$96,865$0$0$0$0
Pledges receivable less allowance for doubtful accounts$0$0$0$0$0$0$0$0
Grants receivable$0$0$0$0$0$0$0$0
Receivables from current and former officers, directors, trustees, and key employees$0$0$0$0$0$0$0$0
Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)$0$0
Other notes and loans receivable less allowance for doubtful accounts$0$0$0$0$0$0$0$0
Inventories for sale or use$0$0$0$0$0$0$0$0
Prepaid expenses and deferred charges$670,597$219,486$528,718$537,012$6,180$3,492$2,565$2,310
Investments - publicly-traded securities$5,693,519$3,882,483
Investments - other securities$9,792,943$15,760,008$17,366,848$16,244,226$13,120,627$6,352,636$0$0
Investments - land, buildings, and equipment less accumulated depreciation$0$0$0$0$0$0$0$0
Investments - other$0$0$0$0$0$0$0$0
Land, buildings, and equipment less accumulated depreciation$17,798$13,335$8,871$0$0$0$0$0
Other assets, including program-related investments$189,453$197,035$203,342$207,465$155,964$60,846$60,348$36,961
Total liabilities$7,698,479$13,319,372$12,051,471$14,474,141$13,377,288$8,196,465$6,430,502$3,534,584
Accounts payable and accrued expenses$118,668$118,401$12,051,471$14,474,141$13,377,288$8,196,465$4,930,502$3,534,584
Grants payable$0$0$0$0$0$0$0$0
Deferred revenue$0$0$0$0$0$0$0$0
Loans from officers, directors, trustees, and key employees$0$0$0$0$0$0$0$0
Tax-exempt bond liabilities$0$0$0$0$0$0$0$0
Mortgages and other notes payable$0$0$0$0$0$0$1,500,000$0
Other liabilities$7,579,811$13,200,971$0$0$0$0$0$0
Total liabilities and net assets/fund balances$17,220,438$20,069,416$18,373,477$17,602,788$14,183,747$6,817,033$6,638,215$4,259,022
Total net assets or fund balances$9,521,959$6,750,044$6,322,006$3,128,647$806,459$-1,379,432$207,713$724,438
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
20002001200220032004200520062007
Total revenue$4,422,695$4,166,219$1,514,468$1,556,528$1,251,599$450,899$0$258,207
Total revenue, gains, and other support per audited financial statements$4,422,695$4,166,219$1,514,468$1,556,528$1,251,599$450,899$0$258,207
Other expenses$0$0$0$0$0$0$0$0
Net unrealized gains on investments$0$0$0$0$0$0$0$0
Donated services and use of facilities$0$0$0$0$0$0$0$0
Recoveries of prior year grants$0$0$0$0$0$0$0$0
Other$0$0$0$0$0$0$0$0
Other revenue$0$0$0$0$0$0$0$0
Investment expenses$0$0$0$0$0$0$0$0
Other$0$0$0$0$0$0$0$0
Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
20002001200220032004200520062007
Total expenses$3,392,690$7,046,760$2,578,034$4,242,083$3,034,978$2,402,575$0$-170,007
Total expenses and losses per audited financial statements$3,392,690$2,951,174$2,578,034$2,758,028$3,034,978$2,399,526$0$-183,316
Other revenue$0$0$0$0$0$0$0$0
Donated services and use of facilities$0$0$0$0$0$0$0$0
Prior year adjustments$0$0$0$0$0$0$0$0
Losses$0$0$0$0$0$0$0$0
Other$0$0$0$0$0$0$0$0
Other expenses$0$4,095,586$0$1,484,055$0$3,049$0$13,309
Investment expenses$0$0$0$0$0$0$0$0
Other$0$4,095,586$0$1,484,055$0$3,049$0$13,309
Current Officers, Directors, Trustees, and Key Employees
Total number of officers, directors, and trustees permitted to vote on organization business at board meetings3
Are any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, related to each other through family or business relationships?Yes
Do any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, receive compensation from any other organizations, whether tax exempt or taxable, that are related to the organization?Yes
Does the organization have a written conflict of interest policy?Yes
Other Information
Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return, and has it filed a tax return on Form 990-T for this year?No
Was there a liquidation, dissolution, termination, or substantial contraction during the year?No
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?Yes
Direct and indirect political expenditures$0
Did the organization file Form 1120-POL for this year?No
Were substantially all dues nondeductible by members?
Did the organization make only in-house lobbying expenditures of $2,000 or less?
Dues, assessments, and similar amounts from members$0
Section 162(e) lobbying and political expenditures$0
Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices$0
Taxable amount of lobbying and political expenditures$0
Does the organization elect to pay the section 6033(e) tax on the amount above?
If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount above to its reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year?
Initiation fees and capital contributions$0
Gross receipts for public use of club facilities$0
At any time during the year, did the organization, directly or indirectly, own a controlled entity within the meaning of section 512(b)(13)?No
Amount of tax imposed on the organization during the year under: section 4911$0
Amount of tax imposed on the organization during the year under: section 4912$0
Amount of tax imposed on the organization during the year under: section 4955$0
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?No
Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912, 4955, and 4958$0
Amount of tax above, reimbursed by the organization$0
At any time during the tax year, was the organization a party to a prohibited tax shelter transaction?No
Did the organization acquire a direct or indirect interest in any applicable insurance contract?No
Did the supporting organization, or a fund maintained by a sponsoring organization, have excess business holdings at any time during the year?No
Number of employees employed in the pay period that includes March 12, 20060
Analysis of Income-Producing Activities (for 2007)
Unrelated business incomeExcluded by section 512, 513, or 514Related or exempt function income
Business codeAmountExclusion codeAmount
Total$0$-258,208$0
Program service revenue
Program service revenue 1000000$000$0$0
Program service revenue 2000000$000$0$0
Program service revenue 3000000$000$0$0
Program service revenue 4000000$000$0$0
Program service revenue 5000000$000$0$0
Medicare/Medicaid payments000000$000$0$0
Fees and contracts from government agencies000000$000$0$0
Membership dues and assessments000000$000$0$0
Interest on savings and temporary cash investments000000$000$0$0
Dividends and interest from securities000000$0Dividends, interest, payments with respect to securities loans, annuities, income from notional principal contracts, loan commitment fees, and other substantially similar income from ordinary and routine investments excluded by section 512(b)(1)$-258,208$0
Net rental income or (loss) from real estate
debt-financed property000000$000$0$0
not debt-financed property000000$000$0$0
Net rental income or (loss) from personal property000000$000$0$0
Other investment income000000$000$0$0
Gain or (loss) from sales of assets other than inventory000000$000$0$0
Net income or (loss) from special events000000$000$0$0
Gross profit or (loss) from sales of inventory000000$000$0$0
Other revenue000000$000$0$0
Information Regarding Taxable Subsidiaries and Disregarded Entities (for 2007)
EIN of corporation, partnership, or disregarded entityPercentage of ownership interestTotal incomeEnd-of-year assets
0%$0$0
0%$0$0
0%$0$0
0%$0$0
Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (for 2007)
CompensationContributions to employee benefit plans & deferred compensationExpense account and other allowances
$0$0$0
$0$0$0
$0$0$0
$0$0$0
$0$0$0
Total number of other employees paid over $50,0000
Statements About Activities (for 2007)
Expenses paid or incurred in connection with the lobbying activities$0
Did the organization receive or hold an easement for conservation purposes, including easements to preserve open space, the environment, historic land areas or historic structures?No
Did the organization provide credit counseling, debt management, credit repair, or debt negotiation services?No
Did the organization maintain any donor advised funds?No
Did the organization make any taxable distributions under section 4966?No
Did the organization make a distribution to a donor, donor advisor, or related person?No
The total number of donor advised funds owned at the end of the tax year$0
The aggregate value of assets held in all donor advised funds owned at the end of the tax year$0
The total number of separate funds or accounts owned at the end of the tax year (excluding donor advised funds included above) where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts$0
The aggregate value of assets held in all funds or accounts included above at the end of the tax year$0
Reason for Non-Private Foundation Status
The organization is not a private foundation because it isNot controlled by disqualified persons/supports non private foundation
Type of supporting organizationType I
Information about the supported organizations
Employer identification number (EIN)Name of organizationType of organizationIs the supported organization listed in the supporting organization's governing documents?Amount of support
362609644Ancilla Systems IncorporatedNo$959,312
356071917Ancilla Domini CollegeNo$0
350867952Ancilla Domini Sisters IncNo$0
364390434Catherine Kasper Life Center IncNo$0
352064919Healthvisions Midwest IncNo$0
311016570St Joseph Health Foundation IncNo$0
351738710St Joseph Medical Center Of Fort WayneNo$0
Total$959,312
Support Schedule
19992000200120022003200420052006
Total$0$0$0$0$0$0$0$0
Gifts, grants, and contributions received$0$0$0$0$0$0$0$0
Membership fees received$0$0$0$0$0$0$0$0
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$0$0$0$0$0$0$0$0
Gross income from interest, dividends, amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable income (less section 511 taxes) from businesses acquired by the organization after June 30, 1975$0$0$0$0$0$0$0$0
Net income from unrelated business activities not included above$0$0$0$0$0$0$0$0
Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf$0$0$0$0$0$0$0$0
The value of services or facilities furnished to the organization by a governmental unit without charge. Do not include the value of services or facilities generally furnished to the public without charge$0$0$0$0$0$0$0$0
Other income$0$0$0$0$0$0$0$0
Lobbying Expenditures by Electing Public Charities (for 2007)
Total exempt purpose expenditures$0
Total lobbying expenditures$0
Total lobbying expenditures to influence public opinion (grassroots lobbying)$0
Total lobbying expenditures to influence a legislative body (direct lobbying)$0
Other exempt purpose expenditures$0
Lobbying nontaxable amount$0
Grassroots nontaxable amount$0
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Number of organizations performing similar types of work
Alaska1
Alabama4
California7
Colorado6
Connecticut2
District of Columbia2
Delaware1
Florida3
Georgia4
Hawaii3
Iowa4
Idaho1
Illinois17
Indiana4
Kansas3
Kentucky3
Louisiana3
Massachusetts11
Maryland2
Michigan7
Minnesota4
Missouri5
Mississippi1
North Carolina6
North Dakota1
New Jersey3
New Mexico2
Nevada2
New York8
Ohio9
Oklahoma1
Oregon3
Pennsylvania9
Rhode Island5
South Carolina2
Tennessee5
Texas8
Utah2
Virginia2
Vermont9
Washington1
Wisconsin2
West Virginia1
Total179
20 biggest affiliated organizations
AffiliationNameAddressStateEstablishedTotal Income
SubordinateSaint Francis Hospital Inc6600 S Yale Ave, Tulsa, OK 74136-3347OK1946-03$3,970,090,877
SubordinateFranciscan Alliance Inc1515 W Dragoon Trl, Mishawaka, IN 46544-4710IN1946-03$2,596,912,525
SubordinatePeacehealth, Ketchikan Medical Center1115 Se 164th Ave Dept 332, Vancouver, WA 98683-8003WA1965-01$2,090,551,281
SubordinateOsf Healthcare System800 Ne Glen Oak Ave, Peoria, IL 61603-3200IL1946-03$1,896,415,307
SubordinateSt Elizabeth Medical Center Inc1 Medical Village Dr, Edgewood, KY 41017-3403KY1946-03$1,877,972,561
SubordinateProvidence Health System-Southern CaliforniaPO BOX 389672, Seattle, WA 98138-9672WA1946-03$1,724,724,506
SubordinateChristus Health919 Hidden Rdg, Irving, TX 75038-3813TX1946-03$1,654,479,614
SubordinateCatholic Health Initiatives198 Inverness Dr W, Englewood, CO 80112-5202CO1946-03$1,639,118,386
SubordinateCatholic Health Initiatives Colorado, St Anthony North Hospital3025 S Parker Road Suite 510, Aurora, CO 80014-2911CO1946-03$1,621,612,108
SubordinateSt Vincent Hospital & Health Care2001 W 86th St, Indianapolis, IN 46260-1991IN1946-03$1,327,567,131
SubordinateCatholic Healthcare West Southern CaliforniaPO BOX 1507, San Gabriel, CA 91778-1507CA1946-03$1,248,417,601
SubordinateProvidence Medical Research Center101 W 8th Ave, Spokane, WA 99204-2307WA1946-03$1,231,839,049
SubordinateFranciscan Health System1717 S J St, Tacoma, WA 98405-4933WA1946-03$1,205,494,228
SubordinateMount Carmel Health System6150 E Broad St, Columbus, OH 43213-1574OH1946-03$1,198,797,166
SubordinateSsm St Clare Health Center10101 Woodfield Lane, St Louis, MO 63132-2937MO1946-03$1,179,575,580
SubordinateUniversity Of Dayton, Phi Sigma Rho337 Stonemill Road, Dayton, OH 45409OH1976-07$1,170,175,935
SubordinateMercy Hospitals East Communities, Mercy Hospital St Louis645 Maryville Centre Dr Ste 100, Saint Louis, MO 63141-5846MO1946-03$1,107,258,738
SubordinatePresence Hospitals Prv9223 W Saint Francis Rd, Frankfort, IL 60423-8330IL1946-03$1,104,334,849
SubordinateMercy Hospital Springfield645 Maryville Centre Dr Ste 100, Saint Louis, MO 63141-5846MO1946-03$965,658,386
SubordinateSt Francis Hospital United States Catholic Conference100 Port Washington Blvd, Roslyn, NY 11576-1347NY1946-03$949,972,252
Number of affiliated organizations
Alaska87
Alabama75
Arkansas52
Arizona235
California1,063
Colorado200
Connecticut195
District of Columbia121
Delaware35
Florida465
Georgia158
Hawaii41
Iowa402
Idaho30
Illinois817
Indiana365
Kansas230
Kentucky119
Louisiana416
Massachusetts600
Maryland399
Maine72
Michigan426
Minnesota309
Missouri520
Mississippi60
Montana57
North Carolina98
North Dakota148
Nebraska299
New Hampshire97
New Jersey457
New Mexico121
Nevada55
New York1,371
Ohio598
Oklahoma90
Oregon141
Pennsylvania860
Rhode Island94
South Carolina43
South Dakota112
Tennessee80
Texas852
Utah18
Virginia137
Vermont62
Washington195
Wisconsin621
West Virginia92
Wyoming19
International36
Total14,245

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