Form •'9 9 9 Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947( a)(1) of the Internal Revenue Code ( except black lung Department of the Treasury benefit trust or private foundation) Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements C;= cL^ c1 M rur me Luu i cale ndar y ear . or sax y ear oe mnm u - ^ u1 cuv., anu enuin uo .iu Luu4 B Check it applicable Please C Name of organization D Employer identification number Address change use IRS IIPMC NORTHWEST 25-0489010 label Or Name change print or Number and street (or P 0 box if mail is not delivered to street address ) Room/suite E Telephone number inmal retun We 200 LOTHROP STREET fmatretun see ^ C / O CORPORATE TAXATION 8114 ) 677-1928 Amended return tnstnl c- City or town, state or country, and ZIP + 4 [ L tb.° d Cash X Accrual Application Lions. pend ing PITTSBURGH PA 15213 . Other (specify) 00. F • Section 501(c )( 3) organizations and 4947 ( a)(1) nonexempt charitable H and I are not applicable to section 527 organizations trusts must attach a completed Schedule A ( Form 990 or 990-EZ). H(a) Is this a group return for affiliates' q Yes q No G Website : ► WWW. UPMC. COM H (b) If "Yes,* enter number of affiliates ► N/ A J Organization type ( check only one) ► g 501(c) (3 ) (Insert no ) 14947( a)(1) or 527 H(c) Are all affiliates included? Yes -0 No K Check here ► if the organization's gross receipts are normally not more than $25,000 The (It "No," attach a list See instructions H(d ) Is this a separate return riled by an organization need not file a return with the IRS, but if the organization received a Form 990 Package org an i zat ion covered byag rou p rul i n g ? Yes X No in the mail, it should file a return without financial data Some states require a complete return . I Group Exemption Number ► N / A M Check ► if the organization is not required L Gross receipts Add lines 6b , 8b, 9b, and 10b to line 12 ► 90 , 452,931 . to attach Sch B (Form 990, 990-EZ, or 990-PF) Revenue , Ex p enses , and Chan g es in Net Assets or Fund Balances ( See p ag e 18 of the instructions.) 1 Contributions , gifts, grants , and similar amounts received STMT 1 a Direct public support , • . . . . . . . . . . . . . . . . . . . . . 1 a 51 , 499. b Indirect public support . . . . . . . . . . . . . . . . . . . . . . 1 b c Government contributions ( grants ) . . . . . . . . . . . . . . . . 1 c 25 , 243. d Total (add lines la through 1c) (cash $ 76,742 . noncash $ ) 1 d 76,742. 2 Program service revenue including government fees and contracts (from Part VII, line 93 ) . . . . 2 68 659 651. 3 Membership dues and assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 Interest on savings and temporary cash investments . . . . . . . . . . . . . . . . . . . . . . . . 4 . 103 , 052 5 Dividends and interest from securities . . . . . . . . . . . . . . 5 554 , 882. 6 a Gross rents ,,,, 6a b Less rental expenses . . . . . . . . . . . . . . . . . . . . . . 6b c Net rental income or (loss ) ( subtract line 6b from line 6a ) . . . . . . . . . . . . . . . . . . . . . . 6c 7 Other investment income ( describe ► 7 > 8 a Gross amount from sales of assets other ( A) Securities ( B) Other d than inventory . . . . . . . . . . . . . . 21 012 340. 8a 46 , 264. b Less cost or other basis and sales expenses , 18 957 292. 8b 885 , 537. c Gain or ( loss) (attach schedule ) . . . . . . 2 055 048. 8c - 839 , 273. d Net gain or ( loss) (combine line 8c , columns (A ) and (B)) .1717 • • . . . . . . S^M+ .1 . . 8d 1 , 215 , 775 . 9 Special events and activities ( attach schedule ) If any amount is from gaming , check here ► q a Gross revenue ( not including $ of contributions reported on line 1a). 9a b Less direct expenses other than fundraising expenses . 9 b c Net income or (loss ) from special events ( subtract line 9b from line 9a) . . . . . . . . . . . . . 9c P 10a Gross sales of inventory, less returns and allowances . . . . . . . Oa 7 b Less cost of goods sold . . . . . . . . . . . . . . . . . . . . . 0b ley c Gross profit or ( loss) from sales of inventory ( attach schedule ) ( subtract line 10b from l ine 1Oa) . . . . 1oc 11 Other revenue (from Part VII, line 103 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 12 ........ Total revenue add lines 1d 2 3, 4 5 6c , 7, 8d, 9c , 10c and 11 ) ........ • 12 70 , 610 , 102. 13 Program services ( from II B)) , , , , , , , , , , , , , , , , , , , , , , 13 58 058 021. d N y 14 ^p Manageme g 1Vh ( C)) , 14 8 , 024 , 110 . a 15 Fundraising fro 4 , cc umn ( D)) U) 15 W 16 Payments to -affil dices (att a sat^ec 6 16 17 1 ................. Total ex en a lire 16 and 44, col rfd A ......... 17 . 66 , 082 , 131 4 18 Excess or (de 1c^ for the t 17 f m line 12 ) . . .......... .••...... 18 4 , 527 , 971. Q 19 Net assets or f nd baFa in - from line 73 , column ( A)) . . . . . . . . . . . . . . 19 77 , 757 , 818. 20 Other changes in nett and balances ( attach explanation ) , . . . S T , 2. . . . . . . . 20 . 31 , 840 , 774 Z 21 Net assets or fund balances at end of year ( combine lines 18 , 19 , and 20 ) • • 21 . 114 , 126 , 563 _ F or Paperwork Reduction Act Notice , see the separate instructions. JSA 3E10102000 TS0352 597Y 07/12/2006 13:34:02 V03-8 Form 990 (2003) 4
41
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999 Return ofOrganization ExemptFrom IncomeTax · Form •'999 Return ofOrganization ExemptFrom IncomeTax Under section 501(c), 527, or4947(a)(1) of the Internal Revenue Code(except
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Form •'9 9 9 Return of Organization Exempt From Income TaxUnder section 501(c), 527, or 4947( a)(1) of the Internal Revenue Code (except black lung
Department of the Treasury benefit trust or private foundation)
Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements
C;=
cL^
c1
M rur me Luu i cale ndar year . or sax y ear oe mnm u - ^ u1 cuv., anu enuin uo .iu Luu4
B Check it applicable Please C Name of organization D Employer identification numberAddresschange
use IRS IIPMC NORTHWEST 25-0489010label Or
Name change print or Number and street (or P 0 box if mail is not delivered to street address ) Room/suite E Telephone number
inmal retun We 200 LOTHROP STREET
fmatretunsee
^C/O CORPORATE TAXATION 8114 ) 677-1928
Amendedreturn
tnstnl c- City or town, state or country, and ZIP + 4
[
Ltb.°
d Cash X AccrualApplication Lions.pend ing PITTSBURGH PA 15213. Other (specify) 00.F
• Section 501(c )( 3) organizations and 4947 ( a)(1) nonexempt charitable H and I are not applicable to section 527 organizations
trusts must attach a completed Schedule A ( Form 990 or 990-EZ). H(a) Is this a group return for affiliates' q Yes q No
G Website : ► WWW. UPMC. COM H (b) If "Yes,* enter number of affiliates ► N/A
J Organization type ( check only one) ► g 501(c) (3 ) (Insert no ) 14947( a)(1) or 527 H(c) Are all affiliates included? Yes -0 No
K Check here ► if the organization's gross receipts are normally not more than $25,000 The(It "No," attach a list See instructions
H(d ) Is this a separate return riled by an
organization need not file a return with the IRS, but if the organization received a Form 990 Package org an i zat ion covered by a g rou p rul i n g ? Yes X No
in the mail, it should file a return without financial data Some states require a complete return . I Group Exemption Number ► N/A
M Check ► if the organization is not required
L Gross receipts Add lines 6b , 8b, 9b, and 10b to line 12 ► 90 , 452,931 . to attach Sch B (Form 990, 990-EZ, or 990-PF)
Revenue , Ex penses , and Changes in Net Assets or Fund Balances (See pa g e 18 of the instructions.)
1 Contributions , gifts, grants , and similar amounts received STMT 1
a Direct public support , • . . . . . . . . . . . . . . . . . . . . . 1 a 51 , 499.
b Indirect public support . . . . . . . . . . . . . . . . . . . . . . 1 b
c Government contributions (grants ) . . . . . . . . . . . . . . . . 1 c 25 , 243.
d Total (add lines la through 1c) (cash $ 76,742 . noncash $ ) 1 d 76,742.
2 Program service revenue including government fees and contracts (from Part VII, line 93 ) . . . . 2 68 659 651.
.................Total ex en a lire 16 and 44, col rfd A ......... 17 .66 , 082 , 131
4 18 Excess or (de 1c^ for the t 17 f m line 12 ) . . .......... .••...... 18 4 , 527 , 971.
Q 19 Net assets or f nd baFa in - from line 73 , column ( A)) . . . . . . . . . . . . . . 19 77 , 757 , 818.
20 Other changes in nett and balances ( attach explanation ) , . . . S T , 2. . . . . . . . 20 .31 , 840 , 774
Z 21 Net assets or fund balances at end of year ( combine lines 18 , 19 , and 20 ) • • 21 .114 , 126 , 563 _For Paperwork Reduction Act Notice , see the separate instructions.
JSA3E10102000
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Form 990 (2003)
4
Form 990 (2003) 25-0489010 Page 2
Statement of All organizations must complete column (A) Columns (B), (C), and (D) are required for section 501(c)(3) and (4) organizations
Functional Expenses and section 4947(a)(1) nonexempt charitable trusts but optional for others (See page 22 of the instructions )
Do not include amounts reported on line6b , 8b , 9b . 10b or 16 of Part I
(A) Total (B) Programservices
(C) Managementand g eneral
( D) Fundraising
22 Grants and allocations (attach schedule)
(cash $ noncash $ ) 22
23 Specific assistance to individuals (attach schedule) 23
24 Benefits paid to or for members (attach schedule) 24
25 Compensation of officers , directors , etc. 25 566 472 . 566 , 472.
44 Total functional expenses ( add lines 22 through 43)Organizations completing columns (B)-(D), carrythese tota ls to lines 13-15 . 44 66 082 131. 58 058 021. 8 , 024 , 110. 1
Joint Costs . Check ► U if you are following SOP 98-2Are any j oint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services '? , , , , , ► E]Yes No
If "Yes," enter ( i) the aggregate amount of these joint costs $ MA , (ii) the amount allocated to Program services $A
(iii) the amount allocated to Management and general $ , and (iv ) the amount allocated to Fundraising $
Statement of Program Service Accomplishments (See page 25 of the instructions.)
What is the or anization's rima exem t ur se? 10, HEALTHCARE _SEE STMT'S 4 &A -------_9 P rY P P Po L---------------J-----Program Service
Expenses
All organizations must describe their exempt purpose achievements in a clear and concise manner State the number (Required for 501 (c)(3) and
of clients served, publications issued, etc Discuss achievements that are not measurable (Section 501(c)(3) and (4)trusts,
(4) ts, ,oand
optionffor(1)al
organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of grants and allocations to others) othershers )
Grants and allocations $ --------------------------------------------------------- - 1 711,890.
e Other p rog ram services attach schedule Grants and allocations $
f Total of Program Service Expenses (should equal line 44, column (B), Program services). . . ► 58, 058, 021.JSA3E1 020 1 000 Form 9903E 1 (2003)
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25-0489010
Form 990 ( 2003') Page 3
Balance Sheets (See page 25 of the instructions.)
Note : Where required, attached schedules and amounts within the descnption (A) (B)column should be for end-of-year amounts only. Beginning of year End of year
Organizations that do not follow SFAS 117, check here ►q and
LL complete lines 70 through 74
70 Capital stock, trust principal, or current funds 700y 71 Paid-in or capital surplus, or land, building, and equipment fund , , , , , . . 71
H 72 Retained earnings, endowment, accumulated income, or other funds , , , , , 72
73 Total net assets or fund balances (add lines 67 through 69 or lines
Z 70 through 72;
column (A) must equal line 19, column (B) must equal line 21) . . . . . . . 77 757 818. 73 114 , 126,563.
74 Total liabilities and net assets / fund balances ( add lines 66 and 73 ) 96 198 148. 74 129 093 105.
Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about aparticular 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
JSA3E1030 2 000
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Form 990 (2003)
25-0489010Page 4
Reconciliation of Revenue per Audited Reconciliation of Expenses per AuatteaFinancial Statements with Revenue per Financial Statements with Expenses perReturn (SPA nano 27 of the instructions ) Return NOT APPLICABLE
a Total revenue, gains, and other support a Total expenses and losses per
per audited financial statements ► a audited financial statements , , , , ► a, ,
b Amounts included on line a but not on b Amounts included on line a but not
line 12, Form 990: on line 17, Form 990.
(1) Net unrealized gains NOT APPLICABLE (1) Donated services
on investments $ and use of facilities $
(2) Donated services (2) Prior year adjustments
and use of facilities $ reported on line 20,
(3) Recoveries of prior Form 990 . . . . . $
year grants . . . . $ (3) Losses reported on
(4) Other (specify) line 20, Form 990 $
(4) Other (specify)
SAdd amounts on lines (1) through (4) ► b $
Add amounts on lines (1) through (4) , ► b
c Line a minus line b ► c c Line a minus line b , , , , , , . . . ► c
d Amounts included on line 12, d Amounts included on line 17,
Form 990 but not on line a: Form 990 but not on line a:
(1) Investment expenses (1) Investment expenses
not included on line not included on line
6b, Form 990 , , , $ 6b, Form 990 . . . $
(2) Other (specify) (2) Other (specify)
E $
Add amounts on lines (1) and (2). ► d Add amounts on lines (1) and (2) ► d
e Total revenue per line 12, Form 990 e Total expenses per line 17, Form 990
line c p lus lined. ► e ( line c p lus line d• • • • • • • • • • ► e
UMW List of Officers. Directors. Trustees. and Kev Emnlovees (List each one even if not compensa ted. see Daae 27 of
tha instructinns1
(A) Name and address(B) Title and average
hours per weekdevoted to position
(C) Compensation( If not paid , enter
-0-.
(D) Contributions toemployee benefit plans &deferred compensat ion
(E) Expenseaccount and other
allowances
SEE STATEMENT 15 566 472. 65 , 586 . NON]
75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your
organization and all related organizations, of which more than $10,000 was provided by the related organizations? ► Yes q No
If "Yes," attach schedule - see page 28 of the instructions SEE STATEMENT 16
Form 990 (2003)
JSA3E1040 2 000
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.Form 990 ( 2003 ) 25-0489010 Page 5
1:M.&IIJI Other Information ( See page 28 of the instructions. ) Yes No76 Did the organization engage in any activity not previously reported to the IRS? If "Yes," attach a detailed description of each activity 76 X
.77 Were any changes made in the organizing or governing documents but not reported to the IRS? . . . . . . . . . . . . . . . . . . . 77 X
If "Yes," attach a conformed copy of the changes
78a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return? . . . . . . . . . 78a X
b If "Yes," has it filed a tax return on Form 990-T for this year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78b N1 P,
79 Was there a liquidation, dissolution, termination, or substantial contraction during the year? If "Yes," attach a statement , , . . . . . . 79 X
80a Is the organization related (other than by association with a statewide or nationwide organization) through common
membership, governing bodies, trustees, officers, etc , to any other exempt or nonexempt organization? 80a X, , , , , , , , , , , , , , , ,
b If "Yes," enter the name of the organization' STMT 17
and check whether it is X exempt or nonexempt
81 a Enter direct and indirect political expenditures See line 81 instructions . . . . . . . . . . . . . . . 81a NONE
b Did the organization file Form 1120-POL for this year? , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 81 b N
82a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge
or at substantially less than fair rental values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82a X
b If "Yes," you may indicate the value of these items here Do not include this amount h4o+ Q i I y
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? 83a X, , , , ,
b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? , , , , , , , , , , , , 83b X
84a Did the organization solicit any contributions or gifts that were not tax deductibles 84a X
b If "Yes," did the organization include with every solicitation an express statement that such contributions
or gifts were not tax deductible? 84b NI K
85 501(c)(4), (5), or(6) organizations a Were substantially all dues nondeductible by members? , , , , , , , , , , , , , , , , , , , , , 85a NI &
b Did the organization make only in-house lobbying expenditures of $2,000 or less? 85b NI ;L, , , , , , , , , , , , , , , , , , , , , , ,
If "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization
received a waiver for proxy tax owed for the prior year
c Dues, assessments, and similar amounts from members 85c N/A
105 Total (add line 104, columns (B), (D), and (E )) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► 70, 533, 360.Note : Line 105 plus line 1d, Part 1, should equal the amount on line 12, Part /
F^Tll Relationship of Activities to the Accomplishment of Exempt Purposes (See page 34 of the instructions.)
Line No.y
Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the accomplishmentof the organization's exempt purposes (other than by providing funds for such purposes)
Information Regarding Taxable Subsidiaries and Disregarded Entities See page 34 of the instructions. )(A)
Name , address, and EIN of corporation ,p artnership , or disregarded enti ty
(B)Percentage of
ownersh ip interest
(C)Nature of activities
(D)Total income
(EEndof-year
assets
STMT 19 % 11. NONE
%• .. Information Reaardina Transfers Associated with Personal Benefit Contracts (See Daoe 34 of the instructions)
(a) Did the organization , during the year , receive any funds, directly or indirectly , to pay premiums on a personal benefit contract '? , • . . . . .
(b) Did the organization , during the year , pay premiums , directly ?
Note : If "Yes" to (b), file Form 8870 and Form 4720 (see instructionUnder p enalties of perj ury, I declare that I have examined this retand belief , it is true , correct , and complete Declaration of prepa
PleaseSign V Signature of officerHere
DAVID D . SHULIK , VP REGIONAL CFType or print name and title
Preparers
Paid signature
Preparer 'sFirm's name (or yours
Use Only if self-employed),address, and ZIP + 4
Yes x No
JSA
3E1050 1 000
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SCHEDULE A Organization Exempt Under Section 501(c)(3) 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 003
Department of the Treasury Supplementary Information - (See separate instructions.)Internal Revenue Service ► MUST be completed by the above organizations and attached to their Form 990 or 990-EZ
Name of the organization Employer identification number
UPMC NORTHWEST J 25-0489010
Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees(See page 1 of the instructions. List each one. If there are none, enter "N one.")
(a) Name and address of each employee paid more (b) Title and average (d) Contributions to (e) Expense
than $50 000hours per week (c) Compensation employee benefit plans & account and other
, devoted to position deferred compensation allowances
Li .J Compensation of the Five Highest Paid Independent Contractors for Professional Services(See Daae 2 of the instructions. List each one (whether individuals or firms). If there are none. enter "None.")
(a) Name and address of each independent contractor paid more than $50,000 (b) Type of service (c) Compensation
NORTHWEST EMERGENCY PHYSICIAN_S_ LLP ---___---___
P.O.BOX 793 , TRAVERSE CITY , MI 49685 EMERGENCY MEDICINE 602 752.
300 STATE STR. , ERIE PA 16507 EMGS , EEGS , PVDS 185 883.
Total number of others receiving over $50,000 forprofessional services ► 3
For Paperwork Reduction Act Notice , see the Instructions for Form 990 and Form 990-EZ.
JSA
3E12102000
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Schedule A (Form 990 or 990-EZ) 2003
10
^ Schedule A (Foam 990 or 990-EZ) 2003 25-0489010 Page 2
Statements About Activities (See page 2 of the instructions. ) Yes No1 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
or incurred in connection with the lobbying activities ► $ ( Must equal amounts on line 38,
Part VI -A, or line I of Part VI-B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 X
Organizations that made an election under section 501(h) by 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
the lobbying activities
2 During the year , has the organization , either directly or indirectly , engaged in any of the following acts with any
substantial contributors , trustees , directors , officers, creators , key employees , or members of their families, or
with any taxable organization with which any such person is affiliated as an officer , director , trustee , majority
owner , or principal beneficiary' (If the answer to any question is "Yes," attach a detailed statement explaining
the transactions ) Sec. S.A1mc-n+ (9)a Sale, exchange , or leasing of property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a X
b Lending of money or other extension of credit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b X
b Do you have a section 403 ( b) annuity plan for your employees? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b X
4 Did you maintain any separate account for participating donors where donors have the right to provide advice
on the use or distribution of funds 4 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)(i)
6 A school Section 170(b)(1)(A)(u) (Also complete Part V )
7 X A hospital or a cooperative hospital service organization Section 170(b)(1)(A)(ul)
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)(iii) 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 El 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)
1 1 b F] A community trust Section 170(b)(1)(A)(vi) (Also complete the Support Schedule in Part IV-A )
12 An organization that normally receives ( 1) more than 33 113% of its support from contributions, membership fees, and gross
receipts from activities related to its charitable, etc , functions - subject to certain exceptions, and (2 ) no more than 33 1/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired
by the organization after June 30, 1975 See section 509(a )( 2) (Also complete the Support Schedule in Part IV-A )
13 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) )
(a) Name(s) of supported organization(s)I (b) Line number
from above
14 An organization organized and operated to test for public safety Section 509(a)(4) (See page 6 of the instructions )JSA3E1220 2 000 Schedule A (Form 990 or 990-EZ) 2003
TS0352 597Y 07/12/2006 13:34:02 V03-8 11
. Schedule A ( Form 990 or 990-EZ 2003 25-0489010 P e 3
MIRTMSupport Schedule (Complete only if you checked a box on line 10, 11, or 12.) Use cash method of accounting.
Nnte:You may use the worksheet in the instructions forconvertina from the accrual to the cash method of accountina. NOT APPLICABLE
Calendar year (or fiscal year beginning In ) ( a ) 2002 b 2001 c 2000 (d ) 1999 (e ) Total
15 Gifts, grants, and contributions received (Do
not include unusual grants See line 28
16 Membershi p fees received . .
17 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
unrelated business taxable income (less
section 511 taxes) from businesses acquired
by the org anization after June 30 , 1975
19 Net income from unrelated business
activities not included in line 18 • • • • • • • • •
20 Tax revenues levied for the organization's
benefit and either paid to it or expended on
....................its behalf
21 The value of services or facilities furnished to
the organization by a governmental unit
without charge Do not include the value of
services or facilities generally furnished to the
p ublic without charge ..............
22 Other income Attach a schedule Do not
include gain or (loss) from sale of capital assets
23 Total of lines 15 throu g h 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 1;TQT, A$1?I,1,C"I . . ► 26a
b Prepare a list for your records to show the name of and amount contributed by each person (other than a
governmental unit or publicly supported organization) whose total gifts for 1999 through 2002 exceeded the
amount shown in line 26a Do not file this list with your return . Enter the total of all these excess amounts ► 26b
c Total support for section 509(a)(1) test Enter line 24, column ( e) ► 26c
b For any amount included in line 17 that was received from each person (other than "disqualified persons"), prepare a list for your records toshow 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 computingthe difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess
d Add Line 27a total and line 27b total . . . . . . . . . . . . . ► 27d
e Public support (line 27c total minus line 27d total) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► 27e
f Total support for section 509(a)(2) test Enter amount from line 23, column (e) . . . . . . . . . . ► 27f
g Public support percentage ( line 27e ( numerator) divided by line 27f (denominator )) . . . . . . . . . . . . . . . . . . ► 27 %
h Investment Income percenta g e ( line 18 , column ( e ) ( numerator) divided by line 27f ( denominator)) 27h %
28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any unusual grants during 1999 through 2002,prepare a list for your records to show, for each year, the name of the contributor, the date and amount of the grant, and a brief
description of the nature of the grant Do not file this list with your return . Do not include these g rants in line 15SSA Schedule A (Form 990 or 990-EZ) 20033E 1221 2 000
TS0352 597Y 07/12/2006 13:34:02 V03-8 12
Schedule A ( Form 990 or 990-EZ) 2003 25-0489010 Page 4
Private School Questionnaire (See page 7 of the instructions.)(To be completed ONLY by schools that checked the box on line 6 in Part IV) NOT APPLICABLE
29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, Yes No
other governing instrument, or in a resolution of its governing body? . . . . . , , , , , , 29
30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its
brochures, catalogues, and other written communications with the public dealing with student admissions,
programs, and scholarships? . . 30.. . . .. .. . ....31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during
the period of solicitation for students, or during the registration period if it has no solicitation program, in a way
that makes the policy known to all parts of the general community it serves? , , , , , , , , , , , , , , , , , 31
If "Yes," please describe, if "No," please explain. (If you need more space, attach a separate statement )
-----------------------------------------------------------------------------32 Does the organization maintain the following:
a Records indicating the racial composition of the student body, faculty, and administrative staff? 32a
b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory
basis? 32b....................................................c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing
with student admissions, programs, and scholarships? , , , . , , , , , , , 32c
d Copies of all material used by the organization or on its behalf to solicit contributions? . . . . . . . . . . . . . . . . 32d
If you answered "No" to any of the above, please explain. (If you need more space, attach a separate statement )
34a Does the organization receive any financial aid or assistance from a governmental agency? , , , , , , , , , , , , ,
b Has the organization's right to such aid ever been revoked or suspended? , , , , , , , , , , , , , , , , , , , , , ,
If you answered "Yes" to either 34a or b, please explain using an attached statement
35 Does the organization certify that it has complied with the applicable requirements of sections 4.01 through 4 05
of Rev Proc 75-50, 1975-2 C.B. 587, covering racial nondiscrimination? If "No," attach an explanation 35JSA3E1230 2 000 Schedule A (Form 990 or 990 EZ) 2003
TS0352 597Y 07/12/2006 13:34:02 V03-8 13
Schedule A Form 990 or 990-EZ ) 2003 25 -04 89010 Page 5
Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions.)
(To be completed ONLY by an eligible organization that filed Form 5768) NOT APPLICABLE(:herb ► if the nrnnni7ntinn halnnne to nn nff Bator nrrnin rhprk ► h if vnu checked "a" and "limited control" orovisions aooly_
(a) (b)Limits on Lobbying Expenditures Affiliated group To be completed
totals for ALL electing(The term "expenditures" means amounts paid or incurred.) organizations
36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 36
37 Total lobbying expenditures to influence a legislative body (direct lobbying) 37
42 Grassroots nontaxable amount (enter 25% of line 41) 42• • • • • • . .
43 Subtract line 42 from line 36. Enter -0- if line 42 is more than line 36 43
44 Subtract line 41 from line 38. Enter -0- if line 41 is more than line 38 44
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 through 50 on page 11 of the instructions.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal (a) (b) (c) (d) (e)
year beginning in ) ► 2003 2002 2001 2000 Total
Lobbying nontaxable
45 amount
Lobbying ceiling amount
46 ( 150% of line 45 ( e))
47 Total lobb yi n g expenditures
Grassroots nontaxable
48 amount ••••••••
Grassroots ceiling amount
49 ( 150% of line 48 (e ))
Grassroots lobbying
50 expenditures . .
Lobbying Activity by Nonelecting Public Charities
( For re p ortin g onl y by org anizations that did not complete Part VI-A (See a e 12 of the instructions.
During the year, did the organization attempt to influence national, state or local legislation, including anyYes No Amount
attempt to influence public opinion on a legislative matter or referendum, through the use of
b Paid staff or management (Include compensation in expenses reported on lines c through h) . . N A
c Media advertisements N A
d Mailings to members, legislators, or the public, , , , , , , , , , , , , , , , , , , , , , , , , , , , , N A
e Publications, or published or broadcast statements , , , , , , , , , , , , , , , , , , , , , , , , , , N A
f Grants to other organizations for lobbying purposes , , , , , , , , , , , , , , , , • . . . . . . . N A
g Direct contact with legislators, their staffs, government officials, or a legislative body • , , , , , , , N A
h Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means , , , , , , NAA
i Total lobbying expenditures (Add lines c through h ) . . . . . . . . . . . . . . . . . . . . . . . . . .
If "Yes" to any of the above, also attach a statement giving a detailed description of the lobbying activities.JSA Schedule A (Form 990 or 990 -EZ) 20033E1240 2 000
TS0352 597Y 07/12/2006 13:34:02 V03-8 14
Schedule A ( Form 990 or 990-EZ ) 2003 25-0489010 Page 6' Information Regarding Transfers To and Transactions and Relationships With NoncharitableExempt Organizations (See page 12 of the instructions.)
51 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section
501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations
a Transfers from the reporting organization to a noncharitable exempt organization of: Yes No
(i) Cash .......................................................(ii) Other assets .............................. .............. . a(ii) X
b Other transactions:
(i) Sales or exchanges of assets with a nonchantable exempt organization . . . . . . .
FORM 990, PART III - STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS----------------------------------------------------------------------------------------------------------------------------------
DESCRIPTION
UPMC NORTHWEST PROVIDES HIGH QUALITY, INTEGRATED, COST
EFFECTIVE CARE TO THE COMMUNITY REGARDLESS OF ABILITY TO PAY
AS EVIDENCED BY THE $3,086,000 OF FREE CARE PROVIDED. IT
PROVIDES ACUTE INPATIENT, OUTPATIENT, SUPPORT & EDUCATIONSERVICES. FOR FISCAL YEAR ENDED JUNE 30, 2004 NORTHWEST HAD34673 PATIENT DAYS, 31,219 E.R.VISITS, AND 5,018 SURGERIES.
THE REHABILITATION CENTER OF UPMC NORTHWEST OFFERS
CARE TO PEOPLE WHO HAVE SUFFERED STROKES, SERVERE ARTHRITIS,
VICTIMS OF SERIOUS FALL INJURIES, AUTO ACCIDENTS, OR SEVERE
ORTOPEDIC PROBLEMS. THE GOAL OF THE REHAB.CENTER IS TO LEADPEOPLE TO THE HIGHEST LEVEL OF INDEPENDENCE POSSIBLE. THEREHAB.UNIT CURRENTLY HAS 16 LICENSED BEDS.
THE PSYCHIATRIC CENTER OF UPMC NORTHWEST OFFERS
ADULT INPATIENT PSYCHIATRIC CARE TO THE PEOPLE OF THEREGION. THE PSYCHIATRIC UNIT IS CURRENTLY LICENSED FOR 15
BEDS.
THE TRANSITIONAL CARE UNIT PROVIDES INPATIENT CARE TO
PATIENTS WHOSE EPISODES OF ILLNESS HAVE PASSED THE ACUTE
CARE PHASE BUT ARE NOT WELL ENOUGH TO BE DISCHARGED. THETRANSITIONAL CARE UNIT IS CURRENTLY LICENSED FOR 16 BEDS.
skilled nursing, and support and education services . The Hospital provides services to all that
present themselves regardless of ability to pay.
Greater than 63% of patients received Medicare or state medical assistance.
During the fiscal year ended June 30, 2004 , UPMC Northwest admitted 7 , 799 patients,
recorded 34,673 inpatient days, had 31 , 219 emergency room visits, performed 5,018 surgeries,
and provided free or uncompensated care as follows:
Measurement of foregone charges:Free Care $3,086,000
The Hospital also provided services to the community in the aggregate of $523,358 throughoutreach programs targeted at patients, patient families and the community, some of which are
enumerated below.
The Hello Hospital Program provided to local kindergarten students in their classrooms, anintroduction of the hospital, including a program and a hands-on review of stethoscopes, bloodpressure cuffs, and miscellaneous equipment.
UPMC Northwest has an extensive diabetes initiative. In addition to management classes thatuse interactive group activities, films, lectures, handouts, and other visual aids to teach thegeneral facts of diabetes, stress management, social support, nutrition, and exercise, etc., theHospital has support groups to assist patients. UPMC Northwest also provides primary carephysicians office staffs with statistics, manuals, referral agencies, and information on self-management classes and support groups.
UPMC Northwest physicians, along with hospital staff, provided the Youth Football Leaguewith physicals, blood pressure screenings, and other help as needed.
"Stethoscope" was a local public access TV show presenting a Bioterrorism update. It detailed
Federal, State, UPMC, and UPMC Northwest preparedness efforts, and provided a narrative on
the challenges that a Bioterrorism event would cause.
STATEMENT 4A
The suicide prevention initiative provided a community educator to meet with volunteers whoanswer the Victims Resource Hotline. The volunteers were instructed how to handle callswhere the caller is threatening suicide.
Drugs, Sex, `Rents, and Raves were evenings of information about local drug problems andother adolescent issues to educate parents and the general public. The Hospital displayprovided information about signs of alcohol or drug use, safety concerns, and the importanceof good communication between parents and teenaged children.
UPMC Northwest's Safe Sitter program provided youth aged 11-13 with instruction in skillsrequired to begin babysitting.
The Hospital's volunteer services coordinated a toy drive for needy children in the area. Itemscollected were donated to the Franklin Salvation Army for distribution.
The Canned Food Drive was a joint effort of UPMC Northwest, Sugar Creek Station, and theVisiting Nurses Association. Items collected were forwarded to the Community Services ofVenango County for distribution. Over 2,500 items were collected.
The Hospital expresses its significant commitment to the surrounding community throughnumerous free screenings and services. Some of the free screenings include blood pressure,diabetes, stroke, cholesterol, body fat checks, osteoporosis, skin cancer, and prostate providedby The Hospital at various fairs and community events. UPMC Northwest also provides alocation for community blood drives, as well as meals for workers, and volunteers to assist.
UPMC Northwest has made monetary donations to help sponsor organizations and eventsthroughout the Franklin and Oil City areas and outlying communities. Some of theseorganizations and events were the Venango County 4-H Club, Rails to Trails Conservancy,Oil City Chamber of Commerce, Stat Medevac, Rocky Grove Volunteer Fire Department,Special Olympics, American Heart Association, March of Dimes, Franklin Light Up Night,and the American Cancer Society Relay for Life.
STATEMENT 4A
UPMC NORTHWEST 25-0489010
FORM 990, PART IV - OTHER NOTES AND LOANS RECEIVABLE^C..1) 5hne.
BORROWER: DAVID BROOKER, M.D.
ORIGINAL AMOUNT: 100,000.
INTEREST RATE: 9.500000
DATE OF NOTE: 09/09/1998
MATURITY DATE: 09/01/2005
REPAYMENT TERMS: $1,634.40 MONTHLY PAYMENT
SECURITY PROVIDED: ANY OF HIS PROPERTY
PURPOSE OF LOAN: ACQUIRE MEDICAL PRACTICE
BEGINNING BALANCE DUE ..................................... 39,591.
ENDING BALANCE DUE ........................................ 23,030.
---------------
BORROWER: VANTAGE-LINEN
ORIGINAL AMOUNT:
INTEREST RATE:
DATE OF NOTE:
MATURITY DATE:
REPAYMENT TERMS:
PURPOSE OF LOAN:
80,500.8.00000001/20/1996
01/20/2003
$2,522.58 MONTHLY PAYMENT
WORKING CAPITAL
BEGINNING BALANCE DUE ..................................... 80,500.
ENDING BALANCE DUE ........................................ 74,502.
---------------
BORROWER: VISITING NURSES ASSOC. OF VENANGO COUNTY
ORIGINAL AMOUNT: 27,000.
INTEREST RATE: 6.750000
DATE OF NOTE: 07/01/2001MATURITY DATE: 07/01/2006
REPAYMENT TERMS: $531.45 MONTHLY PAYMENT
PURPOSE OF LOAN: OFFICE RENOVATIONS
BEGINNING BALANCE DUE ..................................... 17,707.
ENDING BALANCE DUE ........................................ 11,900.
---------------
STATEMENT 5
TS0352 597Y 07/12/2006 13:34:02 V03-8 23
UPMC NORTHWEST 25-0489010
BORROWER: P. DEAN CUMMINGS, M.D.
ORIGINAL AMOUNT:
INTEREST RATE:DATE OF NOTE:MATURITY DATE:REPAYMENT TERMS:PURPOSE OF LOAN:
150,000.9.75000007/01/1999
08/01/2004
$1,250 MONTHLY PAYMENTS
WORKING CAPITAL
BEGINNING BALANCE DUE ..................................... 48,770.
BORROWER: PAMELA CRAWFORD
ORIGINAL AMOUNT: 46,779.
INTEREST RATE: 9.000000DATE OF NOTE: 04/01/1998
MATURITY DATE: 01/01/2001
REPAYMENT TERMS: $852.19 MONTHLY PAYMENT
SECURITY PROVIDED: SEPARATE AGREEMENT
PURPOSE OF LOAN: PURCHASE EQUIPMENT
BEGINNING BALANCE DUE ..................................... 4,981.
TOTAL BEGINNING OTHER NOTES AND LOANS RECEIVABLE 191,549.------------------------------
TOTAL ENDING OTHER NOTES AND LOANS RECEIVABLES 109,432.------------------------------
STATEMENT 6
TS0352 597Y 07/12/ 2006 13:34 : 02 V03-8 24
UPMC NORTHWEST 25-0489010
FORM 990, PART IV - INVESTMENTS - SECURITIES (Line_ 50--------------------------------------------
ENDING
DESCRIPTION BOOK VALUE
----------- ----------
BOARD DESIGNATED FUNDS:
FIXED INCOME:
CORPORATE 226,682.
US GOVERNMENT 898,029.MORTGAGES 454,806.ASSET-BACKED 13,397.
CASH EQUIVILENTS 814,015.
INTERNATIONAL 20,643.
OTHER 186,900.EQUITIES 5,630,608.
LIMITED PARTNERSHIPS 1,267,038.
OTHER UNRESTRICTED INVESTMENTS
FIXED:
CORPORATE 699,981.
US GOVERNMENT 2,773,058.
MORTGAGES 1,404,411.
ASSET-BACKED 41,370.
CASH EQUIVALENTS 2,060,633.
INTERNATIONAL 63,744.
OTHER 79,218.
EQUITIES 16,419,977.
LIMITED PARTNERSHIPS 3,583,586.
TOTALS 36, 638,096.
STATEMENT 7
TS0352 597Y 07/12/ 2006 13:34 : 02 V03-8 25
UPMC NORTHWEST
-FORM 990, PART IV - INVESTMENTS - OTHER
DESCRIPTION
INVESTMENT VANTAGE HOLDING CO.
BENEFICIAL INTEREST
IN FOUNDATION
TOTALS
^Linc. 56)
25-0489010
ENDING
BOOK VALUE
249,717.16, 153, 111.
---------------
16,402,828.------------------------------
STATEMENT 8
TS0352 597Y 07/12/2006 13:34:02 V03-8 26
UPMC NORTHWESTEIN: 25-0489010FEDERAL FORM 990FOR TAX YEAR ENDED 6/30/04
PART IV, LINE 57a-57b, Land, Buildings, and Equipment
Land and Land Improvements
Buildings
Equipment
Construction in Progress
TOTAL
NETACCUM. BOOK
COST DEPR. VALUE
2,253,400 1,137,935 1,115,465
31,541,334 29,659,112 1,882,222
47,768,756 39,639,292 8,129,464
51,578,832 - 51,578,832
133,142,322 70 ,436,339 62 , 705,983
Depreciation is computed using the straight-line method over the estimated useful lives of the assets.
STATEMENT 8A
UPMC NORTHWEST 25-0489010
•. FORM 990, PART IV - OTHER ASSETS (L ine_ 58)
ENDING
DESCRIPTION BOOK VALUE----------- ----------
ASSETS HELD IN TRUST BY OTHERS 196,918.
DUE FR. FOUNDATION FOR CAPITAL 1,500,000.
INVESTMENT IN HC PHARMACY 148,514.
---------------
TOTALS 1,845,432.------------------------------
STATEMENT 9
TS0352 597Y 07/12/2006 13:34:02 V03-8 27
UPMC NORTHWEST 25-0489010
• FORM 990, PART IV - MORTGAGES AND OTHER NOTES PAYABLE inc- 6q b)
LENDER: COMDOC
ORIGINAL AMOUNT:
INTEREST RATE:
DATE OF NOTE:
MATURITY DATE:
REPAYMENT TERMS:
SECURITY PROVIDED:
PURPOSE OF LOAN:
257,590.11.24000002/28/1999
02/29/2004
$5,452.63 MONTHLY PAYMENT
COPIERS/FAX MACHINES
COPIERS/FAX MACHINES
BEGINNING BALANCE DUE ..................................... 41,848.
LENDER: COMDOC
ORIGINAL AMOUNT:
INTEREST RATE:
DATE OF NOTE:
MATURITY DATE:
REPAYMENT TERMS:
SECURITY PROVIDED:
PURPOSE OF LOAN:
18,279.0.54000010/31/2001
10/31/2004
$512 MONTHLY PAYMENTS
COLOR COPIER
COLOR COPIER
BEGINNING BALANCE DUE ..................................... 7,652.
ENDING BALANCE DUE ........................................ 1,535.
---------------
LENDER: CITIBANK
ORIGINAL AMOUNT:
INTEREST RATE:
DATE OF NOTE:
MATURITY DATE:
REPAYMENT TERMS:
SECURITY PROVIDED:
PURPOSE OF LOAN:
2,097,585.8.33000010/04/199912/01/2004
$37,813. 63 MONTHLY PAYMENTS
PHILLIPS MRI SCANNER
CAPITAL LEASE
BEGINNING BALANCE DUE ..................................... 838,570.
ENDING BALANCE DUE ........................................ 437,803.
---------------
STATEMENT 10
TS0352 597Y 07/12/2006 13:34:02 V03-8 28
UPMC NORTHWEST
LENDER: GE ANGIOGRAPHY EQUIPMENT
ORIGINAL AMOUNT:
INTEREST RATE:
DATE OF NOTE:
MATURITY DATE:
REPAYMENT TERMS:
SECURITY PROVIDED:
PURPOSE OF LOAN:
783,808.5.40000011/17/2001
11/17/2006
$13,063.43 MONTHLY PAYMENTS
GE ANGIO SUITE
GE ANGIO SUITE
25-0489010
BEGINNING BALANCE DUE ..................................... 595,090.
ENDING BALANCE DUE ........................................ 467,333.
---------------
TOTAL BEGINNING MORTGAGES AND OTHER NOTES PAYABLE 1,483,160.------------------------------
TOTAL ENDING MORTGAGES AND OTHER NOTES PAYABLE 906,671.------------------------------
STATEMENT 11
TS0352 597Y 07/12/2006 13:34:02 V03-8 29
UPMC NORTHWEST
FORM 990, PART IV - OTHER LIABILITIES
DESCRIPTION
ACCRUED POSTRETIREMENT BENEFIT
THIRD PARTY RATE ADJUSTMENT
DUE TO EXEMPT AFFILIATE
TOTALS
(Jne, 65.
25-0489010
ENDING
BOOK VALUE
4,164,765.909,629.
2,939,143.
---------------8,013,537.
------------------------------
STATEMENT 12
TS0352 597Y 07/12/2006 13:34:02 V03-8 30
UPMC NORTHWEST 25-0489010
FORM 990, PART V - LIST OF OFFICERS,
------------------------------------
DIRECTORS, AND TRUSTEES
------------------------
CONTRIBUTIONS EXPENSE ACCTTITLE AND TIME TO EMPLOYEE AND OTHER
NAME AND ADDRESS DEVOTED TO POSITION COMPENSATION BENEFIT PLANS ALLOWANCES---------------- ------------------- ------------ ------------- ----------
WILLIAM E. LUCIA CFO 135,938. 21,389. NONE100 FAIRFIELD AVENUE 40 HRS/WK
SENECA, PA 16346
NEIL TODHUNTER CEO 294,465. 31,513. NONE100 FAIRFIELD AVENUE 40 HRS/WK
SENECA, PA 16346
EDWARD B. COWART BOARD MEMBER NONE NONE NONE100 FAIRFIELD AVENUE <1 HR/WK
SENECA, PA 16346
JAMES L. DAUGHERTY BOARD MEMBER NONE NONE NONE100 FAIRFIELD AVENUE <1 HR/WK
SENECA, PA 16346
HENRY W. GENT, III, ESQUIRE BOARD MEMBER NONE NONE NONE100 FAIRFIELD AVENUE <1 HR/WK
SENECA, PA 16346
JAMES E. KNARR, D.M.D. BOARD MEMBER NONE NONE NONE
FORM 990, PART V - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES------------------------------------------------------------------------------------------------------------------------
NAME AND ADDRESS
DANIEL PAULO, DVM
100 FAIRFIELD AVENUE
SENECA, PA 16346
RICHARD O. WAY
100 FAIRFIELD AVENUE
SENECA, PA 16346
WILLIAM H. CLARK
100 FAIRFIELD AVENUE
SENECA, PA 16346
ROBERT MILLER
100 FAIRFIELD AVENUE
SENECA, PA 16346
DEAN ECKENRODE
PRESIDENT & CEO UPMC HORIZON
2200 MEMORIAL DRIVE
FARRELL, PA 16121
JAMES MCLAUGHLIN, D.O.
100 FAIRFIELD AVENUE
SENECA, PA 16346
JOHN O. CONNOR, M.D.
100 FAIRFIELD AVENUE
SENECA, PA 16346
KEITH PEMRICK
100 FAIRFIELD AVENUE
CONTRIBUTIONS EXPENSE ACCT
TITLE AND TIME TO EMPLOYEE AND OTHERDEVOTED TO POSITION
FORM 990, PART V - LIST OF OFFICERS, DIRECTORS, AND TRUSTEES
NAME AND ADDRESS
----------------SENECA, PA 16346
WILLIAM SCHAFFNER
ASSOC. COUNCIL UPMC HEALTH SYSTEM200 LOTHROP STREET
PITTSBURGH, PA 15213
GAIL WELCH
100 FAIRFIELD AVENUE
SENECA, PA 16346
W. ROGER MCCAULEY100 FAIRFIELD AVENUE
SENECA, PA 16346
TITLE AND TIMEDEVOTED TO POSITION
-------------------
BOARDMEMBER
<1 HR/WK
BOARD MEMBER<1 HR/WK
SR VP FINANCE& ADMIN40 HRS/WK
GRAND TOTALS
25-0489010
COMPENSATION------------
NONE
NONE
:9136,069.
NONE
NONE
12,684.
EXPENSE ACCTAND OTHERALLOWANCES
NONE
NONE
NONE
566,472 65,586 )K NONE
* FOOTNOTE : COMPENSATION IS IN RELATION TO ROLE IN HOSPITAL MANAGEMENT AND OPERATIONS ACTIVITY.NO COMPENSATION IS PAID FOR INDIVIDUALS' ROLES AS BOARD MEMBERS.
** A PORTION OF THE BENEFITS DISCLOSED RELATE TO EARNED BUT UNPAID DEFERRED COMPENSATION.
,FORM 990, PART VI - NAMES OF RELATED ORGANIZATIONS ^Ljne 800
UPMC HEALTH SYSTEM EXEMPT
VISITING NURSES ASSOCIATION OF VENANGO COUNTY EXEMPT
SUGARCREEK STATION EXEMPT
STATEMENT 17
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UPMC NORTHWEST 25-0489010
FORM 990, PART VIII - ACCOMPLISHMENT OF EXEMPT PURPOSES--------------------------------------------------------------------------------------------------------------
EXPLANATION OF HOW EACH ACTIVITY FOR WHICH INCOMELINE IS REPORTED IN COLUMN (E) OF PART VII CONTRIBUTED
NO. IMPORTANTLY TO THE ACCOMPLISHMENT OF EXEMPT PURPOSES
93A PROVISION OF INTEGRATED HIGH QUALITY INPATIENT ANDOUTPATIENT SERVICES TO RESIDENTS OF THE SURROUNDING
COMMUNITY REGARDLESS OF ABILITY TO PAY.93B REVENUE FROM OTHER PATIENT SERVICES INCLUDING CAFETERIA,
MEDICAL RECORD REVENUE, AND OTHER MISCELLANEOUS SERVICESPROVIDED FOR THE CONVENIENCE OF PATIENTS AND EMPLOYEES.
93C THE HOSPITAL RENTS FACILITIES TO AN AFFILIATED EXEMPT
ORGANIZATION AND AFFILIATED PHYSICIANS IN ORDER TO ACHIEVEGREATER OPERATIONAL EFFICIENCIES AND MORE THOROUGHLY MEETTHE GOALS OF SERVING ITS PATIENTS.
STATEMENT 18
TS0352 597Y 07/12/2006 13:34:02 V03-8 36
UPMC NORTHWEST
FORM 990, PART IX - INFORMATION REGARDING TAXABLE SUBSIDIARIES----------------------------------------------------------------------------------------------------------------------------
PERCENTAGE NATURE OFNAME AND ADDRESS OWNERSHIP BUSINESSEMPLOYER IDENTIFICATION NUMBER INTEREST ACTIVITIES
MEMBERS OF THE BOARD PROVIDED SERVICES TO THE ORGANIZATION. HENRY GENT
PROVIDED LEGAL COUNSEL AND JAMES DAUGHERTY PROVIDED REAL ESTATE ANALYSYS.
ALL TRANSACTIONS OCCURRED ON AN ARM'S LENGTH BASIS.
STATEMENT 20
TS0352 597Y 07/12/2006 13:34:02 V03-8 38
i
UPMC NORTHWEST
EIN: 25-0489010
FEDERAL FORM 990
FOR TAX YEAR ENDED 6/30/2004
Schedule A. Part III - Statements About Activities - Question # 2
All transactions and activities between the entity, UPMC Northwest, and any of its
trustees, directors, officers, creators, key employees, or members of their families, or with taxableorganizations or their associates' businesses are entered into as arm's length transactions and at arm'slength's rates. Any payments made by UPMC Northwest were for goods and/or services rendered.All payments were made to business entities; no payments were made directly to individual taxpayers.
STATEMENT 21
' Form 8868 Application for Extension of Time To File an(December2000) Exempt Organization Return OMB No 1545-1709
Department of the Treasury
Internal Revenue Seance ► File a separate application for each return
• If you are filing for an Automatic 3-Month Extension, complete only Part I and check this box .................... ►• If you are filing for an Additional ( not automatic) 3-Month Extension , complete only Part II (on page 2 of this form).
Note : Do not complete Part 11 unless you have already been granted an automatic 3-month extension on a previously filedForm 8868.
Part I Automatic 3-Month Extension of Time - Only submit original (no copies needed)Note : Form 990- T corporations requesting an automatic 6-month extension - check this box and complete Part I only .... ► q
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.
Type or Name of Exempt Organization Employer identification number
print UPMC NORTHWEST 25-0489010
File by thedue date forfiling yourreturn Seeinstructions
Number, street, and room or suite no If a P 0 box, see instructions.
200 LOTHROP STREET C/O CORPORATE TAXATIONCity, town or post office, state, and ZIP code For a foreign address, see instructions
PITTSBURGH, PA 15213
Check type of return to be filed (file a separate application for each return):
Form 990 q Form 990-T (corporation) q Form 4720
q Form 990-BL q Form 990-T (sec. 401(a) or 408(a) trust) q Form 5227
q Form 990-EZ q Form 990-T (trust other than above) q Form 6069
q Form 990-PF q Form 1041-A q Form 8870
• If the organization does not have an office or place of business in the United States, check this box .................. ► q
• If this is for a Group Return , enter the organization's four digit Group Exemption Number (GEN) . If this isfor the whole group, check this box ► q . If it is for part of the group, check this box ► q and attach a list with the names andEINs of all members the extension will cover.
I I request an automatic 3-month (6-month , for 990-T corporation) extension of time until 02/15 , 20 05 ,
to file the exempt organization return for the organization named above. The extension is for the organization's return for:
► q calendar year 20- or
► tax year beginning 07/01 , 20.9-3, and ending 06/30 -,20-9-4.
2 If this tax year is for less than 12 months, check reason: q Initial return q Final return q Change in accounting period
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less anynonrefundable credits. See instructions ..................................................... $
b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax paymentsmade. Include any prior year overpayment allowed as a credit ....................................
c Balance Due. Subtract line 3b from line 3a. Include your payment with this form, or, if required, depositwith FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System). Seeinstructions ..........................................................................
Signature and VerificationUnder penalties of perjury I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,correct, and complete , and that I am authorized to prepare this form
Signature ► CPA Dates 11/01/2004
For Paperwork Reduction Act Notice, see I Form 8868 (12-2000)
ISA
STF FED9056F 1
orm 8868 (1 2-2000) 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 U if you have already been granted an automatic 3-month extens9t?n a previously filed Form 8868.
• If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1).
Part ll Additional (not automatic) 3-Month Extension of Time - Must File Original and One Copy.
Type or Name of Exempt Organization Employer identification number
print UPMC NORTHWEST 25-0489010File by theextended
Number, street , and room or suite no If a P O box, see instructions For IRS use only
due date for 200 LOTHROP STREET, C/O CORPORATE TAXATIONfiling thereturn See
City, town or post office, state, and ZIP code For a foreign address, see instructions _
instructions PITTSBURGH, PA 15213
Check type of return to be filed (File a separate application for each return)-
q Form 990 q Form 990-EZ q Form 990-T (sec 401(a) or 408(a) trust) q Form 1041-A q Form 5227 q Form 8870
q Form 990-BL q Form 990-PF q Form 990-T (trust other than above) q Form 4720 q Form 6069
STOP: Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868.
• If the organization does not have an office or place of business in the United States , check this box ........ ......... ► q
• If this is for a Group Return , enter the organization ' s four digit Group Exemption Number (GEN) . If this isfor the whole group , check this box ► q . If it is for part of the group , check this box ► q and attach a list with the names andEINs of all members the extension is for.
4 I request an additional 3-month extension of time until MAY 16 _
5 For calendar year , or other tax year beginning JULY 1 , 20 03 and ending JUNE 30 20 04
6 If this tax year is for less than 12 months, check reason : q Initial return q Final return q Change in accounting period
7 State in detail why you need the extension ADDITIONAL TIME IS NEEDED TO GATHER THE
INFORMATION REQUIRED TO FILE A COMPLETE AND ACCURATE TAX RETURN.-
8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less anynonrefundable credits. See instructions .. ..... . ....... .... ....... .......... . .. $
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimatedtax payments made. Include any prior year overpayment allowed as a credit and any amount paidpreviously with Form 8868 . .. .... ..... . . . ..... .. ....... . . .............. $
c Balance Due. Subtract line 8b from line 8a Include your payment with this form, or, if required, depositwith FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System). Seeinstructions .......... .... .. .... ... ................. ... ........ . ...... .. $
Signature and VerificationUnder penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,correct , and complete, and that I am authorized to prepare this form
Notice to licant - To Be Completed by the IRSZWe have approved this application Please attach this form to the organization ' s return
q 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 theorganization 's return ( including any prior extensions ) This grace period is considered to be a valid extension of time for elections otherwise required to bemade on a timely return Please attach this form to the organization 's return
q We have not approved -this application After considering the reasons stated in dem 7, we cannot grant your request for an extension of time to file We arenot granting a 10-day grace period. @*^+^^
q We cannot consider this application because it was filed after the due date of the return for° tefision was requested
q OtherEXTENSION APPROVED
MAR 0 8 2005BT FER 2 8 2009
Director Date^^^CORR
Alternate Mailing Address- Enter the address if you want the copy of this app Ica Ion o a al J1 ftW@MI9flELD DIRECTOR,returned to an address different than the one entered above . SUBMISSION PROCESSING, OGDEN
Name
Type or Number and street (include suite , room, or apt no .) Or a P. O. box number
print
City or town , province or state, and country ( including postal or ZIP code)