The URL can be used to link to this page

Home My WebLink About2003-253P. The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC G es lir ORGANIZATION : The Center for Emotional and Behavioral Health (a,IRMH PROGRAM : Camp Manatee Therapeutic Summer Camp TkBLE OF CONTENTS Please "Y ' the pats of the grant application to indicate they are included. Also, please put the page number where the information can be located. � X Section of the Proposal Pa e # X TABLE OF CONTENTS (Check list) 1 -2 X COVER PAGE (with signatures) . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. ORGANIZATION CAPABILITY (one page maximum) X L Mission and Vision of organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 X 2 . Summary of expertise, accomplishments, and population served . . . . . . . . . . . . . . . . 4 Be PROGRAM NEED STATEMENT (one page maximum) X 1 . Program Need Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 X 2 . Programs that address need and gaps in service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Ce PROGRAM DESCRIPTION (two pages maximum) X1 . Funding priority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X 2 . Description of program activities . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X 3 . Evidence that program strategy will work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 X4 . Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 -7 X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 X 6 . Accessibility of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 X D. MEASURABLE OUTCOMES (two pages maximum) . . . . . . . . . . . . . . . . . . . . . . . . . 8 -9 X E. COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Fe PROGRAM EVALUATION (two pages maximum) X _ 1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X 2 . Measures . I 11 X3 . Reporting . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . X G. TIMETABLE (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . 13 He UNDUPLICATED CLIENT COUNT X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . 14 X 2 . Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . , . . . . . . . . . . . . . . . . . . . 14 1 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC I. BUDGET FORMS X 1 . Budget Narrative Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 - 18 X 2 . Total Agency Budget , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 X 3 . Total Program Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 X 4 . Funder Specific Budget . I . . . . . I . . . I . . . . . . . . * . . . . . . . . . . . . . I . . . . . . . . . . . . . . I . . . . . I . . . . . . . . 21 X 5 . Explanation for Variances — Total Program Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 X 6 . Explanation for Variances — Funder Specific Budget , . . . . . . . . . . . . . . . . . . . . . . . 23 X J. FUNDER SPECIFIC/ADDITIONAL SHEETS X K APPENDIX 2 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional & Behavioral Health (aJ IItNIH Executive Director : Dr. Raymond Dean MD Email : rdean@irmh. com Address : 1190 37"' Street Vero Beach FL 32960 Telephone : 772- 563 -4666 ext 1809 Fax : 772- 770-2025 Program Director: Mariamma Pyngolil, RN Email : mpyngolil@irmh . com Address : 1190 37th Street Vero Beach FL 32960 Telephone : 772- 563 -4666 ext 1838 Fax : 772- 770-2025 Program Title : Camp Manatee Therapeutic Camp Priority Need Area Addressed: Therapeutic, intervention and educational program for children diagnosed with ADHD and other more severe emotional problems in Indian River County Brief Description of the Program : _ Day camp facility that is appropriately staffed and equipped to provide an opportunity for children who have developmental disabilities, emotional disturbances, and/or health impairments who have other limitations or problems which require special facilities or programminl7 to enjoy a cooperative living experience in the out of doors Amount Requested from Funder for 2003 / 04 : 24 , 500 . 00 Total Proposed Program Budget for 2003 /04 : $ 545500 Percent of Total Program Budget : 45 . 0 % Current Funding ( 2002 /03 ) : $ 207000 Dollar increase/( decrease) in request : $ 4 , 500 Percent increase/( decrease) in request : 22 . 5 % Unduplicated Number of Children to be served Individually : 43 Unduplicated Number of Adults to be served Individually : _ Unduplicated Number to be served via Group settings : _ Total Program Cost per Client : 1267 . 44 Will these funds be used to match another source ? No If yes , name the source : Amount : $ _ The Organization s Board ofDirectons has approved this application on (date). WY Name of Pr i ent of the Board Name of Ex ti Director Signature I�a y M0A N D-eQ q 3 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section . In responding to each section of the proposal narrative, please retain the section-label and/or question you are addressing . Type using 12 pt . Font on 8 '/2 X 11 paper and number each page . These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization . Indian River Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork. The Center for Emotional and Behavioral Health n IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team. We will continue to support the Quality First process while working together as a team . Camp Manatee Therapeutic Summer Camp is committed to improving the lives of children and their families who are challenged with ADHD disorder with or without more severe emotional problems and who are at risk for alcohol/drug abuse, crime and school drop-out 2 . Provide a brief summary of your organization including areas of expertise, accomplishments and population served. CEBH provides Mental Health services to children, adolescents and adults . In patient services are provided on a voluntary or involuntary basis to all three age groups . Partial Hospitalization services are available for adolescents and adults . The facility also provides out-patient therapy for children/adolescents and their families, EAP services, urine drug screens/drug free workplace services, a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children and Experiential (ROPES teambuilding) services to the community. Camp Manatee Therapeutic Summer Camp is a structured and closely supervised program focused on the goals of increased self esteem, socialization, appropriate coping skills development, problem solving, creativity, play and communication skill building . These goals are achieved through a variety of carefully planned structured activities utilizing a behavior management feedback and reward program to teach specific skills 4 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC Be PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change? b) Who has the need ? c) Where do they live? d) Provide local, state or national trend data, with reference source, that corroborates that this is an area of need . a. Children diagnosed with psychiatric disorder, ADHD, are lacking a comprehensive day camp in the summer designed to meet their special needs and dispense medications . The children are ages 5 though 14 with the last two years designed as leadership skill development for previously enrolled campers who reside in Indian River county. b . According to http : //www. mentalhealth org/features/sur eongencralreport/chapter3/sect asp ADHD, which Is the most commonly diagnosed behavioral disorder of childhood, occurs in 3 to 5 percent of school-age children in a 6-month period (Anderson et al . , 1987 ; Bird et al . , 1988 ; Esser et al . , 1990; Pelham et al . , 1992 ; Shaffer et al . , 1996c; Wolraich et al . , 1996) . Pediatricians report that approximately 4 percent of their patients have ADHD (Wolraich et al . , 1990), but in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV (Wolraich et al . , 1990) (see also Treatment later in this section) . Boys are four times more likely to have the illness than girls are (Ross & Ross, 1982) . The disorder is found in all cultures, although prevalences differ; differences are thought to stem more from differences in diagnostic criteria than from differences in presentation (DSM-IV) . 2, a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program. - Sandy Pines ADHD Summer Program — Jensen Beach, Fl — closed program due to for-profit business and could not meet financials . No outcome data available -Milestone Charter School, Brevard County Public Schools — In the years past, had a summer camp for ADHD, which modeled the program after Camp Manatee Therapeutic Summer Camp . School principal collaborated with Camp Manatee Manager to institute program in Brevard due to success of their children attending Camp Manatee . No outcome data available due to closing of the camp -No other program like this currently exists in FL; however, several programs throughout the USA exist and are ` slee -over' camps 5 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC C. PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two gages) 1 . List Priority Needs area addressed . It will increase recreation opportunities for children with special needs . Camp Manatee Therapeutic Summer camp offers age appropriate recreational activities to enhance social skills, coping skills, leisure —recreation skill development, education about their disease . It also recreational program that allows ADHD to take their medications . Camp Manatee provides quality childcare before and after camp at an affordable price for working parents to help reduce the amount of juvenile crime. 2 . Briefly describe program activities including location of services. -A written structured, age appropriate schedule of recreational activities to enhance social skills, coping skills, leisure, recreation skill development, education about their disease . -Written Positive Behavior Management Program with immediate feedback in the form of verbal praise, tokens and skill development . —Medication times to ensure continuity of care for ADHD children . -Parents of children enrolled are mandated to attend parenting classes specifically designed for parenting the ADHD child . -Experiential Team building Activities to learn & experience growth in self-esteem, making choices, supporting others, communication and developing trust . - Senior Campers 13 years old , community service education & project. -Camp Manatee Therapeutic Summer Camp is located at the CEBH, but utilizes the recreation and leisure resources within Indian River County to provide optimum services for these children 3. Briefly describe how your program intends to address the stated need/problem . Include reference to any studies or evidence that indicate proposed strategies are effective with target population. The issues and problems ADHD with more severe emotional behavioral problem child face are : * Due to an ADHD child ' s lack of impulse control, decreased self-esteem, poor social and problem solving skills these children are usually unsuccessful in regular camp and recreational settings . There is a lack of recreational opportunities and community service experiences available to ADHD children in general, and no other programs that specifically addresses targeted areas of concern. Research indicates that ADHD children are at a higher risk for drug & alcohol use . Research also indicates that with preventive education such as development of coping skills, better level of understanding of the disorder, parenting education classes, along with social skill development that the incident of substance abuse and delinquency will be decreased . *Pre & post camp childcare hours, at affordable prices, are difficult for working parents to find, Camp Manatee provides quality childcare before and after camp at an affordable price for working parents . * Recreational Activities program that allows ADHD to take their medication . A. List staffing needed foryour program , including required experience and estimated hours per week in program for each staff member and/or volunteers (This section should conform with the information in the Position Listing on the Budget Narrative Worksheet) , Camp Manatee Therapeutic Summer Camp Program Staffing : (Due to a natural decrease of CEBH patient censuses during the summer months we are able to utilize the resources of some CEBH full time staff. ) List of staff follows : ( 1 )Director of Patient Care Services — Advanced Registered Nurse Practitioner in child & adolescent psychiatric nursing- 5 % time of full time position; . 05 position ; published behavior ..program for children with psychiatric disorders, 20 years experience with children & adolescents 6 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC mental health programs . Assist with daily medications, critical incidents and behavior interventions . (2) Psychological Services — Doctoral Level Clinical Psychologist ; 5 % time of full time position ; . 05 position . Provides clinical supervision to behavior program content, revisions, clinical standards and parenting education classes . Assist with more serious behavior problems with children & their families when they occur. (3 )Manager of Activity Therapy — Bachelor degree, certified by National Therapeutic Recreation Society. 10% time of full time position; . 1 position . 15 years experience in Therapeutic Recreation services with children & teenagexs; 4 years experience with Camp Manatee Program . (4) Supervisor of Camp Manatee — Masters Degree, Licensed therapist . 25 % of a full time position; . 25 position . Over ten years experience in services with children & teenagers . (5 )Camp Counselor — High school diploma plus 2 year experience working with children and entering or enrolled in college with a major in mental health related field . 32 hours training on ADHD (provided by CEBH), behavior programming and skills competencies completed and passed . 100% time; 6 positions ; 7 weeks ; 40 hour week; summer only . (6)Assistant Camp Counselor — High school student who has ADHD and will be helping with various aspects of camp . He will report directly to the camp supervisor. Camp Manatee has recruited volunteers through : 1 . IRMH teenage auxilian volunteer (TAV) program. 2 . IRMH Auxilian/Volunteer Services 3 . Volunteer Action Center YVC — Youth Volunteer Program 4 . St . Edward ' s Upper School - Community Volunteer Program Due to IRMH' s policy on client confidentiality, Camp Manatee must use discretion on selecting volunteers and the number of volunteers . 5. How will the target population be made aware of the program ? Camp Manatee Therapeutic Summer Camp reaches clients it intends to help by providing literature to schools, medical doctors, therapist, parents, at health fair in Indian River County, to patients treated at CEBH. Camp Manatee Therapeutic Summer Camp staff welcomes all opportunities to speak at organizations, TV, radio, specialty articles in newspaper, etc CEBH provides collaboration with the community through : ( 1 )Vero Beach Press Journal Ads "IRMH Community Calendar and Special Summer Camp Section in Lifestyles" (2)Camp Manatee flyers are distributed/mailed to all elementary & middle schools in Indian River County (both public & private), all members of exceptional student education through the School board office, all pediatricians, child psychiatrist in private practice, all Mental Health Professionals who treat children and through an extended email list of interested parent, services agencies , etc. and to a mailing list of past campers & their families . (3 )Camp Manatee Open House each April to welcome all community members . (4)IRMH Annual Health Fair — distribute flyer & provide educational information for prevention & treatment of ADHD . (5 ) Vero Beach Health Fair Booth — distribute flyer & provide educational information for prevention & treatment of ADHD . (6)Women ' s Health Fair — distribute flyers & provide educational information for prevention & treatment of ADHD 6. How wil the program be accessible to target population (i. e. location, transportation , hours of operation) ? Camp Manatee Therapeutic Summer Camp is located at CEBH across the street from IRMH and easily accessible from US 1 or Indian River Boulevard . The hours of operation are 9 : 00am- 3 : OOPM, with the option of before care from 8 : OOAM-9 : OOAM and after care from 3 : OOPM- 4 : OOPM. Transportation is provided by Camp Manatee to go on field trips, but parents/guardians must provided own transportation to get child to and from camp . 7 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Description of Intent Use the Meamrable Outcomes form. This descriptionivape does not need to be included in the ro osal. In order to show the impact your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected . OUTCOMES : Describes what you want to achieve with the target population . Indicates the results of the services you provide, not the services you provide. Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes . Activities utilize action words such as complete, establish, create, provide, operate, and develop . The activities should reflect the services described in the PROGRAM DESCRIPTION (C2). Ilse the following elements to develop your outcomes. All elements must be included: • Direction of change • Time frame • Area c?f change • As measured by • Target population • Baseline: The number you will be • Degree of chane measuring against Example 1 (Outcome) , To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (target population) by 75 % (degree of change) in one year (time ,frame) as reported by the 2002 School Board attendance records (as measured by) . Baseline : 2002 School Board attendance records for enrolled boys and girls . Example 1 (Activity) : To provide anger management classes to enrolled boys & girls two times a week for 12 weeks . Example 2 (Outcome) : 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (timeframe) will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry. Baseline : Pre test scores from the academic enrichment test. Example 2 (Activity) : 1 ) Provide pre and post test exercises on the Advanced Learning System software 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE : Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what you are held .accountable to accomplish. Also, the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B 1 ) . All Program Need Statements should flow from the Mission & Vision. Measurable Outcomes should be based on and measure program needs . Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your program need statement . 8 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic summer Camp — IRC- CSAC D. MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all the elements or the Measurable Outcome(v) Add the tasks to accomplish the Outcome(v) 1 . To decrease the number of missed 1 . Provide camper ' s prescribed medications medications of enrolled ADHD campers by under the direction of a qualified professional 100% as reported by the 2002 medication (RN) and counselor to manage the medical chart records : Baseline : Medication chart on needs of each child daily each child 2 . To increase the ability to utilize coping skills 2 . Instruct & provide written feedback of enrolled ADHD campers to 100% as regarding camper ' s coping strategies each day reported by daily feedback report by to parents . Parents respond on sheet and return counselors and returned next camp day with parental signature . Baseline Daily feedback report 3 . To increase the overall parental 3 . Instruct & provide 4 — 1 . 5 hour of education understanding of strategies on how to cope regarding strategies so that their parents can with their children' s maladaptive ADHD better manage the maladaptive behaviors of the behaviors by 100% as reported by parent post ADHD child . education evaluation form . Baseline — Pre- class evaluation assessment . 4 . To increase the ability to demonstrate, attend 4 . Sr. Camper s will receive up to three tokens to and organize daily tasks assigned to Sr. on their point card, per hour for completion of Campers, to 80% of the time as reported by the organized daily tasks . behavior management system and daily feedback sheets . Baseline — Daily feedback sheets 9 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program ' s collaborative partners and the resources they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative agreement letters. Collaborative Agency Resourcesprovided to the program Camp Manatee Jeff Horne Memorial Foundation funds donated to assist lower income Fund families with Camp Manatee fees Budget Rentals of Vero Beach Discounted rate for rental van. Rate is good for all six weeks of camp . Barefoot Bay Homemakers $200 . 00 donation to assist children ' s fees in North Indian River Count IRMH Auxiliary Supplying volunteer to help with marketing materials Florida Institute of Technology Allowing psychology resident students to assist with (F . I . T) ADHD parenting classes Indian River County Schools Student Support Services by supplying educational laws for children with disabilities . Also co-facilitating parenting classes for parents of children receiving scholarship to cam Indian River Memorial Hospital Allowing us to utilize the facilities of CEBH (pool, existing play equipment, ROPES course, playground, gymnasium, art room, van, cafeteria, and lounge) and supplies (postage, phones, electricity, copy machines, and existing arts and craft supplies) to run Camp Manatee for 6 weeks during the summer. 10 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC Fe PROGRAM EVALUATION (Entire Section Fnot to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender and ethnic background) required by the funder in Section H ? What are the pieces of information that qualify them for your target population ? How do you document their need for services or their " unacceptable condition requiring change" from Section B19 We have created a camper database in Microsoft Access that will allow us to track the following demographics of as provided by the parents via the registration form. ❖ Age ❖ Gender •'• Family income •'• School attending •'• Medications ❖ Zip code We are not at this time tracking ethnic background, as we do not ask for that information on the camper ' s registration packet . We have however guessed to our best abilities the ethnic back grounds of our previous and current campers . As an improvement for next year we will include "ethnic background" as part of our registration packet . 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program ? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented ? How often do you need to collect or follow-up on this data ? We have developed a point system (based on the behavior of the camper) and feedback sheet (a written synopsis of the day for each camper given to his/her parent(s)) to track our outcomes and record the statistics . We also have evaluation forms filled pre and post parenting classes to accurately measure goals and outcomes of our interventions and education . , The Feedback sheets and point sheets are filled out on a daily basis by the camp counselors assigned to each group . The numbers will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes 11 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC 3. REPORTING : What will you do with this information to show that change has occurred ? How will you use or present these results to the consumer, the funder, the program, and the community ? How will you use this information to improve your program ? The numbers for the point system will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes to see when improvements in behaviors are being made. We will be keeping all the returned feedback sheets for one year, to reference as needed . Information collected for pre and post parenting classes is complied and then entered in to a database . We will be able to chart the results and accurately measure outcomes . The information is shared with the counselors and parents of the child in camp, with a signed release of information form. It may also be shared with educators and therapists, to he! better serve the child ' s needs . 12 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC G. TIMETABLE Section G not to exceed one page) 1 . List the major action steps , activities or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the fundingyear. In com letin the timetable, review information detailed in prior sections. Month/Period Activities January 2004 ❖ Confirm dates of camp and open house ❖ Contact marketing to update flyers for open house ❖ Call HR department to advertise for 6 counselor positions, rev7criteria. February 2004 ❖ Review, update and print all camp forms (registration, releases, medications) ❖ Update file systems ❖ Review budget March 2004 ❖ Mail open house flyers and order behavior/reward system items ❖ List and compose letter to potential field trip sites ❖ April 2004 Set up interviews for counselor positions ❖ Host open house (call employees to attend open house) ❖ Send memo to food service requesting daily snacks for camp ❖ Secure rental vans for field trips ❖ Inventory and order art supplies, gym equipment, pool supplies, and games ❖ Order camp shirts for counselors ❖ Review registration forms, send out follow up letter to parents ❖ Set scholarship committee meeting to review and reward scholarships to applicants May 2004 ❖ Develop and finalize camp schedules ❖ Review and update 5 -day counselor training, review and update counselors schedule ❖ Research new ADHD information ❖ Secure dates and speakers for parenting classes •'• Sort and stock point store •'• Finalize camp registration forms ❖ June- July 2004 Secure field trips by completing check requests ❖ Week 1 Counselor training and Week 2 Camp begins ❖ Complete and distribute pre-evaluation for parenting classes •'• Hold parenting sessions ❖ Continue to compile goals and outcomes, as well as charting information ❖ Hold daily pre and post counselor meetings ❖ Use feedback from counselors for planning and implementing extension August 2003 program 2x month and complete counselor termination form ❖ Wrap up grant information (employee paycheck, cancelled checks, finance department) . 13 : :.ii •. :: „a it %% ?:.,.•;>;?, �.? ; iii: +.••,••1.;•:;:,•'•.• 'r•?:t , ' ,•��+ 2i:: :% •+` :. ''TWA:` •:.:Fi ,• \p V , <:s � ? `iii. •?>. #`> + viii ?J,.ri?{?}i:•r::v+5.•:. ' 'ii •� i. Gn .My ; :. � :. •. . . .. Ix uO 11.J ` • • . � 1 I v 1 1 I 1 1 t 1 1 1 1 � � � M � 1 N N 1 1 1 a N U x .G .� N cc Iwo foo G:1 a C/� Vi w eet �' ... �••� 400 4mi cc , � ^I OJ OJ 0 1 N ~ 1 1 1 4 ee j'd„ ^ �•v "•$'iii+:;l < ��.) � V `'t: r riv: ' ii3 :•ri? ;: ?•:,,,:: i5:`. + ,�y�, � 1 1 1 1 1 1 1 1 1 1 1 1 1 � +i`•r$. ii NO +i7fY!i 1 1 I 1 CJ '• '' slyly': `}:� ;:;•:i> :. �5,i.+ � � K4 . ;: +: ZWO y h+ti y' !iii •: +'XA . . . � f?. Pro >y � r O U a Urz W 'C U C c 0 0 O aoi ^d o fY E 0 c ° c a UUa � xd /mow/, � ��K^! • - •o W `,a /�� .� .,. .� • o� cd � � Q O � � � � � � O 1`f � . O F+M � 1 .. 4J ISI I rz o � xo 'b � o orae ~ o o �' •� •� + E-, a wa Oa � .� �nrno o In The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer, Camp FUNDERMC - CSAC CAUTION : Do not enter any Figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should I be used for calculations and to write information onl . ; :::: . . . . . . . . . . . . . . . . . . . . :: :::::::. :::,.Iaewpc6Etaic a. . :: .. :. ::::: . . . . . . . . . . . . . :.. . . . . . . . . . . . :. ::::::::::::.: . . . . . . . . . . :. :::::..::: . . . ., . . . . . . . . . . . . :::.:: ::::::: :. . . . . . . . . .: ::::::::::. . . . . . . . . . . . . . . : X. 1 Children's Services Council-St. Lucie 0.00 0.00 0.00 2 Children's Services Council-Martin 0.00 0.00 0.00 3 Children's Services Council-Okeechobee 0.00 0.00 0.00 4 Advisory Committee-Indian River 24 500.00 24500.00 24,500.00 5 United WaySt, Lucie County o 00 6 United Way-Martin County 0.00 0.00 0.00 0.00 0.00 7 United Way-Okeechobee County 0.00 0.00 0.00 8 United Way-Indian River County X 0.00 0.00 0.00 9 Department of Children & Families o 10 County Funds 00 0.00 0.00 0.00 0.00 0.00 11 Contributions-Cash 200.00 200.00 200.00 12 Program Fees 10,000.00 10,000.00 101000.00 13 Fund Raising Events-Net o 14 Sales to Public - Net 00 0.00 0.00 0.00 0.00 0.00 15 Membership Dues 0 00 16 Investment Income 0.00 0.00 0.00 0.00 0.00 17 Miscellaneous o 18 Legacies & Bequests 00 0.00 0.00 2 ,000.00 0.00 2 ,000.00 19 Funds from Other Sources 0.00 0.00 0.00 20a Reserve Funds Used for Operating 0 .00 20b In-Kind Donations (Not Included in total) 0 0. 00 0.00 21 >:<i :z >'`". `:' 0.00 0.00 TOTAL (doesn't include line 206) ' ' ' < $36,700.00 % $34,700.00 $36,700.00 . . . . . . . . .. . . . . :. :. ::::::;::::: ::::::::.:::::::::. :. :. .:: :.:: :::::::.::fir.: . . . . . . . . . . . . ::::::::::: ,. . . . . . . . . . . . . . :::: . . :::.: ::._::: . . . . .::::::.::::::::::::.::::. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t #"u atter :.:;:.: :: . . .:::. . . . . . . . :::::::::::::: . :. . . . . . . . . :..: ::,::::::,:,: . . . . . . . . .. . . . ::.::::::.�::::.: . . . . . :. :�Rld IIS . . . . . . . :::::: .::::. ::::. :. . . . . : . . .::.: :::, . . ;; . .. . . . . :. 9 .. .: fir:.: :: 22 Salaries - (must complete chart on next page) 30 250.00 147,250.00 >: > .>:<; 24929.99 X.v. :: :. . .:; .;:.;: . :. . :.:::::: . : ::.: : :.::;::::. : : • :..;:.;.. ;• ::.::. .: . .::: . . . . . a . . . . . . . . . 23 FICA - Total salaries x 0.0765 .IAN, 0.00 1 ,907. 14 0.00 24 Retirement - Annual pension for qualified staff 0.00 0.00 0.00 25 Life/Health - Medical/Dental/Short-term Disab. 0.00 0.00 0.00 26 Workers Compensation - # employees x rate 0.00 0.00 0.00 I-londa nemp oymen - projected 27 employees x $7,000 x UCT-6 rate 0.00 0.00 0.00 05/27/2003 15 The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp :: : :; : : . . : : ;:; . . . . . . . : . :: . .. ...... :: : :ii:::: ::: ::i:: ::i; : ::> ::::;. . . .:::., .;::.. : ::: ::: :: ::: . . . . . . . . . . . . . . . . . . . . cel { ;::;.;:.;:.;:;;;<.;:.;:.;;:.;:. !:. ::. .. ::.::. ...:::::::. ... .. . . . . . . . . . . . . . afar.. .::: . . . . . . :::. :::::: . . . . . . . . . ::::.. :,.:.: . . . . . . . . €. vi`.Gry .:.;;;;:.;�::.;:.;;:.::::: : :.::::::.:.;;:;::.::::.:;:.;;::;•:.;.,::::::::::::.::::::::::.::.:. :: . ::.::;:.:. . . . . :ri!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e�. . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~t enc ::.;:;;.: :.::;:::::::. :.::::::::, . ::.:..:::,:.: .: . . . . . .: ::::... ..: ::. . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . ::.: ::.: :.: .: ::: :. . . . . . . . . . . . . . . . . . . . . :.::::_:::::. : . . . . . . . : . :::::. :: . . . . . . . . . . . . . . :. :».;:> : � . :: .: . .: . . . . . :: . . . :. . . . . :. . . . .: . . . . : . : . . ..: :.: : . . .. :.: : :.: : . :. . . . . . Yfl;a@t?Uit� . ;: : . . . .: .::.;'. : 1),4�4IfJF# . .. . . . . .: :: : : : :::>:::,: OflffallU , 7` Director o atent Care Services 50,000.00 2 ,500.00 0.00 0.00% Psychological Services 40,000.00 2 , 500.00 0.00 0.00°r6 Manager of Activity Therapy 38 ,000.00 6,000.00 5,679.99 14.95%Camp Manatee Supervisor 61400.00 61400.00 61400.00 100.00% Counselor - A group 20570.00 29570.00 2,570.00 100.00°,6 Counselor - A group 21570.00 25570.00 2 ,570.00 100.00% Counselor - B group 21570.00 2 ,570.00 29570.00 100.00°.6 Counselor - B group 2,570.00 2570.00 29570.00 100.00% Jr. Counselor - Camp Assistant 21570.00 2,570.00 2 ,570.00 100.00% Remaining positions throughout the agency Total Salaries $ 147,250.001 $30,250.00 $24,929.9916.93% 1-5 • . <: . . :. :: . :. ::.:: :.:�. :::::: .: . freC:::::.. f�A:�> �5' .. .: :. : :: . .: . . .:::: ..t;Rest#�.:tn?�>:: : ::: . .:::::::::::::::::::: ::::: .: . .:::::,:: ::::::.:: ::._._::.:_::::.:::�::.�: .._:.::::::::.:::. : :.. : .: . . . . . . . . . . ::.:: : :. : :::.:::. .: . . . . .. . . . . . ::::::::::::::::.: ::. .: :: :. . . . . . . . : ::::: . :•:::::::: . .. :::. t Tom►: . t�l�+vac;;;;:;;;;:�:::.;.::<.>;>;:.;;:.;;;: :.: «.;;:.;:.:•;:;;:.;:.;;:.;::•::::. . ::.;:.;:.;:.;:.;;:•;:.;:.;;::;.: ;«;•;:.;:::;•:,>: :::::: :.;:.;;;;;:.;:.;;::.;;:.;: .;:. :;.;:.; :::•:::::. . •;:.>; : :::::::::::. :::::. ::•:::::::: .:: .::: . . . . . . . . . . . . . . :. :. ::::. ::::::::.::: ::::::::.: ::: . . . . . . . . . . . . . . . ::•::::::. ::::•::::::::::..... . .. . . . . . . . . . . :. . .: : . Director of Patent Care Services 0.00 0.00 0.00 0.00 0.00 0.00 0. 00 Psychological Services 0.00 0.00 0.00 0.00 0.00 0.00 0. 00 Manager of Activity Therapy 51679.99 434.52 0.00 0.00 0.00 0.00 434.52 Camp Manatee Supervisor 6,400.00 489.60 0.00 0.00 0.00 0.00 489. 60 Counselor - A group 21570.00 196.61 0.00 0.00 0.001 0.00 196.61 Counselor - A group 2,570.00 196.61 0.00 0.00 0.00 0.00 196.61 Counselor - B group 2 ,570.00 196.61 0.00 0.00 0.00 0.00 196.61 Counselor - B group 2570.00 196.61 0.00 0.00 0 .00 0.00 196.61 Jr. Counselor - Camp Assistant 21570.00 196.61 0.00 0.00 0.00 0.00 196.61 Total Funder Request Fringe Benefits $24,929.991 $ 1 ,907. 141 $0.00 $0.00 $0.00 $1 05/27/2003 16 The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp • . . . :. . ._._.�: :. . . . . . . . . . . . . . . . . ••::: . . . . . . . . . . . . . . . . . . . :. ::. . . . . . . . . . . . . . . . . . . . :., . . . . . . .j. . . . . . . . . . . . .. :,:. . . . . . . . . . . . . . . . . . . . ::. . . . . . . . . . . . . .: :: . . . . . . . . : : - : : : : : : ::.t.: :- _. : :.::;.::.;.:; .;;:.:;//,•�..:: :.:;:.;;::::::::.;: % :i::: : ::::>:::::::.:.. . ...<:::::; ::>::.::.>:.: ;::::: : .../..`::::::::::;.:�:x:t.:::::.:::::::::: :::>::x.:.:a:.>::.: .: ' . . . . . . . . . . Scai. . i . . ;W,,y�� ttSEGlp X . . . . . . 28 Travel-Daily .. . . ., ,:. :: 0.00 . . . . 0.00 > -: ::: :;::;::;;:;:a: ;:;.; o: :;c;:.:;; ; < .: ::::::,. . . . . . 0.00 # of Staff x average # of miles :_.:_ :. . .: 4. . : :_._::. m,...: :::::: ::::.: .;:.:::; .;: .;:.:; :..: :;.: ;:.;:.. . ...:.::::.: . . . . ..: :::.:. . . . . . . . . . . . . 9 s/wk x 50 wks x $ :. ;;;; ;:.:; :.;:.;:;;: .::: : .::.. . : ;<.;:. : ::. :.::::,:;:_::.;:::._._::::::::.- . .:. . :.;: ::, = Estimated r .; : : :; :. : ed Dally Travel/Mileage Reimb. 29 Travel/Conferences/Training 0.00 • ... . .:. . . . . . ... .. .:: 0.00 0.00National Conference (cost per staff) : . ;;:; . :;. ; .;:. ;; ;. .:: : .:.: . ) : .: :: »::>: ::>:<: ;:»: :<:::>-::; :::::::> :; >;: ::: . :.... . . . :. . . . . :. . . . :. . . - .Training/Seminar costper sta :: . • • Other T rami n9s ( (cost of travel, lodging , registration ,Ist ratio n food 30 Office Supplies PP ies ' ...::<:< :zx: :: • 2 ,300.00 .:::::::::: : . . . . . . . . . 0.00 2 ,300.00Ofce supplies (month) :s < :. : : " : : : : The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp 41 Professional Fees (Legal, Consulting) 0.00 0.00 • Legal ad :: .:;:;;,.: .00wce estimated :::.;:;< :;.: .:.;;:.;:�>:.:::;;; MEW ;:;;:.:<.::::::::::::::. .:.•::::::•:::::. . ,. . . . . . . . . . . . • Consultant fees • Other 42 Books/ Educational tional Materials nal s ::;:::::::<::<:»::>::; :::: :" 200.00 0.00 200.00 • Book a <` > < >< >: > :<:>::>: :.;:.;:.:.:.;:.;:.;;;;;;;;:.;:.;:.:.::.; :::::.:::::.::::::.::::: .:: . . . . . . . . . . • Materials x staff)ffl 43 Food Nutrition ` 3': > > : >. > . . . . . . . . . . . . . . . 1 .050.00 0.00 1 ,050.00 Meals # meals x clients >:: :. .;:.;::• ;.;;:.::.;:.;:.;;;:.:;.;;;:.: .; :::.:::. :.:::::.:::•:::: ,. . . . . . . . . . . . . . . ( x 5da s x 50 wks :.::.;:.;:; :.;:::::::. ;:;.;;:.:;.;:.;;:; :::::: :.::::::::::. . . . . . . . . . . . . . . . . . Y ) • Snacks X. 44 Administrative ive Co sts . . . . . . . . . . . . . . . . . . . . . 0.00 Admin. Cost % of total 0.00 0.00 bud :::::::::::: ::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( get) :.: ::::: :::;:.;:.;:;:.;:.;;:.:::::::::::::::: <.;;;;:.;: 45 Audit Expense se P . . . . . . . . . . . . . . . . . . .::::::::0.00 �;:.;:.;:;:<•;:.;:::;:;.;;:.;:.;;:.;:.;:.;;;;:.;;;;;;:.: :.:<.;:.;;: 0.00 Independent Audit Re0.00 view ::> <: »?>:: :> :: >:7r,.:»:::<: ::: :.::.:::;•:::,:::::. :::: :. ..::::. :. . . . .: . . . . . 46 Specific ific Assistance c n e to Individuals 0.00 0.0Milli 0.00• edical assistance : : .: : ....... . . . . . . . . . . . . . . . . . . . . . . . .. . . .: • Meals/Food • Rent Assistante • Other 47 Oth er/ Misce (lane ous ::»::>: :>::>::::>::::»>:<: ::>: 0.00 0.00 0.00 • Background check/drug <::::::' >::»> _>::::> :» :::::>: ;:: ;;;:.;:.;;:.:;.:;;;;.:;.;:;:.;;:.;:;::;:.;:<.;:.;;:.;:.;;:.;; ::::.::::::.::::::•:. .: . . . . . . . . . . . . . . . . . . . . . . . . . . . . g rug test � :>:<:;.;:;::: .::::,::: .::::::: . . . . . . . . . . . . . . . . . . . . • Other X. 48 Other/Contract : : 320.00Sub contract for program se 0.00 320.00.. 49 TOTAL EXPENSES $37,300.00 $26 ,837. 131 $1549300.00 05/27/2003 18 Tl r.tK Irx Ertxllinnal a1M Pxllanrcal HeaI1N('omp ManMee ThnrapeW r .9rinix fyrtp UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME: The Center for Emotional and Behavioral Health - Cam Manatee Therapeutic Summer Cam FY 01102 FY 02103 FY 03104 '6 INCREASE thru 04103 FYE 09/30/03 FYE 09130/04 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (eoL Ccol. BNeoL a REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt. Lucie 0.00 0.00 0.00 #DIV/O! 2 Children's Services Council-Martin 0.00 0.00 0.00 #DIV/O! 3 Children's Services Council-Okeechobee 0.00 0.00 0.00 #DIV/01 4 Advisory Committee-Indian River 2000000 2000000 24 500.00 22.50% 5 United Wa St Lucie Coun 0.00 0.00 0.00 #DIV/01 M 6 United Wa - artin County0.00 0.00 0.00 #DN/0! 7 United Way-Okeechobee County0.00 0.00 0.00 #DIV/0! e United Wa -Indian River Coun 0.00 0.00 0.00 #DIV/0! 9 Department of Children 8 Families 0.00 0.00 0.00 #DIV/0! to County Funds 0.00 0.00 0.00 #DIV/O! 11 Contributions -Cash 22360.00 22,360.00 200.00 -9g,11 •k t2 Program Fees 4 314v333.00I 61306,463.00 10 000 .00 -99.84°k 13 Fund Raisin Events-Net 0.00 0.00 14 Sales to Public-Net 0.00 #DIV/0! 0.00 0.00 0.00 #DIV/0! is Membership Dues 0.00 0.00 0.00 #DIV/0! 16 Investment Income 0.00 0.00 17 Miscellaneous 0.00 #DIV/01 0.00 0.00 0.00 #DIV/01 7e Legacies 8 Bequests 0.00 0.00 21000.00 #DIV/01 19 Funds from Other Sources 0.001 0.00 20a Reserve Funds Used for O eratin 0.00 #DN/0! 0.00 0.00 0.00 #DN101 lob In-Kind Donations Iroor Included In r«aQ 0.00 0.00 21 TOTAL 0.00 #DIV/01 435669300 6 347 823.00 36 700.00 99.42% EXPENDITURES 22 Salaries 172218700 21969,861 .00 172 320.00 -94.20°/a 23 FICA 125120.00 194 046.00 0.00 -100.00% 2a Retirement 0.00 0,00 ' 0.00 #DIV/0! 25 Life/Health 0.00 0.00 0.00 #DIWOI 26 Workers Compensation 0.00 0.00 0.00 #DIV/0! 27 Florida Unemplovment 0.00 0.00www� 0.00 #D!V/0! 26 Travel Dail 0.00 0.00 0.00 #DN/01 29 Travel/Conferences/Trainin 0.00 0.00 10.00 #DIV/0! 30 Office Supplies 1596000 19 739.00 2 300.00 88.35% 3t Telephone 0.00 0.00 32 Posta e/Shi in0.00 #DIV10! 0.00 0.00 0.00 #DIV/01 33 Utilities 33 738.00 71 933.00 34 Occupancy (Building8 GroundsMwMM 0.00 -100.00% 128 325.00 220 596.00 0.00 -100.00% 35 Printing 8 Publications 977.00 403.00 36 Subscri tion/Dues/Membershi s 180.00 65.33 /° 0.00 0.00 0.00 #DIV/0! 37 Insurance 231000 3,960.00 38 E ui ment: Rental 8 Maintenance 0.00 -100.00% 5 413.00 23 587.00 3 000.00 -87.28039 Advertising 40 Equipment Purchases :Ca ital Expense 0.00 #DMO! 11 492.00 3 694.00 0.00 -100.00% 41 Professional Fees (Legal, Consulting) 0.00 0.00 42 Books/Educational Materials 0.00 #DIV/0! 200.00 #DIWOI 43 Food 8 Nutrition 20j097.00 38,039.00M 050.00 57,44•/, 44 Administrative Costs 721800 129958,00 45 Audit Exp= 0.00 -100.00% 46 Specific Assistance to Individuals 0.00 #DIV/0! 47 Other/Miscellaneous 0.00 #DIV/0! _61054.00 28 652.00 0.00 -100.00% 49 Other/Contract 144 490.00 152 400.00 0.00 -100.00% 49 TOTAL 2 223 371 .00 3 739 8,001 179,050.00 -95.21 5077 OVER/ UNDER EXPENDITURES 2133 322.002,607,965.00 -142,350.00 -105.46% 19 TM Cwter �rc En1Mlnal aM Bet�trrd 1kaIIIW'an% Mer»Ixp llwe{w j, -u Or Camp UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME: The Center for Emotional and Behavioral Health - Carnp Manatee Thera eutic Summer Cam FY 01102 FY 02/03 FY 03/04 % INCREASE FYE0913012002 FYE0913012003 FYE0913012004 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (col. Ccol. BNcol. B REVENUES BUDGETED BUDGETED 1 Children's Services CouncilSt. Lucie 0.00 0.00 0.00 #DIV/O! 2 Children's Services Council-Martin 0.00 0.00 0.00 #DIV/O! 3 Children's Services Council-0keechobee 0.00 0.00 0.00 #DIV/O! 4 Advisory Committee-Indian River 20 000.00 2460000 24 600.00 0.00% 5 United Way-St Lucie County 0.00 0.00 0.00 #DIV/01 6 United Way-Martin County 0.00 0.00 0.00 #DIV/O! 7 United Way-Okeechobee County 0.00 0.00 i 0.00 #DIV/01 a United Way-Indian River County 0.00 0.00 0.00 #DN/0! 9 Department of Children & Families 0.00 0.00 0.00 #DIV/01 10 County Funds 0.00 0.00 0.00 #DIV/Ol tf Contributions-Cash 200.00 200.00 200.00 0.00% 12 Pro ram Fees 10161 .00 51600.00 51600.00 0.00% 13 Fund Raising Events -Net 0.00 0.00 0.00 #DIV/0! 14 Sales to Public-Net 0.00 0.00 0.00 #DIV/0! 15 Membership Dues 0.00 0.00 0.00 #DIV/0! is Investment Income 0.00 0.00 0.00 #DIV/0! 17 Miscellaneous 0.00 0.00 0.00 #DIV/O! 1e Legacies & Bequests 600.00 21000.00 0.00 -100.00% 19 Funds from Other Sources 0.00 0.00 0.00 #DIV/0! 20a Reserve Funds Used for Operating 0.00 0.00 0.00 #DIV/0! 20b In-Kind Donations (Not lncWdedintotal) 0.00 0.00 0.00 #DIV/O! 21 TOTAL 30 951 .00 32 300.00 30 300.00 -6.19% EXPENDITURES 22 Salaries 24 929.99 24,929.99 30 320.00 21 .62% 23 FICA 0.00 0.00 0.00 #DIV/0! 24 Retirement 0.00 0.00 0.00 #DIV/OI 25 Life/Health 0.00 0.00 0.00 #DIV/O! 26 Workers Compensation 0.00 0.00 0.00 #DIV/Ol 27 Florida Unem to ment 0.00 0.00 0.00 #DIV/0! 2e TravelwDaily 0.00 0.00 0.00 #DIV/0! 29 Travel/Conferences/Training 11000.00 1 POOO.00 0.00 0100.00% 30 Office Supplies 200.00 200.00 225.00 12.60% 31 Telephone 100.00 100.00 100.00 0.00% 32 Postage/Shipping 250.00 250.00 250.00 0.00% 33 Utilities 0.00 0.00 0.00 #DIV/O! 34 Occupancy ( Building & Grounds 0.00 0.00 0.00 #DIV/O! 35 Printing & Publications 180.00 180.00 180.00 0.00% 36 Subscri tion/Dues/Membershi s 0.00 0.00 0.00 #DIV/01 37 Insurance 0.00 0.00 0.00 #DIV/0! 3s E ui ment:Rental & Maintenance 31000.00 300000 31000.00 0.00% 39 Advertisina 50.00 50.00 50.00 0.00% 40 Equipment Purchases:Ca ital Expense 0.00 0.00 0.00 #DIV/01 41 Professional Fees (Legal, Consulting) 0.00 0.00 0.00 #DIV/0! 42 Books/Educational Materials 200.00 200.00 200.00 0.00% 43 Food & Nutrition 11060,00 105000 11050.00 0.00% 44 Administrative Costs 500.00 500.00 500.00 0.00% 45 Audit Ex ` ense 0.00 0.00 0.00 #DIV/O! 46 Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/01 47 Other/Miscellaneous 21418.00 2418.00 21418.00 0.00% 4e Other/Contract 320.00 320.00 320.00 0.00% 49 TOTAL 34197.99 34197.99 38 613.00 12.91 % 501 REVENUES OVER/(UNDER) EXPENDITURES -39246.991 -1 ,897.99 -8313.00 337.99% W2712MI 20 The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp FUNDERARC - CSAC A B c FY 03/04 FY 03/04 % INCREASE TOTAL FUNDER TOTAL VS . PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) EXPENDITURES 22 Salaries 30 ,250.00 24,929 . 99 0 82.41 /° 23 FICA 0.00 1 ,907. 14 #DN/0! 24 Retirement 0.00 0 .00 #DN/0t 25 Life/Health 0.00 0 .00 #DN/0! 26 Workers compensation 0 .00 0000 #DIV/0 ! 27 Florida Unem to ment 0.00 0 .00 #DIV/0 ! 28 Travel-Dail 0 .00 0. 00 #DN/01 29 Travel/Conferences/Trainin mmmw� 0.00 0 .00 #DIV/0 ! 30 Office supplies 21300.00 0.00 0 0.00 /o 31 Tele hone 0.00 0 .00 #DIV/01 32 Postage/Shipping 0 .00 0.00 #DIV/0! 33 Utilities wwmwwmw�0.00 ln � #DIV/Ot 34 Occupancy (Building & Grounds 0.00 #DN/0 ! 35 Printing & Publications 180.00 ° 0 .00 /o 36 Subscription/Dues/Memberships 0 .00 .0 #DN/Ot 37 Insurance 0.00 0.00 #DIV/01 38 Equipment: Rental & Maintenance 39000 .00 0.00 0 0.00 /o 39 Advertising0.00 0 .00 #DIV/O ! 4o Equipment Purchases : Capita I Expense 0 .00 0 .00 #DIV/01 41 Professional Fees (Legal, Consultin 0 .00 0.00 #DIV/01 42 Books/Educational Materials 200.00 00001 0 0 .00 /o 43 Food & Nutrition 15050 .00 0.00 0.00% 44 Administrative Costs 0.00 0.00 #DIV/0 ! 45 Audit Expense 0 .00 0.00 #DIV/01 46 Specific Assistance to Individuals 0.00 0 .00 #DIV/01 47 Other/Miscellaneous 0 .00 0 .00 0 .00% 48 Other/Contract320 .00 0 .00 0 .00% 4s TOTAL :::±$ 379300800 1 $26 ,837. 13 $0 .72 05/27/2003 21 The Center for Emotional and Behavioral HeallhiCamp Manal" Tberpeulk Summer Camp UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15%, OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp FUNDER: IRC - CSAS :•}:.V:}v:}•. •.:.}.}:::•:L}}:.:.L}•:::yt{{YM1:.:•:`Liv.:..M1•:•:•:•}:. : M14M1•.{..::.. .�:. }:: "}::: •:: :•::: v:}J .:.:::.v {•:•:•:•:•. . . :h :.: :. :. . ::. ::. . . . :. .L•:. . .t:•h•::r•::h:•: •:::.�1T.� :�. . . ':•}:iyi}:'•} ':•:Y}M1M1V{.}}:..:..{:}�:�::M1M1M1j{:}:{} .{•:•f':•::X:M1:. :::.}.:{M1•:•:.:}} .: . . . . . . . ... .. . .}/!�jJjyA {. .�} . � . L .. .M14M1M1Y. . . .LM1 .::::.:�•.L:•.LM1•:LV::. LLL.. ...:.TM1^JS•. �'�. .�•�.{e. ` . :} .�j'}j(y .]�].e+.. . :..:•.L:..:4}ti{{`{ ' :':•:•:•:::•:{•}:ti}:•}::' :}}}} {•.4•:::.::::{ ':•:::.:.:•:•:{•:.:ti.:•:'•:•:•:{ti:{•: L .S!. .> f.1. :•:'t:{•:{•:?::h•:::{•S:•S:titi.}:•::A{`•:Y}:{{�ii =1F Total Pro ram'IF11 >-__75° 'Total Pro ram't611 " .' M1M1 . =1F Total Pro ram'1F12>=15% 'Tota1 Pro ram'!B12 " " =1F Total Pro ram'IF13>=15% 'Total Pro ram'l813 " " =1F 'Total Pro ram'lF14>=15% 'Total Pr ram'lB14 " " =1F Total Pro ram'IF15>=15% 'Total Pro ram'!B15 " " =IF 'Total Pr ramV16>=15% 'Total Pro ram'!B16 " " =1F Total Pro ram'1F17>=15% 'Total Pro ram'!817 " " =IF 'Total Pro ram'1F18>=16% 'Tota1 Pro ram'!M,": " =1F Total Pro ram'1F19>=16% 'Total Pro ram'IB19 =IF 'Total Pro ram'!F20>=16% 'Total Pr ram'1B20 " " =lF 'Total Pro ram'lF21 >=16% 'Total Pr ram'IB21 =IF 'Total Pr ram'lF22>=16° 'Total Pro ram'IB22 " " =IF 'Total Pro ram'1F23>=15% 'Total Pro ram'!B23 " " =1F 'Total Pro ram'1F24>=15° 'Total Pro ram'!B24 ",3 =IF 'Total Pro ram'IF25>=16° ° 'Total Pro ram'1B25 " " =IF 'Total Pro ram'lF26>=16% 'Total Pro ram'IB26 " " =IF 'Total Pro ram'lF27>=15% 'Total Pro ram'IB27 =1F 'Total Pro ram'lF28>=16% 'Total Pro ram'IB28 =IF 'Total Pro ram'1F29>-_15° ° 'Total Pr ram'1B29 " " =IF 'Total Pro ram'!F30>=16% 'Total Pro ram'!B30 " " =1F Total Pro ram'!F31 >=16% 'Total Pro ram'IB31 =1F 'Total Pro ram'!F35>=15° a 'Total Pro ram'!835 " " We are asking for 5320. 01 less than the budgeted amount for salaries. =1F Total Pro ram'lF36>=15° 'Total Pro ram'l636 " " =IF 'Total Pro ram'1F37>=16° ° 'Total Pro ram'lB37 " " =IF 'Total Pro ram'IF38>=16% 'Tota1 Pro ram'!B38 " " =1 Total Pro ram'1F39>=15% Total Pro ram'IB39 " " =1F Total Pro ram'1F40>=15° e 'Total Pro ram'l840 " " =1F Total Pro ram'!F41 >=15% 'Total Pro ram'1B41 =IF 'Total Pro raW1F42>=15° ° 'Total Pro ram'l842 " " =IF 'Total Pro ram'IF43>=15% 'Total Pro ram'IB43 " " =1F 'Total Pro ram'IF44>=16%. Total Pro ram'1844 " " =1F 'Total Pro ram'lF45>=15° ° 'Total Pro ram'IB45 =1F 'Total Pro ram'lF46>=15% 'Total Pro ram'lB46 " " =1F Total Pro ram'lF47>=16° e Total Pro ram'lB47 " " =IF 'Total Pr ram'1F48>=15% 'Total Pro ram'IB48 " " =IF 'TotalPro ram'1F49>=15% 'TotalPro ramIuS " " =IF 'Total Pro ram'1F60>=16% 'Total Pro ram'l860 " " =1F Total Pro ram'1F51 >=16%%Total Pro ram'1851 " " =1F Total Pro ram'!F62>=15% 'Total Pro ram'1B52 " " =1F Total Pr ram'1F53>=15% 'Total Pro ram'!B53 =IF 'Total Pro ram'lF54>=16% 'Total Pro ram'lB54 " " =IF 'Total Pr ram'!F55>=16% 'Total Pro ram'1856 " " =1F 'TotalPro ram'1F66>=16° ° 'Total Pro ram'!B56 " " =IF 'Total Pro ram'lF57>=15% 'Total Program' B67." 3 =IF 'Total Pro ram'IF58>=15% 'Total Pro ram'lB68 =1F Total Pro ram'lF69>=16° o 'Total Pro ram'l669 " " =1F 'Tota1 Pro ram'!F60>=16% 'Total Pro ram'lB60 " =IF 'Total Pro ram'1F61 >=16% 'Total Pro ram'l861 " " 05272°07 22 The Carder fur Emellonel and BeheN°rei McAhCemp M°nelee TherepWk Sunnier Camp UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE FUNDER SPECIFIC BUDGET AGENCYIPROGRAM NAME: The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp FUNDER: IRC - CSAS - =IF 'Funder S ecific'IE71 >=16% 'FunderS ec!fic91B11 "I "I We are askinq for 5320. 01 less than the budgeted amount for salaries. =IF 'FunderS clfic'lE12>= M"FunderSpecificI1312=1 =1Fffunder SpecificIE113>=16° ° 'Funders eclfic'1813 "1 0 =1F 'FunderS ecific'1E110=16% 'FunderS ec!flc'1614 =IF Funders cific'IE16>-_16°/, 'Funders cific'!B15 =1F Funder Spec Ific'1E76>=15° 'Funders ecir!01616 " " =1F 'FunderS ecific'IE17>=16% 'FunderS ecific'111317 " " =1F FunderS ecific'IE18>=15% 'FunderS ecific'IB78 "1 ff =1F 'FunderS eclfic'1E19>=16° ° 0FunderS ecific'lB19 " " =1F Funder SPecMelE20>=16% 'FunderS Wiic'!820 " " =IF 'FunderS ecific'IE21 >=16% 'FunderS lfic'11321 " " =1F FunderS c!fic'IE22>=16% 8FunderS ecific1822 " " =1F 'FunderS c!fic'1E23>=16% 'FunderS i iic'!823 " " =1F Funder SpeclficwlE24>=15% 7underS ecific'1624 " " =1F 'FunderS cffic'1E25>=16° 'FunderS Specific , " =1F 'FunderS ecific'!E26>=15° 'FunderS ec!fic'IB26 " " =IF 'FunderS ec!fic'1E27>=16° ° 'FunderS cific'IB27 " " =1F 'FunderS ec1fic11E28>=16° ° 'FunderS ecific'!B28 " " =1F FunderS ecWW!E29>=16% 'FunderS eclMOB29 " " =1Fffunder SPeclflc4lE30>=15% 'FunderS ecific41830 " " =1F Funder S ific'1E31 >=16% 'FunderS lfic'1831 " " =1F FunderS eclfic'lE32>=15% 'FunderS ecific'!832 " " =1F 'Funder 5 Ific'1E33>=16% 'FunderS ecific'!B33 =1F 'FunderS clfic'!E30=16% 'FunderS ecific'1634 " " =1F Funders eclflc5IE35>=16° n7under5 c!fic'!B35 ' " =1F 'fun derS eclfic'1E36>=15% 9FunderS ecific'l636 =IF 'FunderS cMc'lE37>=15% 'FunderS !fic'1B37 OWM2003 23 NOT FOR PROFIT AGENCY CERTIFICATION The County of Indian River requires , as a matter of policy, that any Consultant or firm receiving a contract or award resulting from the Request for Qualifications issued by the County of Indian River, Florida , shall make certification as below. Receipt of such certification , under oath , shall be a prerequisite to the award of contract and payment thereof. I (we) hereby certify that if the contract is awarded to me , our firm , partnership, or corporation , that no members of the elected governing body of Indian River County, nor any professional management , administrative official or employee of the County , nor members of his or her immediate family, including spouse , parents, or children , nor any person representing or purporting to represent any member or members of the elected governing body or other official , has solicited , has received or has been promised , directly or indirectly, any financial benefit , including but not limited to a fee , commission , finder's fee , political contribution , goods or services in return for favorable review of any Proposal submitted in response to the Request for Qualifications or in return for execution of a contract for performance or provision of services for which Proposals are herein sought . The undersigned certifies that he/she is a principal or officer of the firm applying for consideration and is authorized to make the above acknowledgments and certifications for and on behalf of the applicant. The undersigned certifies that the Applicant has not been convicted of a public entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida Statutes . Failure to skin this form will result in disvualirication. Handwritten Signature utho 'zed Principal (s : DATE : NAME : ` TITLE : 2 1 P�l � ChUU� �CC Y'� CK-C 4e NAME OF FIRM/PARTNERSHIP/CORPORATION : Tht Cin JE) c � PJW- mtXnye iui II�x �� tt FOR AND ON BEHALF OF THE APPLICANT : Sworn to and subscribed to me , a Notary Public, this ,,r a � day of Y1'1 12003 . BY: �Ci fel' ( L - SUS i �rrs � �J�► + coo (SEAL) (TYPE NAME & TITLE) f USA LICITRA Notary Public - State of Florida My Commission Expires Apr 12, 2004 Commission # CC927373 X Indian River Board of County Commissioners 184025 th Street Vero Beach , FL 32960 AUTHORIZATION FOR RELEASE OF INFORMATION Indian River County and 1 (diun ? tyCrAenW, "41 /6s0 . � el;�A (Agency/ Individual are in the process of negotiation of a contract for I a6.�� ff Indian River County is authorized to make an investigation of the Agency/Individual regarding its experience and qualifications. The Agency/Individual authorized the release of all relevant information concerning prior services furnished , contracts and background information of the Agency/Individual . The Agency/ Individual authorizes any individual or organization that is in possession of relevant factual contract and background information , to release such data to Indian River County in response of the County' s request . When an individual employee of the Agency signs Authorization for Release of Information , such individual authorizes the County to obtain relevant background information concerning such employee ' s criminal record , if any , and such other information that may be relevant to employee ' s good character and work experience. Authorization is given here by the Agency/Individual and such employees who execute this authorization with the understanding and limitation that Indian River County will utilize the information obtained for the purposes set forth herein and that such information shall not be disclosed to third parties except as provided by law. Name Agency/ Individual jhe, CenW :CL( mohloa l sehayiivctl dedflA @ z em Print name Name Employee Providing authorization J� Sus i !7 Print n �' Signature ( in blue ink) s Date 5 � oA 7 - o3 XI SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF RELATIONSHIPS THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS . 1 . This sworn statement is submitted with RFP No . 4046 for Ncje--p lid v►soeA Coi lmiLet Funds of 2 . This sworn statemen Js submitted by: ( Name of entity submitting Statement ) whose business address is : 100O 3Co44 5-)I-rCef , VerV &a�ah , FZ 3-2 Zq& O and ( if applicable) its Federal Employer Ide tification Number ( FEIN ) is Ga � ( If the entity has no FEIN , include the Social Security Number of the individual signing this sworn statement tj liq ) 3 . My name is .,, - f f i �i6si ( Please print name of individual signing ) and my relationship to the entity named above is 4 . 1 understand that an " affiliate" as defined in Section 105 . 08 , Indian River County Code , means : The term " affiliate" includes those officers , directors , executives, partners , shareholders , employees , members , and agents who are active in the management of the entity . XII 5 . 1 understand that the relationship with a County Commissioner or County employee that must be disclosed as follows : Father, mother, son , daughter, brother, sister, uncle , aunt , first cousin , nephew, niece , husband , wife , father-in-law, mother-in-law, daughter- in -law, son-in-law, brother-in-law, sister-in - law, stepfather, stepmother, stepson , stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent , or grandchild . 6 . Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement . [ Please indicate which statement applies . ] Neither the entity submitting this sworn statement , nor any officers , directors , executives , partners , shareholders , employees , members , or agents who are active in management of the entity , have any relationships as defined in section 105 . 08 , Indian River County Code , with any County Commissioner or County employee . The entity submitting this sworn statement , or one or more of the officers , directors , executives , partners , shareholders , employees , members , or agents , who are active in management of the entity have the following relationships with a County Commissioner or County employee : Name of Affiliate Name of Countv Commissioner Relationship or entity or employee XIII si ure ) a00 7 ( date ) STATE OF Ffykrd2 COUNTY OF The foregoing instrument was acknowledged before me this a 7 day of 20 03 , by Te fru, G . Sc/ s i jWFo me or who has produced as identification . NOTARY SIGN : PRINT : State of Florida at Large My Commission Expires : is ;1 od ( Seal ) USA UCITRA Notary Pubrrc - State of Rondo My Commission EVkm Apr I 2o04 Commission # CC927373 XIV SUPPORTING DOCUMENTS CHECKLIST RFP 5054 Cover Page Application List of current officers and directors Latest Financial Audit Report & Management Letter that conforms with the AICPA Audit Guide Most recent IRS Form 990, including all schedules �( Most recent Internal Financial Statement (i . e . : Balance Sheet and Operating Budget Staff Organizational Chart NO Most Recent Annual Report (if available) 501 (C)(3 ) IRS Exemption Letter Articles of Incorporation _Agency ' s Bylaws Y4% _ Agency ' s written policy regarding Affirmative Action Proof of Goals and Outcomes Workshop Attendance XV Out Page 1 of 1 To : <mmasterson@ircgov . com> Subject : Re : GOALS WORKSHOP May 19 14 MANDATORY Cc : Dear Marion, I HAVE NOT ATTENDED A GOALS WORKSHOP AND WILL BE ATTENDING. THERE WILL BE 1 PERSON ATTENDING FOR Camp Manatee @ The Center for Emotional & Behavioral health (agency) ON MAY 19TH. Thanks very much ! Michelle Printed for Michelle Bollinger <michelle@irmh . com> 05/27/2003 Board of Trustees IRMH CEO Jeff Susi COO CNO Carl Barbara Martin Horne Ex. Dir.CEBH Dr. Raymond Dean Dir. Patient Other Medical Admin . Dir. Care attending Directors Dale Mariamma Psychiatrists Doctors Grinstead Pyngolil manager Nurse Assessment Man . Out Man . Act. Manager Patient Therapy Inpatient Pat & Referrak Dr. Richard Michelle Therapist, Bobbins Sarah Greene Bollinger Case Man . , McGann Clinical Care Coord. Psychology Psychology A & R Fellow Resident Out Patient Dr. Joseph Dr. Andrew Clinicians Therapists Cheries Dobo Volunteers Camp Activity Charge Counselors Therapists Nurses UUS Secretary Patient House Celia Teacher Billing Keeping Stacie Front Desk Griffiths LPN RNs Techs Whitney Roche Clemons With amendments incorporated last amendment filed with Secretary of State on 8 /2 /00 BOD consented : 5 /23 /00 as to Art . VIII ( 8 . 1 ) ARTICLES OF INCORPORATION OF INDIAN RIVER MEMORIAL HOSPITAL INC . A Florida Not-For-Profit Corporation WE, THE UNDERSIGNED, hereby associate ourselves together for the purpose of forming a not-for-profit corporation under the laws of the State of Florida, pursuant to Chapter 617 , Florida statutes , and hereby certify as follows : ARTICLE I Name The name of the Corporation shall be : INDIAN RIVER MEMORIAL HOSPITAL, INC . ARTICLE II Purpose The purposes for which the Corporation is organized are exclusively charitable and educational within the meaning of Section 501 (c)(3) of the Internal Revenue Code of 1954 or the corresponding provision of any future United States Internal Revenue Law. Its activities shall be conducted in such a manner that no part of its net earnings shall inure to the benefit of any member, director, trustee, officer or individual. It shall not have the power to issue certificates of stock or declare dividends . Notwithstanding any provision of these Articles , the Corporation shall not carry on any other activities not permitted to be carried on by a corporation exempt from Federal income tax under Section 501 (c)(3) , or by a corporation qualified as a public charity under Section 509(a) , of the Internal Revenue - Code of 1954 (or the corresponding provision of any future United States Internal Revenue Law) . Without in any way limiting the foregoing general purpose , the specific purpose of the Corporation shall be to establish, maintain or operate a Hospital , other health care facilities , and/or home care provider(s) , with permanent facilities for diagnosis and treatment of both in- patients and out-patients and to provide such medical services ; to conduct educational activities related to care of the sick and injured or to the promotion of health; to develop efficient and practical arrangements for the provision of extended care and other categories of long-term services through an effective transfer agreement; to utilize home care services whenever feasible ; to foster the teaching function of the Hospital in cooperation with other health care and educational institutions and thereby assist the community served by the Hospital in meeting its responsibility ; to provide orientation and in-service training programs so that Hospital personnel maintain their skills and learn of new developments in the health field and for any and all other lawful purpose or purposes for which a non-profit Corporation may be organized ; provided , however, that the Corporation shall not engage in activities that are not in furtherance of its charitable and educational purposes other than as an insubstantial part of its activities . In the event of dissolution of the Corporation or the winding up of its affairs , or other liquidation of its assets , the Corporation' s property shall be conveyed or distributed to the Indian River County Hospital District, a special tax district incorporated by act of the Florida Legislature pursuant to Chapter 61-2275 , Laws of Florida, Special Acts of 1961 , as amended , and an exempt organization under Section 501 (c)(3) of the Code . In the event that the Indian River County Hospital District does not qualify , or is not then in existence , or to the extent that it may be prohibited by State law from owning certain assets of the Corporation, the Corporation ' s property shall be conveyed or distributed to the County of Indian River, a political subdivision of the State of Florida . No substantial part of the activities of the Corporation shall consist of carrying on propaganda, or otherwise attempting to influence legislation, and the Corporation shall not participate in or intervene in (including the publishing or distributing of statements) any political campaign on behalf of any candidate for public office . ARTICLE III Powers The Corporation shall possess and may exercise all the powers and privileges granted by Chapters 607 and 617 of the Florida Statutes , or by any other law of Florida, together with all powers necessary or convenient to the conduct, promotion or attainment of the activities or purposes of the Corporation, limited only by the restrictions set forth in these Articles of Incorporation. Such powers shall include, but not be limited to , the power to sue and be sued , to contract and be contracted with, and to acquire, purchase, hold, lease, sell , mortgage and convey such real and personal property as the Board may deem proper or expedient to carry out the purposes of the Corporation; provided , however, that the Corporation shall not engage in activities that are not in furtherance of its charitable purposes other than as an insubstantial part of its activities . 2 ARTICLE IV Membership The Corporation shall be organized as a nonstock, membership corporation. Those individuals who are the duly elected or designated Directors of the Corporation shall be the members of the Corporation. ARTICLE V Term The term of the Corporation shall be perpetual . ARTICLE VI Incorporators The names and addresses of the subscribers to these Articles of Incorporation and Incorporators of the Corporation are as follows : NAME ADDRESS Don Ames , M . D . 777 37th Street Vero Beach, FL 32960 Mr. J . B . Egan, III 4631 9th Place Vero Beach, FL 32960 Mr. Alan C . Guy 1000 36th Street Vero Beach, FL 32960 Mr . Ronald Hudson 3855 47th Street Vero Beach, FL 32960 Mr . John K . Moore Post Office Box 3308 Vero Beach, FL 32964-3308 3 Ms . Garnett Radin 2145 17th Avenue Vero Beach, FL 32960 Mr . Danforth K. Richardson Post Office Box 370 Vero Beach, FL 32961 Broadus Sowell , M . D . 2300 5th Avenue Vero Beach, FL 32960 Mr . Jim Thompson 3360 Buckinghammock Trail Vero Beach, FL 32960 Mr, William G. Whyte 491 Sea Oak Drive John ' s Island Vero Beach , FL 32963 Mr , Charles C . Wurmstedt 450 Beach Road , Apartment 320 John' s Island Vero Beach, FL 32960 ARTICLE VII Directors 7 . 1 Number. The affairs of the Corporation are to be managed by a Board of Directors consisting of sixteen (16) members . 7 . 2 Composition. The Board of Directors of the Corporation shall consist of twelve (12) Independent Directors , which term shall be defined in the Bylaws , the President of the Corporation, the Chief of the Medical Staff of the Corporation, and the Vice Chief of the Medical Staff of the Corporation, each serving ex officio , and the elected representative of the Medical Staff of the Corporation. Nine (9) Independent Directors shall be elected by the Board of Directors and three (3) Independent Directors shall be designated by the Board of Trustees of the Indian River County Hospital District, in the manner set forth in the Bylaws . The elected representative of the Medical Staff of the Corporation shall be elected by the Medical Staff of the Corporation in the manner set forth in the Bylaws . 7 . 3 Powers . The Board of Directors shall act for the Corporation and shall have the power to decide all matters relating to the conduct of business for the Corporation. 4 f ARTICLE VIII Officers 8 . 1 Number. The Officers of the Corporation shall be a Chairman, one or more Vice Chairmen, a President, one or more Vice Presidents , a Treasurer, a Secretary , and such additional officers , including one or more Assistant Treasurers and Assistant Secretaries , as the Board of Directors shall designate from time to time . No person shall hold concurrently more than one office , 8 . 2 Powers and Duties . The powers and duties of the Officers of the Corporation shall be those usually pertaining to their respective offices , or as may be specifically directed in these Articles of Incorporation or the Bylaws of the Corporation. ARTICLE IX Bylaws The Bylaws of the Corporation shall initially be made and adopted by its first Board of Directors . The Bylaws may thereafter be altered, amended, or repealed , and new and other Bylaws may be made and adopted by the Board of Directors as provided and subject to such restrictions as may be set forth in the Bylaws . ARTICLE X Amendments Amendments to these Articles of Incorporation may be made and adopted only by the vote of at least three quarters (3/4) of the voting members of the Board of Directors of the Corporation and with the approval of the Board of Trustees of the Indian River County Hospital District. Amendments shall be effective when a copy thereof, properly executed and acknowledged , has been filed with the Department of State and all filing fees paid . 5 s ARTICLE XI Registered Agent and Registered Office The address of the initial registered office of the Corporation is 1000 36th Street, Vero Beach, Florida 32960 . The registered agent at that address is Mr . Alan C . Guy , ARTICLE XII Principal Office of the Corporation The street and mailing address of the principal office of the Corporation is 1000 36' Street, Vero Beach, Florida 32960 , N:1Clients HMMCORPORATE INFOURTICLES of incorporation through June 2000.doc Last printed 8/ 15/00 2:08 PM 6 POLICY NO . 13 - 121 Anti -Harassment Page 1 of 3 POLICY : ANTI -HARASSMENT INITIAL, EFFECTIVE DATE : 1 / 1 /01 REVISION DATE : POLICY NO . 13 - 121 President/CEO Date ( 77tis policy rescinds any previous publication covering the same material) A . Policy The policy of Indian River Memorial Hospital is that all employees shall have the opportunity to work in an atmosphere and environment free from any form of harassment or retaliation based on race, color, religion, gender, sex, national origin, age, handicap , disability , marital status, or any other characteristic protected by law . Such forms of harassment or retaliation constitute discrimination under various state and federal laws and will not be tolerated by the Hospital . Indian River Memorial Hospital is further committed to continuing the practical application of this nondiscriminatory policy in its daily conduct of business affairs . B . Purpose The purpose is to comply with governmental guidelines on harassment, and to maintain a non-discriminatory environment . C . Definitions Harassment is defined as verbal or physical conduct that denigrates or shows hostility or aversion toward an individual because of his or her race, color, religion, gender, sex, national origin, age, handicap, disability , marital status, or other protected characteristic that of his/her relatives, friends, or associates , and that : 1 . Has the purpose or effect or creating an intimidating, hostile, or offensive working environment ; or 2. Has the purpose or effect of unreasonably interfering with an individual 's work performance; or 3 . Otherwise adversely affects an individual's employment opportunities. D . Amplification Harassment has no place in the work environment and will not be tolerated by the Hospital . Because of the Hospital ' s strong disapproval of offensive or inappropriate behavior at work, all employees must avoid any action or conduct which could be viewed as harassment including but not limited to : 1 . Epithets, slurs, negative stereotyping, or threatening, intimidating , or hostile acts, verbal graphic, or physical conduct relating to an individual' s race, color, religion, gender, sex, national origin, age, handicap, disability , marital status or other protected characteristic . 2 . Creating a hostile or offensive working environment . Written or graphic material that denigrates or shows hostility or aversion toward an individual or group because of race, color, religion, gender, sex, national origin, age, handicap, disability , marital status or other protected characteristic and that is placed on walls, bulletin boards , or elsewhere on Hospital premises, or circulated in the workplace . 3 . Harassment also includes unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature . The following are examples of sexual harassment : a. Verbal -- sexual innuendo, suggestive comments, insults, threats , stories or jokes about gender-specific traits, sexual propositions , http : //web/search?NS -search-page=document&NS -rel -doc -name=/manuals/personnel/ 13 _ 1 05 / 15 /2003 POLICY NO . 13 - 121 Anti -Harassment Page 2 of 3 b . Nonverbal --making suggestive or insulting noises, leering, whistling, or making obscene gestures; c. Physical -unnecessary touching, pinching, brushing the body , coercing sexual intercourse, or assault . Similarly , sexual harassment involves : 1 . Making, as a condition of employment , unwelcome sexual advances or requests, requests for sexual favors , or other verbal or physical conduct of a sexual nature ; 2. Making submission to or rejection of such conduct the basis for employment decisions ; or 3 . Creating an intimidating, offensive, or hostile work environment by such conduct . No manager or other person shall threaten or insinuate, either explicitly or implicitly , that an employee' s refusal to submit to sexual advances will adversely affect the employee's employment, evaluation, wages, advancement, assigned duties , shifts, or any other condition of employment or career development . E . Responsibilities Any employee who feels that he or she has suffered any form of harassment or retaliation by anyone, including a supervisor, coworker, or visitor must immediately report the alleged conduct to the Director of Human Resources in the Human Resources Department so that a confidential investigation of the complaint can be undertaken. This report may be verbal or written . The preferred approach is a written complaint . (See attached form . ) Alternatively , the employee should report the alleged conduct to the Department Director or any member of the Executive Management Team . Further, any employee who observes conduct by another employee which he or she believes to be harassing, retaliatory , or discriminatory must report such conduct as outlined above. There will be no retaliation against anyone who in good faith submits a complaint or who participated in an investigation of a complaint of harassment . 1 . All management personnel have the responsibility to use nondiscriminatory techniques and methods to ensure that the merits of the individual are the sole criteria for the evaluation of eligibility for employment and advancement . 2. Department Directors and Supervisors are responsible for reporting any known violations of this policy to the Director of Human Resources or any member of the Executive Management Team . 3 . The Director of Human Resources shall be responsible for the immediate investigation of any and all allegations of harassment, shall keep the reporting employee fully informed as to the progress of the investigation ; and shall detennine the appropriate remedy for the given circumstance, including disciplinary measures up to and including discharge when justified, to remedy all violations of this policy . Bob Zomok, Director, Human Resources, 12/31/01 Reiewed without Change/Date HARASSMENT COMPLAINT FORM Indian River Memorial Hospital prohibits harassment of our employees on the basis of race, color, sex, religion, national origin, age, handicap , disability, marital status , and all other forms of harassment. As part of our policy, we are committed to investigating claims of such harassment and taking disciplinary or other appropriate action to stop the harassment when the facts show that harassment has occurred. In order that we may conduct an appropriate and confidential investigation of your concerns , please complete the form below. http : //web/search?N S -search -page=document&NS -rel -doe-name=/manual s/personnel/ 13 _ 1 05 / 15 /2003 POLICY NO . 13 - 121 Anti -Harassment Page 3 of 3 Name : Date : I wish to complain about the following events . (Use additional sheets of paper as required) What action or actions do ,you wish the Hospital to take regarding your complaint ? I, (name), hereby consent to the Hospital 's conducting a complete and thorough investigation of the above complaint. I further authorize the Hospital to disclose to others portions of the information I have provided and may in the future provide, with respect to the complaint, as certain information may have to be released in order to insure that a complete investigation can be conducted. I acknowledge that I have read and understand the above statements. Employee Signature Date http : //web/search?NS -search -page=document&N S -rel -doc -name=/manual s/personnel/ 13 _ 1 05/ 15/2003 POLICY NO . 13 - 104 . 9 - Equal Employment Opportunity Page 1 of 2 POLICY : EQUAL EMPLOYMENT OPPORTUNITY INITIAL EFFECTIVE DATE : 1 / 10/80 REVISION DATE : I / 1 /01 POLICY NO . 13 - 104 . 9 President/CEO Date (This policy rescinds any previous publication covering the same material) A. Policy Indian River Memorial Hospital provides equal employment opportunities for all individuals . It is the policy of the Hospital to seek the best qualified applicants for employment and to make employment decisions without regard to race, color, handicap, disability , sex, religion, age, creed, national origin, marital status, disability , veteran status, citizenship, or any other characteristic or trait prohibited by law. Employment decisions include, but are not limited to those involving recruitment , referrals, hiring, placement, promotions and discharge, as well as pay , fringe benefits, job training, and all other conditions of employment . B . Purpose To ensure that all applicants and employees are treated fairly and in a nondiscriminatory manner and to ensure compliance with applicable local , state, and federal laws and regulations. C . Amplification 1 . The Human Resources Department shall investigate alleged violations of this policy . 2 . The Grievance Procedure (Policy 13 -400) is to be used by an employee alleging discrimination under this policy . It is very important that an employee alleging discrimination report any such instances to Indian River Memorial Hospital pursuant to the Grievance Procedure immediately . This will ensure that a complete investigation and appropriate corrective action is taken. 3 . Each employee is responsible for being aware of and conforming to applicable laws and regulations regarding equal employment opportunities. 4 . The Director of Human Resources is responsible for providing employees with up to date information relative to this policy . This includes posting Employment Discrimination posters in prominent areas in the workplace and including statements on Equal Employment Opportunity in all recruitment and application materials. 5 . All management personnel have the responsibility to use nondiscriminatory techniques and methods to ensure that the merits of the individual are the sole criteria for the evaluation of eligibility for employment and advancement . The Human Resources Department will monitor these activities . 6 . The Human Resources Department will ensure that adequate copies of this policy and the required equal employment opportunity posters are displayed throughout the hospital . 7 . Employees are not to show prejudice or discrimination in matters concerning patients, visitors , or fellow employees , under any circumstances. Employees who witness or are subject to harassment, discrimination, or other offensive behavior must immediately report the alleged conduct to his/her Department director or any member of the Executive Management Team , either orally or in writing , as outlined in the Hospital 's Anti -Harassment Policy (13 - 121 ) . 8 . Management personnel who receive a report of complaint of harassment, discrimination, or other offensive behavior, or who witness such behavior must report the complaint or conduct to the Director, Human Resources immediately . http : //web/search?NS -search -page=document&NS -rel -doc-name=/manuals/personnel/ l 3 _ 1 05/ 15 /2003 POLICY NO . 13 - 104 . 9 - Equal Employment Opportunity Page 2 of 2 9 . Failure to comply with this policy will result in corrective action, up to and including discharge . 10 . IRMH reasonably accommodates employees with bona fide handicaps, disabilities, and religious beliefs . Bob Zomok, Director, Human Resources 2/3/03 Reviewed with Change Bob Zomok, Director, Human Resources 4/1 /02 Reviewed with Change http : //web/search ?NS -search -page=docum ent&NS -rel -doc -name=/manual s/personnel / 13 _ 1 05/ 15/2003 INDIAN RIVER MEMORIAL HOSPITAL, INC BOARD OF DIRECTORS IRMH--� PRESIDENT & CEO 1RMH FOUNDATION JEFFERY L SUSI JOINT CONFERENCE AUXILIARY VICE PRESIDENT FOUNDATION "'-- '—"'—'—"""""""" MEDICAL STAFF JAN DONLAN Foundation Director Marksting/Public Relations r SENIOR VICE PRESIDENT & SENIOR VICE PRESIDENT CHIEF FINANCIAL OFFICER CHIEF OPERATING OFFICER" GREG GARDNER W. CARL MARTIN Director of Financial Reporting Director Imaging Sciences . Pa Director DiagnostleMmbulatory Svcs i Payroll .Laboratory Manager .General Accounting VICE PRESIDENT $ Manager Rehab Services Director Human Resources VICE PRESIDENT VICE PRESIDENT Director Materials Management CHIEF NURSING OFFICER Manager Cancer Center BOB ZOMOK MEDICAL MANAGEMENT MEDICAL DEVELOPMENT .Purchasing BARB HORNE .Manager Cardio Pulmonary/Cath Lab I DUDLEY TEEL, MD JAMES LARGE, MD .Mail Center Executive Director ofCEBH- Manager Education .DMS Manager — Director PCS/Med/Surg Director CEBH Administration Medical Directors L Director, Medical Staff Servi Director Patient Accounting NAS Director of Facilities Services Manager, Case Management .Manager Patient Financial Services NM Surgical Manager Environmental Services Partners Program Director Management Reporting NM Medical Manager Facilities Director QMIRIskiCornpliance .Reimbursemeni/Managed Care Diabetes Director Pharmacy Corporate Compliance . Decision Support Intems Operational Manager Pharmacy Risk Management .TCU Director Food ServicelNutrition Regulatory Compliance DirectorPCS/CFAM Executive Chef/Operations Manager Manager Medical ReCanis/HIPAA Director PCS/ Surgical Services Crinical Nutritian Manager Quality Management .Operations Manager Surgery Director Volunteer Services .PACU Director MIS .Ambulatory Surgery Center Telecommunications Director PCS1 ED & Critical Care .ICLMalysis .Nurse Managerl mer e n r _� .Nurse Maneger/Emergency " Denotes responsible officer in .Nurse ManagerMomen's Health y L. I, PresitlentF EO absence of President/CEO 2t7I 20 Consumer' s Certificate of Exemption DR - 1 FE R. 10/9 Issued Pursuant to Chapter 212, Florida Statutes (>FREVTEENNUE 41 - 05 - 012521 - 56C 09 / 12 / 00 09 / 12 / 65 Cfl01-1i� =-j gZl I:iflN Certificate Number Effective Date ' Expiration Date V.. This certifies that u _ ..vr yf3 ' J � • 4� �Y.-ML� � " • - INDIAN RIVER MEMORIAL HOSPITAL INC IF; 1000 36TH ST ' t'` r , - ` = , , . � VERO BEACH FL 32960 - 4862 i`• zs% -}'.a� _ is exempt from the payment of Florida sales and use tax on real property rented, transient teRtal -:tangible personal property purchased or rented, or services purchased. r = =_ =_ ==` 1 Im ortant Information for Exem t Or anizations DR-1a p p g Re 10/99 DEPARTMENT OF REVENUE 1 . You must provide all vendors and suppliers with an exemption certificate before making tax-exempt purchases . See Rule 12A- 1 .039 , Florida Administrative Code (FAC) , or request Form DR-97 , Suggested Format for Blanket Certificate of Exemption. 2 , Your Consumer's Certificate of Exemption is to be used solely by your organization for your organization's customary nonprofit activities. 3 . Your organization's purchases will only be exempt when a signed exemption certificate is presented to the seller and payment is made directly by your organization . 4 . Purchases made by an individual on behalf of the organization are taxable , even if the individual will be . reimbursed by the organization . 5 . This exemption applies only to purchases your organization makes . The sale or lease to others by your organization of tangible personal property, sleeping accommodations or other real property is taxable . Your organization must register, and collect and remit sales and use tax on such taxable transactions . Note : Churches are exempt from this requirement except when they are the lessor of real property ( Rule 12A-1 .070, FAC) . 6. It is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no circumstances should this certificate be used for the personal benefit of any individual . Violators will be liable for payment of the sales tax plus a penalty of 200% of the tax, and may be subject to conviction of a third degree felony: Any violation will necessitate the revocation of this certificate. . . t 7 . If you hA* questions regarding your exemption certificate , please contact the Exemption Unit of Central Registration , at 850-487-4130 . The mailing address is 5050 West Tennessee Street , Tallahassee , FL 32399-0100 . Xlve� _ - Section 4. 2 -3h Approved by the Board of Directors on August 22, 2001 mid the Board of Trustees on September 18, 2001 Section 6. 1 Approved by the Board of Directom on September 26, 2001 Section 4. 2-3, 4. 3, 5. 3, 6. 1 -4a and 6. 1 -6a Approved by the Board of Directors on April 3 , 2002 Section 4. 2 -3 Approved by the Board of Trustees on April 18, 2002 Section 5 . 1 , 5 . 2, 5 .3, 5 . 5 & 5. 6 Approved by the Board of Directors on December 12, 2002 BYLAWS OF INDIAN RIVER MEMORIAL HOSPITAL , INC . A Florida Nonprofit Corporation ARTICLE I DEFINITIONS AND POWERS Section 1 . 1 DEFINITIONS . The terms set forth below shall have the following meanings unless otherwise required by the context in which they may be used : Articles of Incorporation . The term " Articles of Incorporation " shall mean the Articles of Incorporation of the Corporation filed with the Secretary of the State of Florida on the 10th day of December , 1984 , and any amendments thereto . Board . The term " Board " shall mean the Board of Directors of the Corporation. Board Committee . The term " Board Committee " shall mean a body which may be authorized to exercise a designated portion of the authority of the Board when the Board is not in session . Bylaws . The term " Bylaws " shall mean the Bylaws of the Corporation except where reference is specifically made to the bylaws of another entity or unit. District . The term " District " shall mean the Indian River County Hospital District . Ex Officio . The term " Ex Officio " means service as a member of a body by virtue of office or position and , unless otherwise expressly provided , includes the right to vote . Hospital . The term " Hospital " shall mean the hospital and/or any other health care facilities operated by the Corporation . Independent Director. The term " Independent Director " shall mean a Director whom the Nominating Committee or the District , as the case may be , has specifically determined , 1 before his or her nomination for election or designation to the Board , can act without being unduly influenced by a current or prior affiliation , financial or otherwise , with the Corporation , its subsidiaries , its management , or its Medical Staff. Majority . The term " Majority " shall mean fifty- one percent (51 % ) or more of the applicable total number . Medical Staff. The term " Medical Staff" shall mean the formal organization (composed of all licensed physicians , dentists , other practitioners and health care personnel who are regularly privileged to admit , attend or consult with respect to patients of the Hospital) created and operated pursuant to the provisions of Article VII of these Bylaws . Medical Staff Bvlaws . The term " Medical Staff Bylaws " shall mean the bylaws , rules , regulations and procedures collectively setting forth the purposes , functions , organization and operation of the Medical Staff. Member . The term " Member " shall refer to a Member of the Corporation as described in Article III of these Bylaws . Officer. The term " Officer " , shall mean one or more of the positions as provided in Article V . Public Official . The term " Public Official " shall mean and refer to ( 1 ) every person who is elected to office in the State or any political subdivision of the State , or any other governmental entity created within the State ; or (2) every person who is appointed to fill a vacancy in such an elective office . State . The term " State " shall mean the State of Florida unless otherwise specifically indicated . Trustee . The term " Trustee " means a member of the Board of Trustees of the Indian River County Hospital District , Section 1 . 2 POWERS . Except as limited by the Articles of Incorporation or these Bylaws , the Corporation shall have and exercise such powers in furtherance of its purposes as are now or may hereafter be granted by Chapters 607 and 617 of the Florida Statutes . Such powers shall include but not be limited to the power to sue and be sued , to contract and be contracted with , and to acquire , purchase , hold , lease , sell , mortgage and convey such real and personal property as the Board may deem proper or expedient to carry out the purposes of the Corporation . 2 ARTICLE II OFFICES The Corporation shall have and continuously maintain in the State a registered office and resident agent , and may have such other offices within or without the State as the Board may from time to time determine . ARTICLE III MEMBERSHIP Section 3 . 1 . COMPOSITION OF MEMBERSHIP. Those individuals who are the duly elected or designated Directors of the Corporation shall be the Members of the Corporation . Members shall not be entitled to vote . As the Board of Directors and the Membership of the Corporation are composed of the same individuals , the act of the Board of Directors shall be the act of the Membership when an act by the Membership is required by law . Section 3 . 2 . ANNUAL AND SPECIAL MEETINGS . There shall be no annual or special meetings of the Membership . As the composition of the Board of Directors and the Membership of the Corporation is identical , the vote of the Board of Directors shall be deemed to be the vote of the Membership when required by law . Section 3 . 3 . RESIGNATIONS AND REMOVAL. Any Member of the Corporation shall be deemed to have resigned his/her Membership in the Corporation at such time as he/ she submits his/her resignation as a member of the Board of Directors of the Corporation to the Chairman , Vice Chairman or the Secretary and , unless otherwise specified herein , the acceptance of such resignation shall not be necessary to make it effective . Any Member shall be deemed to have been removed at such time as he/she is removed as a Director of the Corporation . Section 3 . 4 . TERM OF MEMBERSHIP. A Member of the Corporation shall serve a term which is coextensive with his or term as a Director of the Corporation . Section 3 . 5 . LIABILITY OF MEMBERSHIP. Members of the Corporation shall not be personally liable to the Corporation ' s creditors for any indebtedness or liability and any or all creditors of the Corporation shall look only to the assets of the Corporation for payment . Section 3 . 6 . TRANSFER OF MEMBERSHIP. Membership in the Corporation and/ or any rights derived therefrom are not transferable or assignable . 3 ARTICLE IV BOARD OF DIRECTORS Section 4 . 1 . POWERS . The affairs of the Corporation shall be conducted by the Board in a manner consistent with these Bylaws and applicable law . The Board shall make appropriate delegations of authority to the Officers and , to the extent permitted by law and consistent with its responsibility to the patient population served , by appropriate resolution , to Board Committees . The Board shall adopt a Strategic Plan that is consistent with the Corporation ' s mission statement . The Board shall be responsible for monitoring and reviewing the projects and services undertaken to accomplish the objectives of the Strategic Plan . Section 4 . 2 . QUALIFICATIONS , TENURE AND ELECTION . 4 . 24 Number and Voting . There shall be sixteen members of the Board . Each member , except the President , shall have a vote . 4 . 2-2 Composition , Qualifications and Terms . A . Composition . The Board shall be composed of twelve Independent Directors , three of whom shall be designated by the District ; one elected Medical Staff Representative ; and three ex- officio Directors ; the President ; the Chief of the Medical Staff; and the Vice Chief of the Medical Staff. B . Qualifications . Any adult Florida resident is eligible to serve as an Independent Director other than : ( 1 ) a Public Official ; (2) a member of the Medical Staff with current clinical privileges ; or (3) an employee of Indian River Memorial Hospital , Inc . or any of its subsidiaries . The Nominating Committee or the District , as the case may be , shall find one or more of the following characteristics in a prospective Independent Directors : demonstrated management or professional acumen , prior experience in health care delivery , a history of voluntary service , or a particular attribute or skill considered desirable . C . Terms . Independent Directors shall be divided into three equally-sized annual classes . Each class shall be elected for a term of three years . The Medical Staff Representative shall serve two-year terms . 4 . 2-3 Election Procedures . A . Elected Directors . A Nominating Committee shall be appointed annually in accordance with Section 6 . 1 - 1 . The Nominating Committee shall present its nominees for Independent Director to the Board no later than the regular Board meeting 4 preceding the Annual Meeting . The number of nominees presented shall equal the number of Independent Directors to be elected by the Board at such meeting . The Board shall elect Independent Directors from among those persons nominated by the Nominating Committee at or before its regular monthly meeting immediately preceding the Annual Meeting . A newly- elected Independent Director shall assume his or her position at the start of the Annual Meeting . B. Designated Directors . The District shall designate one Independent Director at or - before its regular monthly meeting immediately preceding IRMH , Inc . ' s Annual Meeting . A Director designated by the District shall assume his or her position at the start of the Annual Meeting following his or her designation . C. Medical Staff Representative. The Active Staff, as defined in the Medical_Staff Bylaws , shall elect from among its members a Medical Staff Representative to serve on the Board . The Active Medical Staff shall determine its own rules and procedure for electing the Medical Staff Representative , except that any member of the Active Medical Staff shall be eligible for election and the vote shall be by written secret ballot if two or more candidates are nominated for the position . The Medical Staff Representative shall assume his or her position at the start of the next Board meeting following his or her election . 4 . 24 Tenure . After completing two consecutive full terms , no Independent Director shall be eligible for either election or designation as a Director until the next Annual Meeting other than a serving Chairman of the Board , and , in that case , only if the Chairman indicates in writing to the Nominating Committee a wish to continue and only for so long as he or she holds the office of Chairman . In no case shall an Independent Director serve as an Independent Director for more than a total of ten years . No Medical Staff Representative shall serve as a Director in that capacity for more than three consecutive full terms . Section 4 . 3 . MEETINGS . The Annual Meeting of the Board shall be held each January on the fourth Wednesday for the purposes of: ( 1 ) approving Board Committee appointments , (2 ) fixing the times , dates , and places for regular meetings of the Board for the next twelve ( 12 ) months , and ( 3) transacting such other business as may come before the meeting . If the Board does not prescribe the time , date and place for the holding of regular meetings , such Meetings shall be held at the time , date and place specified by the Chairman in the notice of each such regular meeting . The Board shall meet at least once each calendar quarter . Meetings of the Board , whether regular or Special , may be held at any place as the Board may designate from time to time , or , if not designated as shall be specified in the notice of the meeting or waiver of notice thereof. Neither the business to be transacted at , nor the purpose of any regular meeting of the Board need be specified in the notice or waiver of notice of such meeting unless required by statute . Section 4 . 4. SPECIAL MEETINGS . Special Meetings of the Board shall be held whenever called by the Chairman, the Vice Chairman , or the written request of a majority of 5 the members of the Board . The purpose of any Special Meeting must be specified in the notice of the meeting , and no other business may be conducted at the Meeting . Section 4 . 5. NOTICE. Notice of each meeting shall be given to each Director not later than forty-eight (48 ) hours before the meeting by United States mail , hand delivery , fax , telephone , or email ; however , no notice need be given of those meetings whose times and places were fixed at the Annual Meeting . Notice of a meeting need not be given to any Director who signs a waiver of notice either before or after the meeting , or who attends the meeting without protesting , at its commencement or prior thereto , the lack of notice to such Director . Section 4 . 6. QUORUM . At all meetings of the Board a majority of the members shall be necessary and sufficient to constitute a quorum for the transaction of business . The act of a majority of the members present at any meeting at which there is a quorum shall be the act of the Board . If less than a majority of the members of the Board are present at such meeting , a majority of those members present may adjourn the meeting without further notice , until a quorum shall be present . A member shall be considered to be present at any meeting which the member attends either in person or by telephone provided that each member can hear each other member . Section 4 . 7 . FORMAL ACTION BY BOARD . The act of the majority of the members of the Board present at a meeting at which a quorum is present shall be the act of the Board , unless the act of a greater number is required by statute , the Articles of Incorporation or these Bylaws . Section 4 . 8 . RESIGNATIONS AND REMOVAL . Any member of the Board may resign from the Board at any time by giving written notice to the Chairman , President or the Secretary and , unless otherwise specified therein, the acceptance of such resignation shall not be necessary to make it effective . Any Director may be removed from office at any time by an affirmative vote of at least three quarters (3/4) of the voting members of the Board , in the Board ' s sole discretion , without assigning any cause . Any Independent Director may be removed by vote of a majority of the Board of Trustees of the District but only if such Director repeatedly acts in a manner inconsistent with the public purpose for which the District was created . Conduct which is contrary to this standard shall be deemed to be repeated if it re-occurs after the Board of Trustees of the District adopts a Resolution identifying the offending individual and the conduct complained of and delivers a copy thereof to the Chairman of the Board . Section 4 .9 . VACANCIES . Any vacancy occurring in the membership of Board-elected Independent Directors shall be filled by the Board from a list of nominees presented by the Nominating Committee . The number of nominees presented shall equal the number of vacancies to be filled by the Board . A vacancy created by the resignation or removal of the President shall be filled by the Board . Other vacancies shall be filled by the District or the Active Medical Staff, depending on the particular vacancy . An Independent Director elected to fill a vacancy shall be elected for the unexpired term of such Director' s predecessor in office . In no event , however, shall an individual who has been removed from the Board by 6 •kt o — either the Board or the District be eligible to be elected to fill the vacancy created by his or her removal . Section 4 . 10. COMPENSATION. Members of the Board shall not be compensated for their services as Board Members , however, they may be reimbursed for expenses pre-approved by the Chairman and incurred in attending to their authorized duties . Section 4 . 11 . PROCEDURE. The Board may adopt its own rules or procedure which shall not be inconsistent with the Articles of Incorporation , these Bylaws or applicable law. In the absence of the Board_ adopting its own special rules of procedure as provided for herein , Robert ' s Rules of Order shall serve as the rules of procedure to be followed . Section 4 . 12. ATTENDANCE. Any member of the Board who is not present at more - than 50 % of the meetings of - the Board duly called under these Bylaws in any calendar year shall be deemed to have resigned at the end of the last regular meeting in each calendar year. Section 4 . 13 . PERFORMANCE REVIEW . At least annually , the Board shall review and evaluate its performance . The evaluation shall be summarized and presented to the Board so that it may develop and take action necessary to address the issues raised by the evaluation . 11 /30/99 Formerly Artlrle V1 - New V - ARTICLE V - OFFICERS - Section 5 . 1 . IDENTIFICATION. The Officers of the Corporation-shall be a Chairman , one or more Vice Chairmen , a President , a Treasurer, a Secretary , the Immediate Past Chairman ; ( if - qualified) , and such additional officers , including one or more Vice Presidents , Assistant -Treasurers and Assistant Secretaries, as the Board -of Directors shall designate from time to time . - No person shall hold concurrently more than one office . Upon nomination by the Governance Committee , the Board , at any time , may elect one of the Vice Chairman as Chairman- Elect, such Office to be installed as Chairman when the Office next becomes vacant . Section 5 . 2 . QUALIFICATIONS . The Chairman , each Vice Chairman , the Treasurer , and the Secretary shall be elected from among those persons who are , at the time ofthe Annual Meeting , will be Independent Directors . The Chairman shall not be eligible for reelection as Chairman after completing two full terms as Chairman . The Immediate Past Chairman shall be an Officer until his successor is qualified so long as he or she remains an Independent Director , Section 5 . 3 . ELECTION AND TENURE . The Chairman , each Vice Chairman , the President , the Treasurer , and the Secretary shall be elected for terms of one ( 1 ) year by the Board of Directors at the regular meeting immediately preceding the Annual Meeting . If the election of Officers shall not be held at such meeting , it shall be held at the next regularly scheduled meeting of the Board . Each Vice President , Assistant Secretary, and Assistant Treasurershall be appointed by the President subject to the concurrence of the Board . Each Officer elected by the Board of Directors shall hold office from the close of the meeting on the day of such Officer ' s election for one ( 1 ) year and until such Officer' s successor shall have been duly elected and qualified , unless such Officer shall sooner resign or be removed . Each Officer appointed by the shall hold office from the date of the concurring vote of the Board until such Officer shall eitherresign or be removed . Section 5 . 4 . RESIGNATIONS AND REMOVAL, Any Officer may resign at any time by giving written notice to the Chairman , the President or the Secretary , and , unless otherwise specified therein , the acceptance of such resignation shall not be necessary to make it effective . Any Officer may be removed by the vote of a majority of the members of the -- Board of Directors whenever in its judgment the best interest of the _ Corporation would be - served thereby . A vacancy in an office elected by the - Board of Directors may be filled by - - the Board for the unexpired portion of the term . A vacancy in an office appointed by the - President with the concurrence of the Board may be filled by the President with the concurrence of the Board . Section 5 . 5 . DUTIES . The Officers of the Corporation shall have the following duties in addition to those required by law : A . Chairman , - The Chairman shall preside at all meetings of the Board - of Directors , shall appoint, with the- - concurrence of the Board , all committees and the chairmen thereof with the exception of the- _ chairman of the Finance Committee ; shall assume such responsibilities and perform such duties as may be set forth in a position description -adopted - by the Board of Directors ; and shall perform such - other duties as may be assigned by the Board . B . Vice Chairman & Immediate Past Chairman , The - Vice Chairman and the Immediate Past _ Chairman , if any , shall assist the Chairman generally and shall exercise such other powers and perform such other duties as shall be prescribed by either the Chairman or the Board of Directors and as may be set forth in a position description adopted by the Board of Directors . During the absence or inability of the Chairman to render and perform the Chairman ' s duties or exercise the Chairman ' s powers , as set forth in these Bylaws or in the laws under which this Corporation is organized , the same shall be performed and 8 exercised by the Vice Chairman, and when so acting , the Vice Chairman shall have all the powers and be subject to all responsibilities hereby given to or imposed upon the Chairman . In the event that more than one ( 1 ) Vice Chairman is serving , the Chairman-Elect, shall perform the duties of the Chairman . If there is no Chairman- Elect , then the Vice - Chairman designated by the Board for such - purpose shall perform the duties of the Chairman . C . President : The President shall be- Chief Executive Officer and , subject to - the - direction_ of the Board , shall - _ - exercise executive -control-over the affairs of the Corporation . The President shall perform such duties as may be set forth in a position description adopted by the Board of Directors and in general shall perform all duties- incident to the office of President . The President may sign , with the Secretary or any other Officer authorized by the Board , any deeds , mortgages , bonds ; contracts or other instruments which the Board has authorized to be executed , except- fin cases where the signing- = and execution -thereof shall be expressly delegated by the Board - or, by these Bylaws or by statute , to some other Officer or agent of the Board or Corporation .- - - D . Vice President : The Vice President(s) shall perform such duties as may be assigned from time to time and as may be set forth in a position description adopted by the President . The Vice President(s) ( in order of designation or, if no - designation , in the order of appointment) shall - perform the duties of the President in the event of the President ' s absence or inability to perform the duties of the office. E . Treasurer : The Treasurer shall oversee the finances of the Corporation ; shall be the chairman of the Finance Committee ; and shall perform such other duties as may be assigned either by the Chairman or the Board of Directors and as may be set forth in a position description adopted by the Board of Directors . It is understood that the Treasurer ' s principal responsibility is that of oversight of the 9 Corporation ' s finances and that the Treasurer shall delegate the day to day performance of these duties to the Vice President of Finance and Chief Financial Officer of the Corporation. F. Secretary : The Secretary shall have responsibility for ensuring that proper minutes are maintained for all meetings of the Board of Directors and that all notices of the meetings of the Board of Directors are given in accordance with the provisions of these Bylaws and as required by law ; shall be the -- - custodian of the Corporate Seal ; -shall affix the Seat to documents when required by law ; and shall - perform such other -duties as may - be - assigned - either by the Chairman or by the Board of Directors and as may be set forth in a position description adopted by the Board of Directors . The Secretary ' s principal responsibility is that of oversight of the maintenance of minutes of meetings and the giving of notices . The Secretary may delegate the day to day performance of these duties to others by an instrument in _writing , a copy - of which shall be maintained - in the records of the _ Corporation . - G . Assistant Treasurers . If appointed , the Assistant Treasurers shall perform such duties as shall be assigned to them by the President. H . Assistant Secretaries . If appointed , the Assistant Secretaries shall perform such duties as shall be assigned to them by the President . Section 5 . 6 . COMPENSATION . The Chairman , any Vice Chairman, the Treasurer , the Secretary and the Immediate Past Chairman , if any , shall not be compensated for their services as Officers ; however , they may be reimbursed for expenses pre-authorized by the Chairman and incurred in attending to their authorized duties . Section 5 . 7 . BONDS OF OFFICERS . The Board may secure the fidelity of any or all Officers by bond or otherwise , in such terms and with such surety ' or sureties , conditions , penalties or securities as shall be required by the Board . (12/2/99 - Formerly Arlie le V - Ne , Arride VI) ARTICLE VI 10 BOARD COMMITTEES Section 6 . 1 . STANDING COMMITTEES . The Board shall have the Standing Committees enumerated in this Article . Except for Committee members who are appointed by the District , or are specified in these Bylaws , Committee members and Committee chairmen (other than the chairmen of the Executive Committee and the Finance Committee) shall be appointed annually by the Chairman at - the Annual Meeting , subject to confirmation by the Board . Unless stated to the contrary in these Bylaws , each Committee member shall have the right to vote . The chairman of each Standing Committee shall be a Director . The Chairman may recommend the addition and/or replacement of any Committee Member at any Meeting of the Board at which time the Board will either approve or disapprove of such recommendation . - The recommendation of addition - and/or replacement shall be effective upon the Board ' s = approval . 6. 14 NOMINATING C(YMMITTEE. A . Composition and Appointment . The Nominating Committee shall- be composed of five members ; two Board-appointed Independent Directors whose terms as Independent Directors do not -expire within a year , two District=appointed Trustees, and one person , who may not be the President , selected by the majority of the other members . The chairman of the Committee shall be an- Independent Director. - B . Authority and Functions . The Nominating Committee shall have the - authority and shall function in the -manner set- forth in Section 4 . 2 of these Bylaws , except as such authority and function may be limited by statute . - 6 . 1 -2 EXECUTIVE COMMITTEE. A . Composition and Appointment . The Executive Committee shall consist of the Officers elected annually by the Board , the Chief of Staff, and at least one other Independent Director , appointed by the Chairman with the concurrence of the Board . The Chairman shall be the chairman of the Executive Committee , B . Authority and Function . The Executive Committee shall have and -may exercise all of the authority of the Board , except as such authority is limited by statute or by resolution creating or controlling the Executive Committee or by these Bylaws . The Executive Committee will meet at the call of the Chairman to discuss matters the Chairman deems appropriate . C . Limitations. The Executive Committee shall take action for the Board only if the Chairman determines , at the Chairman ' s discretion , that the Corporation ' s interest will be better served if an Executive Committee meeting is held rather than waiting for the next regular meeting of the Board or calling a special Board meeting . 11 D . Manner of Acting . A majority of the members of the Executive Committee shall constitute a quorum for the transaction of business at any meeting of the Committee . 6. 1-3 FINANCE COMMITTEE, A . Composition and Appointment . The Finance Committee shall consist of at least four (4) members of the Board , in addition - to the Chairman and the President, one ( 1 ) Trustee appointed by the District, one ( 1 ) other person appointed by the District who shall not be a 'Trustee, and such other persons as shall be duly appointed . The - Treasurer shall be the chairman of the Finance Committee. B . Authority and Function . The authority and function of the Committee shall be to oversee the finances of the Corporation . The Committee shall be responsible for assuring that management maintains in a timely fashion accurate books of account and prepares monthly financial statements in accordance with generally accepted accounting principles and other applicable regulations , directives , and statutes . The Committee shall anticipate the future cash requirements of the Corporation and shall recommend to the Board courses of action to meet these _needs when raising external capital is required or desirable . The Cofnmittee shall - also review the annual operating and capital budgets submitted by the President and shall- forward these budgets with its recommendations to the Board . 6 . 14 _ JOINT CONFERENCE COMMITTEE. A . Composition and Appointment . The Joint Conference Committee shall consist of the Chief of Staff, the Vice Chief of Staff, Secretary of the Medical Staff, the elected representative of the Medical Staff to the Board , Medical Staff Credentials Committee chairman , Patient Care Committee chairman and the annually elected Officers . The chairman of the Committee shall be the Chairman . B . Authority and Function . The authority and function of the Committee shall be to serve as a bridge between the Medical Staff and the Board relative to matters of mutual- interests . The Committee shall review Medical Staff credentialing and make recommendations thereon to the Board . 6. 1 -5 COMPENSATION COMMITTEE. A . Composition and Appointment . The Compensation Committee shall consist of those annually elected Officers who are Independent Directors . B . Authority and Function . The authority and function of the Committee shall be to review , evaluate and approve the compensation of the Officers of the corporation 12 appointed by the President . The committee shall review and evaluate the compensation of the President and forward its recommendations to the Board . 6. 14 PATIENT CARE COMMITTEE, A . Composition and Appointment . The Patient Care Committee shall consist of no less than three (3) Directors , in addition to the Chairman and the President , and the chairman of the- Medical Staff Performance Improvement Committee .-- B . - - - Authority and Function . The authority -and function of the Committee shall be to ensure continuous improvement through the review and evaluation of reports and objective performance measures of patient care and services . In addition , the committee shall review and act upon routine reports of medical staff and hospital performance improvement activities , risk management activities ( including malpractice and claims review) , patient satisfaction , safety activities (environment of care) and summary findings of staff competency . The committee shall also oversee hospital licensing , accreditation , and reporting requirements relative to patient care ( i . e . . JCAHO , AHCA reporting , etc .) . _ As appropriate , the committee shall recommend patient care related policies to the full Board . The committee shall participate in the annual appraisal of the effectiveness of the Performance -Improvement Program . - - 6. 14 COMPLIANCE/AUDIT COMMITTEE, A ._ Composition and Appointment . The Compliance/Audit Committee shall consist of at -least -three (3 ) Independent Directors in addition to-the Chairman . ' Be Authority and Function . The authority - and function of the Compliance/Audit Committee shall be to advise the Compliance Officer and to oversee the implementation of the Compliance Plan . It shall formulate recommendations for Board approval regarding the appointment of the Corporation ' s Independent _ Certified Public Accountants . It shall review the activities and reports of the Independent Certified Public Accountants as well as the internal audit activities of the Corporation . It shall also review the Corporation ' s financial reporting process and internal financial controls . 6A4 INVESTMENT COMMITTEE . A . Composition and Appointment . The Investment Committee shall consist of at least three (3) members of the Board , in addition to the Chairman and the President , one ( 1 ) Trustee appointed by the District , and such other persons as shall be duly appointed . 13 B . Authority and Function . The Committee shall oversee the investment of both the Corporation ' s non-pension investment portfolio and the Corporation ' s pension investment portfolio . It shall formulate recommendations for Board approval on matters relating to : investment objectives and policy , employment of consultants and money managers , and asset allocation . To assist in portfolio structuring , it shall receive from the Finance Committee both short term and long term forecasts of ( 1 ) operating cash flow and (2) any changes in the Corporation ' s debt structure . It shall review quarterly the performance of both investment portfolios and provide - summaries of such reviews to the Board . 6 . 1 -9 GOVERNANCE COMMITTEE. A . Composition and Appointment . The Governance Committee shall consist of at least three (3} members of the Board in addition to the Chairman -and- the President. B . Authority and Function . The Committee shall nominate a slate of officers at each Annual Meeting . - It shall also be responsible for planning and implementing an annual self-evaluation of the Board ' s performance . It shall also recommend to the Board changes in the Bylaws and Articles of Incorporation . It shall also plan the Board ' s educational program . Section 6.2 - TERM OF CONMUTEE MEMBERS . The term of each- -member - appointed to a Standing committee- shall- extend until the next Annual Meeting and until his or her successor is duly appointed . Na member of-a Standing committee shall be eligible to serve- more than six (6) consecutive terms on the same committee except a committee member who _ serves on _ the committee by reason of his or her office_, by reason of appointment by the District,- or by reason of being the Chairman . Section 6 .3 AD HOC COMMITTEES . _ A . Composition and EIection . The Board may from time to time create by resolution ad hoc Committees consisting of at least three (3) Directors , and such other individuals , if any , as may be designated by the Board . If an ad hoc Committee is created , the resolution creating it shall designate the manner in which the members of the Board who are to serve as the members of the Committee - are to be appointed and removed . The chairman of any ad hoc Board Committee shall be a Director and shall be appointed by the chairman ,- with_ the concurrence of the Board . B . Powers and Functions . The resolution creating an ad hoc Committee shall designate the authority which such Committee shall have and exercise and the functions such Board Committee shall discharge . co Strategic Planning Committee. If the Board creates either a Standing or an ad hoc Strategic Planning Committee , one ( 1 ) Trustee who shall be appointed by the District 14 and one ( 1 ) other person appointed by the District who shall not be a Trustee , shall be among its members . Section 6 . 4 DISTRICT APPOINTEES . Wherever these Bylaws specify that a committee shall include one or more members appointed by the District , such appointment rights may be changed only with the approval of the District . The District shall make its committee appointments annually at its organization meeting in January and shall fill with reasonable promptness any vacancy with respect to a District appointee . District appointees may be removed only by a vote of the Trustees . Section 6 . 5 GENERAL, 6.54 Chairman 's Committee Membership. _The Chairman shall serve ex=officio on all Board Committees , 6. 5-2 President 's Committee Membership. The President shall serve as a non-voting member , ex-officio , on all committees with the exception of the Nominating Committee , the Compensation Committee , and the Compliance/Audit Committee . 6 . 5-3 Medical Staff Representation . Board Committees that deliberate issues- affecting the discharge of Medical Staff responsibilities shall have Medical Staff representation . - - 6 .54 Ouorum , With the exception of the Executive Committee ,_ a quorum shall exist at any committee meeting which is attended by either three (3) members of the committee or one-third ( 1 /3 ) of the committee' s membership , whichever is greater. 6. 5-5 Responsibilities and Staffing, The Board shall approve annually a detailed written statement of the responsibilities of each committee . The President shall - prepare annually a written assignment of staff support for each committee . Version: 12/16/99 ARTICLE VII MEDICAL- STAFF Section 7 . 1 . ORGANIZATION . The Practitioners , as that term is defined in the Medical Staff Bylaws , shall organize themselves into a Medical Staff .in accordance with such Bylaws , Rules , Regulations , Policies and Procedures for the Medical Staff (herein collectively " Medical Staff Bylaws " ) as the Board shall deem appropriate to cause such Medical Staff, as an effective administrative unit , to discharge the functions and responsibilities assigned to it by the Board . 15 Section 7. 2 . MEDICAL STAFF BYLAWS AND RULES . There shall be Medical Staff Bylaws setting forth purposes , functions , organization and operation of the Medical Staff. The Medical Staff shall have the initial responsibility to periodically review, formulate , adopt and recommend , to the Board , Medical Staff Bylaws and amendments thereto which shall be effective when approved by the Board . If the Medical Staff fails to exercise this responsibility in good faith and in a reasonable , timely and responsible manner, after written notice from the Board to such effect including a reasonable period of time for response , the Board may resort to its own initiative in reviewing , formulating or amending the Medical Staff Bylaws . In such event , the Medical Staff recommendations and views shall be carefully considered by the Board during its deliberations and in its actions .. No provision in the Medical Staff Bylaws shall be valid if it is inconsistent with the Articles of Incorporation , these Bylaws or resolutions adopted by the Board . Section 7. 3 .- MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES . 7 . 3- 1 ASSIGNMENT BY THE BOARD . The Board shall assign to the Medical Staff, and the _ Medical Staff shall investigate and evaluate all matters relating to Medical Staff membership , staff category and departmental - assignments , privileges , prerogatives and corrective action . Based upon such investigation and evaluation , the Medical Staff shall adopt and forward to the President , specific written -professional recommendations supported and documented in a manner that will allow the Board to take informed" action . 7 . 3-2 = ACTION BY THE BOARD . Final Action on all matters of -the nature referred lo in this Section _ shall be taken by the Board after- - considering the Medical Staff recommendations , provided that the Board shall act in any event _ if the Medical Staff fails to adopt and submit-any- such recommendation within a reasonable period of time as determined by the Board or as may be more specifically defined within the Medical Staff Bylaws or Policy on Appointment, _Re-Appointment & Clinical Privileges . - Such Board action without a Medical Staff recommendation shall be based on the same kind of- documented investigation and evaluation of qualifications as is required for Medical Staff recommendations . 7 . 3-3 CRITERIA FOR BOARD ACTION. In acting on matters of the nature referred to in this Section , the Board shall consider the improvement of patient care in light of patient care criteria including , without limitation : the needs of the community ; the purposes , dedication , needs , functions , priorities , capabilities of and financial impact on the Hospital ; the existing capabilities and balance of capabilities of the Medical Staff as a whole ; the personal and professional qualifications of members and applicants ( including , without limitation , background , licensure , training , experience , demonstrated competence , reliability , responsibility , character , adherence to professional ethics , reputation , ability to work with others , physical , mental and emotional condition and stability , ability to perform the privileges requested , and previous performance and contribution as a team participant within institutional settings ) ; such additional criteria as may be specified in the Medical Staff Bylaws or Policy on Appointment, Re-Appointment & Clinical Privileges ; and the Medical Staff' s professional recommendations and supporting information with respect thereto . No aspect of Medical Staff membership nor specific clinical privileges shall be limited or denied to a practitioner on the 16 basis of gender, race , creed , color or national origin, or on any basis which is prohibited by law . 7 . 34 TERMS AND CONDITIONS OF STAFF MEMBERSHIP AND CLINICAL PRIVILEGES . The terms and conditions of membership in the Medical Staff, and of the exercise of clinical privileges , shall be as specified in the Medical Staff Bylaws and Policy on Appointment, Re-Appointment & Clinical Privileges or as more specifically defined in the notice of individual appointment . Only practitioners appropriately licensed with clinical privileges in the Hospital granted as herein contemplated shall participate in patient care within the Hospital . All members - of the Medical Staff shall be obligated to observe_ all ethical principles promulgated for general application to the member ' s profession and such additional ethical principles as may be adopted by the Board for application within the Hospital. _ - 7 . 3-5 CORRECTIVE ACTION. The Board , the Chief of the Medical _ Staff, the President , such other individuals from or committees of the Hospital or Medical Staff as may be specified in the Medical Staff Bylaws , Policy on Appointment, Re Appointment & Clinical Privileges or Board resolutions , - shall have authority to initiate corrective action with - respect to the membership , privileges or prerogatives of any practitioner or other health care professional providing patient care related services . Such corrective action may include , without limitation, the denial , termination , modification , suspension or reduction of membership , privileges or prerogatives , which corrective action may be made ' immediately effective , but shall be subject . to the hearing and appellate review procedures - to the extent provided pursuant hereto and shall not become final until confirmed by the Board . 7 . 34 PROCEDURE. The procedure to be followed by the Medical Staff and the Board in acting on matters of Medical Staff membership , staff category - and departmental assignments, - privileges , prerogatives and corrective action , may be further specified in the Medical Staff Bylaws , Policy on Appointment, Re Appointment & Clinical Privileges and Board resolutions . - - Section 7 . 4 . FAIR HEARING PROCEDURES . 7 . 44 MEDICAL STAFF. The Board shall require that any action (except with respect to actions relating to temporary privileges , applications submitted by practitioners who are not then members of the Medical Staff or other actions for which specific provision is made in the Medical Staff Bylaws) taken by officials or agencies of the Medical Staff or the Hospital , the effect of which would be to deny , terminate , suspend or otherwise significantly diminish an individual practitioner ' s membership , privileges or . prerogatives , shall be accomplished in accordance with the hearing and appellate review procedures adopted by the Board and as set forth in the Policy on Appointment, Re Appointment & Clinical Privileges . Such procedures shall assure fair treatment and afford opportunity for the presentation of all pertinent information . The Board may , also , in its discretion , cause any action , the effect of which would be the denial in whole or in part of an initial application for membership submitted by a practitioner who is not then a member of the Medical Staff, to be accomplished 17 in accordance with hearing and appellate review procedures adopted by the Board if and to the extent that such provision is included within the Medical Staff Bylaws , Policy on Appointment, Re Appointment & Clinical Privileges or otherwise specifically authorized by the Board . 7 . 42 MEDICO-ADMINISTRATIVE OFFICIALS . From time to time the Hospital may engage one or more practitioners as medico-administrative officials under such terms and conditions as are specified in an engagement agreement. The engagement agreement must require that any such medico-administrative official be a member of the Medical Staff and that his membership be processed and his -privileges be delineated on the basis of patient care criteria as provided herein . Unless otherwise provided in the engagement agreement , neither the Medical Staff membership nor_ the privileges of a medico-administrative - _ - official shall be terminated without the same hearing and appellate review opportunities as are -- provided for other members of the Medical Staff. The term . " medico-administrative official " shall mean a practitioner engaged by the Hospital -on a full-time -or part-time basis to perform duties which , although partially administrative , .include clinical responsibilities (e . g . , direct medical care or supervision of the professional activities of other practitioners) . Section 7 . 5 . STATUS AS INDEPENDENT CONTRACTOR . The members of the - Medical Staff (when attending patients and when acting as officials of the Medical Staff or as members of Committees of the Medical Staff, the Hospital or the Corporation) , shall perform their duties as independent contractors in accordance with their professional judgments . Nothing contained in these Bylaws shall - be interpreted to cause the Medical Staff or the - - practitioners who are members thereof to be- employees or agents of the Hospital or Corporation . The Corporation may , however, by specific written contract so stating , retain - - individual practitioners as employees to perform services-for the Hospital or Corporation . version MOV99 - - - — ARTICLE VIII QUALITY OF PROFESSIONAL SERVICES Section 8 . 1 . BOARD RESPONSIBILITY . The Board shall require , after considering the recommendations of the Medical Staff and other health care professionals providing patient _ care services , the performance of specific review and evaluation activities to assess , preserve - and improve the overall quality and efficiency of patient care in the Hospital . The Board , through the President , shall provide whatever- administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operation of these review and evaluation activities . Section 8 . 2 . ACCOUNTABILITY OF MEDICAL STAFF AND OTHER PROFESSIONALS TO BOARD . The Medical Staff and other health care professionals providing patient care services shall conduct activities that contribute to the assessment , preservation and improvement of the quality and efficiency of patient care provided in the 18 Hospital and shall report and be accountable to the Board therefore . Such activities shall include making recommendations to the Board concerning , 8 .24 Definition of the clinical privileges which may be appropriately granted within the Hospital and within each department , consistent with the patient care criteria set forth herein ; 8 . 2-2 Delineation of clinical privileges for individual members of the Medical Staff in accordance with the procedures outlined herein and , in general , the assignment of patient care responsibilities to other health care professionals consistent with individual qualifications and demonstrated ability ; 8 .2-3 Allocation. of the Hospital ' s resources _ through utilization review procedures ; - - 8 .24 Contemporaneous review and evaluation of patient care practices through defined functions of the Medical Staff, the other health care professional services, and the Hospital administration ; 8 .2-5 Retrospective review and evaluation of the quality of patient care through a valid and reliable patient care evaluation procedure ; ' - 8 .2-6 Provision of continuing professional education , shaped primarily by the needs identified through the review and evaluation activities outlined above ; and , 8 .2=7 Such other matters as the Board , after considering the advice of the Medical Staff, the other health care professionals and the Corporation ' s administrative staff, may deem- necessary for the assessment , preservation and improvement of the quality and efficiency of patient care . - - - Section 8 . 3 . ADMINISTRATIVE RESPONSIBILITY . - Under the general oversight of the President , all professional departments within the Hospital shall conduct activities designed to assess , preserve and improve the quality and efficiency of patient care provided in the hospital . These activities will be reported routinely to the Board of Directors and shall include , but not be limited to the following : - Definition of skills and credentials required to ensure competency to provide patient care services consistent with established criteria . Periodic performance evaluations , at least annually , based on the job description to ensure competency of individuals providing direct patient care . Quality of patient care monitoring , review and improvement outlined in department established policies that are routinely reported through the Quality Assessment Committee and subsequently the Board . The appropriate allocation of supplies , equipment , staff and other resources for the provision of patient care . 19 ARTICLE IX MISCELLANEOUS Section 9 . 1 . CONTRACTS . The Board may authorize any Officer or agent of the Corporation , in addition to the Officers so authorized by these Bylaws , to enter into any contract or execute any instrument in the name of and on behalf of the Corporation, and such authority may be general or confined to specific instances . Section 9 .2 . CHECKS, DRAFTS . ETC . All checks , drafts or other orders for the payment of money , and all notes or other evidences of indebtedness issued - in _the - name of the Corporation shall be signed by-such Officer or Officers , agent or agents of the Corporation and- in ndin such manner as shall- from time to time be determined by resolution of the Board . - Section 9 . 3 . DEPOSITS . All funds of the Corporation shall be deposited from time to time to the credit of the Corporation in one or more such banks , trust companies or other depositories as the Board may from time to time designate , upon such terms and conditions as shall be fixed by the Board . The Board may from time to time authorize the opening and keeping , with any such depository- as it may designate , of general and special bank accounts and may make such special _rules and regulations with respect thereto , not inconsistent with the provisions of these Bylaws , as it may deem necessary . _ Section 9 . 4. - GIFTS . The Board may accept on behalf of the Corporation any contribution , gift, bequest or devise for and consistent with the general purposes; -or for and consistent with any specific purpose , of the Corporation. Section 9 . 50 BOOKS- AND RECORDS . The Corporation shall_ keep correct and complete books and records - of account and shall also keep records of the actions of the Corporation , which records shall be open to inspection by members of the Board at any reasonable time . Section 9 . 6. FISCAL YEAR: ACCOUNTING ELECTION. The fiscal year of and method of accounting for the Corporation shall be as the Board shall at any time determine . Section 9 . 7. ANNUAL OPERATING REPORT . The President shall cause an Annual Report to be submitted to the Board no later than 150 days after the close of each fiscal year of the Corporation . Such Annual Report shall include , without limitation , the following identified elements : 9 . 74 The Organization Chart for the Corporation ' s current fiscal year and a listing of those persons serving as ; ( i) members of the Board and Board Committees , and ( ii) Officers : of the Board and Administrative Officers ; and 20 9 . 7-2 Such summary financial information as will present an accurate representation of the financial results of the Corporation during the previous fiscal year. Section 9 . 8 . ANNUAL FISCAL REPORT. The President and Treasurer shall cause an annual audit to be conducted and the results thereof certified by a recognized independent certified public accounting firm , and an annual report to be submitted to the Board after the close of each fiscal year of the Corporation. Such annual fiscal report must conform to accounting standards promulgated by the American Institute of Certified Public Accounts and shall include , without limitation , the following identified elements concerning the Corporation : 9 . 84 The assets and liabilities , including the trust funds , of the Corporation as of the end of the fiscal - year- immediately preceding the date of the report . -- - 9 . &2 - The principal changes in assets and liabilities including trust funds , during the year immediately preceding the date of this report. - 9 . 8-3 The revenue or receipts of the Corporation , both unrestricted and restricted to particular purposes , for the year immediately preceding the date of the report , including separate data with respect to each trust fund held by or for the Corporation . 9 . 8-4 The expenses or disbursements of the Corporation , for' both general and restricted purposes , during the year immediately preceding the date of the report , including separate data with respect to each trust fund held by or for the Corporation . Section 9 . 9 . NOTICE. - 9 . 9- 1 EFFECTIVE DATE. Any notice required or permitted to be given pursuant to the provisions of the Articles of Incorporation , these Bylaws , or applicable law , shall be sufficient and effective as - of the date personally communicated , transmitted or delivered or , if sent by mail , on the date deposited with the United States Postal Services , prepaid and addressed to the intended receiver at such receiver ' s last known address as shown in the records of the Corporation . 9 . 9-2 WAIVER OF NOTICE. Whenever any notice is required to be given under the provisions of the Florida General Corporation Statute or Corporation Not- For- Profit Code of the State or under the provisions of the Articles of Incorporation , these Bylaws , or applicable law , a waiver thereof in writing signed by the persons entitled to such notice , whether before or after the time stated therein , shall be deemed equivalent to the giving of such notice . The attendance of a member at any meeting shall constitute a waiver of notice of such meeting , except where a member attends a meeting for the express purpose of objecting to the transaction of any business on the ground that the meeting is not lawfully called or convened . Section 9 . 10 . LOANS TO MEMBERS OF THE CORPORATION MEMBERS OF THE BOARD AND OFFICERS PROHIBITED . No loans shall be made by the Corporation 21 to Members of the Corporation, members of the Board or to any Officer. The members of the Board who vote for or assent to the making of a loan to a Member of the Corporation , member of the Board or Officer, and any member of the Board or Officer participating in the making of such a loan , shall be jointly and severally liable to the Corporation for immediate repayment of the amount of such loan . Section 9. 11 . INDEMNIFICATION OF MEMBERS OF THE BOARD OFFICERS AND OTHERS . The Corporation shall indemnify any person . who was or is a party to any proceeding (other than an action by , or in the right of, the Corporation) , by reason of the fact that he. or she is or was a director, officer , employee , or agent of the Corporation or is or was serving at the request of the Corporation as a Director, Officer, employee , or agent of another corporation , partnership , - joint venture , trust , or other enterprise against liability incurred in connection with such proceeding , including any appeal - thereof, if he or she acted in good faith and in amanner he or- she reasonably believed to be in ; or not -opposed to , the best interests of the Corporation and , with respect to any criminal action _ or proceeding , had no reasonable cause to believe his or her conduct was unlawful . The determination of any proceeding by judgment , order , settlement , or conviction or upon a plea of nolo contendere or its equivalent shall not , of itself, create a presumption that the person did not act in good faith and in a manner which he or she reasonably believed to be in, or not opposed to , the best interests of the Corporation or, with respect to any criminal action or proceeding , had reasonable cause to believe that his or her conduct was unlawful . ' The Corporation shall indemnify any person , who was or -is a party to any -proceeding by or _in the right of the Corporation to procure a judgment- in its favor- by reason of the fact that the person is or was a Director , Officer, employee , or agent _ of the - Corporation or is or was serving at the request of the Corporation as a director, officer, employee , or agent of another corporation , partnership , joint venture , trust , or other enterprise , against expenses and amounts paid in - settlement not exceeding , in the judgment of the Board of Directors , the estimated -expense -of litigating the proceeding to conclusion; actually and reasonably incurred in connection with the defense or settlement of such proceeding , including any appeal thereof. Such indemnification shall be made if such person acted in good faith and in a manner he or she reasonably believed to be in , or not opposed to , the best interest of the Corporation , except that no indemnification shall be made under this paragraph in respect of any claim , issue , or matter as_ to which such person shall have been adjudged to be liable unless , and only to the extent , the court in which the proceeding was brought , or any other Court of competent jurisdiction , shall determine upon application that , despite the adjudication of liability but in view of all circumstances of the case , such person is fairly and reasonably entitled to indemnity for such expenses which such court shall deem proper . Any indemnification unless pursuant to a determination by a court; shall be made by the Corporation only as authorized in the specific case upon a determination that indemnification of the director, officer , employee , or agent is proper under the circumstances because he or she has met the applicable standard of conduct set forth above . Such determination shall be made in accordance with the provisions of Florida Statutes Section 607 . 0850 as the same now exists and as it may be amended from time to time . 22 Section 9 . 12 . INSURANCE. Nothing herein provided shall limit or otherwise affect the power of the Corporation to purchase and maintain insurance on behalf of any person who is or was an Officer , member of the Board , employee or agent of the Corporation or is or was serving at the request of the Corporation , against any liability asserted against him and incurred by him in any such capacity or arising out of his status as such , whether or not the Corporation would have the power or would be required to indemnify him against such liability under the provisions of these Bylaws or any applicable law. To the extent such insurance operates to protect any person against liability , the Corporation ' s obligation to indemnify shall be deemed satisfied . Section 9 . 11 - ADDITIONAL ORGANIZATIONS . The Board may authorize- the formation of such - subsidiary , auxiliary , associated and affiliated organizations as would in the opinion of the Board assist in the fulfillment of the purposes of the Corporation . The organizational documents of any subsidiary , auxiliary , associated or affiliated - organization so authorized shall be subject to the approval of the Board . Such organization shall be subject to these Bylaws and all authorizations , irrespective of their terms , shall be revocable at any time in the discretion of the Board . Section 9 . 14 . REVOCABILITY OF AUTHORIZATIONS . No authorization , assignment , referral or . delegation of authority by the Board to any committee , Officer , agent or other official of the -Corporation , employee , or any other organization which is auxiliary to, associated or affiliated with , _or conducted under the auspices of the Corporation shall preclude the Board from exercising the_ authority required to meet its responsibility for the conduct of the business of the Corporation . The Board shall retain the right - to rescind - any such authorization , assignment, referral or delegation in its sole discretion . Section 9. 15. DUALITY OF INTERESTS . Except for contracts and transactions between the Corporation_ and any subsidiary corporation , any contract or transaction between the Corporation and one or more of the members of the Board or Officer , or a member of such persons family , or between the Corporation and any other corporation , firm , association or other entity in which - one or more of the members of the Board or Officer, or a member of such person ' s family are members of the board , trustees , officers or investors or have a financial or influential interest , shall be declared void unless all of the following - conditions are met : - - 9 . 154 The relevant and material facts as to such member of the Board or Officer , or a member of such person ' s , families , interest in such contract or transaction and as to any common directorship , officership , or financial or influential interest were disclosed in good faith in advance , by such member of the Board or Officer , to the Board or Board Committee , and such facts are reflected in the minutes of the Board or Board Committee meeting ; and 9 . 15.2 The relevant and material facts , if any , known to such interested member of the Board or Officer with respect to such contract or transaction which might 23 reasonably be construed to be adverse to the Corporation ' s interest were disclosed in good faith in advance by such member of the Board or Officer to the Board , and such facts are reflected in the minutes of the Board meeting ; and 9 . 15-3 Such interested member of the Board or Officer has , as determined by the judgment of the Board ; ( i) made the disclosures and fully responded to questions concerning the matters referred to in (4 ) and (-2) above ; ( ii) fully met the burden of proof that the contract or transaction is fair and reasonable to the Corporation at the time such contract or transaction is authorized ; and (iii) not otherwise significantly influenced the action of the Board with respect to the contract or transaction ; and all such determinations by the Board_ _ are reflected in the minutes of the Board meeting ; and 9 . 154 Such interested member of the Board or Officer was not present at - the meeting table , if the meeting -is _ a public meeting , or the meeting room , if the meeting is - - - one in which the public is not entitled to attend , during the discussion of and vote on the - contract or transaction that results in a conflict of interest ; and 9 . 15-5 The Board authorized such contract or transaction by a vote - of - at least a majority of the members of the Board present at a meeting at which a quorum was present , and such interested member of the Board or Officer may be counted in determining the presence of a quorum . - Section 9 . 16. RULES . - The Board may adopt, - amend or repeal rules (not inconsistent with these Bylaws) forthe the management of the internal affairs of the Corporation_ and_ the - governance of its Officers , agents , Board_ Committees , and employees . Section 9 . 17 . VOTING OF SHARES OWNED BY THE CORPORATION. - Unless otherwise ordered by the Board , the Chairman shall have full power and authority on behalf of the Corporation to attend , . to Note and - to grant proxies to be used at any meeting of shareholders of any corporation or otherwise exercise rights of any entity in which the Corporation may hold stock or otherwise be a member . The Board may confer like powers upon any other person or persons . Section 9 . 18 . VOTE BY PRESIDING OFFICER . The person acting as presiding officer at any meeting held pursuant to these Bylaws shall , if a voting member thereof, be entitled to vote on the same basis as if not acting as a presiding officer . Section 9 . 19 . GENDER AND NUMBER. Whenever the context requires , the gender of all words used herein shall include the masculine , feminine and neuter , and the number of all words shall include the singular and plural thereof. Section 9 . 20 . ARTICLES AND OTHER HEADINGS . The Article and other headings contained in these Bylaws are for reference purposes only and shall not affect the meaning or interpretation of these Bylaws . 24 ARTICLE X AMENDMENTS TO ARTICLES AND BYLAWS Section 10. 1 . ARTICLES OF INCORPORATION. Subject to such restrictions as may be set forth in the Articles of Incorporation, the power to make, alter, amend , repeal_ or adopt the Articles of Incorporation of the Corporation shall - be vested in the Board; provided , however, that . any exercise of such power shall require an affirmative three-quarters (3/4) vote of the entire Board . Section 10. 2. BYLAWS . The power to make . alter, amend, - repeal or adopt these Bylaws shall be vested in the Board ; provided, however- , that the exercise of such power with respect to Section 4 . 2-2 , 4 . 2-3 , 4 . 274 , 4. 2-5 , 43,_ 4 . 9 , 6 . 1 - 1 and 6. 4 of these Bylaws, shall require an affirmative three-quarters (3/4) vote of the entire- Board ,-as well as the approval of the Board of Trustees of the District. Section 10 . 3 . BYLAWS REVIEW . As needed , and at _least annually the Board will review the governing body Bylaws . 25 Rcvisrd 12/ 20 /03 - _ • _ •ISI/' , _ - - _ 2003 MEMBERS BOARD OF DIRECTORS INDIAN RIVER MEMORIAL HOSPITAL, INC . Name Address Lee M . Klinetobe 1150 Beach Rd. , Apt. 31, Chairman Vero Beach, FL 32963 Charles V. Sheehan 884 Indian Lane Vice Chairman — Chairman Elect Vero Beach, FL 32963 Felix Demartini, M . D . 975 Saint Ann's Lane Vice Chairman Vero Beach, FL 32967 Earl C . Conway_ - 1020 Olde Doubloon Drive Vice Chairman - Vero Beach, FL 32963 - Florence Booms - _ 1845 -5 Waterford Drive — Secretary Vero Beach, FL 32966 Thomas Segura 1048 Indian Mound Trail Treasurer - Vero Beach, FL 32963 Charles N . Celano, M . D . 3607 15th Ave. Suite A Chief of Staff Vero Beach, FL 32960 Katharine Lum, M .D . = 777 37th Street, B- 103 - Vice Chief of Staff = Vero Beach; FL 32960- Victor Rodriguez-Viera, M . D . 1820 43`d Avenue, Suite 2 Medical Staff Representative Vero Beach, FL 3296a Howard Gray 700 Beach Road - Vero Beach, FL 32963 - Richard McDermott Regional President, U. S . Trust Company 700 Beachland Blvd . Vero Beach, FL 32963 Beverly O 'Neill , RN 9790 61 " Place Sebastian, FL 32958 Richard Weil, M . D . 746 Riomar Drive Vero Beach, FL 32963 Ernestine W . Williams Harbor Federal Baiik Indian River Mall Office 6080201h Street Vero Beach, FL 32966 567-7200, FAX 778 -2898 George Wright, M . D . 890 Bowline Drive Vero Beach, FL 32963 Regular Attendees Jeffrey L. Susi IRMH President/CEO 1000 36 h Street &mail: jsusi@irmh. com Mitch Goldman Duane Morris LLP Hospital Counsel One Liberty Place Philadelphia, PA 19103 Dudley Teel, M. D . MMH Vice President Medical Management 1000 Wh Street Vero Beach, FL 32960 James W. Large , M .D . 1RMH Vice President Medical Development 1000 36 h Street Vero Beach, FL 32960 _ � �} �{ � Indian ■ - Memorial Hospital , and - Subsidiaries Report„ on Audits of Consolidated Financial Statements . Supplemental , , . , theYears Ended September ■ 2002 and 2001 � �. � � � �. � � � : : : � � � Indian River Memorial Hospital , Inc. and Subsidiaries Table of Contents Page(s) Report of Independent Certified Public Accountants 1 Consolidated Financial Statements: Consolidated Balance Sheets 2-3 Consolidated Statements of Operations 4 Consolidated Statements of Changes in Net Assets 5 - Consolidated Statements of Cash Flows i Notes to Consolidated Financial Statements 8_29 Supplemental Information: Report of Independent Certified Public Accountants on Accompanying Consolidating Information 30 Consolidating Balance Sheet 31 -32 Consolidating Statement of Operations 33 Notes to Consolidating Balance Sheet and Statement of Operations - - 34 _ Y) C' 1. ) 11 t M. PRICaVATEWECGQPER5 2 PricewaterhouseCoopers LLP Bank of America Suite 2400 390 North Orange Avenue Orlando FL32801 -9865 Telephone (407) 236 0550 Facsimile (407) 236 5149 Report of Independent Certified Public Accountants To -the Board of Directors of Indian River Memorial Hospital, Inc.: In our opinion, the accompanying consolidated balance sheets - and the related consolidated _ statements of operations, of changes in net assets and of cash flows present fairly, in all material respects, the financial position of Indian River Memorial Hospital, Inc. and Subsidiaries (the "Hospital") at September 30, 2002 and 2001 , and the results of their operations and their cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America. These financial statements are the responsibility of the Hospital's management; our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits of these statements in accordance with auditing standards generally accepted 'in the United States of America, which require that we plan and perform- the audit to obtain reasonable assurance about whether the financial statements are free of material = misstatement. An audit includes examining, on a test basis, 'evidence supporting the amounts and disclosures in the financial statements, -assessing the accounting principles used and significant estimates made by management, and evaluating the overall financial statementP resentation. - We believe that our audits provide a reasonable basis for our opinion. December 6, 2002, except for Note 10, as to which the date is May 1 , 2003 A 1 I - 1 - • t Indian River Memorial Hos ital Inc. an . p d Subs � diaries Consolidated Balance Sheets September 30 , 2002 and 2001 2002 2001 Assets Current assets : Cash and cash equivalents $ . 51896,329 $ 1 , 825,279 Investments 25,7873,487 . 34,362, 125 Accounts receivable from patients, less allowances for doubtful accounts of $ 10,793, 000 and $9,944,000 1742872885 18245230914 Other receivables 322,793 42230711 Inventories 2,047, 160 221172622 Due from the District and others - - 1 ,0022070 742627 Prepaid expenses 1 ,075,996 1 ,246,598 Restricted contributions receivable - _ 1,258,687 13013830115 Assets limited as to use - held in escrow for - payment of bond principal and interest 943 ,820 1 ,491 ,566 Total current assets 55, 622 227 61 131 557 Assets limited as to use or restricted: By Board for designated uses 462481 ,256 5221892759 Under indenture and irrevocable trust agreements - held by ' trustee - 73, 8723,482 91575, 521 By donors for property and equipment additions = 8,911 ,970 515182166 - By Trustee for workers' compensation - 505000 1002000 Total assets limited as to use or restricted- 63,315,708 671383 ,446 Property and equipment, net 5933442141 6020972916 Bond issuance costs, net 211913,395 223842279 Other assets - 708,702 2525397 62,2441238 62, 734, 592 Total assets $ 181 , 1822173 $ 191 ,249, 595 The accompanying notes are an integral part of these consolidated financial statements . Indian River Memorial Hospital , Inc. and Subsidiaries Consolidated Balance Sheets - Continued September 30 , 2002 and 2001 2002 2001 Liabilities and Net Assets Current liabilities: Accounts payable $ 32562,938 $ 5, 0343250 Accrued payroll 32663 ,329 3,4283209 Other accrued liabilities 92709;907 430867,204 Estimated third party payor settlements 214280151 1, 195-, 857 Accrued interest payable 75,951 108,027 Due to affiliated organizations - - 94,664 Current portion of bond obligations payable 1 ,235,000 1,3802000 Current portion of self in liability for professional - liability and workerscompensation-claims 9003,372 - - 629,548 Current portion ofnote payable 9482565 7582783 Total current liabilities 22,4242213 173496, 542 Other long term liabilities 4152193 3942200 Bond obligations payable after one year 5628252304 582049,406 Note payable 3 , 101 ,637 32975 , 137 Self-insurance liability for professional liability and - workers' compensation claims 35007, 557 1 ,34010452 Total liabilities - - 85,7731904 81 ,2555737 Commitments and contingent liabilities - .N Net assets. Unrestricted- 85 ,80-52312 1032461 , 107 Temporarilyrestricted - 923921460 6,322,254 Permanently restricted 210,497 210,497 Total- net assets 95,408,269 109, 993 , 858 Total liabilities and net assets $ 181 , 182, 173 $ 191 ,249, 595 The accompanying notes are an integral part ofthese consolidated financial statements. -3 - Indian River Memorial Hospitil , Inc.- and Subsidiaries Consolidated Statements of Operations For the Years Ended September 30 , 2002 and 2001 2002 2001 Unrestricted revenues, gains and other support: Net patient service revenue $ 12223352177 $ 12237633,946 Other revenue 826337232 57078,734 Total revenues, gains and other support 130,968,409 127,8422680 Expenses . Salaries and benefits 67,039,230 573F5242612 Professional fees 8, 8902084 99606,537 Supplies 223298,569 212095, 177 Other 183,718,470 1329652444 Provision for bad debts _ 1322652172 - 15,451,341 Interest - 1 ,953, 809 2,566,682 Depreciation and amortization 10, 102,934 91759,566 Total expenses 14222682268 129,969,359 Operating loss - (11 )2992859) (211262679) Other income (expenses) . Investment income 3 ,0602827 32545,325 Other, net (1 , 138, 866) - (122688) (Deficit) excess of revenues over-expenses (9,377,898) - 1 ,4x5,958 Unrealized (losses) -gains on other than trading securities - _ (5)691 ,441 ) {102839)027) r Net assets released from restrictions used for purchase of @' property and equipment 7461%265 423 , 105 Other decrease in unrestricted net assets - (27, 066) Additional minimum pension liability (2, 104, 835) - Cumulative effect of change in accounting method (Note 13 ) (3182305) - Discontinued operations : Loss from operations of discontinued business (868,691 ) (3873508) Loss on disposal of discontinued business including provision for operating losses during phase-out period (40, 890) - Decrease m unrestricted net assets ., $ ( 17,6552795) $ (9,424,538) The accompanying notes are an integral part of these consolidated fmancial statements . -4- Indian River Memorial Hospital , Inc. and Subsidiaries Consolidated Statements of Changes in Net Assets For the Years Ended September 30 , 2002 and 2001 2002 2001 Unrestricted Net Assets (Deficit) excess of revenues over expenses $ (913772898) $ 13405,958 Unrealized (losses) gains on other than trading securities (526912441 ) ( 102839,027) Net assets released from restrictions used for purchase of property and equipment 7462265 4233, 105 Other decrease in unrestricted net assets - (27,066) ' Additional minimum pension liability . (2, 104,835) Cumulative effect of change in accounting method - (318,305) - - = Discontinued operations: - -_ - Loss from operations or discontinued business (8682691 ) (3872508) - Loss 387,508) -Loss on disposal of discontinued business including provision for operating losses during phase-out period (409890) - Decrease in unrestricted net assets (1776552795) (9,4242538) Temporarily Restricted Net Assets Restricted gifts for property and equipment 42942,939 213602194 Income from investments- - - - 173, 748 1712985 = - Change in unrealized losses - (795,283) (856, 139) Net assets released from restrictions - (7462265) (423 , 105) - Fund-raising expenses - _ (5922268) (863 , 181 ) Net assets received from satisfaction of endowment restriction 87,335 279066 - Increase in temporarily restricted net assets 3207030206 41.65820 Permanently Restricted Net Assets - - Income from investments 872335 27, 066 Net assets released from restrictions (87,335) (27,066) Increase in permanently restricted assets - - Decrease in net assets _ (1425852589) (9, 0073718) 1 Net assets, beginning of year 109,993 , 858 119, 001 ,576 ( Net assets, end of year $ 952,4082269 $ 10979933858 t 1 . I The accompanying notes are an integral part of these consolidated financial statements . I' -5- Indian River Memorial Hospital , • H spital , Inc. and Subsidiaries �( Consolidated Statements of Cash Flows For the Years Ended September 30 , 2002 and Z01 2002 2001 Cash flows from operating activities , Change in net assets $ (14,585,589) $ (92007,718) Adjustments to reconcile change in net assets to net cash provided by operating activities: Depreciation and amortization 1021022934 91759,566 Bond discount amortization 10, 898 - 109897 i Provision forbad debts - 13,26551172 152451 ,341 Loss on disposal ofproperty and equipment . - 1,680,216 27,723 (Incrrase) decrease in: Accounts receivable frompatients (12, 100, 143)- - (17,7392307) Other receivables - • 99,918 (642967) Inventories :_ - 70 462 39 659 (1 ,022, Due from affiliated organizations 107) (264) Restricted contributions receivable, (120:0572) Prepaid expenses . 1702602 (364,929) (Decrease) increase in: - Accounts payable (1247130312) 538,222 Accrued payroll 235, 120 39,512 Dther accrued and long term liabilities - 4,8632696 1 , 111 , 119 Estimated third partypayor settlements 1 ,232,294 (50,360) Accrued interest payable (32,076) (97,316) Self insurance reserves for professional liability - - and--reserves for workers' compensation claims _ 12937;929 4402000 Net cash provided by operating activities $ 4,337,442 $ 93, 178 i I The accompanying notes are an integral part of these consolidated financial statements. I -6- i ii Indian River MemorJal Hospital , Inc . and Subsidiaries Consolidated Statements of Cash Flows - Continued For the Years Ended September 30 , 2002 arta 2001 2002 2001 Cash flows from investing activities: Decrease in investments 825742638 528712218 (Increase) decrease in other assets (456,305) 3332106 Decrease in fiends held by trustee for professional liability program 252,736 _ 3462056 Acquisitions of property and equipment (102,9062608) (11 ,661,968) Proceeds from sale of property and equipment 702117 - Dec reaw in board designated funds 51455,767 _ 4,7572486 Decrease in permanently restricted funds - held by trustee 502000 37,256 Net cash used in investing activities 32040,345 (31650847) Cash flows from financing acfivities : Payments on bond obligations ( 1103802000) (1 ,0853,000) Proceeds from note payable - 520003,000 Payments on note payable (783 ,718) (266,080) Decrease. (increase) in trustee held debt service reserve funds - 2,2502785 (21476,554) (Increase) decrease in unused restricted donations for _ - property and equipment additions_ (323932804) - 30,063 Net cash provided by financing activities (3,3062737) 112021,429 Net increase in cash and cash equivalents 420712050 9783760 Cash and cash equivalents at beginning of year 1 , 8252279 846,519 Cash and cash equivalents at end of year $ 5 , 896,329 _ $ 1 ,8252279 Supplemental disclosure of cash flow information: Interest paid during the year $ 3 ,4015596 $ 4,0212000 The accompanying notes are an integral part of these consolidated financial statements, -7- Indian River Memorial - Hospital , Inc . and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 20D1 1. Summary of Significant Accounting Policies Principles of Consolidation and Reporting Entity The accompanying consolidated financial statements include Indian River Memorial Hospital, Inc. ( MMI-P'), and its wholly-owned subsidiaries, Health Systems of Indian River, Inc. (USM!), Indian River Health Services Corporation ("HSC"), Indian River Hospital Foundation, Inc. (the "Foundation") and Treasure Coast Billing, Inc. ("TCB") (collectively referred to as the "Hospital"). IRMH applies the equity method of accounting for investments between 20% and 50%. IRUH wasincorporated in December 1984 as a not-for_profit corporation under the laws of the State of Florida. IRIAH operates a261 -bed short-term acute care hospital and a 28-bed skilled nursing unit ("SNU") located in Veru Beach, Florida. In February 1989, IlZMH - purchased the Psychiatric Institute of Vero Beach ("PIVB' and transferred its ownership to the Indian River County Hospital District (the "District"), an affiliated organization which is a special taxing district. During fiscal year 1994, PNB changed its name to the Center for Emotional and Behavioral Health ("CEBH") . CEBH is a 46-bed acute- care unit located proximate to the IRMH campus . CEBH is operated as a department of IRMI3. Collectively the aforementioned entities are referred to as the "Hospital Facility" . IRMH is leasingxhe Hospital Facility from the District. -The lease expires in December 2010, unless extended due to the financing of additions or improvements, at which time the net assets of IRMH will be transferred to the District. - - In 1997, IlZMH established HS IR to assist in the development of an integrated delivery system. HSIR is a not for-profit corporation under the laws of the State of Florida and is exempt from federal and state income taxes under Section 501 (c)(3) of the Internal Revenue Code. HS1R is the parent of two subsidiaries, Indian River Walk In Clinic - Vero Beach, LLC ("Vero Beach") and Indian River Walk In Clinic — Sebastian, LLC ("Sebastian"). These clinics were established in June 2001 . Operations began in Sebastian on July 16, 2001 and on August 1 , 2001 for Vero Beach. The Hospital gave the operations of the Vero Beach Clinic to a third party effective August 1 , 2002 (see Note 4) . In 1987, IRMH established HSC to function as a parent holding company for TCB . HSC is a - not-for-profit corporation under the laws of the State of Florida and is exempt from federal and state income taxes under Section 501 (c) (3 ) of the Internal Revenue Code. TCB was incorporated as a for-profit corporation under the laws of the State of Florida. TCB was formed primarily to provide billing services for various entities . The Foundation was incorporated in September 1985 as a not-for-profit corporation under the laws of the State of Florida and is exempt from federal and state income taxes under Section 501 (c) (3 ) of the Internal Revenue Code. The Foundation was formed to solicit and administer funds for the benefit of H MH. - s - Indian River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 20) 1 Use of Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. The more significant areas subject to management estimates include estimated third-party payor settlements, reserves for professional liability and workers' compensation claims and allowances for patient receivables. Actual results could differ from those estimates. Cash and Cash Equivalents Cash and cash equivalents include investments in highly liquid instruments with original maturities of three months or less when purchased, excluding amounts limited as to use by arrangements under trust agreements or with thirdparty payors . Investments Investments consist of amounts invested in common stocks, U. S . Government Agency obligations and short-term pooled fixed income funds, corporate obligations, temp6rary - - investments, certificates of deposit and accrued interest receivable with original maturities when purchased- of greater than three months. Investments are recorded at fair value, based on quoted market prices, in the consolidated balance sheets. Investment income or loss, Itwhich includes realized gains and losses on investments and interest and dividends is included mi (deficit) excess of revenues over expenses unless the income or loss is restricted by donor or law. Unrealized gains and losses are excluded from (deficit) excess of revenues over expenses . Inventories Inventories, consisting principally of medical and pharmaceutical supplies, are stated at the lower of cost or market. Cost is determined on the basis of the FIFO (first in = first out) method. Assets Limited as to Use or Restricted The Board of Directors has designated certain funds for capital additions and for its self- insured program for health insurance claims . These funds are invested in common stocks, U. S . Government Agency obligations and- short-term pooled fixed income funds, corporate obligations, temporary investments, certificates of deposit and accrued interest receivable. The investments are carried at fair value in the accompanying consolidated balance sheets . Realized earnings on investments designated for capital additions and health insurance claims are classified as investment income. -9 . Indian River Memorial Hospital , Inc . and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 The trust indentures for the Series 1985 , 1988 , 1989 and 1990 Bonds require the establishment and maintenance of a construction account and a debt service reserve fund.- These arrangements require the Trustee to control the expenditure of bond proceeds and to maintain a debt service reserve fund. These funds are invested primarily in U.S . Treasury notes, bonds and accrued interest receivable. Investments are carried at fair value in the accompanying consolidated financial statements. Realized earnings on the investments for the debt service reserve fund are classified as other revenue. In 1990, the Hospital established an irrevocable bank-administered trust to fund the self- ' insured portion of the professional liability program. Under the terms of the trust agreement, these funds are to be. utilized for the payment of professional liability claims and related - expenses and-the cost of administering the trust These funds are primarily iirvested in common stocks, U. S . Government Agency obligations, foreign obligations, corporate obligations and cash and cash equivalents. Realized earnings on these investments are ( classified as other revenue. In 1993 , the Hospital established an account to fund liabilities associated with workers' 4 compensation deductibles and related expenses . These funds are invested in bank certificates of deposit. Earnings on these investments are classified as investment income. During fiscal year 2002, the Hospital entered into a letter of credit to fund workers' -compensation and related expenses. - Assets restricted by donors for property and equipment.additions include cash and -cash - ' equivalents, pledges receivable, common stocks, U. S . Government Agencyobligations and corporate obligations . The pledges receivable represent the estimated net realizable value of amounts pledged to the Foundation. Property and Equipment Property and equipment including betterments of existing facilities are recorded at cost. Maintenance, repairs and minor renewals are charged to expense as incurred. Donated property and equipment are recorded at fair market value at the time of the donation. Depreciation is provided using the straight-line method over the following estimated useful lives, which are m agreement with American Hospital Association guidelines : Years Land improvements 10-20 Buildings 540 Fixed equipment 8-20 Major movable equipment 5 - 15 Minor equipment 5 40 - - - - - - - - - - - - ' emorl I HospitalInc. and Subsidiaries Indian River M p , Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 20D1 rBond Issuance Costs Bond issuance costs are deferred and amortized to operations over the term of the relaxed financing agreement using the effective interest method Net Patient Service Revenue Net patient service revenue is recorded on an accrual basis of accounting which provides for recognition of revenue at established rates as service is provided. The Hospital has agreements with third party payors that provide for payments to the - -_ Hospital at amounts different from its established rates. Payment arrangements include prospectively determined rates -per discharge, reimbursed cost, discounted charges and per diem payments. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors and others for services rendered, including 1 estimated retroactive adjustments under reimbursement agreements with third-party payors. Retroactive adjustments are accrued on an estimated basis in the period the related services are rendered and adjusted in fixture periods as final settlements are determined. Temporarily and Permanent) Restricted Net Assets . Temp y Y Temporarily restricted net assets are those whose use by the Hospital has -been limited by - donors to a specific time period or-purpose. Permanently restricted net assets have been - restricted by donors to be maintained by the Hospital in perpetuity. _ (Deficit) Excess of Revenues Over Expenses The consolidated statements of operations includes (deficit) excess of revenues over expenses: Changes in unrestricted net assets which are excluded from (deficit) excess of - revenues over expenses, consistent with industry practice, include changes in unrealized gains and losses on other than trading securities and -net assets released from restrictions used for the purchase of property and equipment. ! Charity Care The Hospital provides care to patients who meet certain criteria under its charity care policies without charge or at amounts less than established rates . Because the Hospital does not - pursue collection of amounts determined to qualify as charity care, these amounts are not reported as revenue. Under contractual agreements, the District reimburses the Hospital for a. portion of its qualified charity care. Reimbursement is classified as other revenue in the accompanying consolidated financial statements . ' a Hos ital Inc . and Subsidiaries Indian River Memori , 1 p , Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 20) 1 Functional Expenses The Hospital does not present expense information by functional classification because its resources and activities are primarily related to providing health care services. Further, since the Hospital received substantially all of its resources from providing health care services in a manner similar to a business enterprise, other indicators contained in these financial statements are considered important in evaluating how well management has discharged their stewardship responsibilities. Donor Restricted Gifts -- - Unconditional promises to give cash and other assets to the Hospital are reported at fair value - at the date the promise is received. Conditional promises to give - and intentions to give are reported at fair value at the date the gift is received The gifts are reported as Either temporarily or permanently restricted support if they are received with donor stipulations that limit the use of the donated assets. When a donor restriction expires, that is, when a stipulated time restriction ends or purpose restriction is accomplished, temporarily restricted net assets are reclassified as unrestricted net assets and reported in the statement of operations as net assets released. from restrictions . Donor-restricted contributions whose restrictions are met within the same year as received are reported as unrestricted contributions in the , - accompanying financial statements. Estimated Professional Liability, Workers ' Compensation and Health Insurance Costs The provision for professional liability, workers' compensation and health insurance claims - includes estimates of the ultimate costs for both reported claims and claims incurred but not reported - Income Taxes - - IRMH is a not-for-profit corporation and has been recognized as atax-exempt organization by the Internal Revenue Service pursuant to Section 501 (c) (3 ) of the Internal Revenue Code (the "Code") . Income earned in furtherance of IRH' s tax-exempt purpose i Ms exempt from ( federal and state income taxes. The Code provides for taxation of unrelated business income R - under certain circumstances . Mhffl has no material unrelated business income; however, such status is subject to final determination upon examination of the related income tax returns by the appropriate taxing authority. Reclassifications Certain amounts in the 2001 consolidated fitiancial statements have been reclassified to conform to the 2002 presentation. These reclassifications had no effect on net assets or change in net assets. - 12 - i • • r Indian River Memorial Hospital , Inc. and Subsidiaries 4 Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2W 2. Net Patient Service Revenue The Hospital has agreements with third parry payors that provide for payment to the Hospital at amounts different from its established rates. A summary of the basis of payment with major third-parry payors follows : Medicare - Inpatient acute care services, skilled nursing services and hospital outpatient services rendered to Medicare program beneficiaries are paid at prospectively determined rates. These rates vary according to a patient classification system that is based on clinical, diagnostic, and other factors. Rehabilitative services, Psychiatric services, certain ` outpatient services rendered to Medicare beneficiaries, and direct graduate medical education costs are•paid based upon a cost reimbursement methodology. The Hospital is reimbursed for cost reimbursable items at a tentative interim rate with final settlement determined after submission of annual cost reports by the Hospital- and audits by the Medicare fiscal intermediary. The Hospital's Medicare cost reports have been audited and final settlements determined by the Medicare intermediary for all years through September 30, 1999 . Retroactive adjustments for cost report settlements are accrued on an estimated basis in the period when the related services are rendered and adjusted in future periods when final settlements are determined. Medicaid - Inpatient and outpatient services (except for- laboratory and pathology services) rendered to Medicaid program beneficiaries are reimbursed under a cost reimbursement methodology. Reimbursable cost is determined in accordance with the principle - f reimbursement established by the Florida Title XIS Hospital Reimbursement Plan, supplemented by the Medic.4re Principles of Reimbursement. The interim rates are tentatively established on an individual-per diem basis for each hospital, subject to- cost ceilings with exceptions . The Hospital is reimbursed at a tentative interim rate with final settlement determined when the prospectively determined rate is adjusted after the intermediary audit of the combined Medicare and Medicaid cost report that was used to determine the prospective rate. Retroactive adjustments for interim rate changes anticipated after the intermediary audit of the cost report are accrued on an estimated basis in the period when final settlements are determined. The Hospital ' s Medicaid interim rates are based on the Medicare/Medicaid cost report which has been audited by the fiscal intermediary through September 30 , 19990 The Hospital classification of patients;and the appropriateness of their admission are subject to review by the fiscal intermediaries administering the Medicare and Medicaid programs. - 13 - Indian River Memorial Hospital , lnc . and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30, 2002 and 2m1 The Hospital has also entered into payment arrangements with certain commercial insurance carriers, health maintenance organizations, and preferred provider organizations. The basis for payment to the Hospital under these arrangements includes prospectively. determined rates per discharge, discounts from established charges, and per diem rates. Some of these arrangements provide for review of paid claims for compliance with the terms of the contract and result in retroactive settlement with third parties. Retroactive adjustments for other third P claims are recorded in the period when final settlement is determined. Laws and regulations governing the Medicare and Medicaid Programs are complex and subject to interpretation. The Hospital believes that it ism compliance with all- apphcaUe laws and regulations ani is not aware of any pending or threatened investigations `involving _ allegations of potential wrongdoing: While no such regulatory inquiries have been made, - _ compliance with such- laws andregulations can be subject to future governmental review and interpretation as well as significant regulatory action including fines, penalties, and exclusion from the Medicare and Medicaid Programs. The components of net patient service revenue for the years ended September 30 are summarized as follows : - 2002 2001 - Gross patient service-revenue - $ 308, 803,642 $ 27629219356 - Contractual adjustments and other-deductions ( 1863,468,465) ( 154, 1.5731410) Net patient service revenue $ 1222335, 177 $ 122276331946 3 . Concentrations of Credit Risk - The Hospital grants credit without collateral to its patients, most of whom are local residents and are insured under third-party payor agreements. The mix of receivables from patients and third-party payors at September 30, was as follows : 2002 2001 Medicare 32% 33 % Medicaid 9 4 Managed care , 18 21 Insurance 6 5 Self pay and other 35 37 100% 100% 1 44 - Indian River Memorial Hospital , Inc: and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30, 2002 and 20D1 4. Discontinued Operations In July 2002, the Hospital gave its Vero Beach walle in clinic to a third party with certain stipulations that the third partywould continue to operate the clinic within the community. Accordingly, the operating losses of the Vero Beach walk in clinic of approximately $ 869,000 and $388,000 for the years ended September 30, 2002 and 2001 , respectively, as well as provisions for losses during the phase-out period of approximately $41 ,000 have been segregated from continuing operations and reported as separate line items in the consolidated statements of operations. The Hospital has reclassified the 2001 operating results of the Vero Beach walk-in clinic as a - discontinued operation. The components of the Vero Beacliwalk in clinic reflected in the consolidated statements of operations and consolidated balance- sheets are as follows : 2002 2001 Statements of Operations data.: Total revenues $ 1 ,0975,093 $ 142,996 r Total expenses 2,0062674 530,504 Loss from operations _ $ (909,581) $ (387,50$) Balance Sheets data: - - Total assest - $ 257,936 $ 180;877 Total liabilities 101 ,965 203,385 - Net assets (deficit) $ 1552971 $ (22,508) - The accompanying financial statements-have been restated to conform to discontinued operations treatment for all historical periods presented. 5. Pledges Receivable Unconditional promises are expected to be realized in the following periods : 2002 - In oneless or ear 240.1207 Y $ Between one year and five years 3605,500 More than five years 839,263 1 ,439,970 Less : Allowance for uncollectible pledges (181 ,283) $ 122587687 45 - Indian River Memorial Hospital , Inc. and Subsidiaries fNotes to Consolidated Financial Statements For the Years Ended September 30, 2002 and 2m1 IPledges . receivable at September 30, 2002 and 2001 are classified as follows. 2002 2001 Temporarily restricted $ 12258,687 $ 1 , 138, 115 6. Charity Care and Program Reimbursement The Hospital maintains records to identify and monitor the level of charity care itprovides. Theserecords include the amount of charges foregone for services and supplies fiunished under its charity care-policy. _ Because the Hospital does not pursue collection of amounts that p p qualify as chanty care, these amounts are not included in net patient serve revenue. Charges foregone, based on established rates, due to the provision of care to charity and indigent patients amounted to approximately $9, 1383000 in 2002 (charity - $279, 000; indigent - $ 8 , 859,000) and $ 6,373 , 000 in 2001 (charity - $240,000 ; indigent - $ 6, 1332000) . This represents Iapproximately 3 % and 2% of the Hospital's gross patient charges for 2002 and 2001 , respectively. Effective October 1 , 20D0, the Hospital is reimbursed by the District for qualifying indigent care -based on a methodology of cost per day for inpatients and cost per visit for outpatients. I Between October 1 , -1998 and September 30, 2000, the Hospital wasreimbursed for indigent care at rates consistent with those paid by the Florida Medical program: Between October 1 , 1996 and September 30, 1998, the amount reimbursed_to the Hospital for indigent care t -represented a fixed dollar amount. Reimbursement for indigent care amounted to t approximately $3 , 1759000 in 2002 and $2, 120 ,000 in 2001 . _ The District reimburses the Hospital for the portion of operating expenses that are represented as a percentage of qualifying indigent care visits to total visits for certain programs . Reimbursement for these programs amounted to approximately $422,000 in 2002. i The District reimburses the Hospital for a portion of the operating expenses over revenue received for certain programs. Reimbursement for these programs amounted to approximately $ 838 ,000 in 2002 and $ 600,000 in 2001 . Amounts due from affiliated organizations represent program reimbursement from the District. 7. Fair Value of Financial Instruments The following methods and assumptions were used to estimate the fair value of each class of financial instruments for which it is practicable to estimate that value: - 16- Indian River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30, 2002 and 20) 1 Cash and Cash Equivalents Cash and cash equivalents are recorded at cost, which approximates fair value. Investments Investments are stated at fair value based on quoted market prices and are comprised of the following atSeptember 30: - 2002 2001 Common stocks - $ 1296359055 $ 171935 ,431- Corporate obligations 1298629074 1690269719 Temporary investments - 290 , 358 3999975 $ 25 , 787,487 $ 34,3629125 Assets Limited as to Use — HeId in- Escrow for Payment of Bond Interest Assets limited as to use - held in escrow for payment of bond interest_ are stated at fair value based on quoted market prices and are comprised of the following at September 30 : 2002 - - 2001 - Cash and cash equivalents - $ 9432820 $ _ 12491-,566 Assets Limited as to -Use or Restricted - By Board for designated uses: Boardted-funds are-stated at fair value designa based on quoted market prices andare comprised of the following at September 30 : 2002 2001 Common stocks $ 21 ,4323193 $ 25,791 ,929 U. S . Government Agency obligations and shortteen pooled fixed income funds 297,781 294,710 Corporate obligations 222951 , 521 243137,947 Foreign debt obligations 51 ,908 54,034 ITemporary investments 1 , 5382055 1 ,2722521 Money market investments 1802565 • 1771290 Cash and cash equivalents 295233 461 ,328 $ 462481 ,256 $ 5221897759 - 1 7- Indian River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 Under indenture and irrevocable trust agreements at, held by trustee: Investments under indenture and irrevocable trust agreements are stated at fair value based on quoted market prices and are comprised of the following at September 30 : 2002 2001 U. S . Treasury notes $ 59602,342 $ 5093.0 ,278 Bonds . 618 , 027 6189027 Endowment fund - 253 ,551 280, 699 Cash and. cash equivalents _ - 1 ,3779554 21694, 899 Accrued interest receivable 219008 51 , 618 - 7, 8729482 $ 9,5751521 By donors for property and equipment additions: Investments restricted by donors for property and equipment are stated at fair market value based on quoted market prices and are comprised of the following at September 30 : 2002 2001- _ Cash and cash equivalents $ 23651 , 146 $ 1 ,4613420 Common stocks _ - 219062921 2,733 ,338 Preferred stocks _ 447,600 467, 940 _- US. Government Agency obligations 616,245 68,383 Corporate obligations 704,285 501, 831 Money utual market investments 863, 880 - 7213893 165, 754 _ Other - - 119, 500 - $ 8 , 911 ,970 $ 57518166 By Trustee for workers ' compensation: Assets restricted for workers ' compensation claims are recorded at fair value based on quoted - market prices and are comprised of the following at September 30 : 2002 2001 Certificates of deposit $ 50 , 000 $ 100 , 000 I IAs - Indian River Memorial Hospital, Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 Investment income and gains on investments and assets limited as to use or restricted are comprised of the following for the years ending September 30 : 2002 2001 Included in other revenue: Interest income $ - 89o794 $ 586,063 Investment income. Interest income and dividend earnings 2,348, 822 21656,943 Income on pooledfunds -- - 273 097 Realized gains and losses on sales of securities 824,470 718,450 Less: investment management fees (1125465) (103, 165) $ 35060,827 $ 3 ,545,325 Bond Pa Obligations able g Y The fair value of the Hospital's fixed rate bond obligations payable (Series 1996 Bonds and S eries 1997 Bonds) is estimated based on quoted market prices for the same or similar issues and amounts to approximately $37,351 , 000 and $37,504,000 at September 30, 2002 and - 2001 , respectively. The fair value of the Hospital ' s variable rate bond obligations payable (Series- 1985, Series 1988, Series 1989 and Series 1990) approximates the book value due to the variable interest rates associated with those_ instruments. - -8. Investment in Treasure Coast Rehabilitation Hospital The Hospital maintains a 40% limited partnership interest in Treasure Coast Rehabilitation__ - Hospital. For the years ended September 30, 2002 and 2001,- the Hospital received approximately $ 124, 000 and $ 30,000, respectively, in distributions . For the years - ended September 30, 2002 and 2001 , the Hospital recorded approximately $ 662 ,000 and $ 0, respectively, in income which is recorded in other, net in the consolidated statements of operations . 1 1 - 19- Indian River Memorial Hospital , Inc: and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 9. Property and Equipment Property and equipment at September 30 is summarized as follows : 2002 2001 Land $ 5, 167,371 $ 52167,371 Land improvements 32329,982 3,2972982 Buildings and building improvements 444686,361 42,923,453 Fixed equipment 31, 168,905 . 301001,392 Major movable equipment 73,598,013 _6. 7,30031603 Minor equipment 3059208 - - _ 54330920 158,2552840 149,234,721 - Less - axanu:ilated depreciation (100, 879,570) (92, 120,69 57,376,270 57, 1142028 Construction in progress 1 ,9675871 229831, 888 Property and equipment; net $ 592344, 141 $ 60,097,916 es non-o eratin real e Land includes p g r state which is being held with management' s intent of future- expansion. This land was purchased for approximately $ 732,000 in November 1996 in Sebastian, Florida. Land was purchased for approximately $ 1 ,600,000 in January 2000 in Vero Beach, Florida. _ In November 2000, additional land was purchased for approximately $ 1 ,2000000 in Sebastian, Florida. _ Construction in progress at September 30, 2002 consists primarily of several renovation and systems projects. Estimated costs to complete these projects amount to approximately $ 129132000 . 4 I 1 -20 - Indian River Memorial Hospital , Inc. and Subsidia In P tics Notes to Consolidated Financial Statements For the Years Ended September 30, 2002 and 20D1 10. Bond Obligations Payable Bond obligations payable at September 30 is summarized as follows: 2002 2001 Hospital revenue bonds, Series 1985 $ 153,400,000 $ 153p400,000- Hospital revenue bonds, Series 1988 1331900,000 142350,1000 Hospital revenue bonds, Series 1,989 6,500 000 50000 Hospital revenue bonds, Series 1990 211100,000 2127002000 Hospital revenue refunding bonds,. Series 1996 13,730,000 13,975,000 Hospital revenue refunding bonds, Series 1997 20,6002000 219135,000 - _ 91 ,230,000 9330692000 Less amounts payable by the District: - - - Series 1985 Bonds (939 398) (939,398) Less unamortized Series 1996 bond discount (152, 563) (1632462) Less amounts payable from irrevocable trusts for crossover debt (322077, 735) (32,527,734) 583060, 304 59,429,406 Less bond obligations payable within one year, , net of available -amounts in irrevocable trusts = - for crossover debt maturities_ - (1 ,235,000) (1 ,3802000) - Bond obligations payable after one-year - $ 56, 8253304 $ 5820491,406 The Series 1985 Bonds were issued to refund the Series 1984 Bonds. The Series 1984- Bonds were issued to finance new construction and capital improvements to the Hospital ' s facility. The Series 1985 Bonds bear-interest at a variable rate approximating a defined market rate, _ not to exceed 15 % per annum, which averaged approximately 1 ,4% in 2002 and 3 . 1 % in 2001 . Approximately $ 940, 000 of the Series 1984 Bonds were used to finance the construction of the Human Services Building which is a District asset. The Series 1985 Bonds reflected in the accompanying consolidated financial statements have been reduced accordingly. The bonds are subject to mandatory redemption requirements from 2010 through 2015 . The Series 1988 Bonds were issued in January 1988 to finance new construction and capital improvements to the Hospital Facility. The bonds bear interest at a variable rate equal to a defined market rate, provided that it does riot exceed 15% per annum, which averaged 1 . 6% m 2002 and 3 .3 % in 2001 . The bonds are subject to mandatory redemption requirements at graduating amounts through 2017. -21 - Indian River Memorial Hospital , Inc . and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002and 2001 The Series 1989 Bonds were issued in February 1989 to purchase the PNB . The bonds bear interest at a variable rate equal to a defined market rate, provided that it does not exceed 15 % per annum, which averaged 1 . 8% in 2002 and 3 .3 % in 2001 . The bonds are subject to mandatory redemption requirements from 2005 through 2019 at graduating amounts, The Series 1990 Bonds were issued in June 1990 to finance new construction and capital improvements to the Hospital Facility. The bonds bear interest at a variable rate equal to a defined market rate, provided that it does not exceed 15% per annum, which averaged 1 . 6% in 2002 and 3 .2% in 2001 . The bonds are subject to mandatory redemption requirements at graduating- amounts through 2024. -- _ - The principal and interest payments on the Series 1985, 1988,1989 and 1990 Bonds (the Bonds ) are secured by irrevocable letters of credit totaling approximately $633,500,000 with a bank which expire on October 1 , 2004; unless extended at the sole discretion of the bank. The letters of credit are utilized to purchase bonds which are tendered by the bondholders and not remarketed under a remarketing agreement between the Hospital, the District and an investment banking firm. Amounts drawn on the letters of credit bear interest at prime rate plus 1 % or LIBOR plus 1 %, payable monthly in arrears on the first day of each month. The Hospital and the District are required to pay, in arrears, fees on the available letter 6f credit equal to 1 % of the highest letter of credit commitment during the quarterly period. The Bonds will be subject to mandatory purchase by the Hospital and the District if the letters of credit expire or are terminated and no alternative letters of-credit are provided which would maintain the existing rating on the Bonds. The irrevocable letters of credit include restrictions on the issuance of new debt and requirements on the maintenance of certain operating ratios and unrestricted net assets. The letters of credit will be withdrawn in the event of default by the Hospital or the District or upon the conversion of the Bonds to fixed interest rates as allowed under the existing trust indentures. The Hospital is in breach of the - debt service coverage ratio covenant at September 30, 2002 and onMay 1 , 2003 received a letter from Financial Security Assistance noting the Hospital is following remedies under the Master Indenture, The Indian River County Hospital District Hospital Revenue Refunding Bonds, Series 1996 were issued on September 30, 1996 and are referred to as the Hospital Revenue Refunding Bonds, Series 1996. The net proceeds of approximately $ 13 , 700,000 were utilized in June 1997 to advance refund a portion of the Orange County Health Facilities Authority Refunding Program Revenue Bonds, Series 1985A (Pooled Hospital Loan Program) issued in December 1988 (the "Hospital Revenue Refunding fonds, Series es 1988-Y) . The Hospital Revenue Refunding Bonds, Series 1996 consist of two serial bonds and two term -honds. The serial bonds bear interest at fixed rates of 4 . 7% and 5 .2% and mature in 2001 and 2006, respectively. The term bonds bear interest at fixed rates of 5 . 5 % and 5 . 7%, mature in 2011 and 2015 , respectively, and are subject to mandatory redemption requirements from 2010 through 2015 . -22- Indian River Memorial - Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 The Indian River County Hospital District Hospital Revenue Refunding Bonds, Series 1997 were issued on March 5, 1997, and are referred to as the Hospital Revenue Refunding Bonds, Series 1997. The proceeds of $22, 875,000 were utilized in June 1997 to advance refund a portion of the Hospital Revenue Refunding Bonds, Series 1988-X and the Orange County Health Facilities Authority Refunding Program Revenue Bonds, Series 1985A (Pooled Hospital Loan Program) issued in October 1989 (the "Hospital Revenue Refunding Bonds, Series 198940 ). The Hospital Revenue Refunding Bonds, Series 1997 consist of multiple serial bonds and a term bond. The serial bonds mature at graduating amounts through 2. 011 and bear interest at fixed rates ranging between 4.25 % - 6%. The term bond matures in 2018 and bears interest ata fixed rate- of 6. 1 %. _ The Series 1985,- 1988, 1989,- 1990., 1996 and 1997 Bonds are collateralized by the net nontax revenues of the District and the Hospital. The related trust indentures include restrictions on the issuance of new debt and requirements on the maintenance of certain operating ratios. Interest incurred on all outstanding bond obligations amounted to approximately- $2,902, 000 in 2002 and $3 ,937,000 in 2001 , and is reduced by interest earnings on escrowed funds of approximately $ 1 ,959,000 in 2002 and $2,003 , 000 in 2001 . Interest earnings on related trustee funds amounted to approximately $ 130,000 in 2002 and $319,000 in 2001 and are classified-as other-revenue. - - Maturities of bond obligations payable, assuming an interest rate of 3 .2 % for variable rate debt'; that are the responsibility of the Hospital under .the lease agreement, net of escrowed assets and related interest income, are as follows : _ Year Principal 2003 - $ 1 ,235,000 2004 I7285,000 2005 1,335,000 2006 1 , 885;000 2007 2,230;000 Thereafter 50,090,304 $ 58,060) 304 -I1 . Note Payable In May 2001 , the Hospital entered into a note payable agreement with a finance company for $ 5 , 000, 000, due June 2006. The note bears interest at 5 .65 % . Aggregate maturities for the next five years are approximately as follows : 2003 - $ 8492000 ; 2004 . - $9242000 ; 2005 - $ 978 ,000 ; 2006 - $ 1 ,200,000 . -23 - Indian River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated financial Statements For the Years Ended September 30 , 2002 and 2m1 12. Temporarily and Permanently Restricted Net Assets Temporarily restricted net assets are available for the following purposes at September 30 : 2002 2001 Foundation operations $ 8,012,716 $ 5,666, 132 Programs, property and equipment additions 1 ,310,454 577,690 Employee education endowment fund 6930290 78,432 - -_ $ 993922460 $ 623227254 - Unconditional ,322,254 _Unconditional- pledges receivable for property andequipment additions are recorded net of allowances of approximately $181,000 and $211 ,000 at September 30, 2002 and 2001 , . - respectively. Permanently restricted net assets at September 30, 2002 and 2001 of $210,487 represent an endowment fund to be held in perpetuity, the income of which is expendable to support expenses associated with the chapel. 13. Pension Plan The Hospital has a noncontributory defined benefit pension plan (the "Plan") covering_ - substantially all employees-who are over twenty and one-half years of age and have -a_ t least - six months of service. -The benefits are based on years of service and employee's compensation levels and are calculated using the projected unit credit actuarial cost method. - The Hospital's funding policy is to contribute at leastthe minimum amount required, annually. - Participants with five or more years of credited .service are entitled to a monthly pension benefit beginning at normal retirement age (65) equal to 1 . 5 % -of their average monthly earnings, during the highest five consecutive years of the last ten years of credited service, times the years of credited service, subject to certain limitations . The Plan permits early retirement at ages 55-64 upon completion of five years of credited service. At September 30, 20022 the Plan's accumulated benefit obligation exceeded the Plan assets by $ 6243028158 At September 30 , 2001 , the Plan's accumulated benefit obligation did not exceed the Plan assets . The Hospital also has a Supplemental Executive Retirement Plan ("SERP ") for a select group of full-time management. The SERF provides eligible executives defined pension benefits outside the Plan based on average earnings; years of service, and age at retirement. At September 30, 2002 and 2001 , the SERP 's accumulated benefit obligation exceeded the SERP 's assets by $ 490,934 and $ 161 , 859, respectively. -24- All Indian River Memorial Hospital, Inc. and Subsidiaries - i Notes to Consolidated 2 Financial Statements For the Years Ended September 30, 2002 and 2m1 The following table sets forth the change in ro ' assets, weighted average assumptions and components of bennet periodic pens t obligation, change for Plan: the Change in projected benefit obligation 2002 2001 . Projected benefit obligation, beginning of year $ 48,996,091 .Service cost � $ 40,780,844 I Interest cost 2,468,370 - 1 , 883,646 Actuarial assumptions 3,627,612 3,21531862 _ Actuarial (gain) loss 843,005 32559,847 - Benefits paid - (1 ,387,977) 1,006, 193 1 (1 ;757,477) 1450,301 Projected benefit obligation, — ) _ _ gation, end ofyear - 52,789 624 482996,091 - Change in plan assets Plan assets at fair value, beginning of year 40,965,774 Actual return on Plan assets 43, 186, 150 Hospital contributions (22066,323) (770,075) Benefits paid 1 ,3612571 _ (1 , Plan assets at fair value, end of (1 ,757,477) 450,301 ) year 38, 75724 5 401965,774. - Funded status of the plan - (14,286,079 - Unrecognized net loss ) (8,030,31 ' 9 960 099 _ - � prior service cost 5,021 ,395 - 13058,571 1 ,220,030 Accrued benefit cost - _ $$ (3,2679409) 1 (1 , 788,892) ----__. Weighted average assumptions as of " September 30: Weighted average co discount rate - Rate of increase in ft=ue 7.25% 7.50 compensation levels 4. 00 4.50 Expected long terra rate of return on plan assets 8.50 8.50 Components of net periodic pension cost: Service cost $ 2,468,370 Interest cost $ 1 , 883,646 Expected return on plan assets 31627,612 32215, 862 Amortization of. (324283842) (32507,528) UUnrecognized net loss 11 ,489 _ gnized prior service cost 161 ,459 161 ,459 Net periodic pension cost $ 2, 8402088 $ 1 , 7532439 -25- k• :�rs�t+f i�riv�..e..+e,.Xa^avme�'.o"`� +^rR Indian River Memorial - Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 The following table sets forth the change in projected benefit obligation, change in plan assets, weighted average assumptions and components of net periodic pension cost for the SERF : 2002 2001 Change in projected benefit obligation - Prnj ected benefit obligation, beginning of year $ 1951267 $ 652629 Service cost 763332 7330550 Interest cost 250 , 14,645 5 Actuarial assumptions - 11,577 15v250 Actuarial loss 257,732 371,826 Projected benefit obligation, end of year 555,553 195,267 Change iii plan assets - Plan assets at fair value, beginning of year Actual return on Plan assets = _ Hospital contributions Benefits paid _ Plan assets at fair value, end of year _ Funded status of the plan _ - (5552553) (1957267) Unrecognized net loss 502838 Unrecognized prior or service cost _- 6150983 - Acciuedbenefit cost $ - (555,553) _ $ - (82,446) Weighted average assumptions as of September 30, _ Weighted average discount rate 7.25% 7.50% Rate of increase in future compensation levels 3.50% 3.50% Components of net periodic pension cost: Service cost $ 76,332 $ 732550 Interest cost 14,645 5,250 Amortization of Unrecognized net loss 320, 147 - Unrecognized prior service cost 613983 3,646 Net periodic pension cost $ 473, 107 $ 822446 During fiscal year 2002, the Hospital modified the SERP . Those modifications included all gains and losses related to salary and assumption changes being recognited immediately and upon termination of employment, the liability related to the participant will be recognized immediately. Management believes this to be a preferable method for recognizing gains and Iosses . The cumulative effect of changing methods in the current year increased expense for the SERP by approximately $318 ,000 for the year ended September 30, 2002 . -26- ' - Indian River MemorialHospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2 (D1 Amortization Method The amortization of any prior service cost is determined using a. straight line amortization of the cost over the average remaining service period of employees expected to receive benefits under the Plan. Plan assets are invested principally in pooled fixed income and equity funds with certain amounts maintained as cash to meet anticipated short term needs . 14. Related Party Transactions _ Facility Lease The Hospital leases the Hospital Facility from the District, an-affiliated organization. The - lease payments are equal to the debt service requirements on debt issued by the District to finance additions or improvements to the Hospital Facility. Lease payments amounted to approximately $2,324,000 in 2002 and $2,535,000 in 2001 which includes approximately - $944, 000 and $ 1 , 93$,000, respectively, of interest expense. 15. Commitments and Contingent Liabilities Professional Liability Insurance The Hospital currently provides for professional liability insurance through a claims-made policy with a commercial insurance carrier which provides primary coverage, with a $50,,000 deductible per claim, limited ta _$1 ,000,000 per claim. Excess insurance coverage at $ 10,000,000 per claim and $ 10,000,000 in the aggregate, annually, is maintained with the same carrier. In addition, the Hospital maintains $ 10,000,000 in umbrella coverage. During the period October 1 , 1992 through March 31 , 1994, the Hospital rovided for P P- professional liAbility insurance through participation in the Florida Hospital Trust Fund A CFHTF A), a pooled risk malpractice trust fund, which provides primary coverage, limited to $250, 000 per claim and $ 1 ,000,000 in the aggregate per annum. Excess insurance coverage at $ 10, 000 , 000 per claim and $ 10, 000, 000 in the aggregate, annually, is provided for through participation in the Florida Hospital Excess Trust Fund B- (FHTF B), a pooled risk malpractice trust fund, The FHTF A and B are grantor trust funds and may levy additional assessments as determined necessary. Management of the Hospital believes that any future potential assessments by the-FHTF A andB , if any, will not be in excess of the amounts recorded. ' Estimated losses from asserted and unassezted claims are accrued when the incidents which give rise to the claims occur and the amount of the liability can be reasonably estimated. In addition, the Hospital has accrued estimated losses on incurred but not reported claims . -27- _ -- Indian River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2(D1 During the period April 1 , 1990 through September 30, 1992, the Hospital was self-insured for a portion of its professional liability insurance limited to $ 1 ,000,000 per claim and $3 ,000, 000 in the aggregate, annually. Upon discontinuation of the self-insurance program on October 1 , 1992, the Hospital maintained responsibility for cases which were reported during the period of self-insurance. The accompanying consolidated financial statements include a liability which represents an estimate of the expected losses for these incidents which will be covered under the Hospital's self-insurance program Management of the Hospital believes that ultimate losses will not be in excess of the liability recorded. Professional liability insurance expense-amounted to approximately $2,341 ,000 in 2002 and -- $ 84530000 in 2001 , and is included in other expenses in the accompanying consolidated financial statements. _ Health Insurance The Hospital is self-insured for group health insurance. The Hospital pays approximately 85 % of the coverage for employees and dependents . The Hospital maintains reinsurance through a commercial excess coverage policy which covers annual individual employee claims paid * 'in excess of $ 90 ,000, subject to a $200, 000 deductible, for the year ending September 30, 2002. Health insurance expense amounted to approximately $ 7, 629, 000 in 2002 and $5, 122,000 in 2001 . - - Workers ' Compensation- Insurance - - The Hospital has maintained insurance coverage for workers' compensation claims since October 1 , 1991 . The insurance coverage provides for a deductible level to be paid by the Hospital. The current deductible level is $250,000 per individual occurrence. Workers' compensation insurance expense amounted-to approximately $ 1 , 147,000 in 2002 and $949,000 in 2001 . - - Operating Leases The Hospital leases various equipment under operating leases expiring at various dates through fiscal 2005 . Total rental expense in 2002 and 2001 for all operating leases was approximately $ 545,000 and $431 , 000., respectively. - -28- - Indi• an River Memorial Hospital , Inc. and Subsidiaries Notes to Consolidated Financial Statements For the Years Ended September 30 , 2002 and 2m1 The following is a schedule by year of approximate future minimum lease payments under operating leases as of September 30, 2002 that have initial or remaining lease terms in excess of one year: Year Ended September 30, 2003 - $ 56330000 - 2004 3452000 2005 1592000 - 2006 - - - 59,000 - 2006 - - - 319000 _ _ $ 13,0982000 16. Subsequent Event Effective December 31 , 20023, the Hospital froze entry into their defined benefit pension plan for all participants less than 60 years of age. In conjunction with this action, the Hospital created a defined contribution plan in accordance with Internal Revenue Code Section 403 (b) . Employees are eligible to participate in the plan with the exception of fixed rate, temporary, per diem and certain employees under collective bargaining agreements. The Hospital will match 50% of employee contributions up to 4%. In addition, for those employees who have at least 1 ,000 hours of service -and are employed on December 31 of a calendar year, the Hospital will contribute an amount-equal to 2% of an employee's pay. In December 2002 the Hospital formed a captive insurance company incorporated in the Cayman Islands in order to provide professional liability insurance for the Hospital. lip -29- --i - --r- -- _ - - - • ftXffATERHOUSECCOPERS PricewaterhouseCoopers LLP Bank of America Suite 2400 390 North Orange Avenue Orlando FL 32801 -9865 Telephone (407) 236 0550 Facsimile (407) 236 5149 Report of Independent Certified Public Accountants on Accompanying Consolidating Information To the Board of IIirectors of Indian River Memorial Hospital, Inc. : The report on our audit of the consolidated financial statements of Indian River Memorial Hospital, Inc. and Subsidiaries as of September 30, 2002 and for the year then ended appears on page 1 of this document That audit was conducted for the purpose of forming an opinion on the consolidated financial statements taken as a whole. The consolidating information is presented for purposes of additional analysis of the consolidated financial statements rather thanto present the financial position-or results of operations of the individual companies. =Accordingly, we do not express an opinion on the financial position or results of operations of the individual companies. However, the consolidating information has been subjected to the auditing- procedures applied in-the audit of the -consolidated financial statements and, in our opinion, is _ fairly stated in all material respects in relation to the consolidated financial statements taken as a whole. AoL December 6, 2002 - -30- ?4 '�•� � r:r: i �� f Ir3.�x,. 1.. �.1 :., 'r' � �F .r:E yY !y Y �_,�, ( �, 4 � ( 1; _ _ -r +f ;h'4 1 1 1 I 1 1 1 1 1 1 • 1 • • 1 1 11 1 1 • 1 i l l 1 1 1 1 1 • 1 1 11 11 1 1 1 i 1 . • 11 1 1 / • / 1 � 1 � ' 1 1 1 1 • 1 ' 1 i • • 1 • I \ 1 I • \ : • 1 11 ' i 1 • 1 I ' 1 • � � � � � ' � � 1 1 1 ' 1 \ 1 • 1 . 1 1 1 ' 1 1 \ 1 � I � 11 1 ' 11 1 1 • ' , ' 1 man Indian River Memorial Hospital , Inc . and Subsidiaries Consolidating Balance Sheet, continued September 30 , 2002 Consolidating Information Indian Indian Indian Health River River Treasure Elimination River Systems of Health Hospital Coast Entries Memorial Indian Services Foundation, Billing, , Debit Consolidated Hospital, Inc. River, Inc. Corporation Inc. Inc. (Credit) Balance Liabilities and Net Assets Current liabilities: Accounts payable $ 3 ,346,825 $ 208,482 $ 39850 $ 3,781 $ - S - $ 395629938 Accrued payroll 3,5722918 62,967 - 27,4444 396639329 Other accrued liabilities 8 ,9419791 - - 768, 116 - - 99709,907 Estimated third-party payor settlements 234289151 - - - - - 2,4289151 Accrued interest payable 75,951 - - - - - 759951 Due to affiliated organizations - 5629907 - 109,449 - (672,356) (1 ) - Current portion of bond obligations 192352000 - - - - - 1,235,000 payable Current portion of self-insurance for professional liaiblity and workers' compensation claims 9009372 - - _ _ - 900,372 Current portion of note payable 848,565 - 8489565 T• Total current liabilities 219349,573 834,356 3 . 850 908,790 (672,356) 2294242213 Other long-term liabilities 415, 193 - - - - - 4159193 Bond obligations payable after one year 56,825,304 - - - 56,825,304 Note payable 3 , 101 ,637 - - - - 39101 ,637 Self-insurance liability for professional liability and workers' compensation claims 37007,557 - 390079557 Total liabilities 849699,264 8349356 39850 9085790 (672,356) 85,7732904 Net assets: Unrestricted 86, 177,441 3,3019053 215,411 - 23,407 (3,912,000) (2) 859805,312 Temporarily restricted 863,881 - - 81441 ,244 879335 (4) 9,392,460 Permanently restricted 297, 832 - - - - (87,335) (4) 2109497 Total net assets 877339, 154 39301 ,053 215 ,411 824419244 23 ,407 (3191270001 9594082269 - Total liabilities and net assets $ 172,0382418 $ 42135,409 . $ 219 ,261 $ 99350,034 $ 232407 $ (41584,356) $ 181 , 182, 173 32 M Min- a- I& A AS' is. M! is -in -11 -is Indian River Memorial Hospital , Inc . Consolidating Statement of Operations For the Year Ended September 30 , 2002 Consolidating Information Indian Indian Indian Health River River Treasure Elimination River Systems of ; Health Hospital Coast Entries Memorial Indian' Services Foundation, Pilling, Debit Consolidated Hospital, Inc, River, Inc. Corporation Inc. . Ince (Credit) Balance Unrestricted revenues, gains and other support: Net patient service revenue $ 121 ,4120187 $ [ ;9221 ,990 $ $ - $. $ - $ 122,335, 177 Other revenue 816299237 43 39952 493949809 , (4 ,394,809) (3) 896339232 Total revenues, gains and other support 1309041 ,424 9232033 3,952 4,3949809 �__ (4,394,809) 130,9689409 Expenses : Salaries and benefits 6691879074 852, 156 - 292,590 (292,590) (3) 67,039,230 Professional fees 81529,837 358,797 1 ,450 360 - (360) (3) 8,890,084 Supplies 22,251 ,231 47,338 - 18,799 - ( 180799) (3) 22,2989569 Other 189313,649 403 ,330 61 2809519 1 ,430 (280,519) (3) 18,7189470 Provision for bad debts 121944,710 3209462 - - - 13,2650172 Interest 199539809 - - - - 11953,809 Depreciation and amortization 92863, 167 239,767 - - - 70, 102,934 Total expenses 14070432477 212219850 1 ,511 5922268 1 ,430 (5929268) 1422268,268 Operating (loss) income (102002,053) ( 1 ,2989817) 22441 31802,54'1 ( 19430) (3 ,802,541) ( 11 ,299,859) Other income (losses): Investment income 3 ,0609535 1 199 - 1739748 93 ( 173,748) (3) 3,060,827 Other, net ( 11048 , 866) - (909000) - NO (1 , 1389866) (Deficit) excess of revenues over expenses (7,990,384) ( 1 ,298,618) (879559) 39976,289 ( 19337) (39976,289) (99377, 898) Change in unrealized (losses) and gains on other than trading securities (5 ,691 ,441 ) 795- 283 ( ) 795,283 (3) (5,6919441 ) Net assets released from restrictions used for purchase of property and equipment 746,265 - - - 746,265 Additional minimum pension liability (2,11042835) - - - - (2, 104,835) Cumulative effect of change in accounting (318,305) - method (318,305) - Discontinued operations: Loss from operations of discontinued - (8689691 ) - - - (868,691 ) business Loss on disposal of discontinued business including provision for operating losses during phase-out period - (40,890) - - - - (40, 890) (Decrease) increase in unrestricted net assets S ( 15,358,700) $ (2,2089199) $(87,559) $ 391819006 $ ( 19337) $ (391819006) (3) $ ( 179655,795) "WOMEN OMMMMOM� 33 (; Indian River . . . Hospital , , , Subsidiaries Notes . consolidating Balance Sheet and Statementof Operations . For the Year Ended September 30 , 2002„ . eliminate . - , . , . , - - , . - . . . , , . . - s. . - . . . - , - i . - . , consolidated subsidiaries. . - . , . . - intercompany contributions - . to the Foundation. / . reclassify net released from permanently r - . ed net assets to temporarily restricted net assets. � bit � � � � � : � � � : � � � � � � 4 ,j Form , 9 9 0 Return of Organization :Exempt From IncomeTax i 0MBNo. 1545±0U4 Under section 501 (c) of the Internal Revenue Code (except black lung benefit trust or ' Department of the Treasury private foundation) or section 4947 (a) ( 1 ) nonexempt charitable trust r • , - - , Internal Revenue Service ► The organization may have to use a copy of this return to satisfy state reporting requirements. A For the 2000 calendar year, OR tax year period beginning 10 / 01 2000 and ending 09 / 30 / 2001 B Check Chfngeof : Please C Name of organization D Employer Identification number Change et P � address use IRS Change of label or name INDIAN RIVER MEMORIAL HOSPITAL INC . 59 - 2496294 name Initial rehan �e r Number and street (or P.O. box if mail is not delivered to street address) Room/suite E Telephone number Final return See Specific 1000 36TH STREET 561 567 - 4311 Instruc- Amend return dons. City or town, state or country, and ZIP code F check ► 1:1 If application pending IVERO BEACH FL 32960 G Organization type (check .only one) ► X 501 (c) ( 3 ) , (insert no.) 27 OR 4947 (a)(1 ) Note: (H and I are not applicable to section 527 orgs.) • Section 501(c)(3) organizations and 4947(x)(1) nonexempt charitable trusts must H(a) Is this a group return for affiliates? a Yes ❑X No attach a completed Schedule A (Form 990 or 900-EZ), HP If "Yes, " enter number of affiliates ► H�c� Are all affiliates included? J Accounting method: Cash X Accrual Other (specify) ► _ (if "No," attach a list. See inst.) Yes X No K -- Check here_ ► if the organization's gross receipts are normally not more than Hid is this separate er�m fled by an Yes X No organizationby a group ruling? Li $25,000. The organization need not file a return with the IRS; but if the organization I Enter 4-digit group exemption no. (GEN) ► received a Form 990 Package in the mail, it should file a return without financial Aata, - L Check this box if the organization is not required - Some states require a complete return, - to attach Schedule B (Form 990 or 990-EZ) ► X Revenue, Expenses, and Changes In Net Assets or Fund Balances See Specific Instructions on page 16. 1 Contributions, gifts, grants, and similar amounts received: a Direct public support , , , , , , , , , , , • • 0 1 a b Indirect public support , , , , , . . . a . . . . lb c Government contributions (grants) . . 1 c d Total (add lines to through 1c) (cash i noncash 5 ) 1 d 2 Program service revenue including government fees and contracts (from Part VII, line 93) , 2 125 , 379r6270 3 25379627 - 3 Membership dues and assessments -, _ • . . . . . . 3 4 Interest on savings and temporary cash investments • , , _ . . 4 62 0 92 6 . 5 Dividends and interest from securities . . _ 0 . y 0 0 a _ 5 2 5 9 6 5 41 . 6 a -Gross rents . . . . . . . 0 . . . a . . . li a - . . _ , , . 533f9600 b - Less: rental expenses , , , , , , , , , , , . : 6 b - 2 3 6 3090 C Net rental income or (loss) (subtract line 6b from line 6a) - 0a- . , 6c � 2977r6510 - 7 Other investment income (describe 10* SEE STATEMENT 1 7 425 205 . 8a Gross amount from sales of assets other A Securities s Other re- than inventory . . . ease, , , , 8a r'r..e _ 145 103 . b Less: cost or other basis and sales expenses . - 8 b 94 2 4 9 . ra c Gain .STMT 24 , , , , , , , 1 , 087 , 212 . 8c 50 854 . :=., d Net gain or. (loss) (combine line 8c, columns (A) and ( B)) , , , , , , a a • 0 0 8 d 1 , 138r0660 9 Special events and activities (attach schedule) ` a Gross revenue (not including $ of contributions reported on line 1a) , , , , , , • • • • . . • • . 9a b Less : direct expenses other than fundraising expenses , , , , , 9 b 3; : c Net income or (loss) from special events (subtract line 9b fromline9a) , , , , , , 9 c 10a Gross sales of inventory, less returns and allowances oa b Less: cost of goods sold . • • , , 0 kob c Gross profit or (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) 1 oc 11 Other revenue (from Part VII, line 103) , , , , , , , , 9 0 a , . . . . . . 0 0 , • . . . ssee s . . 11 1 660 170 - 12 Total revenue add lines 1d 2 31 41 51 6c 7t 8d 9c 10c and 11 12 W 132 118r186 .. 13 Program services (from line 44, column (B)) , , l m : , , , , , , �p, PAYER � p 1 4 113 2 94 2 95 . N14 Management and general (from line 44, column C N 16 414 , 8 9 6 . acs 15 Fundraising (from line 44, column (D)) RETAIN FOR YOUR FILE • 1 s CL , X 16 Payments to affiliates (attach schedule) , , , , , , , , , , , , , • • . • , . . . , . 16 17 Total expenses add lines 16 and 44 column A 17 129 r 709 191 - 18 Excess or (deficit) for the year (subtract line 17 from line 12) , 18 2 J08P995 . 19 Net assets or fund balances at beginning of year (from line 73, column (A)) • , , , , , , 19 111 , 4 4 8 r 9 95 . ZO Other changes in net assets or fund balances (attach explanation) ;STMT, 20 , , , $ TMT, ;30 , 20 — 10 941 274 - Z 21 Net assets or fund balances at end of year combine lines 18 19 and 20 21 102 r 916 t 716 .. .1sA For Paperwork Reduction Act Notice, see page 1 of the separate instructions, Form 990 (2000) OE 1010 2. 000 . B9A003 2830 111986 Form SbGdl ('trrw +r , - - Page 2 • If yt%u are filing for an Additional (n ` • stomatic) 3 -Month Extension, complete on yt II and check this boX , , }{ ' r � , r Note: Only complete Part !1 if you have aCready�been granted an automartc 3-month extension on a previously filed Form 8868. • If are filing for an Automatic 3 -Month Extension , core plete onlPart 1 on pagecrDIfffl' 1 . Additional not automatic 3 -Month Eittension of Time - Must File original and One Co T e or Name of Exempt Organization Employer identification number print INDIAN RIVER MEMORIAL HOSPITAL INC . 59 - 2496294 File by the Number, street, and room or suite no. If a P.O. box, see instructions. For IRS use only extended 1000 36TH STREET - due date for riling the City, town or post office, state, and ZIP code. For a foreign address, see instructions. - '- ; - = return. See - `` � s instructions. O BEACH , VER B E FL 3 2 9 6 0 r„t x�� ;�:��• ,�.;, Check type of return to be filed (File to separate application for each return) : R Form 990 ❑ Form 990-EZ ❑ Form 990-T (sec. 401 (a) or 408 (a) trust) Form 1041 -A Form 5227 F1Form 8870 Form990-BL Form 990-PF Form 990-T (trust other than above) Form 4720Form 6069 STOP: Do not complete Part II if you were not already granted an automatic 3 -month extension on . al previously filed Form 8868. • If the organization does not have an office or place of business in the United States, check this box, , 00 * 00000 , , , , YPLJ • If this is for a Group .Return, enter the or anization's four digit Group Exemption NumberZGEN . If this is for 'the whole group , check this box - )OW - I . If it is for part of the group, check thisbox - ► and attach a list with the names and ENS of all members the extension is for. . _ 4 1 request an additional 3-month extension of time until 08 / 15 / 2002 - 5 For calendar year , or other tax year beginning 10 01 2000 and ending 09 30 . 2001 6 If this tax year is for less than 12 months, check reason: Initial return Final return Change in accounting period 7 Stats+ nsion ADDITIONAL TIME IS NECESSARY TO GATHER 4 ACCURATE AND TIMELY RETURN EXTENSION APPROVED -, 990-PF, 990-T, 4720 , or 6069 , enter the tentative tax, less any 6 2002 S - N UN 990-T, 4720 , or 6069 , enter any refundable credits and estimated or year overpayment allowed as a credit and any . amount paid LINDAWEISKOFF. FIELD SUBMISSION PROCESSING. OGDEN _ _� �'• . . . . . . . . . . . . . . . . . . . . . . . . . ._ . . : . : . . . . . . ; ie 8a. Include your payment with this form,- or, if required, deposit _ _.. ..y using EFTPS (Electronic Federal - Tax Payment System). See Instructions a : . : : . . . . . . . . . . . . . Signature and Verification ` Under penalties of perjury, 1 declare that 1 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 1L 1it�Yft �� Title ► L �l}' Date ► _ 0 Notice to Applicant - To Be Completed by the IRS We have approved this application . Please attach this form to the organization's return. We have . not approved this application. However, we have granted a 10-day grace period from the later of the date shown below or the due date of the organization's return '(ihcluding any prior extensions). This grace period is considered to be a valid extension of time for elections otherwise required to be made on a. timely return . Please attach this form to the organization's return ❑ We have not approved{his application. After considering the reasons stated in item 7, we cannot grant your request for an extension of time 11rT pp I : I j to file. We are niitrgrr Jhg�a 10'-day grace. period ❑ We cannot consider this application because it was filed after the due date of the return for which an extension was requested. Other Director Date Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-month extension returned to an address different than the one entered above. Name ,( PRICEWATERHOUSECOOPERS LLP G O 71 ✓ea D Type or Number and street (include suite, room, or apt. no.) Or a P.O. box number print 101 EAST KENNEDY BLVD SUITE 1500 City or town , province or state, and country (including postal or ZIP code) JsA TAMPA FL 33602 OF8055 2- 000 Form 8868 ( 12 .2000 ) Form } 8868 App ( ation for Extension of Time (' File an (December 2000) Exempt Organization Return Department of the Treasury OMB No. 1545-1709 Internal Revenue service )o, File a separate application for each return, • If you are filing for an Automatic 311111VIonth Extension, complete only Part 1 and check this box . . . . . 91 . . . . . . . . . . . . . . . • If you are filing for an Additional (not automatic) 3-Month Extension, complete only Part 11 (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 filed Form 8868, Part I Automatic 31111lMonth 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 l only . . . . ` ❑ All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to nile income lax returns. Partnerships, REM/Cs and trusts must use Form 8.736 to request an extension of time to frle Form 1665, 1066, or 1041. Type or Name of Exempt Organization Employer Identification number print INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 Fite by the Number, street, and room or suite no, If a P.O. box, see instructions, due Ming yourate 1000 36TH STREET Ming your - retur. See City, town or post office, state, and2IP code, For a foreign address, see instructions, instructions. VERO BEACH FL 32960 Check type of return to be filed (file a separate- application for each return) : ❑X Form 990 ❑ Form 990-T (corporation) ❑ Form 4720 - ❑ Form 990-BL ❑ Form 990-T (sec. 401 (a) or 408 (a) trust) ❑ Form 5227 ❑ Form 990-EZ ❑ Form 990-T (trust other than above) ❑ Form 6069 ❑ Form 990-PF ❑ Form 1041 -A ❑ Fora 8870 • If the organization does not have an office or place of business in the United States, check this box . I I I I I I I . . . is If this is for a Group Return, enter the organization's four digit Group Exemption Number (GEN) 0, E]( ) If this is for the whole group, check this box I• El If it is for part of the group, check this box � ❑ and attach a list with the names and EINs of all members the extension will cover. 1 I request an automatic 3-month (6-month , for 990-T corporation) extension of time until - MAY 15 - 120 - 02 to file the exempt organization return for the organization named above. The extension is for the organization's return for. ► ❑ calendar year 20 — or lip. tax❑X tax year beginning - OCTOBER 1 - :.. , 2000 , and ending SEPTEMBER -30 20 01 - 2 If this tax year is for less than 12 months, check reason : ❑ Initial return ❑ Final return ❑ Change in accounting period 3a If this application is for Form 990-13L, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundable credits, See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ - $- b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments made. 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, deposit with FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System) . See instructions 11 $ Signature and Verification Under penalties of pedury, I declare that 1 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 )o- h+.vTitle ► Date p 1 For Paperwork Reduction Act Not! e, ee Instruction Form 8868 ( 12-2000) PricewaterhouseCoopers LLP Tampa, Florida 3360211,5147 13 -4008324 ISA STF FED9056F. 1 Form 990 (2000) _ 5 9 2 4 9 62 94 Pa e 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 Expensese ' and section 4947(a)(1 ) nonexempt charitable trusts but optional for others. (See Specific Instructions on page 20.) Do not include amounts reported on line (A) Total (B) Program (C) Management 6b, 8b, 9b, 10b, or 16 of Part I services and general (D) Fundraising 22 Grants and allocations (attach schedule) (cash $. noncash i ) 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 " 703 899 . 703 89950 ` 26 Other salaries and wages , , , , , • , 2G 45 837 054 . 45 , 639r33 197 716 . 27 Pension plan contributions , , , , , , 27 1 906 000 . 1 869 f 076 . 36 924 . 28 Other employee benefits , , , , , , 28 5 685 194 . 5 575 058 . 110 136 . 29 Payroll taxes , , , , , , , , , , , , , , 29 3 238 0914 3 175 361 . 62 730 . 30 Professional fundraising fees , , , , 30 31 Accounting fees , , , • , , , , , • , , 31 104 515 . 104 515 . 32 Legalfees 32 751 - 479 . 751 479 . 33 Supplies 33 21 060 063 . 21 060 063 . 34 Telephone- , , , , , , , , , , , , , , 34 519 --641 . 519 r 641 . -- 35 Postage and shipping , , , , , , , , 35 • 296 935 . 296p93 . 36 . Occupancy , , , , , , , , • 36 - 1 976 597 - .- 1" 976 597 . 37 Equipment rental and maintenance , , 37 5 415 857 . 5 -415 857 . 38 Printing and publications , , , , , , , 38 000 914 . 2 8 9 914 . 39 Travel , , , , , , , , , , , , , • , , , , 39 155 575 . 155 575 . 40 Conferences, conventions, and meetings 40 206 709 . 2 0 6 7 0 9 . 41 Interest , , , , , 0 0 0 , 009 , , 0 , 41 2 566 682 . 2 566 682 . 42 Depreciation, depletion, etc. (attach schedule) , 42 9 538 605 . 9 538 605a 43 Other expenses (itemize): a S TMT 4 3 a 2-9 456 381 . 2 7 114 171 . 2 3 4 2 b 3b c 43c - d 3d - e - 3e 44 Total functional expenses (add lines 22 through 43). - Organizatfthese totalst lines 3ng5�s� ); �� , 44 129 709 - 191 . 113 2g4 295 . 16 414 896 . Reporting of Joint Costs. Did you report in column ( B ) (Program services), any joint costs from a combined educational campaign and fundraising solicitation? , , , , , _ Yes No If "Yes," enter (i) the aggregate amount of these joint costs $ ; ()7 the amount allocated •to Program services $ Ji the amount allocated to Management and general $ and ry) the amount allocated to Fundraising $ • Statement of Program Service Accom lishme_nts See Specific Instructions on a e 23 . - What is the organization's primary exempt purpose? 100- HEALTHCARE ORGANIZATION Program service se All organizations must describe their exempt purpose achievements in a clear and concise manner. State the number (Required or 501( c)(3) and of clients served, publications issued, etc. Discuss achievements that are not measurable. (Section 501 (c)(3) and (4) (4) orgs. , and 4947(a)(1 ) organizations and 4947(a)(1 ) nonexempt charitable trusts must also enter the amount of grants and allocations to others.) trusts; otherstonal for a HEALTHCARE SERVICES ( 12 , 826 ADMISSIONS & 69 , 228 PATIENT DAYS ) & VOLUNTEERS WHO WORKED APPROXIMATELY 95 331 HOURS DURING THE YEAR . b - Grants and allocations $ 113 2 94 070r% . ( Grants and allocations $ ) c d ( Grants and allocations $ ) Grants and allocations $ e Other program services attach schedule Grants and allocations $ ) JSA f Total of Program Service Expenses ( should equal line 44 column ( B ) Program services ) )10� 113 , 2 94 , 295 . CE10202. 000 Form 990 ( 2000) B9A003 2830 111986 Form 990 (20001 - 59 - 2496294 Page 3 41 Met 0 Balance Sheets (See Specific Instructions on page 23.) Note: Where required, attached schedules and amounts within the description (A) (B) column should be for end-of-year amounts only, Beginning of year End of year 45 Cash - non-interest-bearing 761 054 . 45 l 374 6450 46 Savings and temporary cash investments , , , , , , , , , , , , , , , , , , 37 585 926 . 46 33 962 331 . 47a Accounts receivable , , , , , _ 0 0 a a 6 . , . 47a 37 711 7150 b Less: allowance for doubtful accounts ; , , , , , 47b 19 4551439m 16 164 948 . 47c 18 256 276 . } 48a Pledges receivable 0a , . , . _ . . _ 9 , 48av b Less: allowance for doubtful accounts , , ; 48b 48c 49 Grants receivable . . , . 49 000 . 0 . . 50 Receivables from officers, directors, trustees, and key employees (attach schedule) , , , 0 8 0 0 , 8 * 86 . , . , . 5 0- . . . . . . . . . . 51a Other motes and loans receivable (attach - schedule) 0 _ . . . . . . . . . 0 0 • . • 0000 . Isla Ig N b Less: -allowance for_ doubtful accounts , , 51 b 51 c a 52 Inventories for sale or use , , , , , , , , , , , , , 2 157 281 . 52 2r117 622o 53 Prepaid expenses and deferred charges . . , . • . . a 0 . . , .- 3 445 895 . 53 1 171 52 9 . 54 Investments - securities (attach schedule) , , , , . . Cost El F-MV — 54 55a Investments - land, buildings, and equipment: basis , 55a . . . . . . . . . . . . . . . . . _ b Less: accumulated depreciation (attach schedule) 0 a a 0 0 0 0 a a a 0 a . . a a 0 8 1 5 5 b 5 5 c 56 Investments - other ( attach schedule) . . SEE , STATEMENT, 5 . . . . 70 001 712 . 56 67 305 243 . 57a Land, buildings, and equipment: basis , , , , , . 57a 148p2-87r6860 b Less: accumulated depreciation STMT23 , ; , , , , , , , , 57b 91 937 670 . 55 609 910 . 57c 56 350 016 . 58 Other assets- (describe )ow SEE STATEMENT 6 ) 622 123 . 58 3A18 5710 59 Total assets add lines 45 throu h 58 must equal line 74 • . . , . ._ . 18r; 348 849 : 1- 59 183 956 233 . 60 Accounts payable and accrued expenses . . . . . . . . . . : . . . . . -. 13 951 345 . s0 13 583 574 . 61 Grants payable 61 62 Deferred revenue_ . , , _ 62 d 63 Loans from officers, directors, trustees, and key employees (attach schedule) 63 0 64a Tax-exempt bond liabilities (attach schedule) : 3XMT, .7 . NONE64a 59 429 406 . J - . -. b Mortgages and other notes payable (attach schedule) , _ 59TWO 8 , , , 59 f 418 0509 . 164b 4 733 920 . 65 Other liabilities ( describe ► SEE STATEMENT 9 ) 1 530 000 . 65 3 , 292 , 6170 66 Total liabilities add lines 60 through 65 74 899 854 . 66 81 039 517 . Organizations that follow SFAS 117, check here )PPX and complete lines . P67 67 through 69 and lines 73 and 74 . 67 Unrestricted , , , , ,. . _ . 111 178 229 . 102 618 884 . 68 m Temporarilyrestricted 68 R 0 . . . 009 . . . 169 Permanently restricted . . . . . . . . . • . . . . • . . , 1 1 9 , . , 270r766 ,. 69 297r832 .. c Organizations that do not follow SFAS 117, check here ► ❑ and ii complete lines 70 through 74. 0 70 Capital stock, trust principal, or current funds , , . 70 w 71 Paid-in or capital surplus, or land, building , and equipment fund 71 y72 Retained earnings, endowment, accumulated income , or other funds 0 a 9 a 72 G 73 Total net assets or fund balances (add lines 67 through 69 OR lines z 70 through 72 ; column (A) must equal line 19 and column ( B ) must equal line 21 ) , 111 448 995 . y73 102 91617160 74 Total liabilities and net assets/fund balances add lines 66 and 73 186 f 348 r 849 . 74 183956 , 233 . Form 990 is available for public inspection and for some people, serves as the primary or sole source of information about a particular organization. How the public perceives an organization in such cases may be determined by the information presented on its return. Therefore , please make sure the return is complete and accurate and fully describes, in Part III , the organization's programs and accomplishments. JSA OE1030 2. 000 B9A0O3 2830 111986 W .W • ?•`,i:i9:f Y• % �cist.;arnyt�:::. •!:": r . it s,+.WWWWWW +:.;?,?'w.,.�:?, {;(,a:!5 :s?;1: �•;.",4 S:"1 >y,, h'e. 't��lit+ji'i,`: f;75}'> J' `%�;^W �`Jr". i,".;v '61 . . . ..!!i::•. ., rs.ti;:*�:7 S•:: :].hi• 1n;.. T •r r:;:: •a:^w,. : : • Z . . •s;•• :'SJ.,. . �, '9 ;. .s : n3� . .n r'+r}:. l.;;v:ys-i`J v�. ?.� ,. rY..4jr<:J: •.�s•)4 :4v#,T! O : 'FyJ„a,` ::a : :'c U}. ?(?t:•: f z;rrSS?-Ar•r o. ^� ; ;; : • n,.4;.�: rs. '::;Y`;-�:::t,:'= 'r@i. S: ,:ri {[.��] PIP-.;.h yT;.r'{:G a,Hi �`3:`.F.}'C`),SiHtRF{ .; ^n,.;;.:;-i ',3"•..;Y','V'• :t°�4' l0 ii : z Si.}*i,•,�:��;�it t•^?Ji. i?ri.. . :':144.1.:{i: p"� W .4 xi r ��: :h"v:5r' : C:;'„k,,;.{•, ..,. . 'x!,,Ft •. ;i;.+gj.'G;::t ,t'�i,>�'wt)) ' , r• YoJ :: .!.5.;::? :�,:1�, i ", liads,ir:i: ',L, Q} O y„JW y n S: •qf.::: v,<",.:::)•••..+. ' Yi;•. '; ;. va,r i.ryl Ni�{trvo:}L"i:,.ht .r�•T lj"'•,'r`"'e •y:%'ir::r ':vx:;.: ti •rn•t .sy' Q� "•:£,�:� n:Y.:h '<Y; rx, i.... M O y O O {y! ; '.,r?i ;k`:l,L,.jrr .. .. f>•risk .7;r{kt . . ji i:) ::+r t i:c4yy::�; }.'i, QVC) O _ <::,cr.� . G V f•1 Q ' :J.d)S! 'r"<:6'i.3;{ :::S:yv .`,Y,rS: :iF.J::y'• :�: tii.: :� . ' ak :lle':'t'.ji`aC :f; :. . .J _ •:'7 Z N �+ yTg.+p. nl:t F !:' ,. ' a, •.• :,y"vv>,".'iJ+'ti':,a .'Y !v+S'..;v d;., In 0 .7;x: :titt :,::f? Y7 . .f:a:. � r!'Y; Mi>� �: .. iY YJ • �" • t•y s 1 .,,�a) :�. a�[: ?)"jL,' }i.. 0f: :?: %^;fir,:A;j!„�( ;�,?.�. � (� � C 'd! 7j::^;.>.;.; • ' ^:•s%.'i i:.G -- -d1 i3r+2�gi.;n?.kyl�,Y:: y��. n.y!::T;MS•dgi ti ?: ; w<vl r::e:i ""e : l i• ', �C •C (A yl� JryJt . : iyi,i"sem• �:,:':;+R'•.<ja}•t,Kt-'" 'xi,". r:a s; . . .. o '. `;:aq 1 .,Yl: :'F::.'S f: "j•i .. d J �{ r lea.j'w?}>r.:{± . }tYx . .:r:.h•iya fSr<p.JJ%`::r{{j? J:r. l'� 1v ,1 :er>r'v.t!"•< . i::;3�a• ;EN: :.0>,'. O U C a Gl .� Q': ' .:.r+,J``:,i �.[.Fs:('";Y"n'.74:':i:}'"•n �.r;.,s S :::a:: L: .jrf,.1r n, :rr•.:. . : h ':i =:;i r's,Ja r+j,:iim :a•�iLf C1 7 C N `':k3: + 3. `•.'k:Z:. Z:i .+.s;;} ,q . ::: ,T:vi `:i:F'.:yw : r,.h . ; r n, . t-.;,L �` 0 �.i) ' ++^n•: ",,.'y"u-i•: „•: ')t.iP�1. :(:Si7.yi,t: • S.jf.'_t'h�lT'!y;! "•vT'F� :;p-','y'i r ,5�:� : 5:rvtr:!::Yi' sj^: S Q CSO m Q> Q = iY::i ' J 'f• •� � : l ��1 .'•". '..V.2 rJ• v }>J� S:`; •} ��?. :^k�4'� . ��:k' .,+•, .7%.W a.�• ' ra•'i�r, r i'{ .<) ;i.%nyye• O Ol 1. J. . :: • iiqq° `� �r'.; q:'iY.�J:. U /� � L iv -' " :x v.j.5•�ti ' 'r::. .... .•.i%;'., + •r%• > T «. Ml ,y.., >.f) .: 4, s,l++-.(' " !i; Q} O N Q• 1•` � t� :. :h .rf<'�Y ;. a :y:". .,:; s:3' •.rii'e:•� : 1 : JC :: .. r. � :.x YP , J ,.:, .'rr� 'J, e• 'y .r.:.. '. ' ��+• . . r. n- .•.. r .:.J.yr,TY y ll ,i:,'i ti?. e.r :s. :•. ;. tS /f ' l,. k':�q,, -� ,t3:• •:.6h. r7!ii•. i'�:�w.. s •. a. ji :..J. .v. < .,.v�i•.'- r.4: '":+i,n:LSS. �:•iir S;rr{: ;.:Sj}tt,,,,In r•S :' e!•'„:•n: .: 'N ]Y[ ' .r.: - . ..f5 r5 ::'-:5"r::.'• , . F:r.3i�i '!':v�.:(p:.:t�y'>�h,4:ri::.tY% 'L -v'r.:y>r'':" :ef Y.1 ".,i, i}y4"4.v `. 1• i-Y1:, Y1 •P'i< MI-o"<,:i:: ::Jul.,h, .. y y �:�at m , 9�(rhiy7q,£jR:;Kt�s3t'�'`};i::::>;ikr>, {!qr1 .,,::':: F3ai N% ??.l! i5, ,.< .P . . .,. .. . ... ... . .... .r::;:. ::'.:::.{' -. ... . . . . . .... . . ..M. St�.•r, :..:-M••:v:• ?,Y�,•:TP y -.y... . r �! .: t ? YR M iw. i3'::t�;;)nu i(''•'4:'i�:i•t� •�}' V •� ^ O to ♦ J... 1 _:. : w � '_ ♦ ♦ ♦ ♦ m � ° r an 1 o to X C N to 0 dyi LO LL Cm d ` o r♦ CL .. vl N E E p . o c E w G L o, O °.. � d .� R ==of Gar 0 !� N N C W r-1 b R ^ il • p ` � v T O Ploollvyi E _ c ^ _ c E N ° w •C 0 r� C v w '� ` N r. y C M; y y a .0 O Q y y y C > Y O 0Y rS Cc c E y m E w w C C C O M o w w = ° g l0 v R d u o y " E N O � N c v c c c c o Q w Eat v H _ y C U U = y w • 9 O) C 3 ., w (� O m c p .. to �? 00 LY. iL rL w c o a € c c �' n m c c 'c v O s �' (Az �- I t ' axi c m a w v rn 2 r t.o 0 °o' ac, v o> a E-t o a ? CU .r d) t W r 1 O C r•, N T w 0) N c v C O) 7 E y X O m o m o r w E m E u E w .. > H o E c c D s a E N aNi s to v m ° E w C � m m o v� Y ° E v H m Q o O m a` 4") Li J c p v c E o o s" v o •c w w c v H .. Q :D Q LL c m O Q F- = H �O O •. N ^ ^ N 0 _ _ ill v -- W :a... .Y]Y:'!'.:u:'.r� .� . �y rr . w O 4Y i w Q} y >ai t Fi�a :'' 1?.:L:[jt:/:r::T: :- .. i�W. .*�! :v`.<ik" IL+y. •L• , :ki;T:. .v? . y +;: . :;": : ::iksx• iii. .::-;:...r . , . O p O. m :k.:..; 1,,, h.�rt•:,•• :i•.::5le4`'irvt"'t!jw `i ' �+" . : ,t;. '?i . .. .} ,: : }ik;.. . .,t�i:. ?' .•tet E ir% .ti+ i V "J • 71"• ,. • ., a' a-` :, m O 'x N i::`: J . ... ' +{:•,,:.5-..+.•: :{''wj.Fi: • Z,M<,4 ��. . JI J..- •...':.a .J . E w N . . , NL'rr,'.';c} l. . , Zi:� n,. r;:. ' •YF. •'r".:>'iri� r � '-P :i?•i of<:rYa, . a r'�ap;T..s. .r..�: g:..j ,xy O (( (� ,,,tis• ` e;.Y ::. r.:. ph,•>afY.i: • • U O L N - .;,.t,;`:. '.b:,i9 : 'STrr x'��yr:Jk;::s•',n:•s r.:.r. � :,1:J' •., i: -:: •.{ti•.::' R1 ::; �.;T:?t!y ;i a i 1 4C+;+a,n<s: `.::3: r!z J; ri, x.;•; :14: .: ..:..r:;4 •Q d ri>Yry ::}. :�itd'•,r 2,n ..,.1 y+•s';i? :+. .wNv !t' '+ Z:Vea!'}:' • . p„' � . of ::. :>;,r'.: i:,,: m a (v K. �' . .r .T >!: '!P':: . . -. :• .. F r. hdy" kt L•;t •jkk ,•>. :`>.} $' >� l9 O.v...J• r,.y ..,,nff4':p...:r^ .Y,;:i•h;>ry2,h': �; } k•a e ..y) vs,:Ye;,•' „> !.; F:. i:. . t0 O7 . v;'h � ':,: ;• "r'v • : r:,•� ,r:,, J... s .-. > ”.r.;::ii• y. J.:k; is;..y!..r:.,, ;i CO ns: , . J'j '§': ,:�f'i:h°•n :' r+r 'xJ.S:v : : .a: ., :.�. Y;:;:.<;:"::£:''::G,a:�yi`:::��: , Q! fC ?•:� . 0 . ; (.. g,•.x;. ..Uf+r�,k. ;., a, k.,.. :'�.,Jr t..ii'}�?•Jrr:-4 M N .Jv:: :x. •:o•.:: cr•• ••. . to j •L .�: T+a:>. , /�v F• •:!: ;r• . 's/ r'i::?"i i+�r� :,-n 'yL . n •.� s J . .`�y.:1.; :i;:p 0 a :ryi;:i'} V' ; :�>'Sitt:. .eT :,,:!'•xkt:�+:;: ;y:'l.•,'t :•i.. .t: „:`•} yi4l: ?}:�}it::� C . .,:6,�; • x }{ •c.r:•:4' k ' ;�74 .Y rit oY c C !kyr.: s,;.kiT'iktlr�,` .Xht,.,:� �•g,,�..,;ti'�a•3 .,^.F .ai�r;<5!.,,;. y i'„.,.,•. '1. ; . . it Eit9. ; t. {2�.`ki:;•'• ' k:: .. : : N r-1 0C oY m Q d (n ,�yJ`n 1"'t {.?,l..y; :{:(;�,y-.r;; :x, ;^F':::... !•�>s;,v!i :. •: n,}' }: kT ) :;w' ,ra;!,, fi;J.yY ,r ej3l .•r'. ..,� 1F`J`:: • „�i�:: tf) ri C m N L > C r) nr4 '- �IJt , J:(°� r hj�( ;7 hx`ri°'S'-'�' i i h +'ly2 ,. > > •st�v a y R( w S k !J J > r} r3t< f•1 5 r• i9 t. xK:iS^v'{}: +7• J'� :a h A twx/r I tm . . } : !! .S• 3{ cq 'ra yS42 )J! 31`F. 1f 5�� ! �J ;ly:!t:' "i. tiF:> y;.ti ; � � L;>:� ' ^T ;” ` ! N tn” 0 CL 0 m ''C1 V .'r.'.'.A R %F : ;} •:• ": .?�< . > .t.. :.;'n;.;.r:.`g:u+5:::> ,.:; •"., ::':.;'., , . i . . : �s. ; frl u E c .� sx,v::r ♦ ...r ,i n":i :"1::�r/r..p" w,;vt..)�`-: :.,• y;.. :.. : : . . :!n'. • r+:r�'"�.}<T Fs�• ,yyJ � yJ r..: 7• r� 'j,.i.: •:...a.. �=yJ'iJ.:i^.•: :!'.4::•:x:�j rr,°Y>J.I' •fW .I- x. L O C ' ° ♦ '° . . :f4 . . . -:' ♦ ♦ ' •: s:rt;:= - Form 990 (2000159 = 2496294 - Paae5 Other Information See Specific lnstrucfions on page 26. Yes No 76 Did the organization engage in any activity not previously reported to the IRS? If "Yes," attach a detailed description of each activity X 7,T 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. ' ' ' ' ' ' it i:<:: 78 a 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? , , , , . . 0 6 4 6 . . . Deese . . . ' ' _• 78b X 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 exempt OR LXJ nonexempt. e i a Enter the amount of political expenditures, direct or indirect as described in the "V'" instructions for line 81 . . . . . 181a NONE ♦ijlil. . v- A;0000 :� q.i..... b Did the organization file Form 1120-POL for this year? , • , . ; , , , , , . . . . . 81b X 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 value? , 82a X 0000 . . . . . . b If "Yes," you may indicate the value of these items here. Do not include this amount as -revenue in Part t or as an expense in Part 11. (See instructions to?reporting in Part III.) . . . . . . . . . . . 6213 . . . �:•;�• �_:`-� ,,x . :: 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? , . . . 63b N A 84a Did the organization solicit any contributions or gifts that were not tax deductible? , 0 0 0 0 84a N A b If "Yes," did the organization include with every solicitation an express statement that such contributions . t`: Y <v ` <' or gifts were not tax deductible? , . . 84b N A 85 501(c) (4), (5), or (6) organizations, a Were substantially all dues nondeductible by members? _ - 85a N A b Did the organization make only in-house lobbying expenditures of $2,000 or less? , 85b N A If "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below uniesi the organization • i„i'v x: received a waiver for proxy tax owed for the prior year. <, c Dues, assessments, and similar amounts from members :A!! d Section 162 (e) lobbying and political expenditures e Aggregate nondeductible amount of section 6033(e)(1 )(A) dues notices `x`"" ''' _ 0000 85e N /A f Taxable amount of lobbyinganitpolitical expenditures (line 85d less 85e) 85f N A ' '" s . Ss' ' :?? rr g Does the organization elect to pay the section 6033(e) tax on the amount in 85f7 , ,- , - 85 N A h If section 6033(e)(1 )(A) dues notices were sent, does the organization agree to add the amount in 85f to its reasonable • .- _ - estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year? 85h N A 68 501(c)(7) orgs. Enter. a Initiation fees and capital contributions included on line 12 88a . N /A b Gross receipts, included on line 12, for public use of club facilities . . . . . . . . . . 8613 N A ....... 87 501(c)(12) orgs. Enter. a Gross income from members or shareholders 8Ta • _• N /A " b Gross income from other sources. (Do not net amounts due or paid to other 0000 ' • 'ii::: ;� :' . Six::. sources against amounts due or received from them.) 87b_ 88 At any time during the year, did the organization own a 50% or greater interest in a taxable corporation or partnership , or an entity disregarded as separate from the organization under Regulations sections 301 . 7701 -2 and 301 . 7701 -3? If "Yes," complete Part IX , , . . . . 88 X 89a 501(c) (3) organizations. Enter: Amount of tax imposed on the organization during the year under. section 4911 )o, NONE ; section 4912 ► = NONE , section 4955 ► NONE . b 501(c) (3) and 501(c) (4) orgs. Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a prior year? If "Yes," attach a statement explaining each transaction . . . . . 0 . . . . . . . . . . . . . . . . 8913 X c Enter: Amount of tax imposed on the organization managers or disqualified persons during the year under 1 . sections 4912 , 4955, and 4958 a . . . . . . . . . . . . . . _ . . . . . . . . . . . ► NONE d Enter: Amount of tax on line 89c, above, reimbursed by the organization , , , , , . ► NONE 90a List the states with which a copy of this return is filed ► b Number of employees employed in the pay period that includes March 12, 2000 (See Inst.) 90b 11587 91 The books are in care of ► GRE G MORGAN Telephone no. ► 561v- 567 - 4311 Located at )o, 1000 36TH STREET - VERO BEACHf FLORIDA ZIP code ► 32960 92 Section 4947(a) ( 1) nonexempt charitable trusts filing Form 990 in lieu of Form 1041 - Check here ► and enter the amount of tax-exempt interest received or accrued during the tax year , 1110, 192 . 1 N /A Form 990 (2000) JSA OE10412.000 B9A003 2830 111986 Form 990 - 2000 59 - 2496294 Page6 Analysis of Income-ProducingActivities See Specific Instructions on paRe 30 . it Enter gross amounts unless otherwise a . Unrelated business income Excluded b r section 512 513 or 514 (E) indicaled. (A) (8) C) D Related or 93 Program service revenue: Business Amount Exclusion Amount exempt function g code income a HOSPITAL CHARGES 125 379 627 . b c d e f Medicare/Medicaid payments , g Fees and contracts from government agencies 94 Membership dues and assessments , , 95 Interest on imvings and temporary cash investment 14 620 9260 96 Dividends and interest from securities . . 14 ��.,,.ai[ iti..ji.: o-. .r. .>'.':.'•:;;i.Y.:a::e::::w::^.::3;•<, :�.i:jxa.: "xti:: `� " > ti '� 97 Net rental inco a 96 541 Income or loss from real estate .." . v .; .fi. . ♦ <-. . .. "„ti`: i:: ar 1._y`�h5e_`i ,:.N.:: ; ?s' ni.: �:<: : ., , ::1 a debt-rmanced property . , . . . . . . . 31120 282 6160 b not debt-financed property . . . . . 98 Net rentafincome or (loss) from personal property. . - 15 035 , 99 other investment income , , , , , , , , 4190 — 4 , 0030- - 14 273 097 . 156 111 . - 100 Gain or(toss) from sales of assets other than Inventory 18 _ 1 13 8 0 6 6 . 101 Net income or (loss) from special events — - 102 Gross profit or (loss) from sales of inventory 103 Other revenue: a b SEE STATEMENT 18 100 921 . 708 495 . 850 754 . C d e 104 subtotal (add columns ( B), (D), and (E)) . . : "= 's ` ' 379 534 . ' ' '- " ' 5 337 125 . 12 6 4 O1 52 7 . 105 Total (add line 104, columns (B), (D), and (E)) a a . . . . . . . . . . . ► 132 , 118 , 18 6 . Note : Line 105 plus line 1d. Part 1, should equal the amount on line 12, Part 1. - Relationshi of Activities to the Accomplishment of Exempt Purposes See Specific Instructions on Pae 31 . Line No. -Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the accomplishment ♦ - of the or anization's -exem t purposes other than by providingfunds far such purposes). SEE STATEMENT 19 - Inforrnation Re ardin Taxable Subsidiaries and Disreciarded Entities See S ecific Instructions on page 31 . (A) Name, address, and EIN of corporation (g) (C) (D) (E) , Percentage of Nature of activities Total income End-or-gar partnership, or disregarded enti ownershi interest assets SEE STATEMENT 21 % - 60 094 . 350 745 . o� % % Information Regarding Transfers Associated with Personal Benefit Contracts See Specific Instructions on page 31 . ) (a) Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? Yes X No (b) Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 8 Yes No Note : If "Yes * to file Form 8870 and Form 4720 see instructions). Please Under penalties of perjury, I declare that I have examined this return, including accom aing schedules and statements, and to the best of my knowledge and belief it is true, correct and complete. Declaration of preparer (other than ofcer� is based on all information of which preparer has any knowledge. (Important: ee General Insirudion W, on page 14.) C42clrOR Ll Sign Here z ® Clj, ari r- , w r.. t,//r. Cc� Signatur f officer Date Type or print name and title. Preparers Date Paid signature ' g/OL self- ck if Preparers SSN or PTIN. em I ed iswFl P00233773 Preparer's Firm's name (or yours PRIC ATERHOUSECOOPERS LLP EIN ► 13 - 4008324 Use Only if self-employed) and 101 ST KENNEDY BLVD SUITE 1500 address, and ZIP code PhoneTAMPA FL 33602 no. ► 813 - 229 - 0221 .rsn oE1050 2.000 Form 990 (2000) B9A0O3 2830 111986 Form 4562 Depreciation and Amortization DMB No. 1i45-0172 it 0 Department of the Treasury (including Information on Listed Property) 2000 r Internal Revenue Service 99 ► lop See separate instructions. Attach this form to your return. sequence t 6 7 Name(s) shown on return Identifying number INDIAN RIVER MEMORIAL HOSPITAL INC : 59 - 2496294 Business or activity to which this form relates GENERAL DEPRECIATION EM Election To Expense Certain Tangible Property (Section 179) Note: if you have an "listed roe , "complete Part V before you complete Partt 1 Maximum dollar limitation. If an enterprise zone business, see page 2 of the instructions 2 Total cost of section 179 property placed in service. See page 2 of the instructions , , , 2 3 Threshold cost of section 179 propertybefore reduction in limitation , 3 4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0- • , 4 5 Dollar limitation for tax year. Subtract rine 4 from line 1 . If zero or less, enter -0-. If married filing separately, see page 2 of the instructions5 (a) Description of property .b . . Cost (business use on (c) Elected cost . 6 :iti}:i:::a,� Liµ%: .• .....: :\::+j..., rt�i:_. .:/ ' 7 Listed property. Enter amount from fine 27 7 - ' s-` '" `- " °s'�� `w•"` . 8 Total elected cost of section 179 properly. Add amounts in column (c), fines 6 and 7 9 Tentative deduction. Enter the smaller of One 5-or line 8 . . . -. 9 - 10 Carryover of disallowed deduction from 1999. See page 3 of the instructions , . . 10 11 Business income limitation. Enter the smaller of business income (not less than zero) or line 5 (see instructions) 12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 12 13 Carryover of disallowed deduction to 2001 . Add lines 9 and 10, less line 12 I• . 13 Note: Do not use Part ll or Part Ill below for listed property (automobiles, certain other vehicles, cellular telephones, certain computers, or property used for entertainment, recreation, or amusement). Instead, use Part V for listed property. MACRS Depreciation for Assets Placed in Service Only During Your 2000 Tax Year ( Do not include listed property.) Section A - General Asset Account Election - 14 If you are making the election under sectiorr 168 (i)(4) to group any assets placed in service duringxhe tax year into one or more general asset accounts , check this box. See page 3 of the instructions Section B - General Depreciation System (GDS (See page 3 of the-instructions.) - {b) Month and (c) Basis for depreciation O d Recovery - (a) Classirrcation of property- year placed in (businessrinvestment use eriod (e) convention Method (g) Depreciation deduction service only - see Instructions) p 15a 3-year property ---g =: ;:v: NONE b 5-year property - E `r' c 7-year property - :. : •' i. :"J �.',; v d 10-year property s,s . :. ,.:^',_;..; . ; ' : ;; e 15-Year propertyi :e ; 'fr ass_.: ;: •t,�<.. .. < , f 20-year property g 25-year property 25 yrs. S / L h . Residential rental 27.5 yrs. MM S/L property 27.5 yrs. MM S /L I Nonresidential real 39 yrs. M M S/L property mm S / L Section C - Alternative Depreciation S stem ADS ) (See page 5 of the instructions . 16a Class life <r'<' ' zF< z: b 12-year ::;;:•a::,, :::: ::>; ::: .: :: 12 yrs . S/L c 40-year 40 yrs. I MM S / L Other Depreciation ( Do not include listed property.) (See page 5 of the instructions.) 17 GDS and ADS deductions for assets placed in service in tax years beginning before 2000 , 17 18 Property subject to section 168(0( 1 ) election 18 19 ACRS and other depreciation , 19 9 538 605 . Summary (See page 6 of the instructions .) 20 Listed property. Enter amount from line 26 , , , , . , - 0 20 21 Total. Add deductions from line 12, lines 15 and 16 in column (g) , and lines 17 through 20. Enter here and on the appropriate lines of your return . Partnerships and S corporations - see instructions . 21 9 538 , 605 - 22 For assets shown above and placed in service during the current year, enter the portion of the basis attributable to section 263A costs F22T� Js For Paperwork Reduction Act Notice, see page 9 of the instructions, Form 45112 ( 2000) OF0931 2. 000 B9A003 2830 111986 Form 4562 (2000) 59 - 2496294 Daae un Listed Property ( Include automobiles, certain other vehicles , cellular telephones , certain computbrs , and property used for entertainment, recreation , or amusement.j Note : For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 23a, 23b, columns (a) through fc) of Section A all of Section B. and Section C if applicable Section A Depreciation and Other Information Caution: See page 7 of the instructions forlimits for Dassengerautomobiles, 23a Do you have evidence to support the businessrinvestment use claimed? iYes X I No 23b If "Yes." is the evidence written? Yes X No c la) (b) Business/ (d) (e) (n (9) h m Type of property (list Date placed in Investment Cost or other Bash for depreciation Recovery Method! Oe reciation Elected vehicles first) service use basis (buslnessNweshnent period Convention deduction section 179 ercenta a �Q °"h') cost 24 Property used more than 50% in a ualified business use See pacie 6 of the instructions-)- % nstructions. :0 25 Pro a used 50% or less in a ualified business use See page 6 of the instructions): SIL %- - - Sir �x?>�;y:;�v.:�:r :. 26 Add amounts in column (h). Enter the total here and on Erne 20, page 1 , 2B ; ; 4 . - . . . . . . . 27 Add amounts in column i . Enter the total here and- on line 7 a e 1 • 27 Section B = Information - on Use of Vehicles Complete this section for vehicles used by a sole proprietor, partner, or othermore than 5% owner," or related person. -If you provided vehicles to your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles. 28 Total businessfinvestment miles driven during (a) (b) (c) (d) (e) (� the year (do not include commuting miles - Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 see page 1 of the instructions) , , , , . . 29 Total commuting miles driven during the year 30 Total other personal (noncommuting) miles driven . . . . . . . . . 31 Total miles driven during the year. Add lines 28 through 30 Yes No Yes -No Yes No Yes No Yes - No Yes No 32 Was the vehicle available for personal use during off-duty hours? -33 Was the vehicle used primarily by a more than 5 % owner or related person? 34 Is another vehicle available for personal use? Section C - Questions for Employers Who Provide Vehicles for Use by Their Employees - Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who are not more than 5 % owners or related persons. See page 8 of the instructions. - Yes No 35 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by your employees? , , , . 36 Do you maintain a written p • olicy statement that prohibits personal use of vehicles, except commuting, by your employees? See page 8 of the instructions for vehicles used by corporate officers, directors, or 1 % or more owners - 37 Do you treat all use of vehicles by employees as personal use? 38 Do you provide more than five vehicles to your employees, obtain information from your employees about - the use of the vehicles , and retain the information received? , 39 Do you meet the requirements concerning qualified automobile demonstration use? See page 8 of the instructions Note: 1/ your answer to 35 36 37. 38 or 39 is 'yes, " do not complete Section 8 for the covered vehicles. . Amortization (a) (b) (c) (d) (e) Iq Description of costs Date amortization Amortizable Code Amortization Amortization for begins amount section period or this year percentage 40 Amortization of costs that begins during our 2000 tax year See page 8 of the instructions. 41 Amortization of costs that began before 2000 • 41 220 ,, 961 - 42 Total. Add amounts in column (f) . See pae 9 of the instructions for where to ort. : 4z 220 , 9610 JSA Form4562 (2000) OF0932 1 . 000 B9A003 2830 111986 SCHEDULE A - - • Organization Exempt Under Section 501 (c) (3 ) ' OMB NO. 1 !54S-0047 ( Form 990 or 990-EZ) (Except Private Foundation) and Section 501Xe), 501 (f), 501 (k), 501 (n) , or Section 4947(a)( 1 ) Nonexempt Charitable Trust l� Supplementary Information - (See separate instructions .) 2000 - Dep of the Treasury Internal Revenue service I► MUST be com ' l2ted by the above organizations and attached to their Form 990 or 990-EZ Name of the organization Employer IdentiricaUon number INDIAN RIVER MEMORIAL HOSPITAL INC . 9 - 2496294 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 "None.' (a) Name and address of each employee paid more (b) Title and average (d) Contributions to (e) 5¢�ense than $50,000 hours per week (c) Compensation employee benefit plans 8 account and other devoted to Rion deferred com ensation allowances HUMBERTO POSADA , _ M _D _ _ _ _ _ _ _ - - - - a/GM PHYSICIAN 909 SURF LANE x VERO BEACH FL 0 ` 239 990 . NONE FELIK _BIGAY a/carr PHYSICIAtr 1014 PALMAR DE AYS DRIVE VERO BEACH FL 0 - =201 034 . NONE JAMES _V__ ATHERTON PHYSICIST - - - - - 1769 CORAL WAY SOUTH - - - - - -- - - - - - ie VERO BEACH FL 0 126 886 . NONE - AAHES 1t . . TONKEL — Special Ash P . O . Bog 64404 $ - - - - - - - - - - - - - to CEO VERO BEACH ,- FL 32964 0 95, 639 NONE KEVIN SMITH _ _ _ _ _ _ _ DIR/DECISION SUPP RT 4235 79TH STREET VERO BEACH - FL - - Total_ number of other employees paid over 0 - 10 70 8 _ NONE �8... ' " �Y, z;4'•�^.^'.s-';.;; '`.^csi' < .v�yrorm. '. •�.�nz+'r�F' r.= .. ev' '`Jrr`-`�1±:'Yr�:' .r.-.:: ' z N ... ! ';:. .`. S.2!-. taV'H.. Sitz •^+.. i?'.^ee`:s Y-`+ �• _ _ �.•�xi: i•.ce:F 93' 4 �,�•.4 � Y" a �y 5 �.. . )+.+if�3�•i+�` . s !A�.•�"�:i! $50,000 189 . I• '� �..�Y.✓'..t. �Ft .:. � > ti-' ;.. FLS;.•.-;?�•`�'caa�'•`?€ UIi • • • • • .? :iY.S,i�[' ri1.r•;s+4F>i." :-�'t . . :�•S F::?$j`'.°�al�'»'r��i tt'q"��.2r ::-.Cis':'.•�''•{Yc'e':e3F'.•:3e'f'. i•.. `s`.''$'s - Compensation of the Five Highest Paid Independent Gontrastors for Professional Services (See page 1 of the instructions. list each one (whether individuals yr 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 SERVICE-MASTER _MANAGEMENT _ SERVICES_ _ _ 22506 NETWORK PLACE CHICAGO IL 60673 ACILITIES MGMT 1 192 037 . MED _QUIST1 _ INC . PO BOX 10832 NEWARK NJ 07193 RANSCRIPTION SVCS 758r887 . INDIAN RIVER BLOOD _BANK _ INC _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1300 36TH STREET VERO BEACH FL 32960 LOOD BANK SVCS 681r469 _ COHR� _ INC - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 21540 PLUMMER ST CHATSWORTH CA 91311 INTENANCE CONTRAC 415 176 . EMERGENCY _ bfEDICINE ASSOCIATION , INC . _ _ _ _ PO BOX 860231 ORLANDO FL 32886 MER ROOM SERVICES 350 500 . Total number of others receiving over $50,000 for ;; > " ' f`ti' ♦. Y -: it ti . �i •...<r+ l;mk+ 4 -s : �' - ��'�: .,. . ,s�,;.,s;:•.s-�� ..,,; ,'.� :;c? ;: ;:., . :�u�.:;:> •:: Yee professional $erVCf?S "'. :.i:>:>:• - `"`;.:..i.�:+c?^':�-a:s ..=.s..r�;: l 'V.'-'.c,`r.'':`S`ir�:y .. @(.�,;r:cCli•Sas=:`a :_.'isr:t. .r:'.:r., .c : ;:vix'�•�tii�n:r.�.�iC';Y;r..`c �!v�,::;-� r, :::. -';i":3 �i:':' "i'1�as';r =. .:i '::`-'•l`•''s'f+s .:�:: •iQi' - ej7i•: l ::cit. ..: 13 ._,. .. _ `. ..=ai.^` .�f.;ri- :'`q'r.:.^..f • ��1.. v' 'r.• �`y. :v. :'tJ:. +.i:'' :a° >i4.� .o5;:zj'•..:'`a w�<-<:�6:+:•�{:C�ri �.r<C t'-'::•.:: rhY�.::�vriY.a ' :' 'Y� "c':'� '::i " �i div - .;:. J..i. - '. For Paperwork Reduction Act Notice, see page 1 of the Instructions for Form 990 and Form 990 -EZ. Schedule A (Form 990 or 990-EZ) 2000 JSA OE1210 2. 000 sir STMT 22 B9A003 2830 111986 SCHEDULE A _ . - - Organization Exempt Under Section - 501 (c) (3) OMB No. *1545-0047 ( Form 990 or 990-EZ) ( Except Private Foundation) and Section 50,1 (e), 501 (f), 501 (k), 501 (n) , or Section 4947( a)( 1 ) Nonexempt Charitable Trust Department of the Treasury Supplementary Information - (See separate instructions.) 2O 00 ' Internal Revenue Service ► MUST be com leted by the above organizations and attached to their Form 990 or 990-EZ Name of the organization r9 - 2496294 ployer Identification number INDIAN RIVER MEMORIAL HOSPITAL INC . 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 " one,") (a) Name and address of each employee paid more (b) Title and average (d) Contributions to I (e) Expense than $50,000 hours per week (c) Compensation employee benefit plans 8 account and other devoted to position deferred compensation allowances HUMBERTO POSADA , _ M _D _ _ _ _ - _ - - )B/GM PHYSICIM 909 SURF LANE VERO BEACH FL 140 239 990 . NONE FELIX _ BIGAY _ _ _ _-- _ _ - - _ - -_ - - - -- - - - = B/M PHYSICIM 1014 PALMAR DE AYS _ DRIVE VERO BEACH FL 40 201r034 - NONE JAMES _V_= ATHERTON _i _ _ _ _ _ _ - - - PHYSICISx 1769 CORAL WAY SOUTH — — - VERO BEACH FL 40 126 8 86 . 1 NONE NU • •k - FL 09— $ g6 . NONE KEVIN _ SMITH IR/DECISION SUPP RT 4235 79TH STREET VERO BEACH FL 0 108 . 708- -1 NONE Totalu be n m r of other employees paid over `s� = �< �� +s •�:.:, �� ,�; `:... ... ��w . ..:.:>f::.:. ..,rz: �� ._�-.��. :� ;•,.-s,y .;� ... ;.; ;..`.". •,�+;rxy.::..,tt`x:y�'s :3�::; S.s� 'vri;�•�.<� ..�Sx�<.....:r. 2a .: �ey�.v i�S: -. ;3.y �Sr�..4:1:>R'.: .'Jt:a:,`�M. `.1.T,-ry�i"O�.\i\ F..r�T ` s6�'�y•\*Vi4:,'t\t. :4' [:.Gin':�i4�titi1'., •i "..�s.:.`.5::'.:� �^ $509000 4 0 1 0 0 . 189 - -e u•: zS+::;Ys% :p` :i.;ti ;5 :-:��wl^•i.,��::�T::+ 'rCl'n ,? :S:T ; :Y;fc.:t','^•,!r�:::•'��xei Compensation of the Five highest Paid Independent Contractors for Professional Services (See page -1 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 SERVICEMASTER MANAGEMENT _ SERVICES _ _ _ _ _ _ _ _ - 22506 NETWORK PLACE CHICAGO IL 60673 FACILITIES MGMT 1 192 037 . MED _129IST1 _ INC _ . . . . . . . . . . . . . . . PO BOX 10832 NEWARK NJ 07193 TRANSCRIPTION SVCS 758 887 . INDIAN RIVER BANK ,_BLOOD _B _ INC _ 1300 36TH STREET VERO BEACH FL 32960 LOOD BANK SVCS 681 469 . COHRl _ INC . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 21540 PLUMMER ST CHATSWORTH CA 91311 MAINTENANCE CONTRACT 415r1760 EMERGENCY _ MEDICINE ASSOCIATION�_ _INC , _ _ PO BOX 860231 . ORLANDO FL 32886 MER ROOM SERVICES 350 500 . Total number of others receiving over $50,000 for professional services ► 13 For Paperwork Reduction Act Notice, see page 1 of the Instructions for Form 990 and Form 990 -EZ. Schedule A ( Form 990 or 990-EZ) 2000 DE1210 2. 000 STMT 22 B9AO03 2830 111986 Schedule A Form sso orsso-Ez 2000 - 5 9 -,; 2496294 e 2 F Statements About Activities Yes No 1 , 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? 1 X If "Yes," enter the total expenses paid or incurred in connection with the lobbying activities . ► $ . . 22 764 • '~ Y... . 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-8 AND attach a statement giving a detailed description of the lobbying activities. v A:;, r., •.i :r::.:A 2 During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any "k<' of its trustees, directors, officers, creators, key employees, or members of their families, or with any taxable " =�s. ; ��•;�'4< :�% s organization with which any such person is affiliated as an officer, director, trustee majority owner, or principal beneficiary a Sale, exchange, or leasing of property? 2a X b Lending of money or other extension of creditf _ _ 2b X c Furnishing of goods, services, or facilities? ,- . . 2c X d Payment of compensation (or payment or reimbursement of expenses if more than $1 ,000)? ,S ); )J , 99 0 P �+. . . _ 2-d X e Transfer of any part of its income or assets? . . _ . . 2e X If the answer to any question is "Yes," attach a detailed statement explaining the transactions. . . . . . 3 Does the organization make grants for scholarships, fellowships, student loans, etc.? , , 3 X 4a Do you have a section 403 (b) annuity plan for your employees? . . . 0 4a X b Attach a statement to explain how the organization determines that individuals or organizations receiving. . . ' "' ' g .-:;<: :: ::: :;,,tr •%:'iii';: 9 grants 'r-::: :: � <°;' =�s:: a 'i: ;>.:i.: or loans from it in furtherance of its charitable programs qualify to receive payments, See page 2 of the instructions. Reason for Non -Private Foundation Status (See pages 2 through 5 of the instructions.) The or anization is not a private foundation because R is: JPlease 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)(i7, (Also complete Part V, page 5) 7 X A hospital or a cooperative hospital -service organization. Section 170 b 1 A lit . - - 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)(ii). Enter the hospitals name, city, and state ► 10 E] An organization operated for the benefit of a college or .university owned oro operated b a governmental unit. Section 170 b 1 A iv . P y s O( )( )C ) (Also complete the Support Schedule in Part IV-A.) 11 a An organization that normally receives a substantial part of its support from a governmental unit or from the general public. Section 170(b) ( 1 ) (A) (vi). (Also complete the Support Schedule in Part IV-A.) - 11b 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 1 /3 % 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) .) Provide the following information about the supported organizations. See page 5 of the instructions. (a) Name(s) of supported organization(s) (b) Line number from above Asn 14 n An organization organized and operated to test for public safety. Section 509(a)(4) (See page 7, of the instructions. ) OE1220 2. 000 B9A003 2830 111986 Schedule A (Form 990 or 990-F1) 2000 Schedule A Form 990 or 990-E 2000 _ 5 9 - 2 4 9 .62 9 4 PaoA 3 Support Schedule (Complete only if you checked a box on line 10, 11 , or 12.) Use cash method of accounting. NOT APPLICABLE M1 Note: You may use the worksheet lh the instructions for convertin from the accrual to the cash method of accounting, Calendar year or fiscal year beginning in a 1999 b 1998 c 1997 d 1996 a Total 15 Gifts, grants, and contributions received. (Do not include unusual grants. See line 28.) . . 16 Membership fees received 17 Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in- any activity that is not a business unrelated 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 organization 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 public without charge so toles 40 22 Other income. Attach a schedule. Do not include gain or (loss) from sale of capital assets 23 Total of lines 15 through 22 24 - Line 23 minus line 1725 - _ Enter 1°A of line �:.r> ` : ,�'�':;::-, ,•::::tr: =:: 26 Organizations described in lines 10 or 11 : a Enter 2 % of amount in column (e), line 24 NOT. AVkJjTJCMJ,,F , )o- 26a - b Attach a iist_ 1which is not open to public inspection) showing the name of and- amount_contributed by each {.�'<<'~� irks;.: 3-':r�•�-t.�';��=^ : person (other than a governmental unit or publicly supported organization) whose total gifts for 1996 through :. vti:AiY:.�iF:V:?tt�:vcV';y-S.'%:.^�' 1999 exceeded the amount shown in line 26a . Enter the sum of all these- excess amounts , ► 26b c Total support for section 509(a)(1 ) test: Enter line 24, column (e) _ _ j 26c _ d Add: Amounts from column (e) for lines: 18 19 22 26b . . . ► Y26d . e Public support (line 26c minus line 26d total) 26e f Public support percentage line 26e numerator divided by line 26c denominator 26f % 27 Organizations described on line 12 : a For amounts included in lines 15, 16; and 17 that were received from a "disqualified person," attach a list (which is not open to public inspection) to show the name of, and total amounts received in each year from, each "disqualified person." Enter the sum of such amounts for each year: . NOT APPLICABLE ( 1999) - - - - - - - - - - - - - - - - ( 1998) - - - - - - - - - - - - - - - - - - - ( 1997) 1996 b For any amount included in line 17 that was received from a nondisqualified person, attach a list to show the name of, and amount received for each year, that was more than the larger of ( 1 ) the amount on line 25 for the year or (2) $5,000. (Include in the list organizations described in lines 5 through 11 , as well as individuals.) After computing the difference between the amount received and the larger amount described in ( 1 ) or (2), enter the sum of these differences (the excess amounts) for each year. ( 1999) - - - - - - - - - - - - - - - - ( 1998) - - - - - - - - - - - - - - - - - - - ( 1997) - - - - - - - - - - - - = - - - - - ( 1996) - - - - - - - - - - c Add: Amounts from column (e) for lines: 15 16 17 20 21 joil 27c d Add : Line 27a total and line 27b total , lloo, 27d e Public support (line 27c total minus line 27d total) . . . . 1► 27e f Total support for section 509(a) (2) test: Enter amount on line 23, column (e) Oel 27f I g Public support percentage (line 27e (numerator) divided by line 27f (denominator)) ► 27 % h Investment income percentage line 18 column a 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 1996 through 1999 , attach a list (which is not open to public inspection) for each year showing the name of the contributor, the date and amount of the grant, and a brief description of the nature of the grant. Do not include these grants in line 15. (See page 5 of the instructions.) OE1221 2. 000 B9A003 2830 111986 Schedule A (Form 990 or 990-EZ) 2000 Schedule A (Form 990or 990 EZ) 2000 _ 59 - 2496294 Page 4 Private School Questionnaire -(See page 5 of the inst, ructions.) ` (To be completed ONLY by schools that checked the box on line 6 in Part M NOT APPLICABLE Yes No 29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, other governing instrument, or in a resolution of its governing body? • , , , , , . , , Z9 3o Does the organization include a statement of its racially nondiscriminatory •policy toward students in all its �:�. ' -- •tet:: brochures, catalogues, and other written communications with the public dealing with student admissions, <:" programs, and scholarships? . , , , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 30 . . . . . .. > 1s r 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) rrrrrrrrrrr rrr rrrrrrrrrr rrrrrrrrrrrrr.rrrrrr - rrrrr - {. r5. < . : t:rr,<ihf< ' - - - - - - - rrrrrrr - - - - - - - - rrrrrrrrfrrrrr yr x :[ '+ �:CA uy; ,�...':•`°i - - - - - - rrrrr — rrrrr rrrrr rr rrrrr 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 aracially nondiscriminatory basis? _ , 3 2 b 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? . . , , , , , , , 3. 2m. - `?Ch:�j:iti .YG•.7�?�'i :f Hyl:..:}.; If you answered " No" to any of the above, please explain. ( If you need more space , attach a separate statement ) - - - - - - - - - - - - - - - - - - - - rrrr r - - rrrrrrrrrrrrrrr :.,. j-::•" :"r. : ..:! v .. .Tn 33 Does the organization discriminate by race in any way with respect to: a Students' rights- or privileges? . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . .- . . . . . . . . . . . 33a b Admissions policies? • . • . • • • ._ • . : , , , . . 33b c Employment of faculty or administrative staff? , , , , , , . . • . . . . . . . . . . . . . . . . . 33c d Scholarships_ or otherfinancial assistance? • . . . , , , , , , , , , , , • , , , , , 33d e Educational policies? . . . . 33e f Use of facilities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33f g Athletic programs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 h Other extracurricular activities? , , , , , , . . 33h If you answered "Yes" to any of the above , please explain. ( If you need more space , attach a separate statement ) rr - - - rrrrrrr - - - - - - - rrrr — rrrr — rrrrr rr - - - - - - - - - - - - •:+v5.'lil } ti.i,`:, - - - - rrrr — rrrr - - - - - - - - - - - - - - - - - - - - - - - - - - - r — rrrrr - - rrr - - - - - - - - - - rrrrrr — rrr — rrr - - - - r r r r rr rrrr - rrrrrrrrrrrr - - rrrrrrrrr r r r r r . rrrrr r r r rrrrrr - rrr - rr r r r r r - rrrr 34a Does the organization receive any financial aid or assistance from a governmental agency? , , ; , , , , , , , 34a b Has the organization's right to such aid ever been revoked or suspended? , , , , , 34b 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 . . 35 Schedule A (Form 990 or 990-EZ) 2000 JSA 0 E 1230 3.000 B9A003 2830 111986 Schedule A Form 990 or 990- 2000 59g-&2,496294 Pa e 5 Lobbying Expenditures by Electing Public Charities (See page 7 of the instructions. ) ' o be completed ONLY b • an eligible organization that filed Form 5768)' NOT APPLICABLE Check here ► aif the organization belongs to an affiliated group. Check here lowb H if you checked "a" above and "limited control" provisions apply, (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 38 Total lobbying expenditures ( add lines 36 and 37) 38 39 Other exempt purpose expenditures , 00 0 0 , , , , , • „ , , , , „ , , , 39 40 Total exempt purpose expenditures (add lines 38 and 39) , , • , 40 • , �. ,. rt. • ,t•« . . ..,x <.•Mt' t> ._.�i -, ' .> f�,<. r�. ' .x 41 Lobbying nontaxable amount. Enter the amount from the following table ;'iY..^ r 4 r .r< > Y.rx y.r- d>¢ xr'< 'tiY .C• If the amount on line 40 is - The lobbying nontaxable amount is 4 •'1{:'-„ j`''+i:' :. .'S;%.. ':`. �:j•1�'' :'ii.:}im::tii:3 aw:t ,.' i::. Not over $500, 000 , 20 � of the amount on line 0 , - , 1ec, s':t < ...=3.>.:: ._..' -2. �:Y..':•r''F' � r::.. . ; `.e.��K:' : C i.c'if "�:i: isTjr,.� ,?::� ' .i.Fy;. ' � : :�e;}` '}: •ia. '>',j.i._'''i:T15.yic JK::'S�!e::a:.`” ..< Over $ 500, 000 but not over $ 1 ,000, 000 , ' , $ 100, 000 plus 15 /6 0l the excess over 5500,000 r•,> r:. r: ,: }r r,.,•, :s. ,., 5•ae -. ; ,,.3 . ; ..,,-, ,ip I., r...,:rc � , R r .ri" Over $ 1 ,000,000 but not over $ 1 , 500,000 $ 175,000 plus 10% of the excess over $1 00000000 41 ir.`.X: '• yt`%i< i=;"}ti��rte.%;?si3=� .. it{i:`.:< : r.[(ti:r::i%F+,-i:i:j<v ii.r�:.� : :�'::'a•:t> Over 51 ,500, 000 but not over $ 17,000, 000 - 1225,000 plus 5% of the excessover $1 ,500,000 �:;, ..,-.''•,y.,, x s s ;�' ^`s' � „�s . s , ; • a^t+ _ _;s,�f='�::: '-sf< _ _ a:::pr-i:.:, '95:.. '`, ::_<_:o}r; ,•:•4ri3'z.- a�.}:}.'"." ' :) �V.... .) . Over $ 17,000,000 E1 000 000 - x <:: '• ` ''=- ',x � - 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- ifline 41 is more than line 38 • . • . 1 44 : ::� s.,i�::::i' -,y2ti i-::-.Y.y;:::: y�G;:•;:zy: -; :f:Yiy;'t^.>j.Y �: C,i%:i': i s.rtaY. ` •-�?'�.:{r^"e :r$\i] S..y,.rSty` i�,EY}.Sy ar..iS�;:.rtz�v.,Li?t,.x:i •„fl: Caution: If there is an amount on either line 43 orline 44 ou must file Form 4-Year Averaging Period Under Section 501 (h) ( Some organizations that made a section 501 (h) election do not have to complete all of the five columns below, See the instructions for lines 45 through 50 on page 9 of the instructions. ) Lobbying Expenditures During 4-Year Averaging Period Calendar year (or fiscal (a) (b) (c) (d) (e) year beginning in ► 2000 - 1999 1998 1997 - = Total Lobbying nontaxable _ 45 amount - - i:k^.c: •wis..r. ,Y,:::'.•rrt:_:i:';.v, .,.a::.>.....t. T'i•:::'rCswr9:s.�' rxtx'T:'r:,`s,.'y.Yi?• .:.':�';,ii;.i.C.,.i3:..`.,:Ctau:;: Lobbying ceiling amount l::'::. ;Y::.a>S.i•t,^.a,:r:S�.':ai<'et. :,Y}i.•rY•'-a•,,t-„;S.:F::�;Cp.:�rrSs. T._r:,ti•,s:S..ir :fY:^'.-..?a�••T1;'_3tv:.:r,E_.i �.*i••.,,Y.y....;.i.trr,?';\:::s,": !i.v'::^t•=ar'7.:.Z:•_,.._°'.�3.:::¢:.$-:.:::l;i;�,>T.�fi::z::t;y•<':_.}:c:}..”::�1+z.�>1r.'.S"::;CL_•y:i°:�-x.:'•.`<. -- - - - _ - 'a'`:::. "`''w ..ha•-. : '�ti i.' I.-•,w 3•Yq:Y.-JJ . t..ti S. 'Y:�.:. - ��+=Y;>'c•.<:•.:;..3:i"tr:'<•..p..: .t.+f(�3,:Za.•�<.:.-.:."..."_..' .a.Fx:::. [ri>..:•.,:<i,i r:<,.:,;:a.,i,;j.•.•rx><<�yr,>s. ns.xrv,.,..ro<,,.i.:,-1r?}.i�.f;3 .tt:;. :�t.�l...fG•?di..�y.'<w,. nr;•. :s. e 46 150G of line 45 a t s<'3:N•'....,..Y,-,.•„•,S''1_.: a:`Fi`}::F:F>y iest,:b'<;.:yY:`�-t,.'St.z'�,�;:'%y?,:..s;9".,,4r'.n:,;::i.'.>f.:,ie.: - - . - - w .. 47 Total lobbying expenditures Grassroots nontaxable _ 48 amount • • • sees • . f.. .. h. . t.: .:Y.T .A'. -Y.C}R� "��+.:Fi'� yltTiy} ry..a' .t:<e:5_i�r.v'[• :f ':3:4'` f 4z'- ..a2 .:x,< rix.4:•+i :,ia ,ci~t,•. .gi . .S,' i4::•�., : .d:5 Grassroots ceilin(� amount ^.::..< :�;�.\s..<5;;;,F. =,. : . <cti ; .,� :•.,,<,}�:;Y ., ,x.;,-.7s . �•fl : :� . . O . ..:., .._ .. •... ... . .. .a . _:- \... .. . .. ... . .... . ...:.: . a ). . .. 4 .. . . . .. l .} v,x..,w iG)C y';QiT Q')t�::c:�}t�:�"l:":::'::v':} . �:��^<,-- 49 (150 % of line 48 a - Grassroots lobbying 50 ex enditures • . Lobbying Activity by Nonelecting Public Charities NOT APPLICABLE For reporting only by organizations that did not complete Part VI-A) See a e 9 of the instructions . During the year, did the organization attempt to influence national, state or local legislation, including any Yes No Amount attempt to influence public opinion on a legislative matter or referendum, through the use of: a Volunteers . . . . . . . . . . . . . . . . a b Paid staff or management ( Include compensation in expenses reported on lines c through h .) X c Media advertisements X d Mailings to members , legislators , or the public , , , , , , , , , • . , X e Publications , or published or broadcast statements , , X f Grants to other organizations for lobbying purposes , , , , , , , • , X g Direct contact with legislators , their staffs, government officials , or a legislative body , X h Rallies , demonstrations , seminars, conventions, speeches, lectures, or any other means X 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 Schedule A ( Form 990 or 990 -EZ) 2000 JSA OE1240 2.000 B9A003 2830 111986 Schedule A Form 990 or 990- 2000 - 59 -24 96294 Pae 6 Information Regarding Transfers To and Transactions and Relationships. With Noncharitable ' Exempt Organizations (See page 9 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 I Yes No (i) Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , , a 0 51ai X (H) Other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a X b Other transactions: (i) Sales or exchanges of assets with a noncharitable exempt organization , , , , , , , , , , , , , , , b I X (ii) Purchases of assets from a noncharitable exempt organization , , , , , , , , , , , , , , . . , . . . . b ii X (iii) Rental of facilities, equipment, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . bili X (iv) Reimbursement arrangements , , , , , , , . , , , , , , . . . . . . . . . . . . . . . . . . . . . . . b iv X (v) Loans or loan guarantees , , , , . , a . . 0 . 0 . . . . . . , . KV). X. . (vi) Performance of services or membership or fundraising soliicitagons , , ,- , . . . . . . . . . . . . . . . . : b vi X c Sharing of facilities, equipment, mailing lists, other assets, or paid employees , , , _ , , , , , , • . . , c X d If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value of the goods, other assets, or services given by the reporting organization. If the organization received less than fair market value in any transaction or sharing arran ement show in column the value of-the goods, other assets or services received: - (a) (b) (c) - (d) Line no. Amount involved Name of noncharitable exempt organization Description of transfers transactions and sharing arrangements N /A 52a Is the organization directly or indirectly affiliated with , or relatedto , one or more tax-exempt organizations describedinsection 501 (c) of the Code ( other than section 501 (c)( 3 )) or in section 527? , , , , , , lo- Yes QX No b If "Yes " complete the following schedule : (a) (b) (c) - Name of organization Type of organization Description of relationship N /A JSA Schedule A ( Fo �rr. 990 or 990 -EZ) 2000 OE1250 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 FORM 990 , PART I - OTHER INVESTMENT INCOME DESCRIPTION AMOUNT ORDINARY INCOME FROM PREMIER PURCHASING PARTNERS , L . P . INVESTMENT 152 , 108 . INCOME ON POOLED FUNDS 2731097 . TOTAL 425 , 205 . STATEMENT 1 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL 8OSPITAL , INC . 59 - 2496294 e t . FORM 990 , PART I — OTHER INCREASES IN FUND BALANCES DESCRIPTION AMOUNT NET ASSETS RELEASED FROM RESTRICTIONS USED FOR PURCHASE OF PROPERTY AND EQUIPMENT r, 423 , 104 . TOTAL 423 , 104 . STATEMENT 2 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL ,- INC, . 59 - 2496294 it , , FORM 990 , PART I - OTHER DECREASES IN FUND BALANCES DESCRIPTION AMOUNT INVESTMENTS : >PREMIER PURCHASING PARTNERS , L . P . _ 196 , 015 . >OCEAN HEALTH ASSOCIATES , LTD . ilk 286 , 122 . DEMUTUALIZATION BENEFITS 43 , 214 . CHANGE . IN UNREALIZED GAINS & LOSSES ON - OTHER THAN TRADING SECURITIES - 10 , 839 , 027 . - - TOTAL- - 111364 , 378 . - it STATEMENT 3 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , -INC . 59 - 2496294 - I � I FORM 990 , PART II - OTHER EXPENSES PROGRAM MANAGEMENT DESCRIPTION TOTAL SERVICES AND GENERAL INSURANCE 21017 , 736 . 21017 , 736 . BAD DEBT / CONTRACTUAL ALLOWANCE 115443615 . 15443615. PROFESSIONAL SVCS - PHYSICIAN 11872 , 092 . 1 , 872 , 092 . PROFESSIONAL SVCS - OTHER 61813 , 454 . 61813 , 454 . ADVERTISING 239 , 097 . 239 , 097 . DUES & SUBSCRIPTIONS 224 , 876 . 224 , 876 . LICENSES & TAXES 11703 , 450 , 11703 , 450 . OBSOLETE INVENTORY 166 , 953 . 166 , 953 . SPECIAL SERVICES 1401242 . 140 , 242 OTHER OPERATING EXPENSES 510 , 392 . 510 , 392 . INVESTMENT / PORTFOLIO EXPENSES 103 , 320 . 103 , 320 . CHARITABLE CONTRIBUTIONS 1930 1930 AMORTIZATION 220 , 9616 220 , 961 . TOTALS 294563810 2711' 4171 , . 21342 , 210 . t I I I OSPSLN 5.000 INDIAN RIVER MEMORIAL HOSPITAL , , INC : " 59 -2496294 Q FORM 990 , PART IV - INVESTMENTS - OTHER ENDING DESCRIPTION BOOK VALUE CASH AND CASH EQUIVALENTS 41647 , 793 . CERTIFICATES OF DEPOSIT 100 , 000 . COMMON STOCKS . 25 , 791 , 929 . U . S . GOVT AGENCY OBLIGATIONS 294 , 710 . CORPORATE OBLIGATIONS 24 , 137 , 947 . FOREIGN DEBT OBLIGATIONS 541034 . BONDS 618 , 0270 TEMPORARY INVESTMENTS 11272 , 521 . MONEY MARKET INVESTMENTS _ 177 , 290 . U . S . TREASURY NOTES _ -- 5 , 930 , 278 . ENDOWMENT FUND 2801699 . ACCRUED INTEREST -RECEIVABLE INVESTMENT IN SUBSIDIARIES - 3 ,t9 " 13970 TOTALS. 67 , 305 , 243 . STATEMENT 5 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , - INC : . ' 59 - 2496294 FORM 990 , PART IV - OTHER ASSETS ENDING DESCRIPTION BOOK VALUE DUE FROM AFFILIATES 6411435 . OTHER RECEIVABLES 3921857 . BOND ISSUANCE COSTS , NET 2 , 384 , 279 . TOTALS 31418 , 571 . STATEMENT 6 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL ; INC . 59 - 2496294 FOW 990 , PART IV - TAX- EXEMPT BOND LIABILITIES ENDING DESCRIPTION BOOK VALUE HOSPITAL REVENUE BONDS : >SERIES 1985 . 15 , 400 , 000 . LESS : PAYABLE BY THE INDIAN RIVER COUNTY HOSPITAL DISTRICT - 9391398 . >SERIES 1988 14 , 350 , 000 . >SERIES 1989 6 , 500 , 000 . >SERIES 1990 211700 , 000 . HOSPITAL REVENUE REFUND BONDS : - - >SERIES 1996 1319751000 . LESS . UNAMORTIZED BOND DISCOUNT - - - - 163 , 462 : >SERIES 1997 21 , 135 , 000 . PAYABLE FROM IRREVOCABLE TRUSTS FOR CROSSOVER DEBT - 32 , 527 , 734 . TOTALS 59 , 429 , 406 . ST.'%,TEMENT 7 OSPSPR 2. 000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL ,, INC . _ 59 - 2496294 L ) • r 1 • 1 • • FORM 990 , PART IV - MORTGAGES AND OTHER NOTES PAYABLE LENDER : GE CAPITAL PURPOSE OF LOAN : CAPITAL EXPANSION ENDING BALANCE DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 , 733 , 920 . TOTAL ENDING MORTGAGES AND OTHER NOTES PAYABLE 4 , 733 , 920 . STATEMENT 8 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , , INCA ' 59 - 2496294 „ fFOW 990 , PART IV - OTHER LIABILITIES ENDING DESCRIPTION BOOK VALUE SELF - INSURANCE LIABILITY 11970 , 000 . DUE TO AFFILIATES 126 , 760 . EST 3RD - PARTY PAYOR SETTLEMENT 11195 -1857 . TOTALS 31292 , 617 STATEMENT 9 OSPSPR 2.000 B9A0O3 2830 111986 - INDIAN RIVER MEMORIAL HOSPITAL , INC . . _ 59 - 2496294 - FORJIJ 990 , PART IV-A - OTHER REVENUE ON BOOKS BUT NOT ON RETURN DESCRIPTION AMOUNT INVESTMENT MANAGEMENT EXPENSE - 103 , 165 . TOTAL - 103 , 165 . STATEMENT 10 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER- MEMORIAL HOSPITAL , INC .. " 59 - 2496294 FOM 990 , PART IV-A - OTHER REVENUE ON RETURN BUT NOT ON BOOKS DESCRIPTION AMOUNT - - - - - - - - - - - - - - - - - INVESTMENT IN : >PREMIER PURCHASING PTNRS LP 1961208 . >OCEAN HEALTH ASSOCIATES , LTD . 286 , 277 . DEMUTUALIZATION BENEFITS 431214 . TOTAL 5251699 STATEMENT 11 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . - - ' ' 59 - 2496294 , . . FORD 990 , PART IV- B - OTHER EXPENSES ON BOOKS BUT NOT ON RETURN DESCRIPTION AMOUNT INVESTMENT MANAGEMENT EXPENSE - 1031165 . TOTAL - 1031165 . STATEMENT 12 OSPSPR 2000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL ; INC . 59 -2496294 FOvRM 990 , PART IV-B - OTHER EXPENSES ON RETURN BUT NOT ON BOOKS DESCRIPTION AMOUNT INVESTMENT/ PORTFOLIO EXPENSES 155 . CHARITABLE CONTRIBUTIONS 193 . TOTAL - - 348 . ow STATEMENT 13 OSPSPR 2.000 B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . ` 590m, 2496294 _ e FORM 990 , PART V — LIST OF OFFICERS , DIRECTORS , AND TRUSTEES CONTRIBUTIONS EXPENSE ACCT NAME AND ADDRESS TITLE AND TIME TO . EMPLOYEE AND OTHER DEVOTED TO POSITION COMPENSATION BENEFI 'T PLANS ALLOWANCES NICK SAMILO SR VP / FINANCE , & CFO 155 , 639 . 1000 36TH STREET VERO BEACH FL 40 HRS /WX , OR NONE JANICE DONLAN 1000 36TH STREET VERO BEACH FL VP / FDN & COMM I REL 33 , 739 . 40 HRS /WK * NONE JOHN C . KURTZ CHAIRMAN 1000 36TH STREET VERO BEACH FL NONE MINIMAL, NONE NONE LEE M . KLINETOBE VICE CHAIRMAN 1000 36TH STREET VERO BEACH FL NONE . NONE MINIMAL, NONE LORING CATLIN VICE CHAIRMAN 1000 36TH STREET VERO BEACH FLMINIMAL NONE NONE NONE FELIX DEMARTINI , M . D . SECRETARY 1000 36TH STREET VERO BEACH FL MINIMAL, NONE NONE NONE CHARLES V . SHEEHAN TREASURER 1000 36TH STREET VERO BEACH FLNONE NONE NONE MINIMAL ' � � " JAMES W . LARGE , M . D . DIRECTOR 100 N 0 3 ON 6TH STREET E ET VERO BEACH '' FL NONE MINIMAL NONE KATHARINE LUM , M . D . DIRECTOR 1000 36TH STREET VERO BEACH FLMINIMAL NONEi NONE NONE CHARLES N . CELANO , M . D . DIRECTOR 1000 36TH STREET VERO BEACH FL NONE NONE MINIMAL NONE RICHARD G . GITELES DIRECTOR NONE NONE MINIMAL NONE * STMT 22 OSPSLN 5.000 B9A003 2830 I INDIAN RIVER MEMORIAL HOSPITAL , INC . - 59 - 2496294 FORM 990 , PART V - COMPENSATION PROVIDED BY RELATED ORGANIZATION - TITLE AND TIME CONTRIBUTIONS EXPENSE ACCT NAME AND ADDRESS TO EMPLOYEE AND OTHER - - - - - - - DEVOTED TO POSITION COMPENSATION BENEFIT PLANS ALLOWANCES - - - - - - - - - - - - - - - - - - - - - - - _ - - INDIAN RIVER HOSPITAL FOUNDATION - - - - 59 - 0760215 JANICE DONLAN VP / FDN & COMM REL 102 , 077 . ' 1000 36TH STREET VERO BEACH FL 40 , HRS /WK ' NONE NONE , GRAND TOTALS - - - - - - - - - - - - - - � - - - - - - - - - - - I 102 , 077 . NONE NONE i I ' I I OSPSLN 5.000 . B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 FORM 9901 PART VI - NAMES OF RELATED ORGANIZATIONS INDIAN RIVER HOSPITAL FOUNDATION , INC . INDIAN RIVER HEALTH SERVICES , INC . HEALTH SYSTEMS OF INDIAN RIVER , INC . T . C . BILLING CORPORATION STATEMENT • . 17 ' , OSPSPR 2.000 s s B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 FORM 990 , PART V - LIST OF OFFICERS , DIRECTORS , AND TRUSTEES CONTRIBUTIONS EXPENSE ACCT TITLE AND TIME TO EMPLOYEE AND OTHER NAME AND ADDRESS DEVOTED TO POSITION- - - - - - - - - - - - - - - - S TION COMPENSATION BENEFIT CLANS ALLOWANCES 1000 36TH STREET VERO BEACH FL i FLORENCE BOOMS DIRECTOR NONE NONE NONE 1000 36TH STREET VERO BEACH FL MINIMAL MARTIN GIBSON DIRECTOR 1000 36TH STREET VERO BEACH FL MINIMAL NOME NONE NONE ERNESTINE W . WILLIAMS DIRECTOR NONE NONE NONE 1000 36TH STREET VERO BEACH FL MINIMAL EARL C . CONWAY DIRECTOR NONE NONE NONE 1000 36TH STREET VERO BEACH FL MINIMAL CHARLES M . SUMA DIRECTOR NONE NONE NONE 1000 36TH STREET VERO BEACH FL MINIMAL RICHARD MCDERMOTT DIRECTOR NONE NONE NONE 1000 36TH STREET VERO BEACH FL MINIMAE JEFFREY L . SUSI CEO ; 2451373 .., NONE 1000 36TH STREET VERO BEACH. FL 40, HRS /WK CARROL FRISCHKORN SR VP /ADMIN137 , 431 . 1 NONE 1000 36TH STREET VERO BEACH FL 40 HRS /WK JUDITH A . SCHANEL ' SR VP / PATIENT CARE 131 , 717 . , x • NONE 1000 36TH STREET VERO BEACH FL 40 HRS /WK - - - - - - - - - - - - - - - - - - - - - - GRAND TOTALS 7031, 899 . NONE NONE * STMT 22 OSPSLN 5.000 . B9A003 2830 111986 aTam � rrFr, m INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 FORM 990 , PART VII - OTHER REVENUE BUSINESS EXCLUSION RELATED OR EXEMPT DESCRIPTION CODE AMOUNT CODE AMOUNT FUNCTION INCOME 1 - RADIOLOGY 5 , 699 . 1 - MEDICAL RECORDS 964647 . 2 - SCRAP & WASTE 7 .1994 . 2 - SILVER RECOVERY 1 , 779 . 3 - PURCH DISCOUNTS 196 , 659 . 4 - LIFELINE 145 , 764 . 5 - EDUCATION 5 - SUM1 , 134 .MER CAMP i 7 , 203 . � 5 - CEBH COUNSELING 9 , 383 . 6 -MISCELLANEOUS 31307 . 7 - LAB SERVICES 144 , 139 . 8 - DRUG SCREENING 87 , 537 . 9 - HOSPICE HOUSE 127 , 073 . 10 - PULMONARY REHAB 8 , 513 . 10 - CARDIAC REHAB 26 , 971 . 11 - " ROPES " COURSE 5 , 452 . 12 - CEBH STATE BEDS 48 , 000 . 13 - PROF STANDARDS 14 , 500 . CAFETERIA 03 676 , 095 . PHARMACY 03 32 , 400 . PRINTING SERVICES 561439 21 , 509 . COMP / SOFTWARE SVCS 541900 66 , 209 . ACCOUNTING SVCS 541200 131 , 203 . I I I I T - TOTALS 10.0 , 921 . 708 , 495 . 1850 754 . OSPSLN 5.000 B9A003 2830 111986 STATRMRNT IR INDIAN RIVER MEMORIAL HOSPITAL., INC . 59 -2496294 r FORM 990 , PART VIII - ACCOMPLISHMENT OF EXEMPT PURPOSES EXPLANATION OF HOW EACH ACTIVITY FOR WHICH INCOME. LINE IS REPORTED IN COLUMN ( E ) OF PART VII CONTRIBUTED NO . IMPORTANTLY TO THE ACCOMPLISHMENT OF EXEMPT PURPOSES 93B REFER TO ATTACHED STATEMENT FOR COMMUNITY SERVICE PROGRAMS OFFERED BY INDIAN RIVER MEMORIAL HOSPITAL , INC . ( IRHM) 0 98 RENTAL INCOME FROM INDIAN RIVER MRI FOR USE OF IRMH ' S MRI MACHINE , WHICH - FURTHER ENHANCES THE - QUALITY OF MEDICAL CARE _ - PROVIDED TO PATIENTS - IN THE COMMUNITY . 99 ALLOCABLE SHARE OF PARTNERSHIP - INCOME FROM MATERIALS - MANAGEMENT & GROUP PURCHASING PROGRAMS STRUCTURED TO REDUCE COSTS OF MEDICAL -RELATED SUPPLIES PURCHASED BY IRMH , 103B 1 - THE PROVISION OF THESE SERVICES CONTRIBUTES TO THE COMFORT & WELL -BEING OF PATIENTS & INCREASES THE QUALITY OF HEALTH CARE PROVIDED BY IRMH , 103B 2 - REVENUE FROM SALE OF SCRAP /WASTE AND SILVER RECOVERY ARE RELATED TO IRMH ' S EXEMPT PURPOSE AS SUCH PRODUCTS ARE A BY - PRODUCT FROM IRMH PROVISION OF MEDICAL CARE TO PATIENTS . 103B 3 - REVENUE FROM PURCHASE DISCOUNTS IS A RESULT FROM IRMH ' S PURCHASES OF NEEDED SUPPLIES USED IN THE PROVISION - OF DIRECT MEDICAL CARE . - _ 10313 4 - REVENUE FROM - THE_ RENTAL OF LIFELINE UNITS CONTRIBUTES _ TO IRMH ' S EXEMPT - PURPOSE OF - PROVIDING QUALITY HEALTHCARE TO - THE COMMUNITY . - - 103B 5 - REVENUE FROM THE EDUCATIONAL SEMINARS & OTHER VARI.OUG - EDUCATIONAL PROGRAMS CONTRIBUTES TO IRMH ' S EXEMPT PURPOSE BY PROVIDING HEALTH SERVICES TO THE COMMUNITY . 103B 6 - MISCELLANEOUS -REVENUE . FROM THE PROVISION OF VARIOUS . SERVICES IN SUPPORT OF IRMH ' S EXEMPT PURPOSE . 103B 7 - REVENUE FROM GENERAL LABORATORY SERVICES PROVIDED BY IRMH TO AN OFFSITE , UNRELATED FACILITY . THIS SERVICE IS UNIQUE AND IS NOT OTHERWISE AVAILABLE IN THE COMMUNITY . 103B 8 - CEBH OFFERS DRUG SCREENING SERVICES TO COMPANIES FOR THEIR PROSPECTIVE AND / OR CURRENT EMPLOYEES FOR WHICH THEIR EMPLOYMENT IS CONTINGENT - UPON . THIS SERVICE SUPPORTS IRMH ' S EXEMPT PURPOSE OF PROVIDING QUALITY HEALTH SERVICES TO THE LOCAL COMMUNITY . 103B 9 - VNA HOSPICE HOUSE IS A TRANSITIONAL CARE FACILITY WHICH TREATS TERMINALLY - ILL PATIENTS . IRMH ' S PROVIDES SECURITY , FOOD SERVICES , MEDICAL SUPPLIES , MAINTENANCE , ETC . AND IS - REIMBURSED BY THE HOSPICE HOUSE . THESE SERVICES FURTHER IRMH ' S MISSION OF PROVIDING UNIQUE HEALTH SERVICES , WHICH ARE NOT OTHERWISE OFFERED IN THE SURROUNDING COMMUNITIES . 103B 10 - REHABILITATION IS EXTREMELY IMPORTANT TO CARDIAC AND PULMONARY PATIENTS . IRMH OFFERS A FITNESS CENTER TO PATIENTS AS WELL AS INDIVIDUALS IN THE LOCAL COMMUNITY TO USE THE FITNESS CENTER AS A TOOL FOR THEIR PHYSICAL THERAPY . STATEMENT 19 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL ] INC . . • 59 - 2496294 , FORM 990 , PART VIII - ACCOMPLISHMENT OF EXEMPT PURPOSES EXPLANATION OF HOW. EACH ACTIVITY FOR WHICH INCOME LINE IS REPORTED IN COLUMN ( E ) OF PART VII CONTRIBUTED NO . IMPORTANTLY TO THE ACCOMPLISHMENT OF EXEMPT PURPOSES 103B 11 - THE " ROPES " COURSE IS A TEAM-BUILDING EDUCATIONAL TRAINING PROGRAM OFFERED TO ALL MEMBERS OF THE COMMUNITY . . 103B 12 - REIMBURSEMENT FROM DEPARTMENT OF CHILDREN & FAMILIES TO PROVIDE BEDS FOR SELF - PAY PATIENTS . IRMH ENTERED INTO CONTRACT WITH THE DEPARTMENT -ON 6/ 18 / 2001 . _ 103_B - 13 - AN APPLICATION FEE COLLECTED MOM _ PRIVATE PHYSICIANS _ IN -THE SURROUNDING COMMUNITIES TO GAIN PRIVILEGES WITH IRMH ( I . E _ , ADMISSIONS , ANCILLARY CARE , ETC . ) . STATEMENT 20 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , INC . 59 - 2496294 FORM 990 , PART IX - INFORMATION REGARDING TAXABLE SUBSIDIARIES - + PERCENTAGE NATURE OF NAME AND ADDRESS OWNERSHIP BUSINESS TOTAL ENDING EMPLOYER IDENTIFICATION NUMBER INTEREST ACTIVITIES INCOME ASSETS T . C . BILLING CORPORATION 100 . 000000 , BILLINGS 601094 . 350 , 745 1000 36TH STREET VERO BEACH , FL 32960 65 - 0352812 TOTAL INCOME i 601094 . 350 , 745 . OSPSLN 5.000 B9A003 2830 1 1 1 SRF r" ?k mr. * Tn �.'tm INDIAN RIVER MEMORIAL . HOSPITALq) INC . 59 -2496294 FORM 9901 PART V - LIST OF OFFICERS , DIRECTORS , AND TRUSTEES FORM 990 , SCHEDULE A . PART I - COMPENSATION OF THE FIVE HIGHEST PAID EMPLOYEES OTHER THAN OFFICERS , DIRECTORS , AND TRUSTEES * REGARDING CONTRIBUTIONS TO EMPLOYEE • BENEFIT PLANS , ' INDIAN RIVER MEMORIAL HOSPITAL , INC . MAINTAINS A DEFINED BENEFIT PENSION PLAN , ALL CONTRIBUTIONS ARE DETERMINED. USING THE AGGREGATE FUNDING METHOD , THEREFORE , INDIVIDUAL CONTRIBUTION AMOUNTS ARE NOT DETERMINABLE . STATEMENT 22 OSPSPR 2.000 ' B9A0O3 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , - INC . 1 . 59 - 2496294 0 FORM 990 , PART IV , LINE 57 — LAND , BUILDINGS , EQUIPMENT ACCUMULATED BOOK COST DECPRECIATION VALUE - - - - - ---- - - - - - - - - - - - - - - - - = - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - LAND / LAND IMPROVEMENTS 4 , 93'91564 21613 , 568 2 , 3151996 BUILDINGS 42 , 893 , 95e3 18 , 904 , 511 231989 , 442 EQUIPMENT 97 , 607 , 392 70 , 419 , 591 27 , 187 , 801 CONSTRUCTION IN PROGRESS 2 , 856 ,777 — 2 , 856 , 777 TOTAL 148 , 287 ; 686 91 , 937 , 670 56 , 350 , 016 ALL_ DEPRECIATION IS. COMPUTED USING THE STRAIGHT —LINE METHOD OVER DEPRECIABLE LIVES RANGING FROM 5 TO 40 YEARS , STATEMENT 23 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL , . INC : 59 - 2496294 FORM 990 , PART I , LINE 8 - SALES OF ASSETS OTHER THAN INVENTORY DATE ACQUIRED DATE SOLD GROSS ( & BY WHAT METHOD ) ( & TO WHOM ) SALES PRICE BASIS SALES OF SECURITIES FROM INVESTMENTS : > PPP * VARIOUS VARIOUS 351420 > SSB * * VARIOUS VARIOUS 351 , 282 SALE OF FIXED ASSETS - ( STMT 251 - VARIOUS - VARIOUS -66 , 526 94 , 249 TOTAL 453 , 228 94 , 249 THE NET GAIN FROM THE SALES OF ASSETS OTHER THAN INVENTORY IS $ 111381066 . (A) SECURITIES NET UNREALIZED GAIN 0110871212 ( DUE TO THE HIGH VOLUME OF TRADES , DETAILS WILL_ BE PROVIDED UPON REQUEST . ) - _ ( B ) SALES OF FIXED ASSETS ( STATEMENT 25 ) - ( 27 , 723 ) PPP * - NET SHORT - TERM CAPITAL GAIN 35 , 699 NET LONG- TERM CAPITAL LOSS ( 249 ) NET - SECTION 1231 LOSS ( 87 ) DEMUTUALIZATION BENEFITS FROM 43 , 214 SUN LIFE INSURANCE COMPANY 1 , 138 , 066 * PREMIER PURCHASING PARTNERS , L . P . SCHEDULE K- 1 * * STATE STREET - BANK AND TRUST COMPANY SCHEDULE K- 1 STATEMENT 24 OSPSPR 2.000 B9A003 2830 111986 INDIAN RIVER MEMORIAL HOSPITAL, INC. SCHEDULE OF DISPOSALS OF P.P. k E. FYE SEPTEMBER 309 2001 KIN, S9-2496294 GAIN ON LOSS ON DATE OF - GIL ASSET ACCUM. NET BOOK SALE SALE AMT. DATE RE DESCRIPTION ACCI'. 8 NO, COST DEPR, VALUE 9000.7800 9000.7850 RECEIVED ACQUIRED DEPT OU31/2001 MATTRESS LOT 1171 800335 S 1.167.00 I 19167.00 I - 04/01/1974 . 6079 0131/1001 DESK 1171 807013 S _ 53120 I 345.23 S 185.97 I - 18597 04/0111991 _ 6079 01212001 TV CART - 1171 12934 S 6990 I 6990 I - - 071OM987 . 6111 01/31/2001 SETEE 1171 17849 I 943.66 I 845.30 S 9836 I 9836 04/01/1990 6111 _ 01/31/2001 PULSE GENERATOR 1171 - 802890 T 2,045.00 I 29045.00 I . : 091OM981 6111 01/31/1001 TV 1171 806202 $ 34S.00 S 345.00 I - 04/01/1990 6111 0131/2001 TV 1171 806203 S 345.00 S 34S.00 - S - 04/01/1990 6111 Ol/31/SO01 CHAIR SCALE 1171 - 16840 S 33LSS I 33&55 I - _ 10/0111989 6122 01/31/2001 SIDE CHAIR - 1171 - 14981 I 265.00 S 265.00 I - _ - 06MM988 7132 OU3I2001 ROCKER/RECLINER 1171 20049 t 407.00 S 407.00 S - 04,10mm 7192 01/31/2001 TELEPHONE SYSTEM 1161 - 810092 S . 35,762.00 S 26,82131 S 8,940.49 I 8,940A9 10/01/199S 7193 01/31/2001 ROCKER/RECLINER - 1171 _ 20063 S 407.00 S- 407.00 S - - _ 04/01/1992 7293 - - OV312001 TELEPHONESYSTEM/1NSTALL 1171 - 810020 S 39591JS I 3,591.85 S - 10/0111995 7193 OWL2001 STAND MAYO 1171 10869 S - 119.00 _ $ 119.00 S - 11/0111978 - 7211 01/31/2001 LIGHTSOURCE _ - 1171 _ 15128 S - - 2',825.00 S 2,825.00 I - _ - - 12/01/1988 7211 01/312001 LIGHT SOURCE 1171 1833S S 3,99030- S 3y9040 S - 10/0111990 7211 - 01/31/2001 CO2 LASER SURGICAL INSTRUMENT 1171 802948- 8 55,855.00 S 55,655.00 S - 06/0111982 7211 01/3112001 BLOOD PRESSURE MONITOR 1171 802959 S 9801825 S 9001825 S - 08/0/2982 7211 01/312001 STONE DISINTEGRATOR 1171 803696 S 79000.50 I 7,000.50 S - IU01/1984 7211 01/312001 ELECTROCAUTERY D-8 MED SONIC 1171 5085 S - 950.00 5 950.00 S - 0IAM976 7218 01/312001 UROSCOPE 1171 805703 S 2119195.00_ I 211.195.00 S 101OM989 7220 01/3112001 FAX MACHINE 1171 - 808956 S 2,265.00 S 29265.00 S - - 10/01/1993 7220 011312001 MAYO STAND 1171 13982 S 263.65 S 263.65 S - 011OM988 7131 012UZ001 MAYO STAND 1171 13983 S 263.65 S 263.65 S - 01/0111988 7231 01/31/1001 MAYO STAND 1171 13904 S 263.65 $ 263.65 S - 01/012988 7231 01/31/2001 HYDRAULIC STRETCHER - 1171 20215 S 3r303.15 $ 3,303.15 S - S 50.00 S 50.00 10/0111992 7231 01/312001 HYDRAULIC STRETCHER 1171 20219 S 31303.15 S 3,303.15 S - S 50.00 S 5. 0.00 10/0111992 - 7231 01/311001 MONITOR 1171 11811 $ 1,21633 • I 1,21633 S - 114/01/1985 7011 01/31200/ CAMERA 1171 12981 - S _ 79200.00 I 7,200.00 S - 05/01/1987 _ 7011 OU312001 INCUBATOR _ 1171 _ _ -- 14158 $ 29552.00 S - 2,552.00 $ - _ 07/0111980 - 7011 - 01/312001 FLAMMABLE SAFETY CABINET 1171 21575 $ 593.00 S 370.63 S 22237 S 22237 10101/1994 7011 01/312001 COLOR DISPLAY - 1171 _ 808373 S 32950 S 32030 $ - - 10/01/1992 _ 7011 01/312001 HEMATOLOGY SYSTEM 1171 809283- S _ 125 00.00 $ ll5,02OS8 S 10,879.42 S 24962038 S 35,500.00 04/01/1994 -7011 _ OU312001 MICROSCOPE BINOCULARS 1171 - - 7163 I 5,630.00 S 5,630.00 I - 11101/1978 - 701S 011712001 ELECTROENCEPHOLOGRAPH - 1171 - 12665 I 19,036.12 S _ 19,0.76.12 S - - 10/01/1986 7033 0/512001 MEDILOG 9000.11 RECORDER 1171 - 20746 S 1622.00 S 7962LOO $ - - 10/012993 7033 - 0131/2001 SLEEP LAB 2000 1171- - 805496 I- X4,625.00 S 94,625.00 I - - - 10/01/1989 - 7033 . 01212001 TEMP PULSE GENERATOR - 1171 _ __ 20409 S- 4,500.00 S - 49500.00 S - - - -. 04/01/1993 7035 01/712001 ULTRASOUND TABLE 1171 18888 I 49397.66 S 49287.79 S 109.87 S 109.87 04101/1991 7040 01/31/2001 COPIER 1171 _ 2006 S 19464.00 I 19464.00 S - _ 10/01/1988 7040 O1/3V1001 IV POLES 1171 804301 I 51.10 S 4SA9 S 5.61 $ S.61 091OM987 7040 01/3111001 IV POLES 1171 804302 S 51.10 S 45.49 S S.61 $ S.61 08/01/1987 7040 OV3V1001 TYPEWRITER _ 1171 - 15371 S 59S.W S 595.00 S - _ _ 10101/1990 7071 OV3111001 LIFESCAN BRAIN ACTIVITY 1171 - - 14988 S _ 16,694.00 S 16,694.00 S - _ 07/01/1988 _ 7080 OV312001SAMSUNGMONITOR - 1171 22293 S - . 365.00 - S . 365.00 S - 10/011199S 7150 01/312001 DESK 1171 - 800292 S 21052.00 S 1149625 S SS5.75 S 555.75 04/0111992 8181 01/71/1001 DESK 1171 808293 S 2,05200 S' 11496.25 S 555.75 S 555.75 04/01/1992 8181 OV312001 LIGHT SOURCE 1171 20104 S 2,310.00 S 2,310.00 S - 10/01/1992 7190 0/13112001 TASK CHAIR 1171 _ 19921 S 346.61 $ 30338 S 4333 S 4333 - 04/01/1992 - 7283 01/3lnOOI TASK CHAIR 1171 19921 S 346.61 S 30338 S 4333 S 4333 04/01/1992 7283 011712001 TASK CHAIR 1171 19929 S 346.61 I 30328 S 4333 I 4333 04/01/1992 7183 01/312001 MANAGEMENT CHAIR 1171 19939 $ 500.73 S 365.14 S 13559 S 135.59 04/OV1992 7283 01/312001 LOW BACK SLED CHAIR 1171 19944 I 31853 S 278.68 S 39.85 S 39.85 04/01/1992 7283 01/31/1001 PMR2ADULT 1171 808824 S _ 1,838.05 S 1,838.05 S - 10/0111993 7420 01/712001 CANON TYPEWRITER 1171 12027 S 91S.40 S 915AO S - 1010111985 - 8052 01/312001 STEEL WORKTABLE 1171 809907S _ . 1,46&07 S 844.15 S 623.92 S 623.92 04/01/1995 - 8052 01/312001 OFFICETRAILER 1171 806267 I 65929&71 S 53,871.43 I 11/127.28 S 11,427.28 04/0111990 8061 01712001 OVERHEAD PROJECTOR 1171 - 19078 $ 464.00 S 464.00 S - 04/01/1991 8090 01131/2001 ARM CHAIR 1171 11375 S 405.50 $ 40550 S - 05/01/1986 - 8211 01/312001 FILE CARD SYSTEM 1171 6020 S 180.00 S 180.00 S - 07/01/1972 8232 01/312001 MAGNAVISION MONITOR 1171 24336 $ 309.00 S 231.75 S 7725 $ 7725 04/01/1997 8232 01212001 MAGNAVISION MONITOR 1171 24343 S 309.00 S 231.75 S 7725 S 7725 04/01/1997 8232 01/31200/ CRT-COLOR VIDEO 1171 809462 S 985.80 S 985.80 S - 10/01/1992 8232 01/712001 CRT-COLOR VIDEO 1171 808463 I 98SJI0 S 985.80 S 10/01/1992 8232 01/3U1001 CRT-COLOR VIDEO 1171 808464 S 985.80 S 985.80 S - 10/9111992 8232 01/312001 CRT-COLOR VIDEO 1171 808465 I 985.80 I 985.80 S - 101012992 8232 03212001 CRT-COLOR VIDEO 1171 808466 S 985.80 I 985.80 S - 10/OU1992 8232 011312001 CRT-COLOR VIDEO 1171 808467 S 985.80 S 985.80 S - 10/01/1992 8232 01312001 CRT-COLOR VIDEO 1171 808468 S 985.80 S 985.80 S - 10/012992 8232 01/11/2001 CRT-COLOR VIDEO 1171 808469 S 985.80 S 985.80 I - 10/01/1991 8232 01212001 CRT-COLOR VIDEO 1171 808470 S 985.80 $ 985.80 I - 10101/1"1 8232 011312001 CRT-COLOR VIDEO 1171 808471 S 985.80 $ 985.80 S - 10/0111992 8232 011312001 CRT-COLOR VIDEO 1171 808475 S 985.80 S 985.80 S - 10/01/1992 8232 01/312001 CRT-COLOR VIDEO 1171 808476 S 985.80 S 985.80 I 10/01/1992 8232 01/312001 CRT-COLOR VIDEO 1171 808477 S 985.80 S 985.80 S - 10/01/1992 U32 STATEMENT 25 Papre 1 of 6 INDIAII RIVER MEMORIAL HOSPITAL, INC. . SCHEDULE OF DISPOSALS OF P.P. & L FYE SEPTEMBER 30, 2001 EIN: S9-24%294 GAIN ON LOSS ON DATE OF GAL ASSET ACCUM. NET BOOK SALE SALE AMT, DATE J/E DESCRIPTION ACCT. 0 NO, COST DEPR. VALUE 9000.7800 9000-7850 RECEIVED ACQUIRED DEPT 01/31/2001 CRT-COLOR VIDEO 1171 806178 S 995.80 S 985.80 S - 10101/1992 8232 01/3112001 CRT-COLOR VIDEO 1171 809479 S 985.80 S 985.80 S _ - 10/01/1992 8232 011318001 CRT-COLOR VIDEO 1171 808480 S - 985.80 S 985.80 ; - IOJ01n992 8232 _ 01/31/2001 CRT-COLOR VIDEO 1171 808481 S 985.80 S 985.80 S - 10/01/1992 8232 01/31R001 CRT-COLOR VIDEO 1171 808482 S 985.80 S 985.80 S . ; - 101011992 8232 01)31/2001 CRT-COLOR VIDEO 1171 808483 S 985.80 S 985.80 8 - 10/01/1992 - 8232 01/31/2001 CRT-COLOR VIDEO - _ 1171 808484 S - 985.80 S 985.80 -s - 10.+018992 8232 01131/2001 CRT-COLOR VIDEO - 1171 808485 S 985.80 S - 98S.80 S - - 10/01/1992 8232 - - 01/31/2001 CRT-COLOR VIDEO 1171 808486 S 985.80 S - 985.80 S - - - _ 10/02/1992 8232 OWLIZ001 CRT-COLOR VIDEO 1171 808487 S 985.80 S 985.80_ S - 101018992 8232 -01/31/2001 CRT-COLOR VIDEO 1171 808488 S 985.80 $ 285.80 S - 10/01/1992 8232 _ CLOW001 CRT-COLOR VIDEO 1171 808489 S 985.80 S 985.80 S - - - 10/01/1992 - 9232 01/318001 CRT-COLOR VIDEO 1171 808490 S 985.80 s - - 985.80 t - 1010111992 8232 01/311MI CRT-COLOR VIDEO - 1171 80819t S 985.80 S 985.80- S - 10/01/1992 8132 - - _ 011318001 -CRT-COLOR VIDEO- 1171 808492 S 985.80 S _ 985.80 -S - 10101/1992 - 8132 01/318001_ CRT-COLOR VIDEO - 1171 808493 $ 985.80 S _ 985.80 _ S _ - - - - 10/01/1992 8232 01)318001 CRT-COLOR VIDEO 1171 808494 S 985.80_ S 995,80 - S - - 10/01/1992 - 8232 _ 01/31/2001 MONOCROME DISPLAY 1171 808836 S 19000.00 S 1,600.00 f - 10/01/1993 8232 01/318001 HP VECTRA PC 1171 810253 S 1,340.00 S 11273.00 S 67.00 S 67.00 04101/1996 8232 0113/8001 CANONTYPEWRTTER 1171 13733 S 704.20 S 704.20 S - 111011987 8261 011318001 CONFERENCE RECORDER 1171. 14186 S 19565.00 S 1¢65.00 S - - 11/01/1980 8311 01318001 VIEWSONICMONITOR 1171 22805 S 345.00 S - 29315 S - 51.7S- S 51.75 10/01/1996 8311 -01/31/2001 EZSHUTTLECART 1171 812140 S 7,183.67 S 4,190A8 S 2,993.19 S 493.19 S 29500.00 04/01/1999 8313 01318001 REGARD CAR 1181 16868 S 8,498.00 S 8,498.00 S - - 0910111989 8313 01/31/2001 EZ 1997 PERSONNEL CARRIER 1181 811327 S 69773.00 S 5,079.75 S 1,693.25 S 806.75 S 2,500.00 04101/1997 8313 - OU318001 GUEST CHAIR 1171 13583 S 414.05 S 361.10 S . 5255 S 5L95 12/01/1997 0316 011318001 AV CART 1171 5003 S 740.00 S 740.00 S 11/011978 8320 01/31/2001 STACK CHAIR 1171 10152 S 17.00 .S 17.00 $ - - ) 1/01/1978 8320 01/318001 FOLDING TABLE 1171 11521 S 287.39 S 287.39 S _ _ 11/01/1984 8320 8113=01Ol/301 DESK - 1171 13552 S 3,41055 S _ - 2,97450 S - 435.65 - S 435.65 12/011987 8320 01/31/2001 DESK 1171 13554 S 3907255 S 29679.99 S 39236 S 39236 12/01/1987 8320 - 01018001 CRT-COLOR VIDEO_ 1171 808831 S 390.00 S _ 390.00 S _ _ 101011993 8324 _ - _ 01/318001 CHAIRS _ 1172 10005 S 19046.40 S 19046AO 5 - - _ _ 10/01/1988 7220 _ - Ol)318001 END TABLE 1172 10006 S 319.80 S _ 319.80 S _ - 101018988 7220 01/518001 TABLE 1172 10050 S_ 357.00 S. 357.00 S _ 10/018988 7220 - 018I8001 ARM CHAIR 1172 10058 S 445.64 3 -364.12 S - 8132 S 81.52 10/01/1988 7220 - 0IM/2001 ARMCHAIR 1172 10059 9 445.64 -S - 364.12 = S _ - 8132 S 8132 10/01/1988 7220 -- 01/318001 ARMCHAIR - 1172 10060 S - 445.64 S 364.12S 4132 S 8132 10/018988 7220 _ - 01/318001 ARM-CHAIR • 1172 10061 $ 44SM $ 364.12 S $132 _ S 8132 10/018988 7220 01/31/2001 ARM CHAIR 1172 10062 S "S.64 $ _ 364.12 S 8132 S 8132 10/018988 7220 _ 61)318001 ARM CHAIR 1172 10063 S 44S.64 S- 364.12 S 8132 S 81.52 10101/1988 7220 01/318001 ARM CHAIR 1172 10064 S _ 445.64- S 364.12 S 8132 S 8132 10/018988 _ 7220 - - 01/3MOOl ARMCHAIR 1172 10077 S 445.64 S 364.12 --S 8132 $ 8132 10101/1988 _ 7220 - -01/318HA 001 ARM CIR _ 1172 10078 S - 445.64 5 - -364.12 S 8132 S 8132 - 10/0111988 7220 _ - 011=001 END TABLE 1172 10079 3 - 31330 S 255.86 - S 57.44 S 57A4 10101/1988 7220 _ 01/318001 ARTUROSCOPE SHEATH 1172 20025 S 440.00 S- 440.00 S - 10/018988 7220 02288001 COMPAQ PROLINEA/MONITOR 1171 809566 S 1,904.09 S 1,904.09 $ - 041018995 6001 02282001 COMPAQ PROLINEA 1171 809669 S 1,460.00 S 19460.00 S _ - 010018995 6111 _ 0228/2001 SAMSUNG MONITOR 1171 22409 S 365.00 S - 352.83 S- 12.17 S 12.17 04/01/1996 6135 - 02288001 BEDSPREADS 4171 810439 S 1,710.00 S 1,653.00 S 57.00 S 57.00 041018996 7192 - 02882001 COMPAQ PROLINEA 1171 809635 $ 10550.00 S 11550.00 S 04/018995 7231 02882001 COMPAQ PROLINEA 1171 809636 S 1,550.00 $ 1,550.00 S - 04/01/1995 7231 02888001 COMPAQ PROLINEA 1171 809637 S 1,550.00 S 10550.00 S - 04/011995 7231 02288001 COMPAQPROLINEA 1171 809638 S 1.550.00 S 1,550.00 S - 000M995 7231 02/28/2001-COMPAQ PROLINEA 1171 W9639 S 19550.00 1 1,550.00 S 041018995 7231 02882001- K MODULE GR 1171 801212 S 260.00 S 260.00 - S- - 1110VI978 7250 02/282001 MOTOROLA PAGER 1171 806384 S 292.00 S 29LOO 5 - - 10/018990 7252 02882001 COMPAQ PROLINEA 1171 809715 S 11460.00 $ 1,460.00 $ - 04/018995 7011 - - 02888001 COMPAQ PROLINEA 1171 809716 S 1,460.00 S 19460.00 f - 04/018995 7011 02/282001 HP VECTRA PC 1171 22283 S 040.00 5 19340.00 S - 10/018995 7150 02888001 HP VECTRA PC 1171 22288 S 1,340.00 S 19340.00 S - 10/018995 7150 022812001 IBM PS VALUEPOINT 1171 808608 S 11653.00 $ 1,653.00 S - - 10/0111992 7283 01/188001 COMPAQ PROLINEA/MONITOR 1171 809679 $ 17815.00 S 19815.00 S - 84/011995 7283 02282001 HP VECTRA PC 1171 21191 S 19712.00 S 1,712.00 S - - 10/018995 8052 02882001 14 IN MONITORS 1171 809486 S 750.00 S 750.00 S - 10/018994 8052 02282001 COMPAQ PROLINEA 1171 809697 S 1,558.10 S 1,55&10 S - 04/01/1995 8052 02282001 COMPAQPROLINEA 1171 809698 S 1,55&IO S 1,55&10 3 - 04/0111995 8052 STATEMENT 25 Psae 2 of (, INDIAN RIVER MEMORIAL HOSPITAL, INC. SCHEDULE OF DISPOSALS OF P1. & E. FYE SEPTEMBER 30, 2001 EINs 59-24%294 GAIN ON LOSS ON DATE OF GIL ASSET ACCUM. NETBOOK SALE SALE AMT- DATE J/E DESCRIPTION ACCT. / NO. COST DEPR. VALUE 9000.7800 9000-7850 RECEIVED ACQUIRED DEPT 02128/2001 IBM PS VALUEPOINT 1171 807151 S 49017.00 S 4,017.00 f - 04/01/1991 8061 02/2812001 IBM PS/2 _ 1171 808327 f 1,143.00 S 19143.00 S - - _ 04/01/1992 8211 01282001 COMPAQ PROLINEA/MONITOR 1171 809623 f 1,910.00 f 19910.00 S - _ 04341/1995 8211 02/28/2001 HP VECTRA PC - 1171 21187 f 19712.00 f 1,712.00 f - - 10/01/1995 8221 02/282001 COMPAQ PROLINEA 1171 809667 f IIS59.00 f 19559.00 f 04/01/1995 8221 02/282001 HP VECTRA PC 1171 21192 f 19712.00 S 1971LOO $ - 10101/1995 8232 02/282001 HPXM2 COMPUTER/MONITOR 1171 22254 S 1,730.00 S 19730.00 � S - 103417199S 8232 0228/2001 HP VECTRA PC - - _ 1171 . _ 22308 S 1,349.17 - S 19349.17 f - 10/012995 - 8232 02/28/2001 RP VECTRA PC 1171 22904 S 19780.00 S 1,542.67 f 23733 f 23133 10101/19% 8232 02128200/ IBM PS 2 4MEG 1171 809305 S 19502.00 $ 1,502.00 f - _ 04/01/19% 8232 01282001 IBM PS24MEG- 1171 809306 f 1,302.00 S 1$02.00 f - 04341/1994 8232 01282001 IBM PS 2 4MEG - 1171 809307 S 1,502.00 S 105OLOO f - _ - 04101/1994 8232 02282001 IBM PS 2 4MEG 1171 809308 f 195OLOO S 19502.00 S - 04/01/1994 8232 02282001 _COMPAQ PROLINEA - - 1171 809374 f -999.00 f 999.00 f - - - - - 10/01/1991 - 8232 . 0228/2001 COMPAQ PROLINEA - - - - 1171 _ 809538 S 10660.00 f 19660.00 f - _ - - - _ _ 1011/1994 8232 02282001 COMPAQ PROLINEA _ - 1171 809545 S 29012.00 S 2701LOO S - - 10/01/1994 8232- 02282001 COMPAQ PROLINEA _ 1171 809546 S - 2,012.00 S 2,013.00 f - _ 10/01/1994 8232 022&2001 COMPAQ PROLINEA 1171 809547 S 2,012.00 S 29012.00 S - 10101/1994 8232 02282001 COMPAQ PROLINEA/MONITOR 1171 809598 f 1,92237 S 1,922.27 S - 04/012995 8232 0228/2001 HP LE PC/MONITOR - - 1171 810041 S 1,730.00 S 1,730.00 S - - 10/01/1995 8232 02282001 COMPAQ PROLINEA _ 1171 810556 S 1,475.00 S 1,425.83 S 49.17 f 49.11 04/012996 8232 02282001 HP VECTRA PC - - - 1171 810884 S 1,340.00 S 1116133 S 178.67 - f 17&67 10/0111996 - 8232 0228/2001 HPVECTRA PC _ - 1171 810885 S 1340.00 S 1,16133 S 178.67 S 178.67 10/01/1996 8232 02282001 HP VECTRA PC - 1171 810886 S 10980.00 S 1,716.00 S 264.00 S 264.00 10/012996 8232 02282001 HP VECTRA PC 1171 812026 S 865.00 S 403.67 S 46133 S 46133 10101/1998 8232 02282001 COMPAQ PROLINEA/MONITOR 1171 809683 S 1,815.00 S 19815.00 S - - 041012995 8241 02282001 HP VECTRA PC 1171 21196 S 1,712.00 S 1971LOO S - - 10MM995 8311 0228/2001 COMPAQ PROLINEA/MONITOR -- 1171 809678 S 1,815.00 • S 1,815.00 $ - -- 94/01/1995 8311 02282001 COMPAQ PROLINEA _ - 1171 809565 S 10904.08 S 10904.08 S - - _ - 04101/1995 8316 02282001 COMPAQ PROLINEA 1171 809541 S 1,49025 S 1/19015 - f - _ _ - - 10101/1994 8320 _ 0228/2001 HP VECTRA PC _ - 1171 22356 S 19934.00 S 1,86933 S 64.47 - S 64.47 04101/1996 8331 0228/2001 BP VECTRA PC 1171 - 22358 S 10934.00 S ]1869.53 S 64.47 f 64947 04/01/19% 8331 02282001 COMPAQ PROLINEA - " - 1171 809371 S 999.00 S - 999.00 $ _ - _ - _10/01/1994 8371 02282001 TELECOPIER _ - 1171 19821 S 19623.00 S 1,623.00 S - - _ _ 04/0]/1992 8383 021282001 HPVECTRA PC _ - _ 1171 22298 S 19340.00 S 19340.00 _ f - _ 101012995 8901 04/302001 DESK - - 1171 11865 f 337AO f 32933 f 817 - S - &27 06101/1985 6001 01/30/2001 FILE CABINET- . - - - _ - - 1171 803040 S 507.85 f 457.10 S 50.75 - - _ - - 3 - 3&75 06/01/1983 6001 04/302001 REFRIGERATOR 1171 807618 f 520.00 f 493.97 f 26.03 S 26.03 10/01/1"1 6046 0450/2001 DESK _ - 1171 806883 S 233.98 S 156.00 S 77.98 $- _ 77.98 04/01/1"1 6080 - 04/302001 VIEWSONIC MONITOR 1171 22800 f 345.00 S 31050 f 34.50 " _ - f 34.50 1010129% 6090 04/302001 RADIOUCENT BED 1171 11491 S 79173AS S 5,260.47 S 1,91298 - f 21298 f 1,700.00 04/0111"0 6111 04/302001 RADIOUCENT BED/MATTRESS 1171 17509 f 79173AS S 5/02138 f - 29152.07 - -- S 452.01 S 19700.00 10/01/1990 6111 04/30/2001 TASK CHAIR 1171 806386 f 347.05 S _ 243.01 S 104.04 S 104.04 10101/1990 6111 04/30/2001 TASK CHAIR - - _ 1171 806387 $ 347.05 S 243.01 S 104.04 _ - - f _ 104.04 / 0/012990 6111 4/3 00200IT 1 ZENH VCR � 1171 . 13380 f 448.95 S 44&95 S - 10/012987 7132 04/30/2001 INTRA-ARC POWER CONSOLE 1171 Inn f 8,015.79 S 8,015.79 S - 18/01/1990 7211 04/302001 VIDEO CAMERA 1171 19715 S 9,86130 S 9,86130 S - 10/01/1"1 7211 04/3012001 BATTERY CHARGER 1171 19719 S 29395.00 S 2,395.00 f 04341/1992 7211 04/302001 SOLOS ELS-2 XENON LIGHT SOURCE 1171 20381 S 8,200.00 S 8,200.00 S - - 04/01/1993 7211 04/30/2001 SONY COLOR MONITOR 1171 20383 f 1300.00 S 7,300.00 S - 04/012993 7211 04302001 SONY COLOR MONITOR 1171 20384 S 19300.00 f 19300.00 S - 04/01/1993 7211 04/30/2001 SONY COLOR MONITOR 1171 20305 S 1300.00 S 19300.00 $ - 04/01/1993 7211 041302001 SEITZ VIDEO CART - 1171 20412 f 3370.00 f 3370.00 f - 04/012993 7211 041302001 TELECAM SL CAMERA SYSTEM 1171 22718 f 8,940.00 S 5,747.13 S 3,192.87 f _ 39192.87 10/01/1996 7211 04/302001 AUTO SUTER INSTRUMENTS _ - 1171 800899 f 5,174.00 S 5,174.00 f - - 041012980 7211 041302001 SHAVER BLADE SET 1171 800900 f 672.00 S 672.00 S - "" 04/012980 7211 04/302001 OSCILLATING SAW SET 1171 803781 S 11305.60 S 11,505.60 S - 09/012984 7211 04/30/2001 DRILL GUIDE 1171 SM798 S 856.80 f 856.80 S - - 06MI11985 7211 04/30/2001 SAGITAL SAW 1171 804566 f 19705.50 S 1,70530 f - 02/012988 7211 04/302001 RECIPOCATING SAW 1171 804567 S 19705.50 S 1,70550 S - 02341/1988 7211 04/302001 SAGITAL SAW 1171 804789 .5 3,063.96 S 3,06396 S - 08101/1988 7211 04/302001 BATTERYCHARGER 1171 804790 f 2,111.40 S 2,111.40 S - 08/012988 7211 04202001 REAMER 1171 804791 S 3,055.00 S 3,055.00 $ - 08/012988 7211 04302001 SAW PARTS - 1171 805014 S 245.73 S 245.73 S - - 010117989 7211 04/30/2001 AUTO TRANSFUSION MACHINE 1171 805433 S 239289.08 S 2349.08 S - 08/012989 7211 04/302001 LAMP/HEAT 1171 805462 f 833.70 S 833.70 $ - 09/01/1989 7211 STATEMENT 25 Pane 3 of 6 1 - INDIAN RIVER MEMORIAL HOSPITAL, INC. SCHEDULE OF DISPOSALS OF P.P. & E. FYE SEPTEMBER 30, 2001 EIN: S9-24%294 GAIN ON LOSS ON DATE OF G/L ASSET ACCUM, NETBOOK SALE SALE AMT. DATE J/E DESCRIPTION ACCT, 0 NO, COST DEPR VALUE 9000-7800 9000.7850 RECEIVED ACQUIRED DEPT 04130/2001 BATTERY SYSTEM 1171 805889 S 119167A8 S 179167.48 S - 04/0111990 7211 04/ ODI VIDEO ENDO CART 1171 806376 s 29943.81 S 2,943.81 S 10/0111990 7211 04/30/2001 BATTERY OP POWER SYSTEM 1171 00660S S 17,541.72 $ 12,279.14 8 S926238 S 5;26238 10101/1990 7211 04/30/2001 MEDICAL TV CAMERA 1171 806626 S 6,39130 S 6,39130 s J - 10101119" 7211 041302001 SAGITAL SAW 1171 807765 S 3,800.98 s 3,80058 $ ' - 10/011199I 7211 04/30!2001 BATTERY CHARGER - 1171 808103 S 2941290 S 29412.90 s - 04101/1992 7111 04 M OOl LAPAROSCOPE ACCESS KIT 1171 - 808427 S 21550.00 s 2v550.00 -S - 10/0111991 7211 04130/2001 OPERATING LAPAROSCOPE 1171 808428 S 3,828.25 S 3,82825 S - /010111991 7111 04302001 TELECAM VIDEO CAMERA SYSTEM 1171 809331 s 12,159.70 S 119291.15 S 8683S s 86835 10101/1994 7211 04/30/200/ SAGITAL SAW 1171 810209 S 3,105.00 S 391Os.00 s - 1/00111995 7211 04/302001 LOT SURGICAL INSTRUMENTS - - 1191 -- 802719 s 9,105.00 S 91105110 s - 11/01/1978 7211 - 048W2001 LOT SURGICAL INSTRUMENTS - _ 1191 _ 802730 s - 486.00 S 49000 S - - _ 1U01/I978 M1 0//302001 INSTRUMENTS O.R - 1191 - 802886 s 1,99030. S 1,99030 s - - 0910111981 7211 - 04/342001 SAGITAL SAW _ - 1171 806644 S 2,490.00 S 2,490.003 _ lomi/1990 - 7220- 04=001 SURGICAL INSTRUMENTS 4171 809632 S 2,72433 s 2,72433 $ - e41oln99s nzo _ 041302001 SAGITAL SAW 1171 811448 S 1,999.25 -s 2,099A8 s 899.77 $ 899.77 - 10/01/1997 -7220 - - 041 M ODI ESCORT ECG MONITOR 1171 _ 20763 s 9,845.00 S 9,&5.00 S - S 1,289.00 S 1,289.00 - 10/0411993 7231 04/30/2001 ESCORT ECG MONITOR 1171 20764 S 9,845.00 S 9,845.00 S - S 19289.00 s 1,289.00 10/01/1993 7131 041302001 ESCORT ECG MONITOR 1171 20765 S 9,845.00 $ 9984S.00 $ - S 19289.00 S 11289.00 10/01/1993 7231 04/30/2001 ESCORT ECG MONITOR 1171 20766 S 9,845.00 s 91845.00 S - s 1,289.00 $ 1,289.00 10/01/1993 7231 04/302001 CARDIAC MONITOR 1171 808626 S 9,631.00 S 8,106.07 S 1952493 s 15453 s 1p370.00 04/01/1993 7231 04/30/2001 CARDIACMONITOR 1191 808621 S 9,596.00 S 8,076.65. s 1,519.35 $ 14935 S 1,370.00 04/0111993 7231 04/30/2001 CARDIAC MONITOR 1171 808618 s 9,597.00 S 8,077.47 S 1951933 $ 14933 $ 1,370.00 04101/1993 _ 7231 04/302001 CARDIAC MONITOR 1171 808629 S 97595.00 s 8,075.77 S 1,51923 S 14923 S 1,370.00 04/01/1993 7231 04130/2001 CARDIAC MONITOR 1171 808630 S 9,595.00 s 8,075.77 S 1,51923 S 149.23 S L370.00 04/01/1993 7231 04/30/2001 CARDIAC MONITOR 1171 808631 S 9,595.00 S 81075.77 S 1,51923 s 14923 S 1p370.00 04/01/1993 7231 04/302001 CARDIACMONITOR 1171 808632 $ 905.00 S 8,075.77 S 11519.23 S 149.23 S 1,370.00 0410111993 . 7231 04!302001 CARDIAC MONITOR 1171 808633 $ - 9,597.00 's 89077A7 S 141933 S 14933 S 1,370.00 $0111993 -- 7231 04/30/1001 CENTRAL STATION W/RECORDER 1171 808634 S - 27,374.00 S 231139.80 S 4}3420 S 214.80 S 4449.00 - 04101/1993 - 7231 04/302001 CART WASHER = 1171 _ 804980 s 45,747.00 $ 459747.00 S - - - - _ 12/01/1988 7150 04502001 DRILL INSTRUMENTS 1171 808664 S 1936430 S 1936430 S - � - 84/0111993 7250 04/302001 DRILIZURGICAL INSTRUMENTS 1171 809436 S = 14,28&82 S - 149288.82 S - _ - 10/01/1994 - 7250 - 04/3011001 EKG MONITORS _ 1171 - - 15005 $ 9936&76 - s - 9,368.76 S - 17/01/1988 7080 - 64/3W2001 FAX MACHINE - - 1171- _ 809798 8 - 769.00 s 769.00 S - - - _ 10101/1996 7091 041342001 SAMSUNGMONITOR 1171 22%2 S _ 32LOO S 256.80 S 6420 S 6420 04/0111997 . - $lot - 04308001 ULTRASONIC CLEANER - 1171 12492 T 19425.00 s 19425.00 S - - - 17101/1986 _ 7190 04/342001 BP 308 ECG/IEMP/NIBP MONITOR 1191_ - 19558- S -- 5,720.00 s s,no oo S 10101/1991 _ - 7190 04OW001 FIBERSCOPE 1171 - 805011 S - 9,375.00 s 91375.00 S - - 01/01/1989 - 7190 04/302001 SAMTRON MONITOR 1171 22821 3 321.00 S 28850 S 32.10 S 32.10 10/01/19% - 8232 04130/1001 VIEWSONIC MONITOR 1171 22826 $ 420.00 S 37&00 S 42.00 s 42.00 10101/196 8232 04/30200/ IBM CART 1171 809169 S 11100.00 S 19100.00 s - 04/01/1994 8232 04/30/2001 IBM CART .. 1171 - - 809170 s 11100.00 S 19100.00 s - - 04/01/1994 8232 04/30/1001 IBM CART 1171 809171 S 19100.00 S 19100.00 S a04/0111994 04/0111994 8232 04/308001 IBM CART - 1171 809172 S 1,100.00 S 19100.00 s - 04/01/1994 8232 04/308001 IBM CART 1171 809173 S 1,100.00 S 1,100.00 S - 04/0111994 8232 - 04/342001 IBM CART 1171 809174 S 19100.00 S 1,100.00 S - 04/01/1994 8232 04/308001 IBM CART 1171 809175 S 17100.00 S 19100.00 S - 04/01/1994 8232 04/302001 IBM CART 1171 _ . 809176 S 10100-00 S 19100.00 S - 04/0111994 8132 OV302001 IBM CART 1171 809177 $ 19100.00 S 1,100.00 S - - 04/01/1994 8232 04/302001 TYPEWRITER STAND 1171 - 6264 S 65.00 S 65.00 S - - IIAM978 8261 04/542001 SIDE CHAIR 1171 13321 $ 234.00 S 21150 S 2110 S 22.10 09/01/1987 8261 04/!02001 SIDE CHAIR 1171 13324 $ 234.00 S 211.90 S 22.10 S 2110 09/0111987 8261 04/302001 SIDE CHAIR 1171 13326 S 234.00 S 211.90 s 2110 S 22.10 09/0111987 8261 STATEMENT 25 Paoe4ef6 INDIAN RIVER MEMORIAL BOSPITAL, INC. SCHEDULE OF DISPOSALS OF P.P & E, FYE SEPTEMBER 30, 2001 EIN: S9.2496294 GAIN ON LOSS ON DATE OF GIL ASSET ACCUM. NET BOOK SALE SALE AMT, DATE UE DESCRIPTION ACCT. N NO. COST DEPIL VALUE 90007800 9000-7850 RECEIVED ACQUIRED DEPT 04/30/2001 SIDE CHAIR 1171 13329 S 234.00 $ 211.90 S - 22.10 S 22,10 09/01/1987 8261 04/30/2001 SIDE CHAIR 1171 13330 S 234.00 S 21190 S 2LIS S 2210 09/01/7987 8261 04/,10/2001 SONY VIDEO PRINTER 1171 21358 S 11076.16 S _ 1,076.16 S - 10/01/1994 8316 0480/2001 VCR 1171 16699 S 39995 S 39993 S - 07/01/1989 8320 - 0400/2001 TRANSCRIBER 1171 19609 S 423.00_ S 423.00 $ t - 10/01/1991 8322 04/302001 DESK 1171 11478 S 29LOO S 292.00 S - 12/0111984 8371 04/302001 OPERATING LIGHTS 1172 20042 S 9,532.00 S 7,94354 ' S 1,588.46 S 19988.46 10/012988 7220 04/302001 OPERATING LIGHTS 1172 20043 $ 9,532.00 " S 7,94354 S 1998&46 S 19588.46 10/01/1988 7220 04/30/2001 OPERATING LIGHTS 1172 20044 S 9,532.00 S 7,94354 S 1,588.46 $ 1,58&46 - 10/01/1988 7220 - 04801MI OPERATING LIGHTS 1172 10045 $ 99532.00 S 7.943.51 S 1,58&46 S I,S8846 10/012988 7220 - 04/30/2001 ELECTRO-GYN ELECTROSURGICAL 1172 20156 S 2,41250 3- 2,41230 S S 4.00.00 S 400,00 10/01/1988 7220- _ 04/302001 SHAVER POWER CONSOLE 1172 20234 3 500.00 S - _ 5,000.00 S _ 101011988 _7220 _ -- 09/302001 VACUUM CLEANER 1171 246" S 64SA S 505.25 S 139,75 S 139.75 10/012997 601; 09/302001 RECLINER • 1171 16838 S S90,43 S - 590A S - 10/01/1989 6079 _ - 09/302001 ROCKER/RECLINER _ 1171_ 20066 S 407.00 S - -407.00 S - - - 04/0W"I 6080 - 09/302001 PANASONIC VCR 1171 12932 S 369.00 $ _ 369.00 S - 07/012987 _ 6111 - _ 09/3012001 POWER COLUMN/MONITOR SHELF 1171 17591 S 4901515 S _ - 3,056.09 S 959,06 S 959.06 04/012990 6111 0900/2001 CHAIR 1171 12542 S 177.14 S 175.86 S 118 .$ 118 05/012986 6132 09802001 CHAIR 1171 15412 S 17615 S 176.15 S - 03/01/1989 6135 0980/2001 CHAIR - 1171 15424 S 27615 S 1176,15 S - 03/01/1989 6135 - 0900/1001 CHAIR 1171 _ 16034 S 11730 S 11750 S _ - 031OV1989 6138 09802001 GERI CHAIR RECLINER 1171 21813 S 54930 S - 352.60 - S 196.90 - S 19690 04/0111995 6135 - - 09802001 220 PH MONITOR 1171 5913 $ 5,544.00 S _ S,S44.00 S - 10/01/1981 7191 09802001 OBSTETRICS TABLE 1171 11523 S 6,500.00 S 6,500.00 $ - IIIOU1984 7192 09802001 ROCKER/RECLINER 1171 20048 S 407.00 5 407,00 S - 04/01/1992 7192 0980/2001 MONITOR 1171 809432 S 250.00 S 250.00 S 10/0111994 7192 09802001 CENTRIFUGATION SYSTEM 1171 11562 S 21069.23 S 29069.23 S - 01101/1985 7211 09802001 SECRETARIAL CHAIR 1171 13531 S 310.11 •S 310.11 S - 10/01/1987 7211 09/302001 ECT UNIT 1171 14991 S 79980.45 $ - 79980.45 S - 06/0111988 7211 _ _ 0980/2001 HNSII CENTRIFUGATION SYSTEM 1171 - 17090 $ 2,S1Z60 S _ 2,517.60 S - - - 10/01/1989 7211 _ - 09802001TABLE/XRAY TOP 1171 17175 $ 179472.00 S 139880.63 $ 3999137 $ 3,59137 10/012989 7211 - 09802001 HEADLIGHT 1171 8D6371 $ 695.03 S 695.03 S - - 10/01/1990 _ 7211 09802001 SURGICAL TABLE 1171 807647 S 189945.69 S - 18,192.81- S ISLSS S ISLU 10/018990 7211 09/302001 CATARACTTRAY 1191 803644 S 3,564.69 - S _ 39964.69 S - 0910111984 _ 7111 - - 09CM001 CAMERABEAMSPLITTER 1171 16909 S SAIDA S 89951.47 S- 5833 S S833 10/018989 7120 _ 09802001 MURATA FACSIMILE MACHINE 1171 - 17235 S - 11295.00 S 1,295.00_ S - 04/012990 7120 - - 09/302001' LIFEPAK 10 DEFIBRILLATOR 1171 20443 S BXL60 _ S _ 8*02&-60 S - 04/0111993 . -7220- - - - - 09002001 AUXILIARY POWER SUPPLY 1171 20444 -S - 644.00 S -644.00 i - 04/01/1993 7220-- 09802001 BATTERY SUPPORT SYSTEM 1171 20445 S 19288.00 S . _ 1,288/10 S - 0410VI"3 7220 - 09802001 SAMSUNG MONITOR 1171 22432 S 36SM S 365.00 S - 04101/1996 7220 09/302001 LIGHTSOURCE 1171 805992 S . 5,978.75 S 5,97&75 $ - 04/01/1990 _ 7220 098012001 SAMSUNG MONITOR - 1171 810298 S 365.00 S - 365.00 S - 04101/1996 7220 - - - -0900/1001 SONY VIDEOCASSETTE PLAYER _ 1171 13157 S _ 19319,72 S IJ19.71 S - 07/012987 7231 - - 0/30/2001 MICROSCOPE BINOCULARS 1171 7026 S 1,058.00 3 19058.00 $ - 05/01/1975 -7011 _ 09802001 MICROSCOPE 1171 11363 S 21063.00 $ 2,063.00 S - 091OU1984 7011 _ 0900/2001 MARSTERS INCUBATOR 1171 11849 $ 57256 S 57256 S - 05101/1985 7011 09802001 TDX ANALYZER 1171 11913 S 5,541.80 S 5,541.80 $ - 07/01/1985 7011 0900.2001 TISSUE EMBEDDING CONSOLE 1171 - 12319 S 1934034 S- 1,34034 S - 03/01/1986 7011 _ 09002001 MICROSCOPE/CASE 1171 12990 S 1,07&74- 3 1,079.74 S - 05/01/1987 7011 09002001 CENTRIFUGE 1171 14627 S 3,047.00 S - 39047.00 S - 10/01/1981 7011 09002001 AEROSPRAY SLIDE STAINES 1171 18362 $ 5,02295 S 5,02295 S - 10/01/1990 7011 09/302001 CLINITEK 200 PLUS 1171 21996 S 3,940.00 S 39940.00 S - S 19450.00 S 19450.00 IOMII1995 7011 09002001 CRYOSTAT 11 TISSUE TEK 1171 802833 S 5905552 S 5205532 S - 03/01/1981 7011 0900/2001 CENTRIFUGE/ROTOR 1171 808145 $ 1,28234 S 1,28234 S - 04/011991 7011 _ 0900/2001 STORAGE CABINET 1171 7198 S 123.00 S - - 123.00 S - 01101/1976 7012 - - 09002001 MICROTOME 1171 16777 S 99995.00 S 9999S.00 S - - 08/01/1989 7012 - 09138a001 STORAGE CABINET 1171 7172 S 281A0 S _ 281.00 $ - 11101/1978 7015 09002001 STORAGE CABINET 1171 7173 S 28LOtr S 281.00 S 11/01/1978 7015 - - 0900/1001 STORAGE CABINET 1171 7174 S 281.00 $ 281.00 $ - 11/01/1978 7015 0900/2001 LATE POTENTIAL 1171 14842 S 28934338 S 28934338 S - 04/01/1988 7031 0900/1001 TREADMILL 1171 15023 S 23,383.94 S 23,38394 S - 09/01/1988 7031 09002001 METAL SHELF 1171 10110 S 135.00_ S 135.00 S - 11/01/1978 7033 09002001 SHELF 1171 10111 S 135.00 S 135.00 S - 11/01/1978 7033 09002001 SLEEPLAB 2000 UPGRADE 1171 21648 S 62,640.00 S 62,640.00 - S - 10/01/1994 7033 09002001 VCR PANASONIC 1171 12991 S 349.00 S 349.00 S - 06/0U1987 7040 09002001 VIEWSONIC MONITOR 1171 22765 S 367.00 S 360.88 S 6.12 S 6.12 10101/1996 7040 0900/1001 STEREOTIX BIOPSY DEVICE 1171 807112 S 30,100.00 S 30,100.00 S - 04/012991 7040 0900/2001 VIEWSONIC MONITOR 1171 22485 S 367.00 S 360.88 S 6.12 S 6.12 10101/1996 7071 09002001 VIEWSONICMONITOR 1171 21486 S 367.00 S 360.88 S 6.11 $ 6.12 10/01/1996 7071 0900/2001 SUTTER LITELIFT 1171 19573 S 3,140.75 S 39140.75 S - S 10.70 S 10.70 10/01/1991 7091 09002001 MANAGEMENT CHAIR 1171 20133 S 415.00 $ 30834 S 106.66 S 106.66 10/01/1992 - 7091 0900/200/ HP PENTIUM 1171 22469 S 1 ,833.00 S 1,833.00 S - 04/01/1996 7150 0900/2001 SAMSUNG MONITOR 1171 22889 S 321.00 S 315.65 S 535 S 535 10/01/1996 7150 0900/2001 METALTABLE 1171 8222 S 92.00 S 92.00 $ - 11/01/1978 7181 09802001 ESOPU MANOMETRY SYSTEM 1171 17301 S 23,024.00 S 23,024.00 S - 04101/1990 7190 STATEMENT 25 Page 5 of 6 INDIAN RIVER MEMORIAL HOSPITAL. INC SCHEDULE OF DISPOSALS OF P.P. & E. FYE SEPTEMBER 30, 2001 EIN: 59-24%294 GAIN ON LOSS ON DATEOF G& ASSET ACCUM. NETBOOK SALE SALE AMT, DATE J/E DESCRIPTION ACCT. B NO, COST DEPR. VALUE 9000-7800 9000.7850 RECEIVED ACQUIRED DEPT 09/34x1001 DINAMAPMONITOR/PRINIER 1171 21320 S 934530 S 9r34530 S - 04/0111994 7190 09/3012001 AUTO DISSINFECTOR 1171 804931 S 69430.00 S 5,501.14 S 92896 S 928.86 IIAII1988 71" 09f=001 COLOR VIDEO PRINTER 1171 807158 S 69750.00 S 6,750.00 S - _ 04/01/1991 71" 09/302001 DESK - 1171 436 S 174.00 S 174.00 S - 11/0111970 7292 09/342001 VIEWSONIC MONITOR 1171 22495 S 367.00 S 360.88 S . f 6.12 S 6.12 1010111996 7420 09/302001 VIEWSONIC MONITOR 1171 22767 S 367.00 S 360.88 S 6.12 S 6.12 10/01/1996 7420 09/30/2001 ICE MACHINE H71 808568 S 4,581.60 S 4,584.60 - S - - 10/01AM 8052 09130/1001 BUNN-O-MATIC/IN-LINE WARMER 1171 809865 S 38.75 S 38.75 S - _ 04/01/1995' 8052 09/302001 COUNTER UNIT 1171 809901 S 671.61 $ 430.94 S 240.67 S 240.67 04/0111995 8052 _ 09/30/2001 TRAY WASHING MACHINE 1171 810685 S 22,093.00 S 179095.76 S 49997.24 S 4999754 04/01/1996 8052 091302001 CANOPIESIOFFICETRAD.ERS IISt 806557 S 109313.00 S 10,313.00- S 10)01/1990 8061 09/30/2001 TV SET - 1171 13634 S 31232 S 31232 S - - 01/0111988 8061 09/30/1001 TV SET - - - 1171 13651 S 31232 S 312,32 S - - -- - _ _ 01101/1988 8061 09/302001 TV SET _ - - - 1171 13653 S 31232 S 31232 S - _ - - _ OLIM988 8061 09/302001 TV SET 1171 14958 S _ 4325.00 _S 325.00 S - 06/01/1988 8061 _ 09/302001 GE 5 BATTERY CHARGER - 1171 18296 S 33030 S 33050 S10/01/1990- - - 10/01/1990 8061-- 09/302001 VIEWSONIC MONITOR 1171 22760 S 367.00 S - 360.88 S 6.12 S 6.12 10/01/1996 8061 09/30/2001 AQUA MATIC 1171 19476 S 69900.00 S 6900.00 S - 10/0111"1 80" 09/3012001 STAINLESS CABINET CARRY-ALL 1171 1%19 S 642.65 S 642.65 $ - 10/012991 80" 09/30/2001 ADVANCE FOAMATIC 1171 20493 S 11150.00 S 12050.00 S - - 10/01/1993 8090 09/302001 AQUA MATIC 1171 21477 S 1,353.83 S 1v353.83 S - _ 1010111994 8090 09/302001 VACUUM CLEANER - 1171 21768 S 513.00 S 513.00 S - - - 04/0111995 . 8090 09/302001 CARPET EXTRACTOR - 1171 22172 S 7,762.41 S 7,762.41 $ - _ - 10/01/1995 8090 09/302001 ADVANCE UPRIGHT VACUUM 1171 23057 S 645.00 S 63455 S 10.75 S 10.75 10/01/1996 8090 09130/2001 ADVANCE UPRIGHT VACUUM 1171 23058 S 645.00 S 63455 S 10.75 - S 10.75 1010111996 S090 09/302001 ADVANCE UPRIGHT VACUUM 1171 13059 S 645.00 S 634.25 S 10.75 S 10.75 10101/1996 8090 09/30/1001 ADVANCE UPRIGHT VACUUM 1171 23060 S 645.00 S 63455 S 10.75 S 10.75 10/012996 80" 09/302001 HOUSEKEEPING CART - 1171 23871 $ 701.63 - S 39237 S 309.06 S 309.06 )0/012997 80" 09/302001 BENCHES _ - 1171 806710 S 375.00 S 375.00 S - - - 10/0111990 8090 - - 09/302001 LOW-BACK CHAIR - - 1171 19741 S 222.00 S - 13935 S - 82.65- _ - S 82.65 04/01/1992 8211 09130/2001 VIEWSONIC MONITOR 1171 810761 S 367.00 S 360.88 S 6.12 - S 6.12 1010129% 8212 09/302001 HP VECTRA _ -1171 22924 S 1,630.00 S 1143993 S 190.17 S= 190.17 _ 04/01/1997 8232 09f302001 SAMSUNG MONITOR - - 1171 22971 S 321.00 $ 28355 S - _ 37A5 - _ - 5 37.45- _ 0401/1997 8232 - 09/30200/ SAMSUNG MONITOR _ 1171 25197 S 225.00 S 131.25 S 93.75_ _ _ S 93.75 10101/1998 5232 - 09/302001 COMPAQ PROLDVEA/MONITOR - 1171 80%24 S 1,910.00 S 1910.00 S - - - - 04/01/1995 8232 _ 091142001 COMPAQ PROLUWA/MONTIOR 1171 809680 S 1,815.00 $- 1,815.00 S - - - - - _ 04/01/1995 5241 09/3012001 COMPAQ PROLINEA/MONTTOR 1171 809681 S 11815.00 S 4815.00 S _ - _ 04/012995 8241 097342001 COMPAQ PROLINEA/MONITOR . - 1171 80%82 S 1,815.00 S 1,815.00 S 04/0111995 _ 8241 09/302001 STENO CHAIR - - 1171 8610 S 66.00 S 66.00 S - _ _ 11/012978 8261 09/302001 BP PENTIUM - 1171 22782 S 10800.00 S 19770.00 S 30_ .00 - S 30.00 1010111996 8316 097302001 CHAIR 1171 8027 S 102.00 S 102.00 S - 11/01/1978 8331 09/302001 CAMEO LEGGED CHAIR 1171 24838 S 148.95 S 50.90 S 98.05 S 98.05 84701//998 5341 09/30/2001 MONITOR 1171 809430 S 323.00 S 323.00 S 10/01/1994 8371 09/302001 VCR - 1172 2DO07 S 337.64 S 337.64 S - _ 10/012988 7220 09/302001 OPERATING ROOM TABLE 1172 20054 S 14,664.00 S 129627.47 S 2103653 - S 2903633 14/0111988 7220 09/302001 MICROSCOPE 1172 20133 S 13,000.00 S 13,000.00 S - - 10/01/1988 7220 09730/2001 WHIRLPOOL WASHER 1172 20218 S "3.08 S 443.08 $ - 05/012989 7220 S 1,820.228.99 S 19725.98033 S 94,24&66 S 32,75893 S 60,481.79 S 66,525.70 STATEMENT 25 Page 6 of 6 2001 Community Service Programs at Indian River Memorial Hospital I. Lecture Series A. Lunch and Learn 1 . Nine per year - Lunch and Learn is on the first Friday at noon from September through May. Lunch will be served from 11_ :30 = 12 noon. Reservations are _required. Be Diabetes Support Group 1 . Nine per year— This group meets the first Thursday of each month from September to- May to provide support and education for diabetics and their families: C . Speakers Bureau - Members of the hospital staff and the medical staff present talks to public groups on hospital services, history, governances, finances and advances in medical equipment and procedures, as required. - II. Women' s Healthcare Program - A. Lamaze Classes 1 . Ongoing — Birthing classes for pregnant women and their partners. Be Kangaroo Kapers Sibling Program 1 . Ongoing — Classes to help children whose families are expecting new babies to make a positive adjustment to sibling-hood. C . Giveaways 1 . All new moms are provided with a gift package, which includes a canvas bag, diaper pad, thermometers, coupons and much more . D . Teen/Early Pregnancy 1 . Awareness groups/classes are held at the Vero Beach High School and Sebastian River High School regarding teen/early pregnancy. The topics include pregnancy, STD ' s, family planning and midwifery. Page 1 of 4 III. Regard Plus Program for Seniors A package of programs for people 55 years of age and older, including: A. Wellness Walkers Program 1 . Twice weekly - stretching exercises and walking group. B .. Social Functions ,. 1 . Social dinners once a month from June to September. Dinners are held at different restaurants. 2 . Thanksgiving Dinner 3 . Holiday Party - - - 4 . One field trip (usually March or April) 5 . Participation in community events such as St. Patrick ' s Day Parade_ , American Heart Walk, Making Strides Against Cancer, etc, C . Education Series 1 . Regard Plus members are invited and encouraged to attend the 9 lecture - programs of Lunch- and Learn - D . Financial Perks 1 . Discount at IRMH Cafeteria 2 . Merchants discounts 3 . Free Medical Assistance Claims and Insurance Counseling IV. IRMH Health Fairs A. Community Health Fair This health fair is open to the community. The fair features a wide range of healthcare screenings. B . Celebrating Women : A Women ' s Health Expo — This health fair is designed for women. It is similar to the community health fair only 'smaller and features a variety of health education lectures . This fair is held in February C . Diabetes Health Fair — This Bi-Annual Health Fair is for diabetics and their caregivers . It features several health screenings and information on diabetic related issues . Health lectures are scheduled throughout the day. This event is held in March, Page 2 of 4 a Z IV! Childhood Education A. Pediatric Orientation 1 . By request — An orientation to the hospital for pre-school and first graders. 2 . Children' s tours for elementary school age children. V. Community Service Group Membership and Support A. Personal Resources - Members of the hospital management staff donate their - time to represent the hospital through organizations throughout the community, such as Rotary, Exchange Club,_ etc. B . Financial Resources — Indian River Memorial Hospital supports community organizations such as the American Cancer Society, American Heart Association, March of Dimes and the United Way. VI! - Community Health Screenings A. IRMH participates and sponsors health screenings and health fairs irrvarious - sites throughout the community, including Gifford Health Center, Indian River County School District, St! Edward 's School Faculty and Staff, Northern Trust Bank, Indian River Estates, etc.- - B . Cancer Screenings _ 1 . Prostrate Screening — A free screening offered each September through the IRMH Cancer Center. 2 . Colorectal — The Colorectal screening is offered each spring in conjunction with the Health Fair. 3 . Skin Cancer Screenings — Skin Cancer Screenings are provided at health fairs such as Celebrating Women: A Women' s Health Expo , C. Cholesterol Screenings — IRMH Laboratory screens for Total and HDL Cholesterol every month at the Indian River Mall . The screenings are provided at a cost of $ 12 on the first Friday of the month. VII. Hospital- Sponsored Blood Drives Held throughout the year, the hospital encourages employees to donate on hospital time and occasionally advertises the drive in local media. Page 3 of 4 v VIII. Public Tours Tours are provided to the public on the second Wednesday of every month at 10 :00 a.m. These guided tours provide an opportunity for those interested me learning the hospital facility, services, history and governance. IX. Cardiac & Pulmonary Rehabilitation . 1 . Cardiac : Mended Hearts — Nationally recognized program supported and endorsed by the American Heart Association. This is held the second - Saturday of each month and always has a guest speaker (pharmacist, doctor,- - dietitian, etc.).- - 2 .- Health Fairs = Attends every health fair held in Indian River County.- 3 . Speak to various groups/service organizations such as Rotary . Clubs and retirement communities. X. Lifeline 1 . Educates the community on the Lifeline service available . 2 . Visits the Marketing Departments at health care agencies, assisted living facilities, hospitals, etc, to raise awareness of the needs of the elderly should _ they be released to go home. - 3 . Distributes monthly newsletters to subscribers and an annual Spring Tea Party, Page 4 of 4 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional & Behavioral Health @ IRMH Executive Director : Dr. Raymond Dean, MD Email : rdeanOirmh . co _ Address : 1190 37t1i Street, Vero Beach, FL 32960 Telephone : 772- 63 -4666 ext 1809 Fax : 772-770-2025 Program Director : Mariamma Pyngolil , RN Email : mpyngolil (�i irmh . com Address : 1190 37"' Street Vero Beach, FL 32960 Telephone : 772- 563 -4666 ext 1838 _ Fax: 772-770 -2025 Program Title : Camp Manatee Therapeutic Camp Priority Need Area Addressed: Therapeutic, intervention and educational program for children diagnosed with ADHD and other more severe emotional problems in Indian River County Brief Description of the Program : Day camp facility that is appropriately staffed and equipped to provide an opportunity for children who have developmental disabilities, emotional disturbances , and/or health impairments, who have other limitations or problems which require special facilities or programming, to enjoy a cooperative living experience in the out of doors . Amount Requested from Funder for 2003 /04 : 249500 . 00 Total Proposed Program Budget for 2003 /04 : $ 545500 Percent of Total Program Budget : 45 . 0 % Current Funding ( 2002 /03 ) : $ 201000 Dollar in in request : $ 4 , 500 Percent increase/( decrease) in request : 22 . 5 % Unduplicated Number of Children to be served Individually : 43 Unduplicated Number of Adults to be served Individually : - Unduplicated Number to be served via Group settings : - Total Program Cost per Client : 1267 . 44 Will these funds be used to match another source ? No If yes , name the source : Amount : $ - \� oe The Organization 's Board of Director has approved this application on (elate). 3 Name of Pr ident of the Board 4vz � Name of Exe66tive Director C Signature I�aym.o /i N 17eclt,j The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section . In responding to each section of the proposal narrative, please retain the section-label and/or question you are addressing. Type using 12 pt . Font on 8 t/2 X 11 paper and number each page . These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization . Indian River Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork . The Center for Emotional and Behavioral Health @, IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team . We will continue to support the Quality First process while working together as a team . Camp Manatee Therapeutic Summer Camp is committed to improving the lives of children and their families who are challenged with ADHD disorder with or without more severe emotional problems and who are at risk for alcohol/drug abuse, crime and school drop- out 2. Provide a brief summary of your organization including areas of expertise, accomplishments and population served. CEBH provides Mental Health services to children, adolescents and adults . In patient services are provided on a voluntary or involuntary basis to all three age groups . Partial Hospitalization services are available for adolescents and adults . The facility also provides out-patient therapy for children/adolescents and their families, EAP services, urine drug screens/drug free workplace services, a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children and Experiential (ROPES teambuilding) services to the community. Camp Manatee Therapeutic Summer Camp is a structured and closely supervised program focused on the goals of increased self esteem, socialization, appropriate coping skills development, problem solving, creativity, play and communication skill building . These goals are achieved through a variety of carefully planned structured activities utilizing a behavior management feedback and reward program to teach specific skills 4 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC B. PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change ? b) Who has the need ? c) Where do they live? d) Provide local, state or national trend data, with reference source, that corroborates that this is an area of need . a. Children diagnosed with psychiatric disorder, ADHD, are lacking a comprehensive day camp in the summer designed to meet their special needs and dispense medications . The children are ages 5 though 14 with the last two years designed as leadership skill development for previously enrolled campers who reside in Indian River county. b . According to http : //www. mentalhealth org/features/surgeongeneralreport/chapter3/sect asp ADHD, which Is the most commonly diagnosed behavioral disorder of childhood, occurs in 3 to 5 percent of school-age children in a 6-month period (Anderson et al . , 1987 ; Bird et al . , 1988 ; Esser et al . , 1990; Pelham et al . , 1992 ; Shaffer et al . , 1996c ; Wolraich et al . , 1996) . Pediatricians report that approximately 4 percent of their patients have ADHD (Wolraich et al . , 1990), but in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV (Wolraich et al . , 1990 ) (see also Treatment later in this section) . Boys are four times more likely to have the illness than girls are (Ross & Ross, 1982) . The disorder is found in all cultures, although prevalences differ; differences are thought to stem more from differences in diagnostic criteria than from differences in presentation (DSM-IV) . 2. a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program . - Sandy Pines ADHD Summer Program — Jensen Beach, Fl — closed program due to for-profit business and could not meet financials . No outcome data available -Milestone Charter School, Brevard County Public Schools — In the years past, had a summer camp for ADHD, which modeled the program after Camp Manatee Therapeutic Summer Camp . School principal collaborated with Camp Manatee Manager to institute program in Brevard due to success of their children attending Camp Manatee . No outcome data available due to closing of the camp -No other program like this currently exists in FL; however, several programs throughout the USA exist and are ' sleep-over' camps 5 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC CO PROGRAM DESCRIPTION (Entire Section C, 1 — 6, not to exceed two pages) 1 . List Priority Needs area addressed. It will increase recreation opportunities for children with special needs. Camp Manatee Therapeutic Summer camp offers age appropriate recreational activities to enhance social skills, coping skills, leisure —recreation skill development, education about their disease . It also recreational program that allows ADHD to take their medications . Camp Manatee provides quality childcare before and after camp at an affordable price for working parents to help reduce the amount of juvenile crime. 2. Briefly describe program activities including location of services. -A written structured age anoronriate schedule of recreational activities to enhance social skills, coping skills, leisure, recreation skill development, education about their disease. -Written Positive Behavior Management Program with immediate feedback in the form of verbal praise, tokens and skill development . —Medication times to ensure continuity of care for ADHD children . -Parents of children enrolled are mandated to attend parenting classes specifically designed for parenting the ADHD child . -Experiential Team building Activities to learn & experience growth in self-esteem, making choices, supporting others, communication and developing trust . - Senior Campers 13 years old , community service education & project. -Camp Manatee Therapeutic Summer Camp is located at the CEBH, but utilizes the recreation and leisure resources within Indian River County to provide optimum services for these children 3. Briefly describe how your program intends to address the stated need/problem. Include reference to any studies or evidence that indicate proposed strategies are effective with target population. The issues and problems ADHD with more severe emotional behavioral problem child face are : *Due to an ADHD child ' s lack of impulse control, decreased self-esteem, poor social and r�leiri so vtng s ills- -these McTit ren are usually unsuccessfuf In regular camp and recreational - unities settings 11ere is" a Lack o recreational opport and community service experiences available to - ADHD children in general, and no other programs that specifically addresses targeted areas of concern. Research indicates that ADHD children are at a higher risk for drug & alcohol use. Research also indicates that with preventive education such as development of coping skills, better level of understanding of the disorder, parenting education classes, along with social skill development that the incident of substance abuse and delinquency will be decreased . *Pre & post camp childcare hours, at affordable prices, are difficult for working parents to find, Camp Manatee provides quality childcare before and after camp at an affordable price for working parents . * Recreational Activities program that allows ADHD to take their medication . 4 . List staffing needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers ( This section should conform with the information in the Position Listing on the Budget Narrative Worksheet). Camp Manatee Therapeutic Summer Camp Program Staffing : (Due to a natural decrease of CEBH patient censuses during the summer months we are able to utilize the resources of some CEBH full time staff. ) List of staff follows : ( 1 )Director of Patient Care Services — Advanced Registered Nurse Practitioner in child & adolescent psychiatric nursing- 5 % time of full time position; . 05 position; published behavior program for children with psychiatric disorders, 20 years experience with children & adolescents 6 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC mental health programs . Assist with daily medications, critical incidents and behavior interventions . (2) Psychological Services — Doctoral Level Clinical Psychologist ; 5 % time of full time position; . 05 position. Provides clinical supervision to behavior program content, revisions, clinical standards and parenting education classes . Assist with more serious behavior problems with children & their families when they occur. (3 )Manager of Activity Therapy — Bachelor degree, certified by National Therapeutic Recreation Society . 10% time of full time position; . 1 position . 15 years experience in Therapeutic Recreation services with children & teenagers; 4 years experience with Camp Manatee Program. (4) Supervisor of Camp Manatee — Masters Degree, Licensed therapist . 25 % of a full time position; . 25 position. Over ten years experience in services with children & teenagers . (5 )Camp Counselor — High school diploma plus 2 year experience working with children and entering or enrolled in college with a major in mental health related field . 32 hours training on ADHD (provided by CEBH), behavior programming and skills competencies completed and passed . 100% time; 6 positions ; 7 weeks ; 40 hour week; summer only . (6)Assistant Camp Counselor — High school student who has ADHD and will be helping with various aspects of camp . He will report directly to the camp supervisor. Camp Manatee has recruited volunteers through : 1 . IRMH teenage auxilian volunteer (TAV) program. 2 . IRMH Auxilian/Volunteer Services 3 . Volunteer Action Center YVC — Youth Volunteer Program 4 . St . Edward ' s Upper School - Community Volunteer Program Due to IRMH ' s policy on client confidentiality, Camp Manatee must use discretion on selecting volunteers and the number of volunteers . 5. How will the target population be made aware of the program9 Camp Manatee Therapeutic Summer Camp reaches clients it intends to help by providing literature to schools, medical doctors, therapist, parents, at health fair in Indian River County, to patients treated at CEBH. Camp Manatee Therapeutic Summer Camp staff welcomes all opportunities to speak at organizations, TV, radio, specialty articles in newspaper, etc CEBH provides collaboration with the community through : ( 1 )Vero Beach Press Journal Ads "IRMH Community Calendar and Special Summer Camp Section in Lifestyles" (2)Camp Manatee flyers are distributed/mailed to all elementary & middle schools in Indian River County (both public & private), all members of exceptional student education through the School board office, all pediatricians, child psychiatrist in private practice, all Mental Health Professionals who treat children and through an extended email list of interested parent, services agencies , etc . and to a mailing list of past campers & their families . (3 )Camp Manatee Open House each April to welcome all community members . (4)IRMH Annual Health Fair — distribute flyer & provide educational information for prevention & treatment of ADHD . (5 ) Vero Beach Health Fair Booth — distribute flyer & provide educational information for prevention & treatment of ADHD . (6)Women ' s Health Fair — distribute flyers & provide educational information for prevention & treatment of ADHD 6. How will the program be accessible to target population (i. e. location , transportation , hours of operation) ? Camp Manatee Therapeutic Summer Camp is located at CEBH across the street from IRMH and easily accessible from US 1 or Indian River Boulevard . The hours of operation are 9 : 00am- 3 : OOPM, with the option of before care from 8 : OOAM400AM and after care from 3 : OOPM- 4 : OOPM. Transportation is provided by Camp Manatee to go on field trips, but parents/guardians must provided own transportation to get child to and from camp . 7 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC D. MEASURABLE OUTCOMES (Description of Intent Use the Measurable Outcomesform. This descri tion Page does not need to be included in the proposal. In order to show the impact your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected . OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of the services you provide, not the services you provide . Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes . Activities utilize action words such as complete, establish, create, provide, operate, and develop . The activities should reflect the services described in the PROGRAM DESCRIPTION (C2) . Use the .following elements to develop your outcomes. All elements must be included.- 0 ncluded:• Direction of change • Time frame • Area (?f change • As measured by • Target population • Baseline: The number you will be • Degree (?f chane measuring against Example 1 (Outcome) : To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (target population) by 75 % (degree of change) in one year (time .frame) as reported by the 2002 School Board attendance records (as measured by). Baseline : 2002 School Board attendance records for enrolled boys and girls . Example 1 (Activity): To provide anger management classes to enrolled boys & girls two times a week for 12 weeks . Example 2 ( Outcome) . 75 % (degree (?f change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (time frame) will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry . Baseline : Pre test scores from the academic enrichment test. Example 2 (Activity) : 1 ) Provide pre and post test exercises on the Advanced Learning System software 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE , Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what you are held ' accountable to accomplish. Also, the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B1 ) . All Program Need Statements should flow from the Mission & Vision . Measurable Outcomes should be based on and measure program needs . Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your program need statement . 8 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all the elements or the Measurable Outcome (s) Add the tasks to accomplish the Outcome (v) 1 . To decrease the number of missed 1 . Provide camper ' s prescribed medications medications of enrolled ADHD campers by under the direction of a qualified professional 100% as reported by the 2002 medication (RN) and counselor to manage the medical ; chart records : Baseline : Medication chart on needs of each child daily each child 2 . To increase the ability to utilize coping skills 2 . Instruct & provide written feedback of enrolled ADHD campers to 100% as regarding camper ' s coping strategies each day reported by daily feedback report by to parents . Parents respond on sheet and return counselors and returned next camp day with parental signature . Baseline Daily feedback report 3 . To increase the overall parental 3 . Instruct & provide 4 — 1 . 5 hour of education understanding of strategies on how to cope regarding strategies so that their parents can with their children' s maladaptive ADHD better manage the maladaptive behaviors of the behaviors by 100% as reported by parent post ADHD child . education evaluation form . Baseline — Pre- class evaluation assessment . 4 . To increase the ability to demonstrate, attend 4 . Sr . Camper s will receive up to three tokens to and organize daily tasks assigned to Sr. on their point card, per hour for completion of Campers, to 80% of the time as reported by the organized daily tasks . behavior management system and daily feedback sheets . Baseline — Daily feedback sheets 9 The Center for Emotional and Behavioral Health - Camp Manatee Tlierapeutic Summer Camp — IRC- CSAC E. COLLABORATION (Entire Section E not to exceed one page) 1 . List your program ' s collaborative partners and the resources they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative a reement letters . Collaborative Agency Resources provided to the program Camp Manatee Jeff Horne Memorial Foundation funds donated to assist lower income Fund families with Camp Manatee fees Budget Rentals of Vero Beach Discounted rate for rental van . Rate is good for all six weeks of camp . Barefoot Bay Homemakers $200 . 00 donation to assist children ' s fees in North Indian River Count IRMH Auxiliary Supplying volunteer to help with marketing materials Florida Institute of Technology Allowing psychology resident students to assist with (F . I . T) ADHD parenting classes Indian River County Schools Student Support Services by supplying educational laws for children with disabilities . Also co-facilitating parenting classes for parents of children receiving scholarship to cam Indian River Memorial Hospital Allowing us to utilize the facilities of CEBH (pool, existing play equipment, ROPES course, playground, gymnasium, art room, van, cafeteria, and lounge) and supplies (postage, phones, electricity, copy machines, and existing arts and craft supplies) to run Camp Manatee for 6 weeks during the summer. 10 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC F. PROGRAM EVALUATION (Entire Section Fnot to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender and ethnic background) required by the funder in Section H? What are the pieces of information that qualify them for your target population ? How do you document their need for services or their " unacceptable condition requiring change" from Section 1119 We have created a camper database in Microsoft Access that will allow us to track the following demographics of as provided by the parents via the registration form. ❖ Age ❖ Gender •'• Family income •'• School attending •'• Medications •'• Zip code We are not at this time tracking ethnic background, as we do not ask for that information on the camper ' s registration packet . We have however guessed to our best abilities the ethnic back grounds of our previous and current campers . As an improvement for next year we will include "ethnic background" as part of our registration packet . 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels ) for your program ? Are you getting baseline information from a source on your Collaboration List in Section E? Are there results from your Activities in Section D that need to be documented ? How often do you need to collect or follow-up on this data ? We have developed a point system (based on the behavior of the camper) and feedback sheet (a written synopsis of the day for each camper given to his/her parent(s)) to track our outcomes and record the statistics . We also have evaluation forms filled pre and post parenting classes to accurately measure goals and outcomes of our interventions and education . , The Feedback sheets and point sheets are filled out on a daily basis by the camp counselors assigned to each group . The numbers will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes 11 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC 3 . REPORTING: What will you do with this information to show that change has occurred ? How will you use or present these results to the consumer, the funder, the program , and the community? How will you use this information to improve your program ? The numbers for the point system will be complied on a weekly basis and entered in to a database accordingly. From the database we will be able to chart our outcomes to see when : improvements in behaviors are being made. We will be keeping all the returned feedback sheets for one year, to reference as needed . Information collected for pre and post parenting classes is complied and then entered in to a database . We will be able to chart the results and accurately measure outcomes . The information is shared with the counselors and parents of the child in camp, with a signed release of information form . It may also be shared with educators and therapists, to help better serve the child ' s needs . 12 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC G. TIMETABLE Section G not to exceed one page) 1 . List the major action steps, activities or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections . Month/Period Activities January 2004 ❖ Confirm dates of camp and open house ❖ Contact marketing to update flyers for open house ❖ Call HR department to advertise for 6 counselor positions, revie7criteria. February 2004 ❖ Review, update and print all camp forms (registration, releases, medications) ❖ Update file systems ❖ Review budget March 2004 ❖ Mail open house flyers and order behavior/reward system items ❖ List and compose letter to potential field trip sites April 2004 **eSet up interviews for counselor positions ❖ Host open house (call employees to attend open house) ❖ Send memo to food service requesting daily snacks for camp ❖ Secure rental vans for field trips ❖ Inventory and order art supplies , gym equipment, pool supplies, and games ❖ Order camp shirts for counselors ❖ Review registration forms, send out follow up letter to parents ❖ Set scholarship committee meeting to review and reward scholarships to applicants May 2004 ❖ Develop and finalize camp schedules ❖ Review and update 5 -day counselor training, review and update counselors schedule ❖ Research new ADHD information ❖ Secure dates and speakers for parenting classes ••• Sort and stock point store ••• Finalize camp registration forms June- July 2004 **eSecure field trips by completing check requests ❖ Week 1 Counselor training and Week 2 Camp begins ❖ Complete and distribute pre-evaluation for parenting classes ❖ Hold parenting sessions ❖ Continue to compile goals and outcomes, as well as charting information ❖ Hold daily pre and post counselor meetings ❖ Use feedback from counselors for planning and implementing extension August 2003 program 2x month and complete counselor termination form ❖ Wrap up grant information (employee paycheck, cancelled checks, finance department) . 13 'r•.'•!:' $i'<':•:• ryJ . . .r:. :•.•:::::::::.• •: .i !ilii :: i:: ::::::::::::::::: •: : 'sly` :#?� �' �t::ri••>:;% ,.";!74:;5 C� i i 2 ? ::: ;:;: '•; : o:: . • 'E i:•: OMEN rt:,• •::;t •r:: ? • ,::sir $r.;:; cccd . .:: l,:, . .•.:lam, :ss::t�t: . ,! . •,: •: •::. . . . . :;: � is rn N +l ••r. . flf. Zi ,{Lill••J � rJ . ;'J:l:• � ? l�a 1. ll1l:a• ca N N ch NO a � o adLa CJ .�w Pro N � H Wo ,V mog M W y 'C7 MEEN MEMO CL .0 U 40) U U A V 'c?qa #%5 5's's#555 5%5 :.r >,i..::. . . N N now Mums Ind (U .,. : : \/ :.555;':S; M1".•. . •''.•�': :?: tam )MEMO 'o 'b rn E t F" 0 0 0 0 0 F x Z v� `� The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT. The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer,Camp FUNDER : IRC = CSAC I CAUTION : Do not enter any figures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should i , be used for calculations and to write information onl . % itl. Y.:: . . :::::<:: ::;::»>::::>FurtderS . > :.;:.: ;. .>;::> ;:. . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . .: . .::_:: ::::.::: : :. . . . . . . . . . . . . . . rota :. ::::.: . .: :::.::.::::::.::::Ri / . . . :. . ::::. .::: ::::::._.:::. ;:;:; . . . . . . . . . . . . . . . . P % . . . . . . . . . . . . . . . . . . . . . . . . . . . Bird dt. ::::::::::._::: . . . . . . . . :.:, . ::: . . . . . . :. : auwrn ..::.::::.: . .:::. . . . . . :. . . . . . . . . . . . . .::::::.:::. . . . . . . . 1 Children's Services Council-St. Lucie 0.00 0.00 0.00 2 Children's Services Council-Martin 0.00 0.00 0.00 3 Children's Services Council-Okeechobee 0.00 0.00 0.00 4 Advisory Committee-Indian River 24,500.00 24 ,500.00 24,500.00 5 United WaySt, Lucie County 0.00 0.00 0.00 6 United Way-Martin County 0.00 0.00 0.00 7 United Way-Okeechobee County 0.00 0.00 0.00 8 United Way-Indian River County 0.00 0.00 0.00 9 Department of Children & Families 10 Count Funds o.00 0.00 0.00 County 0.00 0.00 0.00 11 Contributions-Cash 200.00 200.00 200.00 12 Program Fees 10,000.00 10,000.00 109000.00 13 Fund Raising Events-Net 0.00 0.00 0.00 14 Sales to Public - Net 0.00 0.00 0.00 15 Membership Dues 0.00 0.00 0.00 16 Investment Income 0.00 0.00 0.00 17 Miscellaneous 0.00 0.00 0.00 18 Legacies & Bequests 2 ,000.00 0.00 21000.00 19 Funds from Other Sources 0.00 0.00 0.00 20a Reserve Funds Used for OperatingX . 0.00 0.00 0.00 20b In-Kind Donations (Not Included in total) 0.00 0.00 0.00 21 TOTAL REVENUES ; ; < < .>< . > 's: (doesn't include line 20b) : ': $36,700.00 $34,700.00 $36 ,700.00 < t.1114. . . .. :: :::: ::::: > ?: i::::>::: ik5.fplt ::.::.,.:..... .:::::... .. :::,.: ::. . :. :. . . ., . . . . :. :::::::::::::::::::. :::::._::._:: . . . ::. ::::::. ::.:::::::::. :. . . . . :. . :::. ::. :::.:: . . . . . . . . . :. ::::::::::::::.:::::::::. ::::::. :::: . . . . . . . . ::. :::::: 'tarltal. . eitic . � . .. :.. :. . . . . . . . . . . . . . . . . . . :. .: :: . .::::: . .::::::: . . . . . . . . . . . . . . . . . . :::.::: .:::::::.::,:::::::::::. . . ` . . . . :.: .:::: :. ::::::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . % ::.:.:::3''::.::.. 22 Salaries - (must complete chart on next page) 30 250.00 24 929.99 1479250.00 ::. .: . Y. ::. . . :. :. . . . . . . . . . .: . . . . . . . . . . . . . . . . . . . . . . . . .o.00 23 FICA - Total salaries x 0.0765 > 7 4av% 0,00 1 ,907. 14 24 Retirement - Annual pension for qualified staff < >': . „ ': < 0.00 0.00 0.00 25 Life/Health - Medical/DentaVShort4erm Disab. 0.00 0.00 0.00 26 Workers Compensation - # employees x rate 0.00 0.00 0.00 Florida nemp oymen - proseW . e 27 employees x $7,000 x UCT-6 rate 0.00 0.00 0 .00 05/27/2003 15 The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " NG ::::::PortiMofs" : ::aP. m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :.. . . . . . . . . . . . . . . . . . . . . . lirs. . . . . . . tl #(1Ut1tl; ;;.;;::<::<>:;::>::::><:>::::> ::; :: SOU ? 4!l: Director of Patent Care Services 50 000.00 2 ,500.00 0.00 0.00% Psychological Services 409000.00 2 ,500.00 0.00 0.00 Manager of Activity Therapy 38 ,000.00 6,000.00 5,679.99 14.95% Camp Manatee Supervisor 69400.00 61400.00 6,400.00 100.00% Counselor - A group 2,570.00 2 ,570.00 2 ,570.00 100.00% Counselor - A group 21570.00 2570.00 2 ,570.00 100.00% Counselor - B group 21570.00 2 ,570.00 2 ,570.00 100.00% Counselor - B group 21570.00 2,570.00 2,570.00 100.00% Jr. Counselor - Camp Assistant 21570.00 2 ,570.00 2570.00 100.00°� . Remaining positions throughout the agency Total Salaries 1 $ 147,250.001 $30 250.0016.93% $24 929.99 lip�l� im' ' � :p:: ::G::��::: r:: �:`::;`; t: :2 ::::: #�:>�:.:2��:::+�.''�. ��' � �JI7i f:�G F1. .; .; .;::. :. . . . . . . . . . :. . ::::::::::.: ::::. :::::::: : .: . . . . . . . . . . . . . . . . . . . . . . :::. :::::�utrcex. . . . . . . . . . . . . . : ::: :. . . . . . . . . . . . ::::::::: : . . . . . . . . . . :: :::.: :: . . . . . . .::::::::::::: ?'B L* . . . . . . . . . . . . . . . . . . t .. :. ::::::::.:::::::: .: . . . . . . . . . . . . . . . . . . ::. ::::::. :: .. . . . . . . . . . . . . . . . . . . . . . . :::. : :. . . . . . . . . . . . . . . :: . :.:T1:> r`::Elf#/ . ':> . . :- :. :: ,.:: :. . . . . . . : . .: . . . . .: : ::::: .: . .:::::::.::::::::: .:{.:::::::;: .::::;:;: . :. . . . . . . . . . . . . :::::. .::::::. :.iTI>7�I:T #�l: .:>t:>:;;:::: : W. ..::Gas;} '::a»:;«:; :< ;.:;; ::: .. . . ! . . : :,:::: .: . .. . :: . . . . . :::> : : : :>::::: :;: > : ' fir6t r of Patent Care' Services 0.00 0.00 0.00 0.00 0.000.00 0.00 logical Services 0.00 0.00 0.00 0.00 0.00 0.00 0.0er of Activity Therapy 5 ,679.99 434.52 0.00 0.00 0.00 0.00 434.52 Manatee Supervisor 6,400.00 489.60 0.00 0.00 0.00 0.00 489.6 Counselor - A group 21570.00 196.61 0.00 0.00 0.001 0.00 196.61 Counselor - A group 21570.00 196.61 0.00 0.00 0.00 0.00 196.61 Counselor - B group 29570.00 196.61 0.00 0.00 0.00 0.00 196.61 Counselor - B group 2570.00 196.61 0.00 0.00 0.00 0.00 196.61 Jr. Counselor - Camp Assistant 20570.00 196.61 0.00 0.00 0.00 0.00 196.61 Total Funder Request Fringe Benefits $24,929.99 $1 ,907. 14 $0.00 $0.00 $0.00 $0.00 $ 1 ,907. 14 05/27/2003 16 The Center for Emotional and Behavioral Heatth/Camp Manatee Therapeutic Summer Camp •./� may/ oiAruheas:Foaz:>: : < « : . . . .: : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cilli . . . *rta . . t..�'� `aifr . ..:- - -:- : . . ::. '.:::::::•:,••_• : . .: . . . . . . . ..: . :::::. .:::::::_:: .:. : .: . . . . . . . . . . . . :• :cta : .. . . . . . . . . . . . • . • ..... : . ...: ...... . ::.: ::.�.::.....::... : ..... ::::: . :. . .::::... .::::::::: .: . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . 51. . . . . . . .,x. . . . . . .. ::•. :.:::.. . . . ..::::::: .:, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :::::::::::::::: . . . . . . . . . . . . . . . . . . . . . . . . . :. :. .J .... . . . . . . . . . . . . . . . . . . . . . . . . . :: .:::: :::. ::. ... Ufa ... .;::......;:.::;:<.:;:. .: ::>::.: . ...... . . :.....>:.;;;;:::: 28 Travel-Daily :::. . . .:::_.••• ••• • . . • o•00 0.00 0.00 o Staff x average # of ' # f miles/w kx50 s wk x 9 $ • • ' ' : • • • • - • • • • •„.. ... . . . ... . . . . . .. .. •< • = : : . .`: : :": • • _ : : : s :: ••• ` ' ' ': ::: ? : %> : : : : : ` . ::: :': %: ....• „. = Estimated Dail Travel/Mileage a Reimb. . : ..... `. . ...... .; . .. .... . . ....:.: . : . :. .:::.;:<;;:..•. .. .... :>:: Y 9 •• .: .: . .:: .:: .... . . . . .. .. .. 29 Travel/Conferences/Training : :::: 0.00 0.00 0.00 • •o NatI nal Conference c ostPe staff)to • a Trainin /Se i mnreost per staff) • Other Trainin9s (cost of travel, lodging , registration , food) 0 3 Office Supplies > :s: •: . 2 ,300.00 0.00 2 ,300.00 • Office supplies (monthly Y average x1 2 months = estimated m ted cost of office supplies P les bas ed on . ..::::::::: .:::: : ::: . Present history. ......:.: : ..... ...;:..... 31 Telephone 0.00 0.00 0.00 # Phonei s I ne x average e costPer mo nth x 12 months = o I calP ho ecost ost • Average e Ion distance ncecall x 12 months - • . . . . . . . . . . . . . . . . . . . . . . . . . :. :. :. :. . . . ... . ...:.:.,..:. :. .::. ..:. ..:. :. .:: .::.;:.:Estimated costo ton distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : ::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 32 Postage/Shipping . :.. :.. . :..• . 0.00 0.00 0.00. . . . . . . . . . . • Quarterly Mailing H of New slette r • Special events, etc.. • Bulk mailings s appeals eals • • :• j :.;;:: • • • • • •• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .• . . . . . . . . . . . . . . . . . . . . . . . . . 33 Utilities .... . ... .......... . 0.00 0.00 0.00 • Electricd xmonths) 12 Y ( ate • W r/Sewer x12months) • Garbage e x 12 months) 9 . . . . . . .::: . . . . :.::: . . . 34 Occupancy (Building & Grounds) . :... .......::::«:...... ... :.. ........... 0.00 0.00 0.00 • Mortgage/Rent 0 x12 months) • Jan' Ito nal $ x 12 months)s • ( Grounds Maint. ( months)x12mo hs • Real I Estate Taxes '' > ':>:»: :s> : . . .. .. .. .. .. .. .. .. .. .. .. . .. . . . . . . . . . . . . . . . . ... . . . . . . . . . .35 Printing & Publications •. . . : :• ......•••• ••-••••••••• • iso 00 0.00 180.00•• • Quarteri Newsletterx4 • Le e Letterheads,rh Envelopes,e etc • u d 9 F n raisin materials nals • Other 36 Subsc _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... Etta:::: • :: . . : _: . ••••• :. ;.. . .. . . . . . . . ... ._. ... . . .. .. . . ..•.:.;;;::;: ::.:_::;:.;.•...•<. :.... .:<::< ;;;........ :.... .c.... . .. ;:.:<.;:.:;.;;:;.;>:.: . . . . . . . . . . . . . . . . . . . . . . . . . . . :::: . 4...4 •::.::....:.... .. ription/Dues/Memberships 0.00 0.00 0.00 • Membership o a . t National Organization anizafo In • • • , . :. :<:; .-_. • •.• . . • _ _: • •.4 : : : •. •Dues . . . 4.•••••••••••••.• . : .:. . • : . ::: ; •• • •• • • . .: : . . r •• :• • •. .t . : : ••• .: • • :: : • % > : • . > : : .. . . : : .. . .. . ;: . . : .. . _; • • : .... <:: : .VV... • : ••• •• •• •• •.. • •.. i : • : .. .. • • : : : :i . ..; <. ;> . .: :» : : . : :« : »: < : . . >: . . • • •_ : . :• • : >:: : ::: : : : . : . .• Subscriptions News ers/ . . . ..: 37Insurance n urance :.4•• ••••••• ::: ........4.4 ••••••••••••••• • •••••••••••: <: <: : : : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o.00 0.00 0.00 • Directors/Officers Llab. ...::.::.. . .. .... .... .. . .. ... .. ...... ::::::. :.... . :.::.:.:.:.:•... . :�... ..::.: :.;.::_. . . . :::. • Commercial/General Insurance .• .. .. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bond• B n Ins. • Auto Insurance n urance . 38 Equipment: Rental & Maintenance • s : > :<:» :: >: • 3,000.00 0.00 3,000.00 • Copier I r lease $ x12months) . . . . . . . . . . . . . . . . . • et Mer lease x12months) • Copier• r Maintenance months)hs P • Computer uter Mainte ance ( x12mo hs • • • • • • • _ • Other . . . . . . . . . . . . , :. . . . . . . . . . . . . . . . . . . . . . . . . ... . ::.:._... �.�:::::::::. :::::::::. :. .....�::;::. ...;:::.::.;;:.;:.. . .:..;..;; ;:.: : :;<.;:.;:. ::;;:.: :.::.; .;:.;;:.:;. :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Advertising • 0.00 0.00 0.00 • Newspaper er ads PP • Fundraising ads/promotions• Other (vacancies) •: . 40 Equipment Purchases :Capital Expense 0.00 0.00 0.00 • Computer/monitor # x • Laser Printer . . .. :::.: . . The Center for Emotional and Behavioral Health/Camp Manatee Therapeutic Summer Camp 41 Professional Fees (Legal, Consulting) 0.00 0.00 0.00 :.; • Legal advice estimated # s >: »:<:: :>::>:::::: <:>::>::::>::::::>;:: <::: <:>:: :: » :::» ::::»::::;::::::>:>:: <;:<:::;:: :::»::>::>:>:_>:: >:<:»:: ::>:::;;.: : :>:::<:.;:;.: ;:.:.>;;• • Consultantf ees • Other 42 Books/Educations I Materials 200.00 0.00 200.00 • Bookstvideos ' • Materials x staff) 3 Food & •t' 4 F Nutrition ::::>::>::::> :: ::: :::>::::::;:::>::>: 1 .050.00 0.00 1 ,o50.00 • Meals # eals m x clients x 5daY s x 50 wks • Snacks k 44 Administrative Costs Admin . Cost of total budget)9 ) 45 Audit EP e nse x . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :::: .::::::::.::::::::.:::::::: 0.00 0.00 0.00 Inde . . . ... . . . . . .Audit : _::::>:::::>:»»»::::>::> ::<:> :;: :::: ::::> :;»>:::«:>::::<;<:>::>::<:::: :>::»::»-;> :»::>::>::::» «::c<>::;; ;;::;;:. :.>;;;;;;:.:;.;: ;;;;;>:.;:;.;: ;;;:.;:.:;;.;:;.;, pe it 46 Specific s fc As stance to Individuals uals 0.00 0.00 0.00 • Medical I assists nce • Meals/ Food • Rents' As istance • Other E,% ... . . . . . . . . . . . 47 Other /Miscellaneous us . . . . . . . . . . . . . . . . . . . . . . . . . . . :::::;::<:>:::< .. ....> : 0.00 0.0 . . . . . . . . . . . . . . . . . . . . .0. ...0. .0 Background c eck/dru test Other 48Other/Contract 320.00 0.00 320.00 Sub-contract for program services 49 TOTAL EXPENSES $37,300.00 $26 ,837. 13 $154,300.00. . 05/27/2003 18 rw '-Mor fix Em)bi a BMaN A M aWW: p Matra " T apftkr irnnrer C UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAME: The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Cam FY 01 /02 FY 02103 FY 03/04 % INCREASE thru 04103 FYE 09/30/03 FYE 09130/04 CURRENT VS. NEXT FY BUDGET A B C p ACTUAL TOTAL PROPOSED (col, ctot B(Icol. 8 REVENUES BUDGETED BUDGETED 1 Children's Services Council-St. Lucie 0.00 0.00 0.00 #DIV/O! 2 Children's Services Council-Martin 0.001 0.00 0.00 #DN/0! 3 Children's Services Council-Okeechobee 0.00 0.00 0.00 #DIV/01 4 Advisory Committee4ndian River 20 000.0020 000.00 24 500.00 22.50% 5 United Way-St Lucie County 0.00 0.00 0.00 #DIV/O! f s United Way-Martin County 0.00 0.00 0.00 #DNIO! 7 United Way-Okeechobee County 0.00 0.00 0 .00 #DIV/01 B United Way-Indian River County 0.00 0.00 0.00 #DIV/O! 9 Department of Children & Families 0.001 0.00 0.00 #DIV/01 10 County Funds 0.00 0.00 0.00 #DIV/O! 11 Contributions-Cash 2236000 22 360.00 200.00 -99,11 % 12 Program Fees 431433300 6305 463.00 10 000.00 -99.84% 13 Fund Raising Events-Net 0.00 0.00 0.00 #DIV/O! 14 Sales to Public-Net 0.00 0.00 0.00 #DIV/O! 15 Membership Dues 0.001 0.00 0.00 #DMO! 16 Investment Income 0.00 0.00 0.00 #DIV/O! 17 Miscellaneous 0.00 0.00 0.00 #DIV/O! 1e Legacies & Bequests 0.00 0.00 21000.00 #DIV/01 19 Funds from Other Sources 0 .00 0.00 0.00 #DIV/O! 2oa Reserve Funds Used for Operating 0.00 0.00 0.00 #DIV/01 20b In-Kind Donations e+otIncluded intotal) 0.00 0.00 0.00 #DIV/0! 21 TOTAL 47356,693.001 6 347 823.00 36 700.00 -99.42% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EXPENDITURES 22 Salaries 1 722187.00 296985100. 172 320.00 -94.20% 23 FICA 125120.00 194 046.00 0.00 400.00% 24 Retirement 0.00 0.00 0.00 #DIV/O! 2s Life/Health 40.00 0.00 0.00 #DIV/01 26 Workers Compensation 0.00 0.00 #DIV/O! 27 Florida Unemployment 0.00 0.00 #DIV/0! 2s Travel-Dail 0.00 0.00 #DIV/0! 29 Travel/Conferences/Training 0.00 0.00 #DIV/O! 30 Office Supplies 1973900 2 300.00 -88.36% 31 Telephone 0.00 0.00 #DIV/0! 32 Postage/Shipping 0.00 0.00 0.00 #DIV101 33 Utilities 33 738.00 7193300 0 .00 -100.00% 34 Occupancy (Building & Grounds 128l325.00 220 596.00 0.00 -100.00% 35 Printing & Publications 977.00 403.00 180.00 55.33% 36 Subscription/Dues/Memberships 0.00 0.00 0.00 #DIV/O! 37 Insurance 21310.001 3 960.00 0.00 400.00% 3e Equipment: Rental & Maintenance 57413.00 23 587.00 39000.00 -87.28% 39 Advertlsin 0.00 #DIV/0! 4o Equipment Purchases :Ca ital Expense 11 492.00 31694.00 0.00 400.00% 41 Professional Fees (Legal, Consulting) 0.00 0.00 0.00 #DIV/O! 42 Books/Educational Materials 200.00 #DIV/0! 43 Food & Nutrition 20 097.00 3803900 11050.00 -97.24% 44 Administrative Costs 79218.00 12 958.00 0.00 -100.00% 45 Audit Expense 0.00 #DIV/0! 46 Specific Assistance to Individuals 0.00 #DIV/O! 47 Other/Miscellaneous 61054.001 28 652.00 0.00 -100.00% 4e Other/Contract 144 490.00 152400001 0.00 0100.00°/a 49 TOTAL 222337100 373985800 179 050 .00 -95.21 % . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. :.: Y: � .G:::::::i::: ;;;;i:: 5o REVENUES OVER/ UNDER EXPENDITURES 2133 322.00 21607,965.00 442,350.00 105.46 /o �znzar+ fs TM Carte for EmM,, aril Ek4w ra Hca°✓�'mro ManMl TM rap °! .:aamwr Carni UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME: The Center for Emotional and Behavioral Health - Camp Manatee Thera eutic summer Cam / FY 01 /02 FY 02!03 FY 03/04 °/a INCREASE FYE0913012002 FYE0913012003 FYE09/30/2004 CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (col. Cool. aNcol. 9 REVENUES BUDGETED BUDGETED 1 Children's Services Council-St. Lucie 0.00 0.00 0.00 #DIV/0! 2 Children's Services Council-Martin 0.00 0.00 0.00 #DIV/0! 3 Children's Services Council-Okeechobee 0.00 0.00 0.00 #DIV/0! a Advisory Committee-Indian River 20 000.00 24 500.00 24,500.00 0.00% 5 United Wa St. Lucie County 0.00 0.00 0.00 #DIV101 s United Way-Martin County 0.00 0.00 0.00 #DIV/0! 7 United Way-Okeechobee County0.00 0.00 0.00 #DIV/01 a United Way-Indian River County0.00 0.00 0.00 #DIV/01 s Department of Children & Families 0.00 0.00 0.00 #DIV/0! 10 CountyFunds 0.00 0.00 0.00 #DIV/0! 11 Contributions-Cash 200.00 200.00 200.00 0.00% 12 Program Fees 10151 .00 51600.00 560000 0.00°k 13 Fund Raisin Events-Net 0.00 0 .00 0.00 #DIV/0! 14 Sales to Public-Net 0.00 0.00 0.00 #DIV/0! 15 MembershipDues 0.00 0.00 0.00 #DIV/O! 16 Investment Income 0.00 0.00 0.00 #DIV/01 17 Miscellaneous 0.00 0.00 0.00 #DIV/0! is Legacies & Bequests 600.00 21000.00 0.00 -100.00% 1s Funds from Other Sources 0.00 0.00 0.00 #DIV/0! 20a Reserve Funds Used for Operating 0.00 0.00 0.00 #DIV/0! 201) In-Kind Donations (Hotinck,dedinrotal) 0.00 0.00 0.00 #DIV/0! 21 TOTAL 30 951 .00 32 300.00 30 300.00 .6.19% EXPENDITURES 22 Salaries 24j929.99 24 929.99 30 320.00 21 .62°/a 23 FICA 0.00 0.00 0.00 #DIV/01 24 Retirement 0.00 0.00 0.00 #DIV/0! 25 Life/Health 0.00 0.00 0.00 #DIV/0! 26 Workers Compensation 0.00 0.00 0.00 #DIV/0! 27 Florida Unemployment 0.00 0.00 0.00 #DIV/0! 2s Travel-Dail 0.00 0.00 0.00 #DIV/0! 29 Travel/Conferences/Training1 000.00 1 000.00 0.00 -100.00% 30 Office Supplies 200.00 200.00 225.00 12.50% 31 Telephone 100.00 100.00 100.00 0.00% 32 Postage/Shipp ng 250.00 250.00 250.00 0.00°k 33 Utilities 0.00 0.00 0.00 #DIV/0! 34 Occupancy Buildin & Grounds 0.00 0.00 0.00 #DIV/0! 35 Printing & Publications 180.00 180.00 180 .00 0.00% 36 Subscri tion/Dues/Membershi s 0.00 0.00 0.00 #DIV/0! 37 Insurance 0.00 0.00 0.00 #DIV/01 38 E ui ment:Rental & Maintenance 31000.001 300000 31000.00 0.00% 39 Advertising50.00 50.00 50.00 0.00°k 40 Equipment Purchases :Ca ital Expense 0.00 0.00 0.00 #DIV/0! 41 Professional Fees (Legal, Consulting) 0.00 0.00 0.00 #DIV/Ol 42 Books/Educational Materials 200.00 200.00 200.00 0.00% 43 Food & Nutrition 1 050.001 050.00 11050.00 0.00% 44 Administrative Costs 500.00 500.00 500.00 0.00% 45 Audit Expense 0.00 0.00 0.00 #DIV/0! as S Specific Assistance to Individuals 0.00 0.00 0.00 #DIV/0! 47 Other/Miscellaneous 21418.00 241800 2p418.00 0.00% a8 Other/Contract 320.00 320.00 320.00 0.00% 49 TOTAL 34197.99 34197.99 38 613.00 1 2.91 % 50 REVENUES OVER/ UNDER EXPENDITURES 3,246.99 -1 ,897.99 $1313.00 337.99% °srnlxna 20 The Center for Emotional and Behavioral Heawcamp Manatee Therapeutic Summer Camp UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Cam FUNDERARC = CSAC A B C FY 03/04 FY 03/04 % INCREASE TOTAL FUNDER TOTAL VS, PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) EXPENDITURES 22 Salaries 309250.00 24,929 .99 82 .41 % 23 FICA 0 .00 1 ,907. 14 #DIV/01 24 Retirement 0.00 0.00 #DIV/O ! 25 Life/Health 0.00 0.00 #DIV/01 26 Workers Compensation 0.00 0.00 #DIV/01 27 Florida Unemployment 0.00 0.00 #DN/0 ! 28 Travel-Daily 0 .00 0 .00mw� #DN/O ! 29 Travel/Conferences/Training 0 .00 0 .00 #DN/0 ! 30 Office Supplies 29300 .00 0 .00 0.00% 31 Telephone 0.00 0.00 #DIV/01 32 Postage/Shipping 0 .00 0.00 #D1V/01 33 Utilities 0 .00 0 .00 #DIV/01 34 Occupancy ( Building & Grounds 0.00 0.00 #DIV/01 35 Printing & Publications 180.00 0.00 0 .00% 36 Subscri tion/Dues/Membershi s 0 .00 0.00 #DN/0 ! 37 Insurance 0 .00 0 .00 #DN/01 38 Eg ui ment : Rental & Maintenance 3 ,000.00 0 .00 0.00% 39 lAdvertising 0 .00 0.00 #DIV/01 4o Equipment Purchases : Capital Expense 0 .00 0 .00 #DIV/01 41 Professional Fees ( Legal , Consulting ) 0.00 0 .00 #DIVIO ! 42 Books/Educational Materials 200 .00 0 .00 0 .00% 43 Food & Nutrition 11050 .00 0.00 0 .00% 44 Administrative Costs 0 .00 0 .00 #DIV/01 45 Audit Expense 0.00 0 .00 #DIV/0 ! 46 Specific Assistance to Individuals 0.00 0200 #DN/01 47 Other/Miscellaneous 0 .00 0.00 0 .00% 48 Other/Contract 320wOO1 0 .00 0.00% 49 TOTAL $37,300 .00 $26 ,837 . 13 $0 .72 05/27/2003 21 The CeTdeT M Emollanal and BehaW" Heaah/Camp Manatee TheWeukk SwmneT Camp UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15016 OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME : The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp FUNDER: IRC - CSAS �j� ] >.. . . . .: .:.:...:.: :. . .... M1 4•::•ivi:•i: r�}"!.$�'. . Y. . . : . .: :•. :::{.vv,{,.r. . .y:. ; . .;: . ..:. :.. . .. . . . ...A . . . .. .. ..M1...{ : .::•::.:::.:.:•::A:..44•:::::::::::.::•.�.: ::.:A-:.Ct:M1•:.1•:::::::.M1•::::::.M1:Y:.::..::.:•:::: . .AM1:l•::J:.4::.:.: .: .M1.:Y44 . . . . .M1 .. .4. . . . .M1A\ . . . . .44.A .4..N.�:::.:•::::•.•::::.:•:::N::: ..•::. .NT.t .S•.�•�t.Tf'.TT•I. .:J.T.•-l'":'. .:T.T:•.T. .-- R, Sl.` J�`. I.T.�.�.`:P:i:•:tifJ:`:?ti:•:J1:?•• ••'J. :titi%C::iJ:•:•If:i:• =IF 'Total Pro ram'1F11 >=15°/a 'Total Pro ram'1B11 " " =IF 'Total Pro ram'IF12>=15°/a 'Total Pr ram'1B12 " " =IF 'Total Pr ram'IF13>=15% 'Total Pro ram'IB13 " " =1F 'Total Pr ram'1F14>=16% 'Total Pr ram'!814 " " =1F Total Pro ram'1F15>=15°/a 'Total Pro ram'!615 " " =IF 'Total Pr ram'1F16>=15°/a 'Total Pro ram'1B16 " " =IF 'Total Pro ram'!F17r_15° a 'Total Pro ram'S17 " " =1F 'Total Pro ram'!F18>=15°a 'Total Pr ram'l818 " " =IF 'Total Pro ram'1F19>=16% 'Total Pr ram'1B19 " " =IF 'Total Pro ram'!F20>=16% 'Total Pr ram'IB20 " " =IF 'Total Pro ram'!F21 >=16°/a 'Total Pro ram'!B21 " " =IF 'Total Pro ram'!F22>=16°/a 'Total Pr ram'1B22 " " =fF Total Pr ram'1F23>=15% 'Total Pro ram'1B23 " " =IF 'Total Pro ram'!F24>=16% 'Total Pr ram'1B24 " " =1F 'Total Pro ram'IF25>=16° 'Total Pro ram'iB25 " " =IF 'Total Pr ram'!F26>=15° a 'Total Pr ram'l826 " " =IF 'Total Pr ram'!F27>=15° 'Total Pro ram'!B27 " " =IF 'Total Pr ram'!F28>=16°/a 'Total Pro ram'IB28 " " =IF 'Total Pr ram'!F29>=15% 'Total Pro ram'1B29 " " =1F 'Total Pro ram'1F30>=16°/a 'Total Pro ram'!B30 " " =IF 'Total Pro ram'1F31 >=15%. Total Pro ram'1B31 " " =1F 'Total Pro ram'!F35>=15° 'Total Pro ram'!635 " " We are asking for 5320.01 less than the budgeted amount for salaries. =1F Total Pro ram'1F36>=15° 'Total Pro ram'IB36 " " =1F Total Pro ram'!F37>=16°/a 'Total Pro ram'1837 " " =IF 'Total Pro ram'!F38>=16% 'Total Pro ram'!M " " =1F Total Pr ram'1F39>=15% 'Total Pro ram'IB39 " " =1F 'Total Pro ram'!F40>=15° a 'Total Pro ram'!B40 " " =IF 'Total Pro ram'!F41 >=15% 'Total Pro ram'!B41 " " =IF 'Total Pro ram'!F42>=15° a 'Total Pr ram'!B42 " " =IF 'Total Pro ram'lF43>=15° a 'Total Pro ram'!B43 " " =IF 'Total Pr ram'1F44>=15°/a 'Total Pro ram'1B44 " " =IF 'Total Pro ram'IF45>=16° a 'Total Pro ram'IB46 " " =1F Total Proqram01F46>=15% 'Total Pr ram'1846 " " =IF 'Total Pro ram'!F47>=16% 'Total Pr ram'1B47 " " =IF 'Total Pro ram'IF48>=16° a 'Total Pro ram'IB48 " " =IF 'Total Pro ram'IF49>=16° a 'Tota1 Pro ram'IB49 " " =IF 'Total Pro ram'IF50>=16% 'Total Pro ram'!B60 " " =IF 'Total Pro ram'1F61 >=16% 'Total Pr ram'1851 " " =IF 'Total Pro ram'IF62>=16° a 'Total Pro ram'IB52 " " =IF 'Total Pr ram'IF53>=16% 'Total Pro ram'IS53 " " =IF 'Total Pro ram'IF54>=15% 'Total Pro ram'1654 " " =IF 'Total Pro ram'IF66>=16% 'Total Pro ram'1856 " " =IF 'Total Pro ram'1F56>=16% 'Total Pro ram'!B56 " " =IF 'Total Pro ram'!F67>=15° a 'Total Pro ram'IB57 " " =1F 'Total Pr ram'1F58>=15% 'Total Pro ram'1B58 " " =IF 'Total Pro ram'IF59>=16° a 'Total Pro ram'IB59 " " =IF 'Total Pro ram'1F60>=16°/a 'Total Pro ram'IB60 " " =IF 'Total Pro ram'1F61 >=15°/a 'Total Pro ram'1B61 " " MM2003 22 TM Center for Em°nonel en° Beh°NmM NeehNCew Menefee TherepeUk Summer Cwnp UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE FUNDER SPECIFIC BUDGET AGENCYIPROGRAM NAME : The Center for Emotional and Behavioral Health " Camp Manatee Therapeutic Summer Camp FUNDER: IRC - CSAS [+::i{}tii::>.>.:?C>..`,i•`.i}'r,Y•:�:i.`,�iiitii}.i}LtL�5:2:tiii}:;}}:::j:{: : :...:ti::}•{.}v}:�::.:;.};.:;.}}:•}}'ti:•:}:+•}}:.y.}}•.vv::::.:•.v. .v •:{•:{Sx24:v:4a:{:{ti.{ii:.:•.::.:ivi•}:{•}:{•%.:{:{:{{G : L.IJ.iG`a�.'...: v::L.. ''}iL3':�i:.`, }:: i+.>.}:;:::. .x; =IF 'Funder S ecific'IE11 >=16° 'Funder S ecifie'1811 " " We are asking for 5320.01 less than the budgeted amount for salar!es. =1F Funder S ecific'1E12>06% 'Funder S ecMOB12 =IF 'FunderS ecrtc'!E13>=16% 'Funders eciffc'1B13 " " =1F 'Funder S eeific'1E14>=16% 'Funder S ecifac'1B14 =IF 'FunderS ecWW1E15>=16°o7underS ific'1B15 " " =1F Funder S cWW1E16>=15° 0 'Funder S ecific'1816 " " =1F 'Funder S ec!fic'1E17>=15% 'Funder S ific'1817 " " =1F 'Funder S ecific'1E18>=16% 'Funder S ifc'IB18 " " =1F 'Funder S ecifie'1E19>=16% 'Funder S cific'!B19 " " =1Ff Funder S ecWW1E20>=16% 'Funder S ecific'1820 " " =1F Funder S clfic'1E21 >=15° 'Funder S ifie'1621 " " =1F 'Funder S ecifW1E22>=16° 0 'Funder S ific'IB22 " " =1F Funder S ecWW!E23>=16% 'Funder S ec!fic'1B23 " " =IF 'Funder5 !fic'1E24>=16°0 'FunderS ecific'1B24 =1Ff Funder S ciffc'1E25>=16% 'Funder S !fic'!B25 " " =Wffunder SpechicIE26>=16°h 'FunderS cific'1B26 " " =IF 'FunderS ecific'1E27>=16° 0 'FunderS ecific'!B27 " " =1F 'Funder S eciffc'!E28>=16% 'Funder S ec!fic'1828 " " =1F Funders ifOE29>=16% 'Funders c!fic'1629 " " =1F Funder S eciffc'1E30>=15% 'Funder S ecific'!B30 " " =Wffunder SpecMcIE31 >=16% 'Funders eciffc'!B31 " " =1 Funder S ecifW1E32>=15% 'Funder S ecific'1832 " " =IF 'Funder S ec!fic'1E33>=15% 'Funder S ifie1833 " " =IF 'Funder S e!ffc'!E34>=15% 'Funder S cific'1834 " " =IF 'Funder S ecific'1E35>=16% 'Funder 5 ecifie'!B35 " " =IF 'FunderS c!fic'!E36>=15% 'Funders !fic'!636 " " =1F 'Funder S !fic'!E37>=15% 'Funder S iffc'1837 " " 05=2003 23 NOT FOR PROFIT AGENCY CERTIFICATION The County of Indian River requires, as a matter of policy, that any Consultant or firm receiving a contract or award resulting from the Request for Qualifications issued by the County of Indian River, Florida , shall make certification as below. Receipt of such certification , under oath , shall be a prerequisite to the award of contract and payment thereof. I (we) hereby certify that if the contract is awarded to me , our firm , partnership, or corporation , that no members of the elected governing body of Indian River County, nor any professional management , administrative official or employee of the County, nor members of his or her immediate family, including spouse , parents , or children , nor any person representing or purporting to represent any member or members of the elected governing body or other official , has solicited , has received or has been promised , directly or indirectly, any financial benefit , including but not limited to a fee , commission , finder's fee , political contribution , goods or services in return for favorable review of any Proposal submitted in response to the Request for Qualifications or in return for execution of a contract for performance or provision of services for which Proposals are herein sought . The undersigned certifies that he/she is a principal or officer of the firm applying for consideration and is authorized to make the above acknowledgments and certifications for and on behalf of the applicant. The undersigned certifies that the Applicant has not been convicted of a public entity crime within the past 36 months , as set forth in Section 287 . 133 , Florida Statutes . Failure to skin this form will result in disgualirication. Handwritten Signature utho 'zed Principal(s): DATE : NAME : TITLE : - e 1 e.✓1 � �hcl' -F z� �CuV� Gee' NAME OF FIRM/PARTNERSHIP/CORPORATION : Cin 1y� o r�ywl Behave oal 14ra ° �i kA) ryl znyluaI 1.1119c:; nLa ( FOR AND ON BEHALF OF THE APPLICANT : Sworn to and subscribed to me , a Notary Public, this _day of C1'1 12003 . BY: SUS i �r�s ► �er►f c�D (SEAL) (TYPE NAME & TITLE) USA LICITRA Notary Public - State of Florida My Commission EKpkw Apr 12, 2004 Commission # CC927373 X Indian River Board of County Commissioners 184025 th Street Vero Beach , FL 32960 AUTHORIZATION FOR RELEASE OF INFORMATION Indian River County and )6 : 2 - 6£g (Agency/IndividualT are in the process of negotiation of a contract for Indian ' River County is authorized to make an investigation of the Agency/ Individual regarding its experience and qualifications. The Agency/ Individual authorized the release of all relevant information concerning prior services furnished , contracts and background information of the Agency/ Individual . The Agency/Individual authorizes any individual or organization that is in possession of relevant factual contract and background information , to release such data to Indian River County in response of the County' s request . When an individual employee of the Agency signs Authorization for Release of Information , such individual authorizes the County to obtain relevant background information concerning such employee' s criminal record , if any, and such other information that may be relevant to employee' s good character and work experience . Authorization is given here by the Agency/ Individual and such employees who execute this authorization with the understanding and limitation that Indian River County will utilize the information obtained for the purposes set forth herein and that such information shall not be disclosed to third parties except as provided by law. Name Agency/Individual 'TIX Cent' �N mo 'ft ! SeivQViAl /1WA & . LkM # Print name Name Employee Providing authorization S a( CA L - • Su5 Print napW Signature ( in blue ink) Date X1 SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIVER COUNTY CODE , ON DISCLOSURE OF RELATIONSHIPS THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS . 1 . This sworn statement is submitted with RFP No . 4046 for 2 . This sworn statemen is submitted by : �o � a na � � �h a ✓1 tN� � I-��u.Q.� Gh � T� ( Name of entity submitting Statement ) whose business address is : _ 1 o00 3Com .5triefi , VefV &a 5-2q& 0 and ( if applicable ) its Federal Employer Ide��jjtification Number ( FEIN ) ( If the entity has no FEIN , include the Social Security Number of the individual signing this sworn statement tjliq ) 3 . My name is J— ( Please print name of individual signing ) and my relationship to the entity named above is 4 . 1 understand that an " affiliate" as defined in Section 105 . 08 , Indian River County Code , means : The term " affiliate" includes those officers , directors , executives , partners , shareholders , employees , members , and agents who are active in the management of the entity . XII 5 . 1 understand that the relationship with a County Commissioner or County employee that must be disclosed as follows : Father, mother , son , daughter, brother, sister, uncle , aunt , first cousin , nephew, niece , husband , wife , father-in -law, mother-in-law, daughter- in-law, son-in-law, brother-in-law, sister-in- law, stepfather, stepmother, stepson , stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent , or grandchild . 6 . Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement . [ Please indicate which statement applies . ] Neither the entity submitting this sworn statement , nor any officers , directors , executives , partners , shareholders , employees , members , or agents who are active in management of the entity, have any relationships as defined in section 105 . 08, Indian River County Code , with any County Commissioner or County employee . The entity submitting this sworn statement , or one or more of the officers , directors , executives , partners , shareholders , employees , members , or agents , who are active in management of the entity have the following relationships with a County Commissioner or County employee : Name of Affiliate Name of County Commissioner Relationship or entity or employee XIII ZO si ure ) Oq 7:3 ( date ) STATE OF COUNTY OF �cQrar� The foregoing instrument was acknowledged before me this 7 day of 20 03 , by a o me or who has produced as identification . NOTARY SIGN : PRINT : State of Florida at Large My Commission Expires :- ( Seal ) USAUC17RA Notary Public - State of Hcddo My commission B pines Apr 12, 2004 Commission # CC927373 XIV SUPPORTING DOCUMENTS CHECKLIST RFP 5054 Cover Page Application List of current officers and directors Latest Financial Audit Report & Management Letter that conforms with the AICPA Audit Guide Most recent IRS Form 990, including all schedules Most recent Internal Financial Statement (i . e . : Balance Sheet and Operating Budget Staff Organizational Chart 00 Most Recent Annual Report (if available) 501 (C)(3 ) IRS Exemption Letter Articles of Incorporation Agency ' s Bylaws Y Agency ' s written policy regarding Affirmative Action Proof of Goals and Outcomes Workshop Attendance XV Out Page 1 of 1 To : <mmasterson@ircgov . com> Subject : Re : GOALS WORKSHOP May 19 14 MANDATORY Cc : Dear Marion, I HAVE NOT ATTENDED A GOALS WORKSHOP AND WILL BE ATTENDING. THERE WILL BE 1 PERSON ATTENDING FOR Camp Manatee (cry The Center for Emotional & Behavioral health (agency) ON MAY 19TH. Thanks very much ! Michelle Printed for Michelle Bollinger <michelle@irmh . com> 05/27/2003 The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC ORGANIZATION : The Center for Emotional and Behavioral HealthOURMH PROGRAM : Cama Manatee Therapeutic Summer Camp TABLE OF CONTENTS Please ' :i" ' the parts of the grant application to indicate they are included. Also, please put the page number where the infot7nation can be located. X Section of the Proposal Pa e # X TABLE OF CONTENTS (Check list) 1 -2 X COVER PAGE (with signatures) , . . . . . . . . . . . . . . * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 A. ORGANIZATION CAPABILITY (one page maximum) X 1 . Mission and Vision of organization . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 X 2 . Summary of expertise, accomplishments, and population served . . . . . . . . 4 Be PROGRAM NEED STATEMENT (one page maximum) X 1 . Program Need Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 X 2 . Programs that address need and gaps in service . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . 5 C. PROGRAM DESCRIPTION (two pages maximum) _X 1 . Funding priority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . 6 X 2 . Description of program activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . I . . . . . . . . . . 0 . 6 X 3 . Evidence that program strategy will work . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . I . . . . . . . . . . 6 X4 . Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6- 7 X 5 . Awareness of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 X 6 . Accessibility of program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . 7 X D . MEASURABLE OUTCOMES (two pages maximum) . . . . . . . . . . . . . . . . . . . . . . . . . 8 -9 X E. COLLABORATION (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 F. PROGRAM EVALUATION (two pages maximum) X 1 . Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 X2 . Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 T X3 . Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 X G. TIMETABLE (one page maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . 13 He UNDUPLICATED CLIENT COUNT X 1 . Projections by Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . I . , . . . . 14 X 2 . Projections by Age Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . 14 1 1r The Center for Emotional and Behavioral Health - Camp Manatee Therapeutic Summer Camp — IRC- CSAC I. BUDGET FORMS X 1 . Budget Narrative Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 - 18 X 2 . Total Agency Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 X 3 . Total Program Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . 20 X 4 . Funder Specific Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . 21 X 5 . Explanation for Variances — Total Program Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 X 6 . Explanation for Variances — Funder Specific Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 X J. FUNDER SPECIFIC/ADDITIONAL SHEETS X K APPENDIX 2