PCIUI ~e t Je n I i or ItQs (subtract line 6b from line 6a) 6c L7

Transcription

1 FMB No o~n Return of Organization Exempt From Income Tax Form J~'V Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except lack loop 2003 enefit trust or private foundation) Department of the Treasury Open t0 Pulic Internal Revenue Service " The organization may have to use a copy of this return to satisfy state reporting requirements. Inspection A For the 2003 calendar year, or tax year eginning OCT 1, 2003 and ending SEP 30, 2004 B Check if please C Name of organization D Employer identification numer applicale useirs ETH ISRAEL DEACONESS MEDICAL CENTER Address lael or DCnarlee PrmtorBSTETRICS AND GYNECOLOGY FOUNDATION INC = Name charig typ se Numer and street (or P.O. ox if mad is not delivered to street address) Room/swte E Telephone numer Initial return Specific BROOKL I NE AVENUE S Final Instruc- =relurn lions City or town, state or country, and ZIP + 4 F nccoununo memos = Cash Ejfl Accrual ~rame~ded =] (s BOSTON, MA spend ~9 " " Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitale trusts H and I are not applicale to section 527 organizations. must attach a completed Schedule A (Form 990 or 990-EZ~. H(a) Is this a group return for affiliates? 0 Yes M No G Wesite : N A H() If 'Yes,' enter numer of affdiatest J Organization type (cneckonly one) l [1] 501(c) ( 3 )1 (insert no) (a)(1) or H(c) Are all affiliates included N/A ~ Yea D No (If'No; attach a list.) K Check here 10 if the organization's gross receipts are normally not more than $25,000. The H(d) Is this a separate return filed y an ororganization need not file a return with the IRS ; ut if the organization received a Form 990 Package anization covered a grou p rulin? 0 Yes EjQ No in the mail, it should file a return without financial data. Some states require a complete return. I Group Exem ption Numer M Check 10 if the organization is not required to attach L Gross receipts : Add lines 6, 8, 9, and 10 to line , Sch. B (Form 990, 990-EZ, or 990-PF). Part I Revenue, Expenses, and Changes in Net Assets or Fund Balances 1 Contriutions, gifts, grants, and similar amounts received: a Direct pulic support 1a 185, 714. Indirect pulic support 1 c Government contriutions (grants) 1c d Total (add lines 1a through 1c) (cash $ 185, 714. noncash$ Id 185, Program service revenue including government fees and contracts (from Part VII, line 93) 2 3 Memership dues and assessments 3 4 Int mporary cash investments 4 1, r-1 t1rvi&filis~derest fr securities 5 32,437. I (D _ Less: reotal-e I,,,s t ose OrD Q t@s I 5 I PCIUI ~e t Je n I i or ItQs (sutract line 6 from line 6a) 6c L7 Z escrie Po. 7 1 t f assets other A Securities B Other d than inventory 106, a Less: cost or other asis and sales expenses S c Gain or (loss) (attach schedule) 106, 904. Sc d Net gain or (loss) (comine line Sc, columns (A) and (B)) STMT 1 Sd 106, Special events and activities (attach schedule). If any amount is from gaming, check here 1 a Gross revenue (not including $ of contriutions reported on line 1a) 9a Less: direct expenses other than fundraising expenses 9 c Net income or (loss) from special events (sutract line 9 from line 9a) 9c 10 a Gross sales of inventory, less returns and allowances 10a Less: cost of goods sold c Gross profit or (loss) from sales of inventory (attach schedule) (sutract line 10 from line 10a) 10c 11 Other revenue (from Part VII, line 103) 11 4, Total revenue ( add lines 1d c 7 8d 9c 10c and , Program services (from line 44, column (B)) , 907. y 14 Management and general (from line 44, column (C)) 14 71, 403. ~ c a 15 Fundraising (from line 44, column (D)) 15 ~ w 16 Payments to affiliates (attach schedule) Total ex p enses add lines 16 and 44 column A , 310. N 18 Excess or (deficit) for the year (sutract line 17 from line 12) 18 <1, > t y 19 Net assets or fund alances at eginning of year (from line 73, column (A)) 19 4, 177, ZQ 20 Other changes in net assets or fund alances (attach explanation) SEE STATEMENT , 817. ~s 21 Net assets or fund alances at end of year comine lines 18, 19, and , ~ ~f,2-~~-oa LHA For Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2003) 1 ~~' BETH ISRAEL DEACONESS MEDIC _1 10

2 BETH ISRAEL DEACONESS MEDICAL CENTER OBSTETRICS AND GYNECOLOGY FOUNDATION INC Part II' Statement o All organizations must complete column (A). Columns (B), (C), and (D) are required for section 501(c)(3) Page 2 Functional Expenses and (4) organizations and section 4947(a)(1) nonexempt charitale trusts ut optional for others. Do not include amounts reported on line (A) Total (B) Program (C) Management (D) Fundraising lo or 16 of Part I services and eneral 22 Grants and allocations (attach schedule) cash $ noncash $ LL 23 Specific assistance to individuals (attach schedule) Benefits paid to or for memers (attach schedule) Compensation of officers, directors, etc Other salaries and wages Pension plan contriutions Other employee enefits Payroll taxes Professional fundraising fees Accounting fees Legal fees 32 12, Supplies Telephone 34 1, Postage and shipping Occupancy Equipment rental and maintenance Printing and pulications Travel 39 4, Conferences, conventions, and meetings 40 4, Interest Depreciation, depletion, etc. (attach schedule) Other expenses not covered aove (itemize) : a c 43a 43 43c d 43d 8 S i5t'i d L /.3 :)U 7. L 7 L 0.)o. L U 00 /. 44 Oanlza~ons iomppeuno ~olum s ( 9)~(Br niry (hese~a~lals to lines , , ,403.1 Joint Costs. Check 1 0 if you are following SOP Are any point costs from a comined educational campaign and fundraising solicitation reported in (B) Program services? " ~ Yea ~ No If 'Yes,' enter (i) the aggregate amount of these point costs $ ; (ii) the amount allocated to Program services $ ; iii the amount allocated to Maria ement and eneral $ ' and iv the amount allocated to Fundraisin Part III Statement of Program Service Accomplishments What is the organization's primary exempt purpose? " SEE STATEMENT 4 Program Service Expenses All organizations must descrie their exempt purpose achievements in a clear and concise manner State the numer of clients served, pulications issued, etc Discuss (Required for 501(cX3) and achievements that are not measurale (Section 501 cx3 ) and (4 ) organizations and 4847 ( a X 1 ) nonexempt charitale trusts must also enter the amount of F ants and (4) orgs, and 4947(aX1) allocations to others ) trusts, ut optional for others a SEE STATEMENT 5 c d e Other program services (attach schedule) (Grants and allocations $ f Total of Program Service Expenses (should equal line 44, column (B), Program services) " 261, Z30~ 103 Form 990 (2003) BETH ISRAEL DEACONESS MEDIC _1

3 BETH ISRAEL DEACONESS MEDICAL CENTER Form 990 (2003) OBSTETRICS AND GYNECOLOGY FOiTNDATION, INC Page 3 Part IV Balance Sheets Note : Where required, attached schedules and amounts within the description column (A) (B) should e for end-of-year amounts only. Beginning of year End of year 45 Cash - non-interest-earing Savings and temporary cash investments 197, , a Accounts receivale 47a 23, 654. Less : allowance for doutful accounts 47 43, c 23, a Pledges receivale 48a Less : allowance for doutful accounts 48 48c 49 Grants receivale Receivales from officers, directors, trustees, and key employees 50 N d 51 a Other notes and loans receivale 51a N Less : allowance for doutful accounts 51 51c 52 Inventories for sale or use Prepaid expenses and deferred charges Investments - securities STMT 6. 0 Cost ~ FMV 3, 598, , 815, a Investments - land, uildings, and equipment, asis 55a Less : accumulated depreciation 55 55c 56 investments - other SEE STATEMENT 7 428, s 367, a Land, uildings, and equipment : asis 57a Less : accumulated depreciation 57 57c 58 Other assets (descrie " ) Total assets add lines 45 throu g h 58 must e q ual line , , 552, Accounts payale and accrued expenses 35, , Grants payale Deferred revenue 62 N ' 63 Loans from officers, directors, trustees, and key employees 63 a 64 a Tax-exempt ond liailities 64a m Mortgages and other notes payale Other liailities (descrie No- DUE TO PARTNERSHIP 54, , Total liailities (add lines 60 throunh 65 ) 90, , 669. Organizations that follow SFAS 117, check here " I-XI and complete lines 67 through 69 and lines 73 and 74. N 67 Unrestricted 4, 177, , 421, Temporarily restricted _ 68 m 69 Permanently restricted 69 Organizations that do not follow SFAS 117, check here " E:1 and complete lines 70 through 74. y 70 Capital stock, trust principal, or current funds 70." y 71 Paid-in or capital surplus, or land, uilding, and equipment fund 71 a 72 Retained earnings, endowment, accumulated income, or other funds 72 Z 73 Total net assets or fund alances (add lines 67 through 69 or lines 70 through 72 ; column (A) must equal line 19 ; column (B) must equal line 21) 4, 177, , 421, Total liailities and net assets / fund alances (add lines 66 and 73) , 267, 629. ~ 74 4,5 52,686. Form 990 is availale for pulic inspection and, for some people, serves as the primary or sole source of information aout a particular organization. How the pulic perceives an organization in such cases may e determined y the information presented on its return. Therefore, please make sure the return is complete and accurate and fully descries, in Part III, the organization's programs and accomplishments BETH ISRAEL DEACONESS MEDIC

4 Form rt IV'A ~ a BETH ISRAEL DEACONESS MEDICAL CENTER )GY FOUNDATION INC Pa g e 4 art IV-B Reconciliation of Expenses per Audited Financial Statements with Expenses per Return a Total expenses and losses per audited financial statements 1 Reconciliation of Revenue per Audited Financial Statements with Revenue per Total revenue, gains, and other support per audited financial statements 00. Amounts included on line a ut not on line 12, Form 990 : (1) Net unrealized gains on investments $ (2) Donated services and use of facilities $ (3) Recoveries of prior year grants $ (4) Other (specify) : STMT 8 $ 261,817. Add amounts on lines (1) through (4) 1 c Line a minus line No. d Amounts included on line 12, Form 990 ut not on line a: (1) Investment expenses not included on line 6, Form 990 $ (2) Other (specify): Amounts included on line a ut not on line 17, Form 990 : (1) Donated services and use of facilities $ (2) Prior year adjustments reported on line 20, Form 990 $ (3) Losses reported on line 20, Form 990 $ (4) Other (specify): c d PENALTY $ 16,000. Add amounts on lines (1) through (4) 1 Line a minus line Amounts included on line 17, Form 990 ut not on line a : (1) Investment expenses not included on line 6, Form 990 $ (2) Other (specify) : Add amounts on lines (1) and (2) (A) Name and address " d e Total revenue per line 12, Form 990 line c plus line d e 3 3 Part V List of Officers, Directors, Trustees, a Add amounts on lines (1) and (2) 1 e Total expenses per line 17, Form 990 (line c plus line d) 00, mployees (List each one even if not compensated.) (B) Title and average hours (C ) Compensatio n (D~Contnutions to e ployee enefit per week devod t e to (If not p aid, enter plans & deferred and SEE STATEMENT 9 75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your organization and all related organizations, of which more than $10,000 was provided y the related organizations? If "Yes ; attach schedule. 1 0 Yes [1] No Form 990 (2003)

5 Form a 79 ` Did the organization engage in any activity not previously reported to the IRS? If 'Yes,' attach a detailed description of each activity Were any changes made in the organizing or governing documents ut not reported to the IRS? If "Yes ; attach a conformed copy of the changes. Did the organization have unrelated usiness gross income of $1,000 or more during the year covered y this return? If 'Yes,' attach a statement against amounts due or received from them.) At any time during the year, did the organization own a 50% or greater interest in a taxale corporation or partnership, or an entity disregarded as separate from the organization under Regulations sections and If 'Yes,' complete Part IX 89 a 501(c)(3) organizations. Enter: Amount of tax imposed on the organization during the year under:, Other Information BETH ISRAEL DEACONESS MEDICAL CENTER If 'Yes,' has it filed a tax return on Form 990-T for this year Was there a liquidation, dissolution, termination, or sustantial contraction during the year? 80 a Is the organization related (other than y association with a statewide or nationwide organization) through common memership, governing odies, trustees, officers, etc., to any other exempt or nonexempt organization? If'Yes ; enter the name of the organization " BETH I SRAEL HOSPITAL ASSOCIATION and check whether it is E_X1 exempt or D nonexempt. 81 a Enter direct or indirect political expenditures. See line 81 instructions ~ 81a ~ 0 Did the organization file Form 1120-POL for this year 82 a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge or at sustantially less than fair rental value? If 'Yes,' you may indicate the value of these items here. Do not include this amount as revenue in Part I or as an section ; section ; section (c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess enefit transaction during the year or did it ecome aware of an excess enefit transaction from a prior year?,z-,7-os Form 990 (2003) BETH ISRAEL DEACONESS MEDIC _1 N/A expense in Part II. (See instructions m Part III.) 1 82 ~ N/A 83 a Did the organization comply with the pulic inspection requirements for returns and exemption applications? Did the organization comply with the disclosure requirements relating to quid pro quo contriutions? 84 a Did the organization solicit any contriutions or gifts that were not tax deductile? If 'Yes,' did the organization include with every solicitation an express statement that such contriutions or gifts were not tax deductile? _ N/A (c)(4), (5), or (6) organizations a Were sustantially all dues nondeductile y memers? N/A Did the organization make only in-house loying expenditures of $2,000 or less? N/A If 'Yes' was answered to either 85a or 85, do not complete 85c through 85h elow unless the organization received a waiver for proxy tax owed for the prior year. c Dues, assessments, and similar amounts from memers ~ 85c ~ N/A d Section 162(e) loying and political expenditures 85d N/A e Aggregate nondeductile amount of section 6033(e)(1)(A) dues notices 85e N/ A f Taxale amount of loying and political expenditures (line 85d less 85e) 85f N/ A g Does the organization elect to pay the section 6033(e) tax on the amount on line 85Y? N/A h If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount on line 85f to its reasonale estimate of dues allocale to nondeductile loying and political expenditures for the following tax year? N/A (c)(7) organizations. Enter: a Initiation fees and capital contriutions included on line 12 86a N/ A Gross receipts, included on line 12, for pulic use of clu facilities 86 N/A (c)(12) organizations Enter: a Gross income from memers or shareholders Gross income from other sources. (Do not net amounts due or paid to other sources c If 'Yes,' attach a statement explaining each transaction I 89 I I X Enter: Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912, 4955, and d Enter: Amount of tax on line 89c, aove, reimursed y the organization a List the states with which a copy of this return is filed " MASSACHUSETTS Numer of employees employed in the pay period that includes March 12, The ooks are in care of " GETCHEN OSTERHOUT Telephone no. " SEE PAGE 1 Located at " SEE PAGE 1 ZIP +4 " SEE PAGE 1 92 Section 4947(a)(1) nonexempt charitale trusts filing Form 990 in lieu o/ Form Check here " D and enter the amount of lax-exempt interest received or accrued during the tax near " 1 92 ~ N/A Page 5 X

6 BETH ISRAEL DEACONESS MEDICAL CENTER Form 990 (2003) OBSTETRICS Part VII Analysis of Income-Producing Activities (See page 33 of the instructions.) Note : Enter gross amounts unless otherwise Unrelated usiness income Excluded y section sit, 513, or 514 indicated. (B) P (p) Business Exclu Amount 93 Program service revenue: code S,~p Amount a c d e f Medicare/Medicaid payments p Fees and contracts from government agencies 94 Memership dues and assessments 95 Interest on savings and temporary cash investments 96 Dividends and interest from securities 97 Net rental income or (loss) from real estate : a det-financed property not det-financed property 98 Net rental income or (loss) from personal property 99 Other investment income 100 Gain or (loss) from sales of assets other than inventory 101 Net income or (loss) from special events 102 Gross profit or (loss) from sales of inventory 103 Other revenue: a.other INCOME c d e 104 Sutotal (add columns (B), (D), and (E)) (E) Related or exempt function income , Total (add line 104, columns (B), (D), and (E)) Note : Line 105 plus line 1d, Part l, should equal the amount on line 12, Part l. Part VIII Relationship of Activities to the Accomplishment of Exempt Purposes (See page 34 of the instructions.) Line No. Explain how each activity for which income is reported in column (E) of Part VII contriuted importantly to the accomplishment of the organization's exempt purposes (other than y providing funds for such purposes). 6 Part IX I Informati A Name, address, and~ein of e Susidiaries and Disregarded Entities (See page 34 of the instructions.) C D of Nature of activities Total income End Part X I Information Regarding Transfers Associated v (a) Did the organization, during the year, receive any funds, directly or indirectly, ti () Did the organization, during the year, pay premiums, directly or indirectly, on a Note : If Yes" to file Form 8870 and Form 4720 see instructions). Under p allies of penury, l declare that I have examined this return, including accoml Please correct d complete Dachan of preparer (other than okcer) is ased on all inforn Sign, lam 4 ~~ I ~, 1 Here Signature of officer---;, /1 Date Preparer's Paid signature & /O Preparer's F,~Sname (o, R. -. GOL - & COMPANY, P. Use Only yours if self-employed),,1601 TRAP ELO ROAD address, and ZIP + 4 WALTHAM. MA

7 SCHEDULE A Organization Exempt Under Section 501(c)(3) (Form 990 or 990-EZ) (Except Private Foundation) and Section 501(e), 501(f), 501(k), 501(n), or Section 4947(a)(1) Nonexempt Charitale Trust Supplementary Information-(See separate instructions.) 2003 Department ollhetreasury Internal Revenue Service jo. MUST e completed y the aove organizations and attached to their Form 990 or 990-E2 Name of the organization BETH ISRAEL DEACONESS MEDICAL CENTER Employer identification numer NONE 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.") OMB No (a) Name and address of each employee paid () Title and average hours ode ploy e e a~~ per week devoted to (c) Compensation P,aS 8 deferred acc01 more than $50,000 DOSIfIOfI compensation 2l Total numer of other employees paid Part II Compensation of the Five Highest Paid Independent Contractors for Professional Services (See uaae 2 of the instructions. List each one (whether individuals or firms). If there are none, enter *None.') (a) Name and address of each independent contractor paid more than $50,000 () Type of service I (c) Compensation NONE Total numer of others receiving over $50,000 for professional services " /12-OS-03 LHA For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Form 990-EZ. Schedule A (Form 990 or 990-EZ) BETH ISRAEL DEACONESS MEDIC _1

8 BETH ISRAEL DEACONESS MEDICAL CENTER Schedule A (Form 990 or 990-EZ) 2003 Palt III Statements Aout Activities (See page 2 of the instructions.) No During the year, has the organization attempted to influence national, state, or local legislation, including any attempt to influence pulic opinion on a legislative matter or referendums If "Yes; enter the total expenses paid or incurred in connection with the loying activities " $ $ (Must equal amounts on line 38, Part VI-A, or line i of Part VI-B.) Organizations that made an election under section 501(h) y fling Form 5768 must complete Part VI-A. Other organizations checking "Yes; must complete Part VI-B AND attach a statement giving a detailed description of the loying activities. During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any sustantial contriutors, trustees, directors, officers, creators, key employees, or memers of their families, or with any taxale organization with which any such person is affiliated as an officer, director, trustee, majority owner, or principal eneficiary? (If the answer to any question is "Yes," attach a detailed statement explaining the transactions.) a Sale, exchange, or leasing of property? X Lending of money or other extension of credit? c Furnishing of goods, services, or facdities9 d Payment of compensation (or payment or reimursement of expenses if more than $1,000) e Transfer of any part of its income or assets? 3 a Do you make grants for scholarships, fellowships, student loans, etc.? (If 'Yes," attach an explanation of how you determine that recipients qualify to receive payments.) Do you have a section 403() annuity plan for your employees 4 Did you maintain any separate account for participating donors where donors have the right to provide advice Reason The organization is not a private foundation ecause it is : (Please check only ONE applicale ox.) 5 0 A church, convenuon of churches, or association of churches. Section 170()(1)(A)(i). 6 0 A school. Section 170()(1)(A)(u). (Also complete Part V.) 7 ~ A hospital or a cooperative hospital service organization. Section 170()(1)(A)(ui). 8 0 A Federal, state, or local government or governmental unit. Section 170()(1)(A)(v). 6 of the instructions.) 9 0 A medical research organization operated in conjunction with a hospital. Section 170()(1)(A)(ui). Enter the hospital's name, city, and state 10 D An organization operated for the enefit of a college or university owned or operated y a governmental unit. Section 170()(1)(A)(iv). (Also complete the Support Schedule in Part IV-A) 11a ~ An organization that normally receives a sustantial part of its support from a governmental unit or from the general pulic. Section 170()(1)(A)(vi). (Also complete the Support Schedule in Part IV-A.) 11 D A community trust Section 170()(1)(A)(vi). (Also complete the Support Schedule in Part IV-A) 12 DO An organization that normally receives: (1) more than 33 1/3% of its support from contriutions, memership fees, and gross receipts from activities related to its charitale, etc., functions - suject to certain exceptions, and (2) no more than 33 1/396 of its support from gross investment income and unrelated usiness taxale income (less section 511 tax) from usinesses acquired y the organization after June 30, See section 509(a)(2). (Also complete the Support Schedule in Part IV-A.) 13 D An organization that is not controlled y any disqualified persons (other than foundation managers) and supports organizations descried in: (1) lines 5 through 12 aove' 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 aout the supported organizations. (See page 5 of th e instructions.) (a) Name(s) of supported organization(s) () Line numer from aove 14 n An and operated to test for Qulic safety. Section 509(a)(4). (See page 6 of the Schedule A (Form 990 or 990-EZ) OS-03 O BETH ISRAEL DEACONESS MEDIC _1

9 . BETH ISRAEL DEACONESS MEDICAL CENTER Schedule A (Form 990 or 990-EZ) 2003 OBSTETRICS AND GYNECOLOGY FOUNDATION, INC Page 3 Part IV-A Support Schedule (Complete only if you checked a ox on line 10, 11, or 12) Use cash method of accounting. Note: You may use the worksheet m the instructions for converting from the accrual to the cash method of accounting. Calendar year (or fiscal year e innin in 1 a I Icl 2000 I Idl 1999 I lel Total 15 Gifts, grants, and contriutions received. (Do not include unusual rants. See line , Memership fees received 17 Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to the organization's 18 Gross income from interest, dividends, amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated usiness taxale income (less section 511 taxes) from usinesses acquired y the organization after June 30, Net income from unrelated usiness activities not included in line Tax revenues levied for the organization's enefit and either paid to it or expended on its ehalf 21 The value of services or facilities furnished to the organization y a governmental unit without charge. Do not include the value of services or facilities generally furnished to the pulic without charge pp Other income. Attach a schedule. Do not include gain or (loss) from sale of capital assets 23 Total of lines 15 through ,114. EE STATEMENT Line 23minus line l , 403, Enter 1% of line 23 1, , , , Organizations descried on lines 10 or 11 : a Enter 2% of amount in column (e), line a N/A Prepare a list for your records to show the name of and amount contriuted y each person (other than a governmental unit or pulicly supported organization) whose total gifts for 1999 through 2002 exceeded the amount shown in line 26a. Do not file this list with your return. Enter the total of all these excess amounts " 26 N/ A c Total support for section 509(a)(1) test Enter line 24, column (e) " 26c N/ A d Add : Amounts from column (e) for lines: g Pulic support percentage (line 27e (numerator) divided y line 27f (denominator)) % h Investment income percentage (line 18, column (e) (numerator) divided y line 27f (denominator)) , 27h I % 28 Unusual Grants : For an organization descried in line 10, 11, or 12 that received any unusual grants during 1999 through 2002, prepare a list for your records to show, for each year, the name of the contriutor, the date and amount of the grant, and a rief description of the nature of the grant. Do not file this list with your return. Do not include these grants in line OS-03 NONE Schedule A (Form 990 or 990-EZ) BETH ISRAEL DEACONESS MEDIC d N/ A e Pulic support (line 26c minus line 26d total) 1 26e N/A r ruuuc suodon percentage nine tae (numerator) amaea oy line zc laenominatorll I I 26f I N / A 27 Organizations descried on line 12 : a For amounts included in lines 15, 16, and 17 that were received from a 'disqualified person; prepare a list for your records to show the name of, and total amounts received in each year from, each disqualified person.' Do not file this list with your return. Enter the sum of such amounts far each year: (2002) _, 0. (2001) 0. (2000) 0. (1999) 0. For any amount included in line 17 that was received from each person (other than disqualified persons'), prepare a list for your records to show the name of, and amount received for each year, that was more than the larger of (1) the amount on line 25 for the year or (2) $5,000. (Include in the list organizations descried in lines 5 through 11, as well as individuals.) Do not file this list with your return. After computing the difference etween the amount received and the larger amount descried in (1) or (2), enter the sum of these differences (the excess amounts) for each year: (2002) 0. (2001) 0. (2000) 0. (1999) 0. c Add : Amounts from column (e) for lines : , , c 483, 953. d Add : Line 27a total 0. and line 27 total 0. " 27d 0. e Pulic support (line 27c total minus line 27d total) 1 27e 483, 953. f Total support for section 509(a)(2) test: Enter amount on line 23, column (e) " 21f 1, 404,

10 BETH ISRAEL DEACONESS MEDICAL CENTER Schedule A (Form 990 or 990-EZ) 2003 OBSTETRICS AND GYNECOLOGY FOUNDATION, INC Page 4 Part V ' Private School Questionnaire (Seepage 7 of the instructions.) N/A (To e completed ONLY y schools that checked the ox on line 6 in Part IV) 29 Does the organization have a racially nondiscriminatory policy toward students y statement in its charter, ylaws, other governing instrument, or in a resolution of its governing ody? 30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its rochures, catalogues, and other written communications with the pulic dealing with student admissions, programs, and scholarships? 31 Has the organization pulicized its racially nondiscriminatory policy through newspaper or roadcast 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? If 'Yes,' please descrie; if "No," please explain. (If you need more space, attach a separate statement.) No 32 Does the organization maintain the following : a Records indicating the racial composition of the student ody, faculty, and administrative staff Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory asis? c Copies of all catalogues, rochures, announcements, and other written communications to the pulic dealing with student admissions, programs, and scholarships d Copies of all material used y the organization or on its ehalf to solicit contriutions? If you answered 'No'to any of the aove, please explain. (If you need mare space, attach a separate statement) 33 Does the organization discriminate y race in any way with respect to: a Students' rights or privileges? Admissions policies? c Employment of faculty or administrative staff? d Scholarships or other financial assistance? e Educational policies f Use of facilities? g Athletic programs h Other extracurricular activities? If you answered 'Yes'to any of the aove, please explain. (If you need more space, attach a separate statement.) 34 a Does the organization receive any financial aid or assistance from a governmental agency Has the organization's right to such aid ever een revoked or suspended? If you answered 'Yes' to either 34a or, please explain using an attached statement 35 Does the organization certify that it has complied with the applicale requirements of sections 4.01 through 4.05 of Rev. Proc , C.B. 587, covennp racial nondiscrimination? If 'No,' attach an explanation Schedule A (Form 990 or 990-EZ) OS BETH ISRAEL DEACONESS MEDIC

11 BETH ISRAEL DEACONESS MEDICAL CENTER Schedule A (Form 990 or 990-EZ) 2003 OBSTETRICS AND GYNECOLOGY FOUNDATION, INC Pag e 5 Part VI-A Loying Expenditures y Electing Pulic Charities (See page 9 of the instructions.) N/A ` (To e completed ONLY y an eligile organization that filed Form 5768) 36 Total loying expenditures to influence pulic opinion (grassroots loying) 37 Total loying expenditures to influence a legislative ody (direct loying) 38 Total loying expenditures (add lines 36 and 37) 39 Other exempt purpose expenditures 40 Total exempt purpose expenditures (add lines 38 and 39) 41 Loying nontaxale amount. Enter the amount from the following tale If the amount on line 40 is - The loying nontaxale amount is - Ova $500,000 ut not over $1,000,000 Over $1,000,000 ut not over $1,500,000 nization elon g s to an affiliated g rou p. Limits on Loying Expenditures term "expenditures" means amounts paid or incurred.) Not over $500, of the amount on line 40 $100,000 plus 15% of the excess over $500,000 $175,000 plus 10% of the excess over $1,000,000 Over $1,500,000 ut not over $17,000,000 $225,000 plus 5% of the excess over $1,500,000 Over $17,000,000 $1,000, Grassroots nontaxale amount (enter 25% of line 41) 43 Sutract line 42 from line 36. Enter -0- if line 42 is more than line Sutract line 41 from line 38. Enter -0- if line 41 is mare than line 38 Caution : I/ there is an amount on ether line 43 or line 44, you must file Form 4720 Check " U if y ou checked "a" and 'limited i 41 (a) Affiliated group totals N/A () To e completed far ALL electing organizations 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 elow. See the instructions for lines 45 through 50 on page 11 of the instructions.) Loying Expenditures During 4-Year Averaging Period Calendar year (or (a) fiscal year eginning in), Loying nontaxale () (c) (d) (e) Total 46 Loying ceding amount 47 Total loying expenditures 48 Grassroots nontaxale amount 49 Grassroots ceding amount 50 Grassroots loying Part VI-B Loying Activity y Nonelecting Pulic Charities (For reporting only y organizations that did not complete Part VI-A) (See page 12 of the instructions.) During the year, did the organization attempt to influence national, state or local legislation, including any attempt to influence pulic opinion on a legislative matter or referendum, through the use of: a Volunteers Paid staff or management (Include compensation in expenses reported on lines c through h ) c Media advertisements d Mailings to memers, legislators, or the pulic e Pulications, or pulished or roadcast statements f Grants to other organizations for loying purposes g Direct contact with legislators, their staffs, government officials, or a legislative ody h Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means Yes No Amount i Total loying expenditures (Add lines c through h.) ~ ~ 0 If 'Yes'to any of the aove, also attach a statement giving a detailed description of the loying activities. iz oe'-oa Schedule A (Form 990 or 990-EZ) BETH ISRAEL DEACONESS MEDIC _1 11 N/ A

12 BETH ISRAEL DEACONESS MEDICAL CENTER Schedule A (Form 990 or 990-EZ) 2003 OBSTETRICS AND GYNECOLOGY FOUNDATION, INC Page 6 Part VII Information Regarding Transfers To and Transactions and Relationships With Noncharitale Exempt Organizations (See page 12 of the instructions.) 51 Did the reporting organization directly or indirectly engage in any of the following with any other organization descried in section (i) Cash 51a(I ) (ii) Other assets Other transactions : (i) Sales or exchanges of assets with a noncharitale exempt organization (i) X (ii) Purchases of assets from a noncharitale exempt organization (ii) $ (iii) Rental of facilities, equipment, or other assets (iii) X (iv) Reimursement arrangements (ly) X (v) Loans or loan guarantees (v) X (vi) Performance of services or memership or fundraising solicitations (A) X c Sharing of facilities, equipment, mailing lists, other assets, or paid employees C X d 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 noncharitale exempt organization of If the answer to any of the aove is "Yes," complete the following schedule. Column () should always show the fair market value of the goods, other assets, or services given y the reporting organization. If the organization received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received : (0 I (d) Line no. Amount involved Name of nonchantale exempt organization Description of transfers, transactions, and sharing arrangements a(ii) Yes No N/A X 52 a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations descried in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? 1 E ]Yes DO No BETH ISRAEL DEACONESS MEDIC _1

13 BETH ISRAEL DEACONESS MEDICAL CENTER OBS FORM 990 GAIN (LOSS) FROM PUBLICLY TRADED SECURITIES STATEMENT 1 DESCRIPTION SALE OF SECURITIES TO FORM 990, PART I, LINE 8 GROSS COST OR EXPENSE NET GAIN SALES PRICE OTHER BASIS OF SALE OR (LOSS) 106, , , ,904. FORM 990 OTHER CHANGES IN NET ASSETS OR FUND BALANCES STATEMENT 2 DESCRIPTION AMOUNT UNREALIZED GAIN ON INVESTMENTS 261,817. PENALTIES <16,000.> TOTAL TO FORM 990, PART I, LINE ,817. FORM 990 OTHER EXPENSES STATEMENT 3 DESCRIPTION EDUCATION INSURANCE RESEARCH EXPENSE RESIDENT EXPENSE BANK CHARGES DUES & SUBSCRIPTIONS PROFESSIONAL FEE - CONSULTING DONATIONS STAFF FUND TEAMS PROJECT ANNUAL REPORT MISCELLANEOUS TOTAL TO FM 990, LN 43 (A) (B) (c) PROGRAM MANAGEMENT TOTAL SERVICES AND GENERAL 4,184. 4, , , , ,599. 3,564. 3,564. 1,158. 1, , , , , , , ,251. 1, , , ,867. (D) FUNDRAISING STATEMENT S) 1, 2, BETH ISRAEL DEACONESS MEDIC _1

14 BETH ISRAEL DEACONESS MEDICAL CENTER OBS FORM 990 STATEMENT OF ORGANIZATION'S PRIMARY EXEMPT PURPOSE STATEMENT 4 PART III EXPLANATION TO PROMOTE AND EXPAND RESEARCH IN THE AREA OF OBSTETRICS/GYNECOLOGY. FORM 990 STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS STATEMENT 5 DESCRIPTION OF PROGRAM SERVICE ONE THE FOUNDATION PROMOTED AND EXPANDED RESEARCH AND EDUCATION IN THE DEPARTMENT OF OBSTETRICS/GYNECOLOGY AT BETH ISRAEL DEACONNESS MEDICAL CENTER AND ENHANCING THE QUALITY AND DIVERSITY OF THE FACULTY AT ALL RANKS. GRANTS EXPENSES TO FORM 990, PART III, LINE A 261,907. FORM 990 NON-GOVERNMENT SECURITIES STATEMENT 6 CORPORATE CORPORATE SECURITY DESCRIPTION STOCKS BONDS SECURITIES TO 990, LN 54 COL B OTHER PUBLICLY TOTAL TRADED OTHER NON-GOV'T SECURITIES SECURITIES SECURITIES 3,815,181. 3,815,181. 3,815,181. 3,815,181. FORM 990 OTHER INVESTMENTS STATEMENT 7 VALUATION DESCRIPTION METHOD AMOUNT INVESTMENT IN PARTNERSHIP COST 367,998. TOTAL TO FORM 990, PART IV, LINE 56, COLUMN B 367, STATEMENT S) 4, 5, 6, BETH ISRAEL DEACONESS MEDIC _1

15 BETH ISRAEL DEACONESS MEDICAL CENTER OBS FORM X90 OTHER REVENUE NOT INCLUDED ON FORM 990 STATEMENT 8 DESCRIPTION UNREALIZED GAIN ON INVESTMENTS TOTAL TO FORM 990, PART IV-A AMOUNT 261, ,817. FORM 990 PART V - LIST OF OFFICERS, DIRECTORS, STATEMENT 9 TRUSTEES AND KEY EMPLOYEES EMPLOYEE TITLE AND COMPEN- BEN PLAN EXPENSE NAME AND ADDRESS AVRG HRS/WK SATION CONTRIB ACCOUNT BENJAMIN SACHS, M.D. PRESIDENT 225 DUDLEY STREET BROOKLINE, MA JONATHAN NILOFF, M.D. TREASURER 54 HAMPSHIRE STREET W. NEWTON, MA HENRY KLAPHOLZ, M.D. CLERK 25 ROCKPORT ROAD WESTON, MA JAMES J. DILLON DIRECTOR 182 BUCKMINSTER ROAD BROOKLINE, MA RUTH FRETTS, M.D. DIRECTOR 1100 WEST ROXBURY PARK CHESTNUT HILL, MA GAIL R. LONG DIRECTOR 10 BENTON ROAD BELMONT, MA BARBARA HIRSHFIELD DIRECTOR 6 STALKER LANE FRAMINGHAM, MA RICHARD REINDOLLAR, M.D. DIRECTOR 975 BRUSH HILL ROAD MILTON, MA STATEMENT S) 8, BETH ISRAEL DEACONESS MEDIC

16 BETH ISRAEL DEACONESS MEDICAL CENTER OBS JODI ABBOTT, M.D. DIRECTOR 30 NEWBURY PARK NEEDHAM, MA JUAN ALVAREZ, PHD/M.D. DIRECTOR 1 DEVONSHIRE PLACE # BOSTON, MA CINDY KOBELIN, M.D. DIRECTOR 34 SPRINGS LANE NEEDHAM, MA HOPE RICCIOTTI, M.D. DIRECTOR 330 CLARK ROAD BROOKLINE, MA MARY POLLARD DIRECTOR 25 CRAFTSLAND ROAD CHESTNUT HILL, MA TOTALS INCLUDED ON FORM 990, PART V SCHEDULE A OTHER INCOME STATEMENT DESCRIPTION AMOUNT AMOUNT AMOUNT AMOUNT OTHER INCOME , , ,142. TOTAL TO SCHEDULE A, LINE , , , STATEMENT S) 9, BETH ISRAEL DEACONESS MEDIC _1

17 ~ Form 8868 Application for Extension of Time To File an (Decemer h00) Exempt Organization Return OMB No Department of the Treasury Internal Revenue Service 1 File a separate application for each return. " If you are fling for an Automatic 3-Month Extension, complete only Part I and check this ox " If you are fling for an Additional (not automatic) 3-Month Extension, complete only Part II (on page 2 of this form) Note: Do not complete Part II unless you have already een granted an automatic 3-month extension on a previously filed Form Part I Automatic 3-Month Extension of Time- only sumit original (no copies needed) Note : Form 990-T corporations requesting an automatic 6-month extension - check this ox and complete Part I only All other corporations Including Form 990-C filers) must use Form 7004 to request an extension of time to file income tax returns. Partnerships, REMICs and trusts must use Form to request an extension of time to file Form 1065, 1066, or Type or Name of Exempt Organization Employer identification numer print BETH ISRAEL DEACONESS MEDICAL CENTER OBSTETRICS AND GYNECOLOGY FOUNDATION INC File y me die dare r«numer, street, and room or suds no. If a P.O. ox, see instructions. filing your return See 330 BROOKLINE AVENUE NO. KS 310 instructions City, town or post office, state, and ZIP code. For a foreign address, see instructions. BOSTON MA Check type of return to e filed (file a separate application for each return). Form 990 D Form 990-T (corporation) ~ Form Forth 990-BL 0 Form 990-T (sec 401(a) or 408(a) trust) ~ Form 5227 Form 990-EZ ~ Form 990-T (trust other than aove) 0 Form 6069 Form 990-PF ~ Form 1041-A ~ Form 8870 " If the organization does not have an office or place of usiness m the United States, check this ox.. " If this is for a Group Return, enter the organization's four digit Group Exemption Numer (GEN). If this is for the whole group, check this ox 1 0. If it is for part of the group, check this ox 1 = and attach a list with the names and EINs of all memers the extension will cover. 1 I request an automatic 3-month (6-month, for 990-T corporation ) extension of time until MAY 16, 2005 to file the exempt organization return for the organization named aove. The extension is for the organization's return for: 10 calendar year or " EEtax year eginning OCT 1, 2003, and ending SEP 30, If this tax year is for less than 12 months, check reason : ' = Initial return 0 Final return 0 Change in accounting period 3a If this application is for Form 990-BL, 990~PF, 990-T, 4720, or 6069, enter the tentative tax, less any nonrefundale credits See instructions If this application is for Form 990-PF or 990-T, enter any refundale credits and estimated tax payments made. Include any prior year overpayment allowed as a credit c Balance Due. Sutract line 3 from line 3a. Include your payment with this form, or, if required, deposit with FfD coupon or, d required, y using EFTPS (Electronic Federal Tax Payment System). See instructions $ N/A Signature and Verification Under penalties pe decl t I e examined this form, i cluding accompanying schedules and statements, and to the est of my knowledge and elief, it is true, corr t, an plate, an t a are this form. Si nature / Title 1 CPA Date jlp.2, 1,3110,5 'CH F r Pape ork wr Reduction *t Notice, see instruction Form 8868 ( ) OS-01-03

18 Form 8888( ) Page 2 0 If you are fling for an Additional (not automatic) 3-Month Extension, complete only Part II and check this ox Note:.ny complete Part II ii you have already een granted an automatic 3-month extension on a previously filed Form If you are filing for an Automatic 3-Month Extension, complete only Part I on age 1). ~~?` ~ ~ Additional not automatic 3-Month Extension of Time - Must file Ori final and One Co Name of Exempt Organization Employer Identification numer Type or BETH ISRAEL DEACONESS MEDICAL CENTER ~'' print OBSTETRICS AND GYNECOLOGY FOUNDATION INC t~t-=. : File ythe s,' :.t. ;;.sa~f extended Numer, street, end room or suite no. If a P.O. ox, see Instructions. ~ For IRS use ony due aye r«filing ft 330 BROOKL INE AVENUE NO. KS 310 `' rsnrn. see City, town or post office, state, and ZIP code. For a foreign address, see instructions. Inatrudlons. OSTON MA `#"? 3 " ~i2.i~~i Check type of return to e flied (File a separate application for each return) : Forth 990 F-1 Form 990-Q ~ Form 990~T (sec. 401(a) or 408(a) trust) EJ Form 1041-A 0 Forth Form 8870 ~I Form 990-BL 0 Form 990~PF 0 Forth 990~T (trust other than aove) 0 Form Form 6069 STOP: Do not complete Part 11 If you were not already granted an automatic 3-month extension on a previously filed Form " K the organization does not have an office or place of usiness in the United States, check this ox...., ,.,.~ 0 " K this is for a (croup Return, enter the organization's four digit Group Exemption Numer (GEN). If this is for the whole group, check this ox 1 =. If it is for part of the group, check this ox 1 =1 and attach a list with the names and EINs of all memers the extension is for. 4 I request an additional 3-month extension of time until ~ AUGUST 15, For calendar year, or other tax year eginning OCT ~1:~2'00 3 and ending SSP 30, If this tax year is for less than 12 months, check reason: EJInitial return Final return ~ Change in accounting period 7 State in detail why you need the extension ADDITIONAL TIME IS NEEDED IN ORDER TO FILE A COMPLETE AND ACCURATE RETURN. 8a if this application is for Form 990-BL, 990~PF, 990~T, 4720, or 6069, enter the tentative tax, less any nonrefundale credits. See Instructions.. $ If this application is for Form 990-PF, 99aT, 4720, or 6069, enter any refundale credits and estimated tax payments made. Include any prior year overpayment allowed as a credit and any amount paid previously with Form 8868 $ c Balance Due. Sutract line 8 from line 8a. Include your payment with this forth, or, if required, deposit with FM coupon or, H required, y using EFIPS (Electronic Federal Tax Payment System). See instructions $ N/A Signature and Verification Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete, and that I am authorized to prepare this form. Signature Do, /Ly6.ca+,~ w. At- Aj-4- Title " CPA Date " s(lplos Notice to Applicant - To Be Completed y the IRS e have approved this application. Please attach this forth to the organization's return. A We have not approved this application. However, we have granted a 10-day grace period from the later of the date shown elow or the due date of the organization's return (including any prior extensions). This grace period is considered to e a valid extension of time for elections otherwise required to e made on a timely return. Please attach this form to the organization's return. We have not approved this application. After considering the reasons stated in item 7, we cannot grant yo~~,ion e to file. We are not granting the 10-day grace period. APPROVED 0 We cannot consider this application ecause it was filed after the due date of the return for which an extension yy~~ re~u tad. a ~,e~ ~~i~ 2005 BY SLiBMiSgI '. FIELD DIREC'TpR, PR Director Date ' %^JLjr-N 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 aove. Name Type Numer and street pnclude suite, room, or apt. no.) Or a P.O. ox numer or print 1601 TRAPELO ROAD City or town, province or state, and country Including postal or ZIP code) WALTHAM MA Form SB68 ( ) BETH ISRAEL DEACONESS MEDIC