K&L GATES
K&L Gates up
70 West Madison Street
Suite 3100
Chicago, IL 60602-4207
January 17, 2013
Mary M. Donners D 312.807.4405 F 312.345.9996
Via Certified Mail
Susana A. Mendoza, City Clerk Office of the City Clerk City Hall - Room 107A 121 North LaSalle Street Chicago, Illinois 60602-1295
Re: Ann & Robert H. Lurie Children's Hospital of Chicago (f/k/a The Children's Memorial Hospital) Property Tax Exemption Application (PTAX-300-H) 225 East Chicago Avenue, Chicago, Illinois
Dear Clerk Mendoza:
Our firm represents Ann & Robert H. Lurie Children's Hospital of Chicago in the matter of the property tax exemption application for its new hospital located at 225 E. Chicago Avenue, Chicago, Illinois. We intend to file the application with the Cook County Board of Review today. In accordance with Section 16-130 of the Illinois Property Tax Code, 35 ILCS 200/16-130, you are hereby given notice of the application, a true and correct copy of which is included herewith.
Should you have any questions or comments concerning this application, please do not hesitate to call me.
Very truly yours,
cc:
Nancy Borders, Esq
C1-9320968 v2
Illinois Department of Revenue
DTA Y-300-H Application for Hospital Property Tax Exemption
^ County Board of Review Statement of Facts
Complaint no.: volume no.: IDOR docket number:
County use only IDOR use only
Step 1: Identify the property
- Ann f, Robert H. Lurie Children's Hospital 4 Dimensions or acreage of this property 1.7147 acres
- Name ot hospital or affiliate applying for exemption of Chicago ^ Attach a p,ol plan of each oud/ng'5 location on the property
2 225 E. Chicago Avenue n , , See
Street address of hospital or affiliate 5 °&e of ownership w. *J±_±J±H J. Addendum (1)
An, 1 | W Attach a copy of proof of ownership (deed, contract for deed,
Chicago : IL QUO 11 title Insurance policy, condemnation order, and proof ot
City ZIP payment, etc.;
- Cook 6 Check the relevant hospital entity:
County In which hospital or affiliate is located _X_ hospital owner - write the license number: 0005843
hospital affiliate - explain relationship:
hospital system - explain relationship:
Step 2: Provide information about exemptions or applications
- For what year Is this exemption being sought? 2012
- If the applicant has an Illinois sales tax exemption number, write it here. EjL_-?_ _? 9
Step 3: Provide the following about the services and activities for the relevant hospital entity
- Check what the value of services and activities below reflect: hospital year average of 3 fiscal years ending with hospital year
IP What is your fiscal year? 9/1/2011 to 8/31/2012
- Write the amount of charity care provided. Attach most recently filed Form AG-CBP-I. See Addendum (2) n $ 1,043,036
- Write the amount of unreimbursed costs for health services provided to low-income and underserved
individuals. Attach a list of identifying activities or services provided. See Addendum (3) 12 $ 387.215
- If the hospital gives a subsidy to a state or local government, write the total amount. Attach a list Identifying
each entity and the amount. See Addendum (4) 13 $ 3,740,129
- If the hospital gives support for Illinois health care programs to low-income individuals, write the amount. 14 $73,678,004 Attach the most recently filed federal Form 990, Schedule H. See Addendum (5)
- If the hospital provides a dual-eligible subsidy by treating Medlcare/Medicaid patients, multiply
- the hospital's ratio of dual-eligible patients to the total number of Medicare patients by
- the total of unreimbursed costs of Medicare.
/ X $ =
1) ratio 2) unreimbursed Medicare 15
16 If the hospital provided relief for the government as it relates to hearth care services for low income individuals,
write the total low-income portion of unreimbursed costs. Attach Schedule A and a copy of the CMS 2552-10,
WorksheetC, Part 1. See Addendum (6) -16 $15,924,669
17 Other. See instructions and identify. 17 1
' Step 4: Calculate and determine the exemption
- Add Lines 11 through 17 and enter the total amount of services or activities provided. 18 $94,773,053
- Has the property been assessed?
Yes. Write the amount of the actual property tax from your property tax bill or the estimated property tax from Schedule E, Line 18, whichever is less. Attach the tax bill. See Addendum (7)
No. Write the estimated property tax amount from Schedule E, Line 1B. Attach Schedule E. 19 $19,106.238*
See Addendum (7)
If Line 19 is equal to or less than Line 18, you qualify for this exemption. If Line 19 is greater than Line 18, you do not qualify for this exemption.
- Is any part of this property leased? 20 SI Yes d No
- If "yes", attach a copy of any contracts or leases.
21 If the assessed or estimated assessed value is $100,000 or more, has the municipality, school district, community college district, and fire
protection district in which the property Is located been notified that this application has been filed? _ _.
Attach a copy of the notices and postal return receipts. See Addendum (8) 21 BLI Yes II No
*Total of Lines 18 from Schedule E - 3 pages
PTAX-300-H front (R-08/12)
State ZIP
Step 5: Identify the person to contact regarding this application
Owner's name (if the applicant is not the owner)
22 Mary M. Donners K&L Gates LLP 23
Name of applicant's representative
70 W. Madison Street. #1100
Mailing address
60602
_IL_
State ZIP
City ( 312
City (
)
Mailing address Chlrngn
Phone number
807 _ 4405
Phone number
) SS.
Step 6: Signature and notarization
State of Illinois
County of Cook
Position
it all of tHe Information is true and correct to the best of my knowledge and belief.
Rant's signature
Subscribed and sworn to before me this
Treasurer & CEO
Paula M. Noble
_, being duly sworn upon oath, say that I have read
Official Seal
iijbed and sworn to before me this<^2_ day of lZ 2Q / Jt Notary PuWic State of l*noto
Notary
County official use only. Do not write below thl» line.
Step 7: County board of review statement of facts
1 Current assessment $
For assessment year 2_
□ Yes □ No
- Is this exemption application for a leasehold interest assessed to the applicant?
- If "Yes", write the Illinois Department of Revenue docket number for the exempt fee interest to the owner,
if known.
- State all of the facts considered by the county board of review in recommending approval or denial of this exemption application.
4 County board of review recommendation
Full year exemption
Partial year exemption from / / to / /
Partial exemption for the following described portion of the property:
Deny exemption
5 Date of board's action / /
Step 8: County board of review certification
I certify this to be a correct statement of all facts arising in connection with proceedings on this exemption application.
Signature of clerk of county board of review
Mail to: OFFICE OF LOCAL GOVERNMENT SERVICES MC 3-520 ILLINOIS DEPARTMENT OF REVENUE 101 WEST JEFFERSON STREET SPRINGFIELD IL 62702
This application must be completed in its entirety and all supporting documentation must be attached. All incomplete applications will be returned.
PTAX-300-H back (R-08/12)
Schedule A
Attach to Form PTAX-300-H
Calculation of Low-Income Portion of Unreimbursed Costs
Step 1: Write the total of unreimbursed costs
- 13,504,855
- 18,349,770
- 31,854,625
- $-
- Emergency
- Trauma
- Bum
- Neonatal
5 Psychiatric
- Rehabilitation
- Medical education
- Research
- Other (describe)
- Other (describe)
- Total. Add Lines 1 through 10.
$_ $_ $_ $_ $_ $_ $_ $_ $_ $_
S 3,208.245
$ 557,203,441 $ 17,713.411
$
$
Step 2: Calculate the low-income ratio
12 Charity 13 14 15 16 17 18 19 20 21
Medicaid
Other moans-tested programs Disabled Medicare for people less than 65 years of age Dual-eligible
Add gross charges for Lines 12 through 16. This is your numerator. Total gross charges. This is your denominator. Multiply Line 17 by cost to charge ratio 0.353307 ss Multiply Una 1B by cost to charge ratio °»353307 = Divide Line 19 by Line 20. This is the low-income ratio.
$ 578.125.097
$ 1,156,442.743 $ 204,255,644 $ 408,579,316
0-499917
$ 15,924,669
Step 3: Determine the low-income portion of unreimbursed costs
22 Multiply Line 11 by Line 21. Write this amount on Form PTAX- 300-H, Line 16.
General Instructions
The portion of unreimbursed costs.of the Relevant Hospital Entity attributable to providing, paying for, or subsidizing goods, activities, or services that relieve the burden of government related to health care for low-Income individuals. Examples of these activities or services are
- providing emergency, trauma, burn, neonatal, psychiatric, rehabilitation, or other special services;
- providing medical education; and
- conducting medical research or training of health care professionals.
The portion of those unreimbursed costs attributable to benefiting low-income individuals shall be determined using the ratio calculated
by adding the Relevant Hospital Entity's costs attributable to charity care. Medicaid, other means-tested government programs, disabled Medicare patients under age 65, and dual-eligible Medicare/Medicaid patients and dividing that total by the Relevant Hospital Entity's total costs. Costs for the numerator and denominator shall be determined by multiplying gross charges by the cost to charge ratio taken from the most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1). In the case of emergency services, the ratio shall be calculated using costs (gross charges by the cost to charge ratio taken from the most recently filed Medicare cost report (CMS 2552-10 Worksheet C, Part 1)) of patients treated in the Relevant Hospital Entity's emergency department.
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PTAX-300-H ADDENDUM
Ann & Robert H. Lurie Children's Hospital of Chicago (Lurie Children's)
Permanent Index Numbers:
17-10-200-014 & -015 17-10-200-030 &-031 17-10-200-034 to-039 17-10-200-051 &-052 17-10-200-058 & -059
Overview: This Form PTAX-300-H is being completed for Ann & Robert H. Lurie
Children's Hospital of Chicago ("Lurie Children's") as a hospital owner for hospital it owns at 225 E. Chicago Avenue, Chicago, IL 60611. Lurie Children's owns only one hospital, and several supporting facilities. In preparing this form, Lurie Children's added together all of the qualifying activities and services that it conducts (not including activities or services of hospital affiliates, other than support for state health care programs provided by two physician hospital affiliates as permitted by 35 ILCS 200/15-86(e)(4)), and compared that amount to the aggregate of the estimated property tax liabilities for all of the properties it owns, not just the estimated property tax liability for the hospital. Also included in the total estimated tax liability are projected taxes for Lurie Children's affiliate Ann and Robert H. Lurie Children's Hospital of Chicago Research Center. Please note that the amounts used in this form do not in all instances match amounts on the Forms 990 or AG-CBP-1 due to differences in timing, definitions or includible entities in the underlying statutes. The descriptions below highlight these differences.
- Step 1, Line 5 Lurie Children's acquired the subject land site in three transactions.
Dates of Ownership:
April 17, 2007 (12 parcels, 1 deed)
May 9, 2008 (2 parcels, 2 deeds)
- Step 3, Line 11: Attached is Lurie Children's most recent Community Benefit Report filed
with the Illinois Attorney General's Office [Form AG-CBP-1]. The Report is for Lurie Children's fiscal year ended August 31, 2011 (fiscal year 2011).
CI-9340506 v3
The charity care amount on the Report is the sum of fiscal year 2011 cost of free or discounted services provided by Lurie Children's and two of its affiliates that are physician entities. The amount listed on Line 11 of PTAX-300-H is the cost of free and discounted services provided by Lurie Children's (only) in its fiscal year ended August 31, 2012 (fiscal year 2012). When Lurie Children's reports charity care on its fiscal year 2012 Community Benefit Report, it will also include the charity care from its two physician hospital affiliates for total charity care of $1,166,832 in fiscal year 2012.
- Step 3, Line 12: While the definition for this Line item is broad, Lurie Children's has only
included two activities benefiting low-income, underserved populations, a primary care pediatrics clinic for complex chronic children located in the Uptown neighborhood of Chicago and a primary care dentistry clinic. The amount listed on Line 12 of PTAX-300-H is composed of unreimbursed costs associated with these two activities in fiscal year 2012. The amount on Line 12 has been reduced to reflect only the portion of unreimbursed costs related to health care for low-income or under-served individuals. Because the statute does not prescribe a methodology for effecting such reduction, the amount on Line 12 was reduced using the percentage methodology prescribed in Schedule A for Line 16, but using actual 2012 numbers.
- Step 3, Line 13: While the definition for this line item is broad, Lurie Children's has only
included the cost of activities for family and patient support services, such as case workers, interpreters and housing for transplant patients and their families. The amount listed on Line 13 of PTAX-300-H is composed of costs associated with these family and patient support services activities for fiscal year 2012. The amount on Line 13 has been reduced to reflect only the portion of unreimbursed costs related to health care for low-income or under-served individuals. Because the statute does not prescribe a methodology for effecting such reduction, the amount on Line 13 was reduced using the percentage methodology prescribed in Schedule A for Line 16, but using actual 2012 numbers.
- Step 3, Line 14: The amount listed on Line 14 of PTAX-300-H is the cost incurred by Lurie
Children's and its two physician entity affiliates of providing services to Medicaid and ALL KIDS Health Insurance patients less all reimbursement received by them from the State of Illinois, calculated in the same
Cl-9340506v3
manner as detailed in IRS Form 990. The attached IRS Form 990, Schedule H is for fiscal year 2011 and includes only the amount calculated for Lurie Children's. The amount listed on Line 14 of PTAX-300-H is for the fiscal year 2012 and also includes the fiscal year 2012 amounts for Lurie Children's two physician entity affiliates.
- Step 3, Line 16: While the definition for this line item is broad, Lurie Children's has only
included the cost of subsidies for medical education and research.' Medical education.costs include salary and administrative costs for faculty, interns, residents and fellows less payments received from the Federal government. Research costs are offset by any State or Federal funding. As required by the applicable statute, the amount on Line 16 has been reduced to reflect only the portion of unreimbursed costs related to health care for low-income individuals. Please note that pursuant to the new hospital exemption legislation, the Line 16 figure is for fiscal year 2011. All other data provided on this PTAX -300-H application covers fiscal year 2012 (see Lines 11 through 14.)
- Step 4, Line 19 Several parcels had tax bills in 2011 (the latest year available). Since the
bills for these parcels represent partial exemptions and vacant land under development, the actual tax figures were not used. Estimated taxes for all properties were calculated based on statutory methodology and are listed on Schedule E.
- Step 4, Line 21 Notices have been sent to the City of Chicago, Chicago Public Schools,
and City Colleges of Chicago. The Chicago Fire Department is a department of the government of the City of Chicago and not a separate fire protection district. No notice, therefore, was sent to the City's fire department.
CI-9340506 v3
US Postal Service
Certified
Mail Receipt
Domestic Mail Only
No Insurance Coverage Provided
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Certified Fee Return Receipt Fee
(Endorsement Required)
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(Endorsement Required)
Total Postage & Fee*
Sent To: Susana A* Mendoza City Clerk
Office of the City Clerk City Hall - Room 107A 121 North LaSalle Street Chicago, Illinois 60602-1295
PS Form 3800, September 2002 US Postal Service Mary M. Donners /
Postmark Here
Certified Mall Receipt
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