Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Virtua Surgical Group PA
Employer identification number
22-2580215
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% 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). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
2,947,129
7,192,116
8,342,708
7,391,796
25,873,749
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
2,947,129
7,192,116
8,342,708
7,391,796
25,873,749
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
0
c
Add lines 7a and 7b..
0
8
Public Support (Subtract line 7c from line 6.)
25,873,749
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
2,947,129
7,192,116
8,342,708
7,391,796
25,873,749
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
4,224
6,176
857
778
12,035
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
4,224
6,176
857
778
12,035
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
100
4,500
1,600
6,200
13
Total support (Add lines 9, 10c, 11 and 12.).
2,951,353
7,198,392
8,348,065
7,394,174
25,891,984
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
99.930 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
99.910 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0.050 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
0.060 %
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
Virtua Surgical Group PA
Employer identification number
22-2580215
Identifier
Return Reference
Explanation
Form 990, Part VI, Section A, line 2
Directors Dioscoro T. Villanueva and Miguel L Deleon together own Surgical Group of South Jersey.
Form 990, Part VI, Section A, line 6
James Dwyer, DO is the Sole shareholder of VSG.
Form 990, Part VI, Section A, line 7a
The Governance Committee of the Board of Trustees makes recommendations for new membership and the Virtua Helath, Inc. Board of Trustees gives the final approval.
Form 990, Part VI, Section A, line 7b
The Chairs of the various Board Committees of Virtua Surgical Group present their recommendations on significant matters to the full Virtua Health, Inc. Board of Trustees for their approval.
Form 990, Part VI, Section B, line 11
The tax return was reviewed by in-house counsel, external tax consultants, and the Board of Trustees before filing.
Form 990, Part VI, Section B, line 12c
Virtua Surgical Group P.A. adopts the policies of Virtua Health, Inc. regarding monitoring and enforcing a conflict of interest policy. Virtua Health Inc, requires each Trustee, officer and member of a committee with Board-delegated powers shall annually sign a statement in which they agree to comply with the conflict of interest policy. The Board of Trustees is responsible for ensuring that periodic reviews of operations are conducted so that the organization operates in a manner consistent with its charitable purposes and does not engage in activities that could jeopardize its status as an organization exempt from federal income tax. In connection with any actual or possible conflict of interest, an interested person must disclose the existence of his or her financial interest and must be given the opportunity to disclose all material facts to the Trustees and members of committees with Board-delegated powers considering the proposed transaction or arrangement. After disclosure of the financial interest and all material facts, and after any discussion with the interested person, he/she shall leave the Board or committee meeting while the determination of a conflict of interest is discussed and voted upon. The remaining Trustees or committee members shall decide if a conflict of interest exists.
Virtua Surgical Group P.A. adopts the policies of Virtua Health, Inc. regarding the process for determining compensation for CEO, Executive Director, Top Management Official, Other Officers, and Key Employees. Virtua Health Inc, policy states that executive compensation is determined using market data and performance criteria. The Compensation Committee of the Board, which is composed entirely of independent trustees with no conflicts of interest, reviews data from an independent human resources consulting firm, including benchmarks by job title, market trends, and competitive analysis. The Committee establishes the salaries for the CEO and Executive Vice Presidents. It also reviews and approves the salary recommendation by the CEO for all Vice Presidents. Each year the Committee receives a reasonableness opinion confirming the appropriateness of the salary recommendations.
Form 990, Part VI, Section C, line 19
Financial statements are available to the public upon request to the Virtua corporate finance department.
Average hours from related organization
Form 990, Part VII, Section A
The average hours per week devoted to related organization for which compensation is reported for officers, directors, trustees and key employees is as follows: Robert Segin - Virtua Health, Inc. (40 hours), Virtua-West Jersey Health System, Inc. (1 hour), Virtua-Memorial Hospital Burlington County, Inc. (1 hour), Summit Health - Virtua, Inc. (1 hour), Virtua Health and Rehabilitation Center at Berlin, Inc. (1 hour), Virtua Health and Rehabilitation Center at Mount Holly, Inc. (1 hour), Virtua Home Care - Community Nursing Services, Inc. (1 hour), Virtua Health Foundation, Inc. (1 hour), Virtua Surgical Group, P.A. (1 hour) James Dwyer - Virtua Health, Inc. (40 hours), Virtua-West Jersey Health System, Inc. (1 hour), Virtua-Memorial Hospital Burlington County, Inc. (1 hour), Summit Health - Virtua, Inc. (1 hour), Virtua Health and Rehabilitation Center at Berlin, Inc. (1 hour), Virtua Health and Rehabilitation Center at Mount Holly, Inc. (1 hour), Virtua Home Care - Community Nursing Services, Inc. (1 hour), Virtua Surgical Group, P.A. (1 hour) Alfred Campanella - Virtua Health, Inc. (40 hours), Virtua-West Jersey Health System, Inc. (1 hour), Virtua-Memorial Hospital Burlington County, Inc. (1 hour), Summit Health - Virtua, Inc. (1 hour), Virtua Health and Rehabilitation Center at Berlin, Inc. (1 hour), Virtua Health and Rehabilitation Center at Mount Holly, Inc. (1 hour), Virtua Home Care - Community Nursing Services, Inc. (1 hour), Virtua Health Foundation, Inc. (1 hour), Virtua Surgical Group, P.A. (1 hour) Robert Michael DiRenzo - Virtua Medical Group, PA (40 hours), Virtua Surgical Group, P.A. (1 hour) Matthew Zuino - Virtua Health, Inc. (40 hours), Virtua Medical Group, P.A. (1 hour)
Independent Contractors
Part VII, Section B, Independent Contractors
All Accounts Payable transactions are paid by Virtua - West Jersey Health System, Inc. (21-0634532)
Changes in Net Assets or Fund Balances:
Form 990, Part XI, line 5:
NET ASSET TRANSFER TO RELIEVE DUE TO AFFILIATE 12,376,731. Total to Form 990, Part XI, Line 5: 12,376,731.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.