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
VILLAGE AT MARYMOUNT
Employer identification number
20-5652595
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.") .
6,405
6,304
27,672
138,980
179,361
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......
12,188,968
16,384,373
17,660,315
17,274,172
63,507,828
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
113,767
233
19,186
102,749
235,935
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.
12,309,140
16,390,910
17,707,173
17,515,901
63,923,124
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
3,500
5,420
2,938
19,330
31,188
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.
c
Add lines 7a and 7b..
3,500
5,420
2,938
19,330
31,188
8
Public Support (Subtract line 7c from line 6.)
63,891,936
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...
12,309,140
16,390,910
17,707,173
17,515,901
63,923,124
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
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.)
13
Total support (Add lines 9, 10c, 11 and 12.).
0
12,309,140
16,390,910
17,707,173
17,515,901
63,923,124
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
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
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
VILLAGE AT MARYMOUNT
Employer identification number
20-5652595
Identifier
Return Reference
Explanation
01. Officer, directors, etc. family relationship (Part VI, line 2)
BUSINESS RELATIONSHIP
02. Management duties delegation (Part VI, line 3)
VILLAGE OF MARYMOUNT HAS DELEGATED THE MANAGEMENT OF PATIENT CARE OPERATIONS TO CREATIVE HEALTHCARE CONSULTING INC CREATIVE HEALTHCARE CONSULTING INC PROVIDES AND SEPARATELY COMPENSATES THE DIRECTOR OF OPERATIONS AND THE EXECUTIVE DIRECTOR OF VILLAGE OF MARYMOUNT
03. Form 990 governing body review (Part VI, line 11)
THE CHIEF OPERATING OFFICER COO RECEIVES A COPY OF THE FORM 990 FROM THE RETURN PREPARER AND CONDUCTS A REVIEW OF THE RETURN FOR COMPLETENESS AND ACCURACY ONCE HE IS SATISFIED THAT THE RETURN IS READY TO BE FILED HE FORWARDS AN ELECTRONIC COPY TO EACH BOARD MEMBER WITH HIS RECOMMENDATION TO FILE THE RETURN AS DELIVERED HOWEVER NO BOARD MEMBER UNDERTAKES ANY REVIEW OF THE FORM EITHER BEFORE OR AFTER FILING
04. Conflict of interest policy compliance (Part VI, line 12c)
ALL OFFICERS DIRECTORS TRUSTEES & KEY EMPLOYEES AT LEAST ANNUALLY ARE REQUIRED TO DISCLOSE OR UPDATE THEIR INTERESTS THAT COULD GIVE RISE TO CONFLICTS OF INTEREST ONCE ANNUALLY EACH MEMBER OF THE BOARD OF DIRECTORS IS PROVIDED WITH A COPY OF THE CONFLICT OF INTEREST POLICY AND IS REQUIRED TO REVIEW THE DOCUMENT TO DETERMINE IF A CONFLICT OF INTEREST EXISTS FOR ALL OTHER TIMES DURING THE YEAR ALL OFFICERS DIRECTORS TRUSTEES & KEY EMPLOYEES ARE EXPECTED TO NOTIFY THE BOARD IF THEY DETERMINE THAT A CONFLICT HAS ARISEN ALL CONFLICTS OF INTEREST ARE DETERMINED AND REVIEWED AT THE BOARD OF DIRECTORS LEVEL RESTRICTIONS IMPOSED ON ANYONE WITH A CONFLICT INCLUDE PROHIBITING THEM FROM PARTICIPATING IN THE GOVERNING BODYS DELIBERATIONS AND DECISIONS IN THE TRANSACTION
05. CEO, executive director, top management comp (Part VI, line 15a)
A COMPENSATION COMMITTEE CONDUCTS A REVIEW OF THE COMPENSATION OF THE TOP MANAGEMENTFINANCIAL OFFICIAL THERE IS NO CEO & THERE IS NO EXECUTIVE DIRECTOR COMPENSATED BY VAMIN DETERMINING THE FAIR COMPENSATION FOR THAT POSITION THE COMMITTEE IDENTIFIES COMPENSATION GUIDELINES THROUGH PROFESSIONAL INDUSTRY AND TRADE ORGANIZATIONS AND OTHER NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS
06. Other officer or key employee compensation (Part VI, line 15b
A COMPENSATION COMMITTEE CONDUCTS A REVIEW OF THE COMPENSATION OF OTHER OFFICERS WHERE APPLICABLE AND KEY MANAGEMENT POSITIONS IN DETERMINING THE FAIR COMPENSATION FOR THOSE PARTICULAR POSITIONS THE COMMITTEE IDENTIFIES COMPENSATION GUIDELINES THROUGH PROFESSIONAL INDUSTRY AND TRADE ORGANIZATIONS AND OTHER NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS
07. Governing documents, etc, available to public (Part VI, line 19)
ALL ORGANIZATION GOVERNING DOCUMENTS CONFLICT OF INTEREST POLICY CONSOLIDATED FINANCIAL STATEMENTS AND THE ANNUAL FORM 990 ARE AVAILABLE TO THE PUBLIC UPON REQUEST THE ANNUAL FORM 990 ALSO IS POSTED TO THE GUIDESTAR WEBSITE FOR PUBLIC ACCESS
08. Audited by an independent accountant (Part XII, line 2b)
THE ORGANIZATIONS FINANCIAL STATEMENTS WERE AUDITED ON A CONSOLIDATED BASIS BY AN INDEPENDENT ACCOUNTANT
09. General explanation attachment
FORM 990 PART IV LINE 12 - THE ORGANIZATION IS INCLUDED IN A CONSOLIDATED AUDITED FINANCIAL STATEMENT ALONG WITH MARYMOUNT HEALTH CARE SYSTEMS AND MHCS REAL ESTATE HOLDING COMPANY & DOES NOT RECEIVE SEPARATELY AUDITED FINANCIAL STATEMENTS FORM 990 PART V QUESTIONS 7G AND 7H - THE ORGANIZATION DID NOT RECEIVE ANY CONTRIBUTIONS OF INTELLECTUAL PROPERTY OR ANY VEHICLES WHICH WOULD REQUIRE FILING FORM 8899 OR FORM 1098-C FORM 990 PART VII COLUMN B - ESTIMATE OF AVERAGE HOURS DEVOTED TO RELATED ORGANIZATIONS BY SECRETARY 42 TRUSTEE EHASZ 42 TRUSTEE KECKAN 41 TRUSTEE KILARSKI 42 TRUSTEE KENNEY 1 TRUSTEE BLABOLIL 41 TRUSTEE MAHER 2 TRUSTEE MASLANKA 41 & COO 4 SCH L PT IV - ADDITIONAL INFO ANTHONY M COURY DIR OF OPERATIONS A DIRECTOR OF VILLAGE OF MARYMOUNT VAM HAS AN INDIRECT BUS RELATIONSHIP WITH VAM THROUGH OWNERSHIP OF MORE THAN 35 OF CREATIVE HEALTHCARE CONSULTING INC CHC & OWNERSHIP OF MORE THAN 35 OF PHARMACY MANAGEMENT GROUP INC PMG WITH FAMILY MEMBERS HE IS ALSO AN OFFICER OF EACH CORP THE AMT & DESCRIPTION OF THE TRANSACTION WITH EACH CORP FOLLOWS CHC - ENTITY MORE THAN 35 OWNED BY A M COURY - AMT OF TRANSACTION 425501 - DESC OF TRANSACTION PROVIDES OPERATIONS MGMT SERVICES TO VAM PMG - ENTITY MORE THAN 35 OWNED BY A M COURY WITH FAMILY MEMBERS AS LISTED ON SCH L PT IV - AMT OF TRANSACTION 1143097 - DESC OF TRANSACTION PHARMACY MGMT SERVICES & PHARMACY INVENTORY SALES TO VAM
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.