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
HERNANDO PASCO HOSPICE INC
Employer identification number
59-2217929
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.") .
5,010
730,034
839,676
1,574,720
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......
57,662,259
69,237,897
71,330,334
60,170,218
57,385,554
315,786,262
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.
57,662,259
69,237,897
71,335,344
60,900,252
58,225,230
317,360,982
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.)
317,360,982
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...
57,662,259
69,237,897
71,335,344
60,900,252
58,225,230
317,360,982
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
170,622
154,522
50,799
23,587
64,737
464,267
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
6,026
5,406
11,432
c
Add lines 10a and 10b.
170,622
154,522
50,799
29,613
70,143
475,699
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.)
131,899
108,921
48,834
34,975
9,892
334,521
13
Total support (Add lines 9, 10c, 11 and 12.).
57,964,780
69,501,340
71,434,977
60,964,840
58,305,265
318,171,202
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
99.750 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
99.680 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0.150 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
0.170 %
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
HERNANDO PASCO HOSPICE INC
Employer identification number
59-2217929
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS BEFORE BEING FILED. A FINANCE COMMITTEE MEETING IS ORGANIZED SPECIFICALLY TO REVIEW AND DISCUSS THE 990.
FORM 990, PART VI, SECTION B, LINE 12C
THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS ALL "INTERESTED PERSONS," WHICH INCLUDES OFFICERS, DIRECTORS, MEMBERS OF ANY COMMITTEE OF THE BOARD, AND MEMBERS OF THE IMMEDIATE FAMILIES OF SUCH INDIVIDUALS. THE DESIGNATED COMPLIANCE OFFICER ROUTINELY REVIEWS THE EXISTING RELATIONSHIPS BETWEEN THE HOSPICE AND ITS "INTERESTED PERSONS", OTHER CARE PROVIDERS, EDUCATIONAL INSTITUTIONS AND PAYERS TO ASSURE THAT ALL RELATIONSHIPS ARE WITHIN THE LAW AND REGULATIONS. IF ANY CONFLICTS OF INTEREST ARE FOUND TO EXIST, THE COMPLIANCE OFFICER IMMEDIATELY REPORTS THE POTENTIAL CONFLICT TO THE CHIEF EXECUTIVE OFFICER. ANY VOTING MEMBER INVOLVED IN A CONFLICT OF INTEREST MUST IMMEDIATELY DISCLOSE IT TO THE CHAIRMAN OF THE BOARD AND IS DISALLOWED FROM VOTING ON ANY MATTERS RELATING TO ANY TRANSACTION WITH AN "INTERESTED PERSON" OR ENTITY.
FORM 990, PART VI, SECTION B, LINE 15
THE ORGANIZATION ENSURES THAT A REASONABLE AND COMPETITIVE PRESIDENT AND CHIEF EXECUTIVE OFFICER COMPENSATION PACKAGE CONSISTENT WITH MARKET-BASED COMPENSATION PRACTICES IS OFFERED. AN INDEPENDENT COMPENSATION AND BENEFITS COMMITTEE IS APPOINTED BY THE BOARD TO REVIEW THE PERFORMANCE OF THE EXECUTIVE OFFICERS, INCLUDING THE PRESIDENT AND CHIEF EXECUTIVE OFFICER. UPON REPORTING TO THE BOARD AT THE SUBSEQUENT BOARD MEETING, THE BOARD THEN APPROVES THE SALARY AND BENEFITS OF THE EXECUTIVE OFFICERS. THE DECISIONS OF THE BOARD REGARDING THE COMPENSATION ARRANGEMENT ARE DOCUMENTED WITHIN THE MEETING MINUTES.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 1,000. PRIOR PERIOD ADJUSTMENTS: -4,044,701. NET ASSET TRANSFER 2,368,793. TOTAL TO FORM 990, PART XI, LINE 5: -1,674,908.
OVERSIGHT OF AUDIT AND SELECTION OF INDEPENDENT ACCOUNTANT
FORM 990, PART XII, LINE 2C
THE FINANCE COMMITTEE IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIALS AND FOR INTERVIEWING INDEPENDENT ACCOUNTANTS. THEY MAKE THEIR RECOMMENDATION TO THE FULL BOARD, WHO VOTE TO SELECT THE INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.