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
Norwalk Health Care dba Honey Hill Rehab & Nursing Center
Employer identification number
22-2577722
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......
14,044,048
14,722,190
14,632,956
15,987,091
16,229,072
75,615,357
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.
14,044,048
14,722,190
14,632,956
15,987,091
16,229,072
75,615,357
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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..
8
Public Support (Subtract line 7c from line 6.)
75,615,357
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...
14,044,048
14,722,190
14,632,956
15,987,091
16,229,072
75,615,357
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
97,499
125,881
25,815
1,614
1,300
252,109
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
97,499
125,881
25,815
1,614
1,300
252,109
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.)
9,367
14,136
8,736
13,081
10,608
55,928
13
Total support (Add lines 9, 10c, 11 and 12.).
14,150,914
14,862,207
14,667,507
16,001,786
16,240,980
75,923,394
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
99.594 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
99.513 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0.332 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
0.426 %
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
Other income includes Barber & Beauty, Guest Trays & Gift Shop Revenue.
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
Norwalk Health Care dba Honey Hill Rehab & Nursing Center
Employer identification number
22-2577722
Identifier
Return Reference
Explanation
Cessation of Services
Form 990, Part III, Line 3
On September 30, 2011 Norwalk Health Care, Inc. closed on the sale of the nursing home business for a sales price of $5,850,000. An escrow for $700,000 was established for a three year period for indemnification obligations under the Medicare & Medicaid programs and such escrow was recorded as other Assets. A loss of $1,743,383 was recorded on the sale. The outstanding debt of Norwalk Health Care, Inc. as of September 30, 2011 of $7,805,000 was defeased and repaid to bondholders on November 15, 2011.
Description of Relationships
FORM 990, PART VI, LINE 2
CERTAIN NORWALK HEALTH CARE, INC. BOARD MEMBERS ALSO SERVE ON THE BOARD OF SWC CORPORATION, AND MAPLE STREET INDEMNITY COMPANY LTD.
The organization's members or stockholders
Form 990, Part VI, Line 6
The sole member of Norwalk Health Care is Norwalk Health Services Corporation.
Members, Stockholders, or other persons who may elect one or more members
Form 990, Part VI, Line 7a
The officers of NHC are appointed by the Governance Committee of NHSC. Up to 14 members of the Board are appointed by NHSC.
Describe the Process used by Management &/or Governing Body to Review 990
Form 990, Part VI, Line 11B
NORWALK HEALTH CARE, INC.'S (NHC) FORM 990 IS PREPARED WITH THE ASSISTANCE OF ERNST & YOUNG AND REVIEWED BY NORWALK HOSPITAL'S MANAGEMENT. FOLLOWING THAT REVIEW THE FORM 990 IS PRESENTED TO THE AUDIT COMMITTEE OF NORWALK HOSPITAL ASSOCIATION FOR REVIEW AND COMMENT. THE COMPLETED FORM 990 IS PROVIDED, via email, TO ALL MEMBERS OF THE BOARD OF Directors OF NORWALK HEALTH SERVICES CORPORATION PRIOR TO THE FORM BEING FILED WITH THE IRS.
Description of Process to Monitor Transactions for Conflicts of Interest
FORM 990, PART VI, LINE 12C
MONITORING THE ORGANIZATION'S CONFLICT OF INTEREST POLICY PROVIDES THAT ANNUALLY, EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS SHALL SIGN A STATEMENT AFFIRMING THAT SUCH PERSON RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, READ AND UNDERSTANDS THE POLICY AND AGREES TO COMPLY WITH THE POLICY. ADDITIONALLY, THE SIGNED STATEMENT AFFIRMS THAT THE PERSON UNDERSTANDS Norwalk Health Care IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS TAX-EXEMPT STATUS, Norwalk Health Care MUST ENGAGE IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. ENFORCEMENT FAILURE TO COMPLY WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY SHALL CONSTITUTE GROUNDS FOR REMOVAL OF A PERSON COVERED BY THE POLICY AS A BOARD MEMBER OR BOARD COMMITTEE MEMBER, AND, IN THE CASE OF KEY MANAGEMENT PERSONNEL, TERMINATION oF EMPLOYMENT. WHO IS COVERED? THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS. LEVEL OF DETERMINATION AND REVIEW OF CONFLICTS IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER PRESENTATION OF A POTENTIAL TRANSACTION OR ARRANGEMENT IS MADE BY AN INTERESTED PERSON, THE REMAINING DISINTERESTED BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. THE CHAIRPERSON OF THE GOVERNING BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE IF Norwalk Health Care CAN OBTAIN, WITH REASONABLE EFFORTS, A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE GOVERNING BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE ORGANIZATION'S BEST INTEREST, FOR ITS OWN BENEFIT AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE GOVERNING BOARD OR COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. RESTRICTIONS PLACED ON CONFLICTED PERSONS IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING 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 GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS.
Document Retention Policy
Form 990, Part VI, Line 14
NORWALK HEALTH CARE IS IN THE PROCESS OF DRAFTING A FORMAL WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY.
Offices & Positions for Which Process was Used, & Year Process was Begun
Form 990, Part VI, Line 15a
NORWALK HEALTH CARE (NHC) DOES NOT COMPENSATE ANY OFFICERS OR ITS EXECUTIVE DIRECTOR. THE OFFICER AND EXECUTIVE DIRECTOR RECEIVING COMPENSATION ARE COMPENSATED BY NORWALK HOSPITAL ASSOCIATION (NHA), A RELATED ORGANIZATION OF NHC. THEREFORE, THEIR COMPENSATION AND BENEFITS ARE DETERMINED BY NHA.
Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public
FORM 990, PART VI, LINE 19
NORWALK HEALTH CARE, INC. MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC ONLY UPON REQUEST. THE CONFLICT OF INTEREST POLICY IS AVAILABLE THROUGH NORWALK HEALTH SERVICES CORPORATION UPON REQUEST.
Changes in Net Assets or Other Fund Balances
Form 990, Part XI, Line 5
Transfers from Norwalk Hospital Foundation, Inc. $ 719 Net Unrealized gains on investments $ 390 ------- Total Line 5 $ 1,109
Compensation Committee
Schedule J, Part I, Line 3
THE COMPENSATION COMMITTEE IS FROM NORWALK HEALTH SERVICES CORPORATION (NHSC) AS PER THE NHSC BYLAWS.
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Daniel DeBarba TITLE:President and Chairman HOURS:56
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Ervin Shames TITLE:Director HOURS:6
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Frank N. Zullo, Esq TITLE:Director HOURS:1
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Barbara Butler TITLE:Director HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Victor Liss TITLE:Director HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Michael Marks, Physician; TITLE:Director until 12/31/2010 HOURS:53
HOURS DEVOTED FOR RELATED ORGANIZATION
FORM 990 PART VII
NAME:Robert Ready TITLE:Director HOURS:4
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.