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
AFFINITY HEALTH ALLIANCE INC
Employer identification number
52-1794697
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)
No
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
No
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
No
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
(1)
UNION HOSPITAL OF CECIL COUNTY INC
520607945
3
Yes
No
Yes
0
(2)
UNION HOSPITAL OF CECIL COUNTY HEALTH SERVICES INC
521794553
9
Yes
No
Yes
0
Total
0
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......
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.
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.)
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...
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.).
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
AFFINITY HEALTH ALLIANCE INC
Employer identification number
52-1794697
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 4
THE BYLAWS WERE REVISED ON OCTOBER 6, 2010 AS FOLLOWS: 1) CLARIFICATION OF "TERM OF SERVICE" FOR THE INDIVIDUAL SERVING OUT A BOARD MEMBER'S TERM WAS APPROVED AS FOLLOWS: SECTION 3.10. VACANCY ON BOARD. IN THE EVENT OF A VACANCY ON THE BOARD, WHICH RESULTS FROM DEATH, RESIGNATION, DISQUALIFICATION, REMOVAL OR FOR ANY OTHER CAUSE, THE COMMITTEE ON DIRECTORS SHALL RECOMMEND TO THE BOARD A CANDIDATE TO FILL SUCH VACANCY AND THE BOARD SHALL VOTE ON THE ELECTION OF SUCH NOMINEE AT THE NEXT REGULAR OR SPECIAL MEETING OF THE BOARD. THE PERIOD OF TIME THAT A DIRECTOR, WHO IS APPOINTED TO THE BOARD TO FILL A VACANCY, SERVES ON THE BOARD FROM INITIAL APPOINTMENT UNTIL THE END OF THE TERM OF THE DIRECTOR WHO IS BEING REPLACED ("REPLACEMENT TERM"), SHALL NOT BE COUNTED AS BOARD TENURE FOR THE PURPOSES OF THE TENURE LIMITATIONS SET FORTH IN SECTION 3.05 UNLESS THE LENGTH OF THE REPLACEMENT TERM IS IN EXCESS OF EIGHTEEN (18) MONTHS, IN WHICH EVENT THAT DIRECTOR'S TENURE SHALL BE LIMITED TO THE REPLACEMENT TERM AND TWO ADDITIONAL TERMS. SUBJECT TO BEING CONFIRMED ANNUALLY, A DIRECTOR ELECTED TO FILL A VACANCY SERVES UNTIL THE NEXT ANNUAL MEETING OF THE BOARD AT WHICH DIRECTORS OF THE CLASS FILLED BY SUCH DIRECTOR IS UP FOR ELECTION, AND UNTIL HIS OR HER SUCCESSOR IS DULY QUALIFIED AND ELECTED. IN THE EVENT THAT THE NUMBER OF DIRECTORS SERVING ON THE BOARD IS INCREASED AS SET FORTH IN SECTION 3.02, THE ADDITIONAL POSITIONS SO ADDED SHALL BE FILLED WITH PERSONS ELECTED BY THE BOARD WHO SHALL HOLD OFFICE UNTIL THE NEXT ANNUAL MEETING. 2) CLARIFICATION IN REGARD TO THE CHAIR OF THE FOUNDATION BOARD HOLDING A SEAT ON THE PARENT BOARD, WITH LANGUAGE APPROVED AS FOLLOWS: SECTION 3.03. MANDATORY BOARD MEMBERSHIP AND GOVERNMENTAL SEAT. (A) THE BOARD SHALL INCLUDE AS DIRECTORS THE FOLLOWING: (I) THE CHAIRPERSON AND VICE-CHAIRPERSON; (II) AT LEAST TWO PHYSICIANS, ONE OF WHOM SHALL BE, AS AN EX-OFFICIO MEMBER (WITH FULL VOTING RIGHTS), THE PRESIDENT OF THE MEDICAL STAFF OF THE HOSPITAL, WHO SHALL BE A MEMBER OF THE BOARD FOR THE FULL TERM THAT HE/SHE SERVES AS PRESIDENT OF THE MEDICAL STAFF OF THE HOSPITAL; (III) THE PRESIDENT WITH FULL VOTING RIGHTS, SECRETARY AND TREASURER OF THE CORPORATION; (IV) THE IMMEDIATE PAST CHAIRPERSON OF THE BOARD WHO SHALL BE EXEMPT FOR THIS PURPOSE FROM THE SERVICE LIMITATIONS SET FORTH IN SECTION 3.05; (V) THE CURRENT CHAIRMAN OF THE BOARD OF THE UNION HOSPITAL OF CECIL COUNTY FOUNDATION WHO SHALL BE EX OFFICIO (WITHOUT VOTING RIGHTS).
FORM 990, PART VI, SECTION B, LINE 11
THE FINANCE COMMITTEE OF THE ORGANIZATION REVIEWS THE FORM 990 PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE.
FORM 990, PART VI, SECTION B, LINE 12C
BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST. THE ORGANIZATION'S CEO REVIEWS THE SIGNED ANNUAL DISCLOSURES. THE CORPORATE COMPLIANCE OFFICER IS MADE AWARE OF ANY DISCLOSED CONFLICT, INVESTIGATES THE CONFLICT, AND REPORTS BACK TO THE BOARD OF DIRECTORS. THE BOARD CONSIDERS THE FACTS AND MAKES AN APPROPRIATE FINDING. ANY BOARD MEMBER WITH A CONFLICT MUST ABSTAIN FROM BOARD DELIBERATIONS AND VOTING ON THE MATTER. ALL VICE PRESIDENTS ANNUALLY RECEIVE A LIST OF THE INDIVIDUALS UNDER THEIR SUPERVISION WHO MAY HAVE A POTENTIAL CONFLICT OF INTEREST. THE LIST IS COMPRISED OF ALL MANAGERS, CERTAIN PROFESSIONAL STAFF WHO MAY HAVE RESPONSIBILITY NEGOTIATING WITH VENDORS, AND ANY OTHER PERSONS HOSPITAL EXECUTIVES DEEM APPROPRIATE. EACH VICE PRESIDENT REVIEWS THE CONFLICT OF INTEREST POLICY WITH THEIR DESIGNATED EMPLOYEES, AND EACH EMPLOYEE IS REQUIRED TO SIGN A FORM STIPULATING WHETHER OR NOT THEY HAVE A CONFLICT. THE FORMS ARE REVIEWED BY THE VICE PRESIDENT OF HUMAN RESOURCES. IF A CONFLICT IS NOTED, IT IS BROUGHT TO THE ATTENTION OF THE APPROPRIATE VICE PRESIDENT AND THE CEO TO DETERMINE WHETHER OPERATIONAL CHANGES NEED TO OCCUR BECAUSE OF THE POTENTIAL CONFLICT.
FORM 990, PART VI, SECTION B, LINE 15
THE COMPENSATION COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE OVERALL COMPENSATION PHILOSOPHY OF THE ORGANIZATION, AS WELL AS SETTING, MONITORING AND REVIEWING THE COMPENSATION PACKAGE OF THE ORGANIZATION'S CEO AND OTHER MEMBERS OF THE EXECUTIVE MANAGEMENT TEAM. THE COMMITTEE USES RELEVANT MARKET INFORMATION, INCLUDING THE USE OF AN INDEPENDENT COMPENSATION CONSULTANT AND COMPENSATION STUDIES OR SURVEYS, TO SET COMPENSATION. DURING THE FISCAL YEAR ENDED JUNE 30, 2011, AN INDEPENDENT COMPENSATION CONSULTANT PROVIDED THE FOLLOWING SERVICES: EXECUTIVE COMPENSATION AND PERFORMANCE EVALUATION.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION WILL MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
AVERAGE HOURS PER WEEK
FORM 990, PART VII, SECTION A, LINE 1A, COLUMN (B)
AVERAGE HOURS PER WEEK LISTED IN PART VII ARE FOR THIS LEGAL ENTITY ONLY. BOARD MEMBERS, OFFICERS AND HIGHEST COMPENSATED EMPLOYEES ALSO DEVOTE TIME TO THE RELATED ORGANIZATIONS LISTED ON SCHEDULE R. TOTAL AVERAGE HOURS PER WEEK FOR THESE INDIVIDUALS FOR ALL RELATED ORGANIZATIONS ARE AS FOLLOWS: PRESIDENT/CEO KENNETH S. LEWIS - 40 HOURS SENIOR VP/CFO LAURIE R. BEYER - 40 HOURS SENIOR VP/COO DAVID GIPSON - 40 HOURS SENIOR VP OF PATIENT CARE SERVICES JOANNE MILLER - 40 HOURS VP OF MEDICAL AFFAIRS JOSE MA - 40 HOURS BOARD MEMBERS - 1 HOUR
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 3,027,377. CHANGE IN UNRESTRICTED NET ASSETS OF AFFILIATES 10,118,999. TOTAL TO FORM 990, PART XI, LINE 5: 13,146,376.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.