Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 01-01-2011 and ending 12-31-2011
BCheck if applicable:
CName of organization
CHAPTERS HEALTH SYSTEM INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
12973 Telecom Parkway
 
Room/suite
City or town, state or country, and ZIP + 4
Temple Terrace, FL33637
D Employer identification number

59-2264957
E Telephone number

G Gross receipts $ 78,533,382
F Name and address of principal officer:
KATHY FERNANDEZ PRESIDENT & CEO
12973 Telecom Parkway ste 100
Temple Terrace,FL33637
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
CHAPTERSHEALTH.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1982
M State of legal domicile: FL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: CHAPTERS HEALTH SYSTEM, INC., THROUGH ITS SUBSIDIARY ORGANIZATIONS, PROVIDES HOSPICE AND PALLIATIVE CARE SERVICES THAT RELIEVE THE SUFFERING OF PERSONS RESIDING IN ITS COMMUNITIES AFFECTED BY LIFE-LIMITING ILLNESSES AND END-OF-LIFE ISSUES SO ALL MAY LIVE AS FULLY AND COMFORTABLY AS POSSIBLE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 16
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 15
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 337
6 Total number of volunteers (estimate if necessary) .... 6 30
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b 0
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 4,554,302 3,336,279
9 Program service revenue (Part VIII, line 2g) ......... 36,948,755 40,705,957
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 898,656 1,433,188
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 323,176 344,870
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 42,724,889 45,820,294
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 24,835,579 19,887,271
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet1,088,577    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 12,948,092 22,423,689
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 37,783,671 42,310,960
19 Revenue less expenses. Subtract line 18 from line 12....... 4,941,218 3,509,334
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 135,181,495 130,776,389
21 Total liabilities (Part X, line 26)............. 43,275,439 39,269,552
22 Net assets or fund balances. Subtract line 21 from line 20..... 91,906,056 91,506,837
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: CHAPTERS HEALTH SYSTEM, INC. (CHS), THROUGH ITS SUBSIDIARY ORGANIZATIONS, PROVIDES HOSPICE AND PALLIATIVE CARE SERVICES THAT RELIEVE THE SUFFERING OF PERSONS RESIDING IN ITS COMMUNITIES AFFECTED BY LIFE-LIMITING ILLNESSES AND END-OF-LIFE ISSUES SO ALL MAY LIVE AS FULLY AND COMFORTABLY AS POSSIBLE. (CONTINUED ON SCHEDULE O)
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 34,803,800 including grants of $   ) (Revenue $ 40,817,669 )
A. CHAPTERS HEALTH SYSTEM, INC. CHAPTERS HEALTH SYSTEM, INC. PROVIDES HOSPICE CARE AND SERVICES TO PATIENTS AND FAMILIES THROUGH ITS TWO HOSPICE SUBSIDIARIES - LIFEPATH HOSPICE, INC. AND GOOD SHEPHERD HOSPICE, INC. BOTH ARE NOT-FOR-PROFIT HOSPICE PROGRAMS CERTIFIED BY THE FEDERAL MEDICARE PROGRAM AND PROVIDE A WIDE RANGE OF PALLIATIVE AND SUPPORTIVE CARE SERVICES TO HELP TERMINALLY ILL PATIENTS, THEIR FAMILIES, AND THEIR LOVED ONES. IN ADDITION, CHAPTERS HEALTH SYSTEM IS THE SOLE MEMBER AND OPERATES THREE ADDITIONAL LLC'S - CHAPTERS HEALTH PALLIATIVE CARE, LLC; CHAPTERS HEALTH PHARMACY, LLC AND CHAPTERS HEALTH STAFFING, LLC. CHAPTERS HEALTH SYSTEM PROVIDES SIGNIFICANT MANAGEMENT DUTIES, INCLUDING WITHOUT LIMITATION, FINANCIAL AND ACCOUNTING SERVICES, HUMAN RESOURCES, LEGAL AND MARKETING SERVICES, INFORMATION TECHNOLOGY SERVICES, TO ITS SUBSIDIARIES AND WHOLLY OWNED LLC'S VIA A WRITTEN MANAGEMENT AGREEMENT. THE AMOUNT OF THESE SERVICES IS REFLECTED IN THE STATEMENT OF REVENUE AS SHARED SERVICES REVENUE" AND MANAGEMENT FEE INCOME. (CONTINUED IN SCHEDULE O)
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 34,803,800
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part IIClick to see attachment.........................
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part I....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part II...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III ....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IV...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
Yes
 
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II.......... Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
 
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2...........
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
895
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
337
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
Yes
 
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
Yes
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
No
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
16
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
15
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
Yes
 
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
Yes
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
FL
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
David J O'Neil
12973 Telecom Parkway Suite 100
Temple Terrace,FL33637
(813) 871-8111
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) GENE FOGARTY
VICE CHAIR
 2.00 X   X       0 0 0
(2) JACK KOLOSKY
CHAIR
 2.00 X   X       0 0 0
(3) KATHY L FERNANDEZ
PRESIDENT & CEO
 40.00 X   X       716,660 0 24,684
(4) MICHAEL ALOIAN
TREASURER
 2.00 X   X       0 0 0
(5) THOMAS E CONGER
SECRETARY
 2.00 X   X       0 0 0
(6) BRIAN HINTON
IMMEDIATE PAST CHAIR
 2.00 X           0 0 0
(7) HERB BELL
BOARD MEMBER
 2.00 X           0 0 0
(8) JAMES JOINER
BOARD MEMBER
 2.00 X           0 0 0
(9) KRISTIN E DIMEO
BOARD MEMBER
 2.00 X           0 0 0
(10) MIKE MARINO
BOARD MEMBER
 2.00 X           0 0 0
(11) R FENN GILES JR
BOARD MEMBER
 2.00 X           0 0 0
(12) REX YENTES
BOARD MEMBER
 2.00 X           0 0 0
(13) RICK LENTZ
BOARD MEMBER
 2.00 X           0 0 0
(14) STANLEY L PIOTROWSKI
BOARD MEMBER
 2.00 X           0 0 0
(15) SUSAN MCMILLAN
BOARD MEMBER
 2.00 X           0 0 0
(16) WILLIAM BECKER JR
BOARD MEMBER
 2.00 X           0 0 0
(17) ANDREW LUTTON
CHIEF OPERATING OFFICER
 40.00     X       263,441 0 84,023
Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) GEORGE H WALLACE
EVP-FINANCE & OPERATIONS - PARTIAL YEAR
 40.00     X       325,694 0 18,666
(19) RONALD S SCHONWETTER
CHIEF MED OFFICER
 40.00     X       457,440 0 139,856
(20) BJ DUDNEY
VP-CLINICAL SERV & EDUC
 40.00       X     207,324 0 383
(21) DAVID J O'NEIL
CHIEF FINANCIAL OFFICER
 40.00       X     225,499 0 48,988
(22) H DARRELL WHITE
CHIEF LEGAL OFFICER
 40.00       X     279,623 0 67,689
(23) JUDITH M GODDARD
VP-HR
 40.00       X     211,232 0 28,850
(24) PEGGY M MADILL
VP-CHIEF QUALITY & COMPLIANCE OFFICER
 40.00       X     206,847 0 29,410
(25) SHARON A JONES
VP-DEVELOPMENT
 40.00       X     169,349 0 21,264
(26) VICKI MARSEE
VICE PRESIDENT
 40.00       X     173,202 0 28,065
(27) ALAN RICE
DIRECTOR OF IT
 40.00         X   132,982 0 27,100
(28) CHAD A FARMER
PHYSICIAN
 40.00         X   186,039 0 9,521
(29) DIPESH PATEL
DIRECTOR OF PHARMACY
 40.00         X   143,240 0 27,941
(30) EDINA VONROTTENTHALER
PHYSICIAN
 40.00         X   136,359 0 9,416
(31) JOSE FERNANDEZ-SEMIDEY
PHYSICIAN
 40.00         X   156,720 0 24,125
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 3,991,651 0 589,981
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet27
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
PALM TERRACE OF LAKELAND
1919 LAKELAND HILLS BLVD
LAKELAND,FL33805 		PATIENT SERVICES 1,653,891
FL CANCER SPECIALISTS
PO BOX 102222
ATLANTA,GA303682222 		PATIENT SERVICES 1,442,887
LAKELAND REGIONAL MEDICAL
PO BOX 102049
ATLANTA,GA30368 		PATIENT SERVICES 1,374,354
ST JOSEPHS HOSPITAL INC
3986 TAMPA ROAD
OLDSMAR,FL34677 		PATIENT SERVICES 979,111
STEVEN'S CONSTRUCTION INC
6208 WHISKEY CREEK DRIVE
FORT MEYERS,FL33919 		CONSTRUCTION 896,846
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet110
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a 145,305
b Membership dues....1b  
c Fundraising events....1c 234,547
d Related organizations...1d 36,000
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		2,920,427
g Noncash contributions included in lines 1a-1f:$ 47,494
h Total. Add lines 1a-1f.......MediumBullet 3,336,279
Program Service Revenue Business Code
2a SHARED SERVICES AGREEMENT 561,000 26,511,770 26,511,770    
b PHARMACY 446,110 8,819,646 8,819,646    
c RENTAL INCOME FROM AFFILIATES 532,000 2,386,504 2,386,504    
d MEDICAL STAFFING SERVICES 900,099 1,901,619 1,901,619    
e PALLIATIVE CARE 624,100 389,214 389,214    
f All other program service revenue . 697,204 697,204 0 0
g Total. Add lines 2a–2f........MediumBullet 40,705,957
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 1,039,767     1,039,767
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 32,286,079 -21,836
b Less: cost or other basis and sales expenses 31,870,822  
c Gain or (loss) 415,257 -21,836
d Net gain or (loss)..........MediumBullet 393,421     393,421
8a Gross income from fundraising events (not including
$ 234,547
of contributions reported on line 1c). See Part IV, line 18 ...
a 33,239
b Less: direct expenses ...b 169,661
c Net income or (loss) from fundraising events..MediumBullet -136,422   -136,422
9a Gross income from gaming activities.
See Part IV, line 19 ...
a 2,201
b Less: direct expenses ...b 1,204
c Net income or (loss) from gaming activities...MediumBullet 997     997
10a Gross sales of inventory, less
returns and allowances .
a 1,009,840
b Less: cost of goods sold ..b 671,401
c Net income or (loss) from sales of inventory..MediumBullet 338,439     338,439
Miscellaneous Revenue Business Code
11a VENDING INCOME 900,099 30,144     30,144
b MISCELLANEOUS 900,099 111,712 111,712    
c            
d All other revenue .... 0 0 0 0
e Total. Add lines 11a–11d ......MediumBullet 141,856
12 Total revenue. See Instructions....MediumBullet 45,820,294 40,817,669 0 1,666,346
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 3,728,189 149,324 3,277,050 301,815
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 49,909     49,909
7 Other salaries and wages 12,939,631 12,636,063   303,568
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 395,373 395,373    
9 Other employee benefits ....... 1,785,061 1,784,880   181
10 Payroll taxes ........... 989,108 853,697   135,411
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 227,348   227,348  
c Accounting ........... 177,885   177,885  
d Lobbying ........... 60,000 60,000    
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 127,746   127,746  
g Other .......... 2,630,631 2,630,631    
12 Advertising and promotion .... 202,782 190,631   12,151
13 Office expenses ....... 3,919,435 3,742,030   177,405
14 Information technology ...... 1,204,943 1,204,943    
15 Royalties .. 0      
16 Occupancy ........... 789,665 789,665    
17 Travel ............ 323,997 303,955   20,042
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 162,997 155,039   7,958
20 Interest ........... 1,076,364   1,076,364  
21 Payments to affiliates ....... 43,236 43,236    
22 Depreciation, depletion, and amortization ..... 3,576,070 2,043,880 1,532,190  
23 Insurance .............. 1,050,785 1,050,785    
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a DRUGS 3,901,170 3,901,170    
b 3RD PARTY SETTLEMENT 729,112 729,112    
c MED, OXYGEN, IV & DMW 165,145 165,145    
d BAD DEBT EXPENSE 11,163 11,163    
e
f All other expenses 2,043,215 1,963,078 0 80,137
25 Total functional expenses. Add lines 1 through 24f 42,310,960 34,803,800 6,418,583 1,088,577
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720). 0      
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 1,300 1 4,100
2 Savings and temporary cash investments ....... 49,603,706 2 31,318,913
3 Pledges and grants receivable, net ......... 352,228 3 177,577
4 Accounts receivable, net ......... 196,107 4 220,919
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..........   5  
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L ..........   6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 427,031 8 453,362
9 Prepaid expenses and deferred charges ............ 1,367,718 9 1,703,865
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 57,295,931
b Less: accumulated depreciation. ..... 10b 20,513,377 35,533,327 10c 36,782,554
11 Investments—publicly traded securities .......... 22,143,516 11 35,533,788
12 Investments—other securities. See Part IV, line 11 ...... 4,026,818 12 6,380,028
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 16,397,333 14 16,397,333
15 Other assets. See Part IV, line 11 ........... 5,132,411 15 1,803,950
16 Total assets. Add lines 1 through 15 (must equal line 34)... 135,181,495 16 130,776,389
Liabilities 17 Accounts payable and accrued expenses . 7,437,760 17 4,916,135
18 Grants payable ..........   18  
19 Deferred revenue ..........   19  
20 Tax-exempt bond liabilities .......... 31,047,250 20 29,426,424
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 4,790,429 25 4,926,993
26 Total liabilities. Add lines 17 through 25..... 43,275,439 26 39,269,552
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 91,219,599 27 90,759,845
28 Temporarily restricted net assets ..... 555,691 28 584,274
29 Permanently restricted net assets ..... 130,766 29 162,718
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 91,906,056 33 91,506,837
34 Total liabilities and net assets/fund balances ..... 135,181,495 34 130,776,389
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
45,820,294
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
42,310,960
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
3,509,334
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
91,906,056
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
-3,908,553
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
91,506,837
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


Software ID: 11000230
Software Version: v2011.1.0
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
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
f
g
(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
(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) LIFEPATH HOSPICE INC
  		205276870 9 Yes   Yes   Yes   0
(2) GOOD SHEPHERD HOSPICE INC
  		205276923 9 Yes   Yes   Yes   0
(3) CHAPTERS HEALTH SENIOR INDEPENDENCE INC
  		275158323 9   No Yes   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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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) 2007 (b) 2008 (c) 2009 (d) 2010 (e) 2011 (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
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
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
AMOUNT OF SUPPORT, SCHEDULE A, PART I, LINE 11H(VII), CHAPTERS HEALTH SYSTEM, INC. PROVIDES SUPPORT SERVICES TO ITS SUBSIDIARIES AND ITS SUPPORTED ORGANIZATIONS (LIFEPATH HOSPICE, INC., GOOD SHEPHERD HOSPICE, INC. AND CHAPTERS HEALTH SENIOR INDEPENDENCE, INC.) IN THE FORM OF INFORMATION TECHNOLOGY, HUMAN RESOURCES, LEGAL, FUND RAISING, COMPLIANCE, ACCOUNTING, MANAGEMENT OVERSIGNT AND HEALTHCARE PERSONNEL.,
 
 
 
Schedule A (Form 990 or 990-EZ) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2011
Name of organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
CHAPTERS HEALTH SYSTEM INC
  		Employer identification number

59-2264957
Part I
Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
CHAPTERS HEALTH SYSTEM INC
  		Employer identification number

59-2264957
Part II
Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions). 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Name of organization
CHAPTERS HEALTH SYSTEM INC
  		Employer identification number

59-2264957
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet $  
Use duplicate copies of Part III if additional space is needed
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b)
Purpose of gift		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.
SchCMd Bullet Attach to Form 990 or Form 990-EZ. SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c) except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2011

Schedule C (Form 990 or 990-EZ) 2011
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check expenses, and share of excess lobbying expenditures).
B Check
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) Total
             
2a Lobbying non-taxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2011


Schedule C (Form 990 or 990-EZ) 2011
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes
No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
60,000
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
1,400
j
Total. Add lines 1c through 1i ...............................
61,400
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ...........................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.
Identifier Return Reference Explanation
Description of the activities reported on Lines 1a through 1i Schedule C, Part II-B, Line 1 A LOBBYIST WAS HIRED TO REPRESENT THE ORGANIZATION BEFORE FLORIDA LEGISLATURE AND THE EXECUTIVE BRANCH OF FLORIDA GOVERNMENT, INCLUDING THE DEPARTMENT OF ELDER AFFAIRS AND THE AGENCY OF HEALTH CARE ADMINISTRATION, AND TO PROVIDE GUIDANCE REGARDING INTERACTION WITH LEGISLATION AND AGENCY STAFF ON MATTERS PERTAINING TO SPECIFIC ISSUE ADVOCACY, LEGISLATIVE AND REGULATORY DEVELOPMENTS OF CONCERN. ALSO, THE ORGANIZATION PAYS ANNUAL DUES TO THE NATIONAL HOSPICE AND PALLIATIVE CARE ORGANIZATION (NHPCO) FOR ITS MEMBERSHIP. 3.03% OF THE TOTAL DUES PAID ARE INDIRECTLY RELATED TO LOBBYING ACTIVITIES.
Schedule C (Form 990 or 990EZ) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .......    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) ...    
4 Aggregate value at end of year .......    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................
9
In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 52283D
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance .... 130,765 125,634 125,458 80,360
b Contributions ........ 31,952 5,131 176 45,098
c Net investment earnings, gains, and losses ... 0 0 0 0
d Grants or scholarships ..... 0 0 0 0
e Other expenditures for facilities
and programs ........ 		0 0 0 0
f Administrative expenses .... 0 0 0 0
g End of year balance ...... 162,717 130,765 125,634 125,458
2
Provide the estimated percentage of the year end balance (line 1g) held as:
a
Board designated or quasi-endowment SchDMd Bullet100.000 %
b
Permanent endowment SchDMd Bullet0 %
c
Temporarily restricted endowment SchDMd Bullet0 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
 
No
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   3,257,377 3,257,377
b Buildings ................   28,809,758 5,599,920 23,209,838
c Leasehold improvements ............   7,482,875 3,862,774 3,620,101
d Equipment ................   17,403,002 11,050,683 6,352,319
e Other .................   342,919   342,919
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 36,782,554
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Book value
Federal Income Taxes 0
INTEREST RATE SWAP AGREEMENT 1,157,978
CHARITABLE GIFT ANNUITIES 424,172
CAPITAL LEASE OBLIGATION 863,708
DEFERRED SERP LIABILITIES 2,481,135





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 4,926,993
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).
Schedule D (Form 990) 2011

Schedule D (Form 990) 2011
Page 4
Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1 Total revenue (Form 990, Part VIII, column (A), line 12) .................... 1 45,820,294
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2 42,310,960
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3 3,509,334
4 Net unrealized gains (losses) on investments .......................... 4 -1,528,852
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV.) ................................. 8 -2,379,706
9 Total adjustments (net). Add lines 4 through 8 ......................... 9 -3,908,558
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10 -399,224
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1 42,177,612
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a -1,528,852
b Donated services and use of facilities ......... 2b 163,885
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV.) ............ 2d -2,277,715
e Add lines 2a through 2d ..................... 2e -3,642,682
3 Subtract line 2e from line 1..................... 3 45,820,294
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV.) ........... 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 45,820,294
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1 42,576,836
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a 163,885
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV.) ............ 2d 101,991
e Add lines 2a through 2d...................... 2e 265,876
3 Subtract line 2e from line 1..................... 3 42,310,960
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV.) ............ 4b 0
c Add lines 4a and 4b....................... 4c 0
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 42,310,960
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Intended uses of endowment funds Schedule D, Part V, Line 4 THE BUILDING ENDOWMENT FUND PROVIDES FUNDS FOR THE NECESSARY MAINTENANCE AND FACILITY UP-KEEP OF ALL CHAPTERS HEALTH SYSTEMS, INC. (CHS) FACILITIES; THE CHILDREN'S ENDOWMENT FUND PROVIDES FUNDS FOR SPECIFIC EQUIPMENT AND STAFFING TO MEET THE NEEDS OF PEDIATRIC PATIENTS, GRIEVING CHILDREN AND FAMILIES; THE MEDICAL STUDENT ENDOWMENT PROVIDES FUNDS TO THE MEDICAL STUDENT PROGRAM THAT EDUCATES FUTURE PHYSICIANS ON THE IMPORTANCE OF END-OF-LIFE CARE.
FIN 48 (ASC 740) footnote Schedule D, Part X, Line 2 CHAPTERS HEALTH SYSTEM, INC., LIFEPATH HOSPICE, INC., GOOD SHEPHERD HOSPICE, INC. AND THE FOUNDATION HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS A NOT-FOR-PROFIT CORPORATIONS AND ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC) AND ALSO FROM STATE INCOME TAXES UNDER THE PROVISIONS OF CHAPTER 220.13 OF THE FLORIDA INCOME TAX CODE. PALLIATIVE CARE, PHARMACY, AND STAFFING ARE ALSO DEEMED TO BE TAX-EXEMPT AS LIMITED LIABILITY COMPANIES WITH CHS AS SOLE MEMBER. THE IRC PROVIDES FOR TAXATION OF UNRELATED BUSINESS INCOME UNDER CERTAIN CIRCUMSTANCES. CHS AND ITS AFFILIATED ENTITIES HAVE TO SIGNIFICANT UNRELATED BUSINESS INCOME; HOWEVER, SUCH STATUS IS SUBJECT TO FINAL DETERMINATION UPON EXAMINATION OF THE RELATED INCOME TAX RETURNS BY THE APPROPRIATE TAXING AUTHORITIES.
Schedule D (Form 990) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0




SCHEDULE G (Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,or if the organization entered more than $15,000 on Form 990-EZ, line 6a.right arrowAttach to Form 990 or Form 990-EZ. right arrowSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

ISLAND NIGHT
(event type) 		(b) Event #2

GOLF TOURNAMENT
(event type) 		(c) Other Events

1
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 180,417 55,914 31,455 267,786
2 Less: Charitable
contributions . . . 		162,818 44,434 27,295 234,547
3 Gross income (line 1
minus line 2) . . . 		17,599 11,480 4,160 33,239
VerticalDirectExpenses 4 Cash prizes . . . 0 0 0 0
5 Non-cash prizes . . 0 638 0 638
6 Rent/facility costs . . 11,914 13,440 2,093 27,447
7 Food and beverages . . 10,631 5,228 167 16,026
8 Entertainment . . . 325 0 1,000 1,325
9 Other direct expenses . 84,440 20,944 18,841 124,225
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 169,661
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow -136,422
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ..........................
Schedule G (Form 990 or 990-EZ) 2011
Schedule G (Form 990 or 990-EZ) 2011
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2011
Additional Data


Software ID: 11000230
Software Version: v2011.1.0
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
Yes
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
Yes
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) DAVID J O'NEIL (i)
(ii)		 172,513
0 		51,304
0 		1,682
0 		16,758
0 		32,230
0 		274,487
0 		51,304
0
(2) BJ DUDNEY (i)
(ii)		 15,989
0 		28,603
0 		162,732
0 		0
0 		383
0 		207,707
0 		28,603
0
(3) H DARRELL WHITE (i)
(ii)		 217,482
0 		61,043
0 		1,098
0 		37,048
0 		30,641
0 		347,312
0 		61,043
0
(4) KATHY L FERNANDEZ (i)
(ii)		 378,914
0 		153,826
0 		183,920
0 		0
0 		24,684
0 		741,344
0 		153,826
0
(5) GEORGE H WALLACE (i)
(ii)		 163,227
0 		63,896
0 		98,571
0 		0
0 		18,666
0 		344,360
0 		63,896
0
(6) SHARON A JONES (i)
(ii)		 133,823
0 		29,728
0 		5,798
0 		0
0 		21,264
0 		190,613
0 		29,728
0
(7) JUDITH M GODDARD (i)
(ii)		 158,058
0 		44,713
0 		8,461
0 		0
0 		28,850
0 		240,082
0 		44,713
0
(8) RONALD S SCHONWETTER (i)
(ii)		 344,522
0 		111,814
0 		1,104
0 		108,825
0 		31,031
0 		597,296
0 		111,814
0
(9) PEGGY M MADILL (i)
(ii)		 173,512
0 		32,471
0 		864
0 		6,413
0 		22,997
0 		236,257
0 		32,471
0
(10) CHAD A FARMER (i)
(ii)		 179,216
0 		5,321
0 		1,502
0 		0
0 		9,521
0 		195,560
0 		5,321
0
(11) ANDREW LUTTON (i)
(ii)		 221,198
0 		41,546
0 		697
0 		59,778
0 		24,245
0 		347,464
0 		41,546
0
(12) ALAN RICE (i)
(ii)		 124,283
0 		7,574
0 		1,125
0 		0
0 		27,100
0 		160,082
0 		0
0
(13) DIPESH PATEL (i)
(ii)		 135,782
0 		6,202
0 		1,256
0 		0
0 		27,941
0 		171,181
0 		0
0
(14) JOSE FERNANDEZ-SEMIDEY (i)
(ii)		 155,057
0 		346
0 		1,317
0 		0
0 		24,125
0 		180,845
0 		0
0
(15) VICKI MARSEE (i)
(ii)		 162,405
0 		8,500
0 		2,297
0 		5,355
0 		22,710
0 		201,267
0 		0
0

Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Health or social club dues or initiation fees Schedule J, Part I, Line 1a THE ORGANIZATION PAYS FOR THE PRESIDENT/CEO TO BE A MEMBER OF THE CENTRE CLUB TO CULTIVATE PROSPECTIVE DONORS AND FOR OTHER BUSINESS PURPOSES. THE USE OF THIS MEMBERSHIP IS BUSINESS RELATED AND THEREFORE THE RELATED BENEFIT HAS NOT BEEN INCLUDED IN THE RECIPIENT'S TAXABLE COMPENSATION.
Severance or change-of-control payment Schedule J, Part I, Line 4a IN 2011, SEVERANCE PAYMENTS WERE MADE TO THE FOLLOWING: GEORGE WALLAGE - $95,403 BETTY J. DUDNEY - $161,923
Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b THE ORGANIZATION HAS A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) IN WHICH SOME OF THE INTERESTED PERSONS PARTICIPATE. DURING 2011, THE FOLLOWING PAYMENTS WERE MADE BY THE ORGANIZATION INTO THE SERP PLANS OF THE PARTICIPANTS: KATHY FERNANDEZ - $181,857 RONALD SCHONWETTER - $108,825 H. DARRELL WHITE - $37,048 ANDREW LUTTON - $59,778 DAVID O'NEIL - $16,758 BJ DUDNEY - $770 JUDITH GODDARD - $6,259 PEGGY MADILL - $6,413 SHARON JONES - $5,072 VICKI MARSEE - $5,355
Schedule J (Form 990) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number
59-2264957
Part I
Bond Issues
(a) Issuer Name (b) Issuer EIN (c) CUSIP # (d) Date Issued (e) Issue Price (f) Description of Purpose (g) Defeased (h) On
Behalf of
Issuer 		(i) Pool
financing
Yes No Yes No Yes No
A CITY OF TEMPLE TERRACE FLORIDA
  		59-6000439   08-13-2009 13,827,500 TO REFUND THE 12/11/2003 BOND ISSUE   X   X   X
B POLK COUNTY INDUSTRIAL DEVELOPMENT AUTHORITY
  		59-1292108 731120MW8 08-13-2009 11,617,500 TO REFUND THE 8/26/2004 BOND ISSUE   X   X   X
C HIGHLANDS COUNTY HEALTH FACILITIES AUTHORITY
  		52-1313569   01-28-2010 7,500,000 BUILD NEW HOSPICE FACILITY   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . 562,500 265,250 0  
2 Amount of bonds legally defeased . . . . . . . . . . 0 0 0  
3 Total proceeds of issue . . . . . . . . . . . . . 13,827,500 11,617,500 7,505,635  
4 Gross proceeds in reserve funds . . . . . . . . 0 0 0  
5 Capitalized interest from proceeds . . . . . . . . . . 0 0 5,635  
6 Proceeds in refunding escrows . . . . . . . . . . . 0 0 0  
7 Issuance costs from proceeds . . . . . . . . . . . 0 0 0  
8 Credit enhancement from proceeds . . . . . . . . . . 0 0 0  
9 Working capital expenditures from proceeds . . . . . . . 0 0 0  
10 Capital expenditures from proceeds . . . . . . . . . . 0 0 7,500,000  
11 Other spent proceeds . . . . . . . . . . . 0 0 0  
12 Other unspent proceeds . . . . . . . . . . . 0 0 0  
13 Year of substantial completion . . . . . . . . . . . 2009 2009
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . X   X     X    
15 Were the bonds issued as part of an advance refunding issue? . . . .   X   X   X    
16 Has the final allocation of proceeds been made? . . . . . . X   X     X    
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . X   X   X      
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X   X   X    
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .   X   X   X    
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2011
Schedule K (Form 990) 2011
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . .   X   X   X    
b If ‘Yes’ to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . .                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . .   X   X   X    
d If ‘Yes’ to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0.0000% 0.0000% 0.0000%   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet 0.0000% 0.0000% 0.0000%   %
6 Total of lines 4 and 5 . . .. . . . . . . . . 0.0000% 0.0000% 0.0000%   %
7 Does the bond issue meet the private security or payment test? . . . X   X   X      
8 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
X   X   X      
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .   X   X   X    
2 Is the bond issue a variable rate issue? X   X   X      
3a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue? X   X     X    
b Name of provider . . . . . . . . SUNTRUST BANK
  		SUNTRUST BANK
  		 
  		 
 
c Term of hedge . . . . . . . . 10.0 15.0    
d Was the hedge superintegrated? . . . .   X   X        
e Was a hedge terminated? . . . . .   X   X        
4a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . .   X   X   X    
b Name of provider . . . . . .  
  		 
  		 
  		 
 
c Term of GIC . . . . . . .        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . . .                
5 Were any gross proceeds invested beyond an available temporary period? . . . . . .   X   X   X    
6 Did the bond issue qualify for an exception to rebate? . X   X   X      
7 Has the organization established written procedures to monitor the requirements of section 148? . . . X   X   X      
Schedule K (Form 990) 2011

Schedule K (Form 990) 2011
Page 3
Part V
Procedures To Undertake Corrective Action
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? . . . . . . . . . . . . . .
Part VI
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Procedures to take corrective action Schedule K, Part V THE ORGANIZATION HAS POLICIES AND PROCEDURES IN PLACE TO ENSURE POST-ISSUANCE COMPLIANCE FOR THE TAX-EXEMPT BONDS. THE ORGANIZATION ALSO HAS A RIGOROUS PROCESS IN PLACE TO PROVE POST-ISSUANCE COMPLIANCE TO THE BOND LENDER. THESE POLICIES AND PROCEDURES HELP TO ENSURE THAT FEDERAL TAX REQUIREMENTS ARE CONSIDERED AND ADDRESSED.
Schedule K (Form 990) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2011
Schedule L (Form 990 or 990-EZ) 2011
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) BEVERLY WALLACE
  		DIRECTOR, THRIFT STORES 49,909 WIFE OF EVP-FINANCE & OPERATIONS, GEORGE WALLACE   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
Schedule L (Form 990 or 990-EZ) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		X 1,009,840 RESALE VALUE
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 3 5,710 SELLING COST
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( EQUIPMENT ) X 81 21,143 DONOR VALUATION
26 Other Right pointing arrow large image ( GOODS FOR AUCTION ) X 19 7,490 DONOR VALUATION
27 Other Right pointing arrow large image ( FOOD FOR FUNDRAISING EVENTS ) X 3 3,285 DONOR VALUATION
28 Other Right pointing arrow large image ( GIFT CARDS ) X 3 9,866 DONOR VALUATION
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
Yes
 
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2011
Schedule M (Form 990) 2011
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33 and whether the organization is reporting in Part I, column (b) the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Identifier Return Reference Explanation
Number of contributions or items contributed. Schedule M, part I, column (b), Line 9  
Number of contributions or items contributed. Schedule M, part I, column (b), Line other=EQUIPMENT  
Number of contributions or items contributed. Schedule M, part I, column (b), Line other=GOODS FOR AUCTION  
Number of contributions or items contributed. Schedule M, part I, column (b), Line other=FOOD FOR FUNDRAISING EVENTS  
Number of contributions or items contributed. Schedule M, part I, column (b), Line other=GIFT CARDS  
Schedule M (Form 990) 2011
Additional Data


Software ID: 11000230
Software Version: v2011.1.0
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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 (CONTINUED FROM PART III) CHS ALSO WORKS TO PROMOTE AN UNDERSTANDING OF THE NEEDS OF PERSONS WITH SERIOUS OR LIFE-LIMITING ILLNESSES AS WELL AS THE NEEDS OF ITS FAMILIES AND CAREGIVERS. CHS PROVIDES SIGNIFICANT MANAGEMENT DUTIES, INCLUDING WITHOUT LIMITATION, FINANCIAL AND ACCOUNTING SERVICES, HUMAN RESOURCES, LEGAL AND MARKETING SERVICES, INFORMATION TECHNOLOGY SERVICES, TO ITS SUBSIDIARIES AND WHOLLY OWNED LLC'S VIA A WRITTEN MANAGEMENT AGREEMENT.
PROGRAM SERVICES FORM 990, PART III, LINE 4A (CONTINUED FROM PART III) B. LIFEPATH HOSPICE, INC. LIFEPATH HOSPICE IS A MEDICARE-CERTIFIED AGENCY THAT PROVIDES END-OF-LIFE CARE IN HILLSBOROUGH COUNTY, FLORIDA. IN 2011, LIFEPATH HOSPICE SERVED 7045 PATIENTS IN ITS COMMUNITY. LIFEPATH HOSPICE PROFESSIONALS CARED FOR 63.9% OF ALL PEOPLE WHO DIED IN HILLSBOROUGH COUNTY IN 2011. (THIS FIGURE ALSO TAKES INTO ACCOUNT SUDDEN DEATHS, ACCIDENTS, HOMICIDES AND SUICIDES.) THE COMPANY HAS 1044 TRAINED VOLUNTEERS WHOSE DONATED TIME IS VALUED AT $1,626,799. LIFEPATH HOSPICE PROVIDED $2,732,000 IN CHARITY CARE IN 2011. C. GOOD SHEPHERD HOSPICE, INC. GOOD SHEPHERD HOSPICE IS A MEDICARE-CERTIFIED AGENCY THAT PROVIDES END-OF-LIFE CARE IN POLK, HIGHLANDS AND HARDEE COUNTIES IN FLORIDA. IN 2011, GOOD SHEPHERD HOSPICE SERVED 3958 PATIENTS IN ITS COMMUNITIES. GOOD SHEPHERD HOSPICE PROFESSIONALS CARED FOR 46.1% OF ALL PEOPLE WHO DIED IN POLK, HIGHLANDS AND HARDEE COUNTIES IN 2011. (THIS FIGURE ALSO TAKES INTO ACCOUNT SUDDEN DEATHS, ACCIDENTS, HOMICIDES AND SUICIDES.) THE COMPANY HAS 580 TRAINED VOLUNTEERS WHOSE DONATED TIME IS VALUED AT $656,265. GOOD SHEPHERD HOSPICE PROVIDED $1,200,000 IN CHARITY CARE IN 2011. D. CHAPTERS HEALTH PALLIATIVE CARE, LLC CHAPTERS HEALTH PALLIATIVE CARE PROVIDES PAIN AND PALLIATIVE CARE CONSULTS IN HOSPITALS AND OTHER FACILITIES IN HILLSBOROUGH AND POLK COUNTIES. IN 2011, CHAPTERS HEALTH PALLIATIVE CARE PROVIDED 3,760 PATIENT VISITS, WHICH INCLUDED 1,280 NEW PALLIATIVE CARE CONSULTS AT THREE HOSPITALS AND THREE NURSING HOME/REHABILITATION CENTERS. E. CHAPTERS HEALTH PHARMACY, LLC CHAPTERS HEALTH PHARMACY IS A NOT-FOR-PROFIT SUBSIDIARY THAT PROVIDES MEDICATIONS FOR THE PATIENTS OF LIFEPATH HOSPICE AND GOOD SHEPHERD HOSPICE. CHAPTERS HEALTH PHARMACY IMPROVED STAFF EFFICIENCY WITH ELECTRONIC MEDICATION ORDERS, FILLING 156,143 PRESCRIPTIONS IN 2011. CHAPTERS HEALTH PHARMACY PROVIDES FREE DELIVERY OF MEDICATIONS FOR HOSPICE PATIENTS, AT A COST OF MORE THAN $892,922. F. CHAPTERS HEALTH STAFFING, LLC CHAPTERS HEALTH SYSTEM ESTABLISHED A NOT-FOR-PROFIT SUBSIDIARY, CHAPTERS HEALTH STAFFING, LLC, IN 2009. CHAPTERS HEALTH STAFFING OPERATES A LICENSED HEALTH CARE SERVICES POOL. THIS COMPANY PROVIDES TEMPORARY STAFFING OF HEALTHCARE PERSONNEL TO OTHER CHAPTERS HEALTH SYSTEM SUBSIDIARIES AND ENABLES CHAPTERS HEALTH SYSTEM TO CENTRALIZE THE MANAGEMENT OF CLINICAL STAFF WHOSE DUTIES CROSS BETWEEN MULTIPLE SUBSIDIARIES. CHAPTERS HEALTH STAFFING STAFF INCLUDES PHYSICIANS, NURSES, RESPIRATORY THERAPISTS AND MANAGERS FOR THE ONCOLOGY PROGRAM, MEDICAL STAFF AND INFUSION SERVICES. G. CHAPTERS HEALTH SYSTEM DEVELOPMENT DEPARTMENT THE CHAPTERS HEALTH SYSTEM DEVELOPMENT DEPARTMENT IS THE FUNDRAISING ENTITY FOR LIFEPATH HOSPICE AND GOOD SHEPHERD HOSPICE. THROUGH COMMUNITY EVENTS AND FUNDRAISING ACTIVITIES, THE DEVELOPMENT DEPARTMENT RAISES FUNDS TO SUPPORT THE UNFUNDED PROGRAMS OF LIFEPATH HOSPICE AND GOOD SHEPHERD HOSPICE, WHICH INCLUDE CHARITY CARE, COMMUNITY GRIEF SUPPORT AND MEDICAL STUDENT EDUCATION. IN 2011, A TOTAL OF 21,954 DONORS CONTRIBUTED $3,119,444.91 TO THE CHAPTERS HEATH SYSTEM DEVELOPMENT DEPARTMENT THROUGH CAPITAL CAMPAIGNS, MEMORIALS, REALIZED PLANNED GIFTS, SPECIAL EVENTS AND OTHER GIFTS. H. CHAPTERS SENIOR INDEPENDENCE, INC. CHAPTERS SENIOR INDEPENDENCE, INC IS A NOT FOR PROFIT CORPORATION FORMED IN 2011. CHAPTERS SENIOR INDEPENDENCE'S MISSION IS TO PROVIDE SERVICES FOR THE SUPPORT AND CARE OF FRAIL ELDERLY PERSONS. CHAPTERS SENIOR INDEPENDENCE WILL PROVIDE THE AFOREMENTIONED SERVICES THROUGH CHAPTERS HEALTH PACE (PACE) AND CHAPTERS NURSING HOME DIVERSION (HOME DIVERSION). PACE PROVIDES COMPLETE HEALTH CARE SOLUTIONS FOR SENIORS WHO WANT TO REMAIN INDEPENDENT. HOME DIVERSION PROVIDES CASE MANAGEMENT SERVICES TO EVALUATE AND COORDINATE VARIOUS SERVICES THAT ARE INDISPENSIBLE TO ELDERLY PERSONS.
Significant changes to organizational documents Form 990, Part VI, Section A, Line 4 THE ARTICLES OF INCORPORATION AND BYLAWS WERE AMENDED FOR THE NAME CHANGE FROM HPC HEALTHCARE TO CHAPTERS HEALTH SYSTEM, INC. IN ADDITION, THE ORGANIZATION'S BYLAWS WERE AMENDED TO INCLUDE ALL C-SUITE EXECUTIVES AS OFFICERS OF THE CORPORATION. THE AMENDED BYLAWS ALSO COMBINE THE CORPORATE COMPLIANCE COMMITTEE AND THE AUDIT COMMITTEE INTO ONE COMMITTEE CALLED THE "AUDIT AND COMPLIANCE COMMITTEE".
Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b CHAPTERS HEALTH SYSTEM, INC. RETAINS AN INDEPENDENT TAX ADVISOR TO ASSIST MANAGEMENT IN THE PREPARATION AND REVIEW OF ITS IRS FORM 990. PRIOR TO FILING THE RETURN, MANAGEMENT AND THE INDEPENDENT TAX ADVISOR REVIEW THE RETURN AND ALL REQUIRED SCHEDULES WITH THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE COMPENSATION COMMITTEE IS COMPOSED OF INDEPENDENT DIRECTORS OF THE COMPANY. UPON COMPLETION OF ITS REVIEW, THE COMPENSATION COMMITTEE RECOMMENDS TO THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS THAT MANAGEMENT BE AUTHORIZED TO SIGN AND FILE THE RETURN. UNDER THE COMPANY'S BY LAWS THE EXECUTIVE COMMITTEE HAS THE AUTHORITY TO TAKE THIS ACTION ON BEHALF OF THE BOARD OF DIRECTORS. A COPY OF THE FORM 990 IS PROVIDED TO THE FULL BOARD PRIOR TO FILING WITH THE IRS AND THE EXECUTIVE COMMITTEE REPORTS ITS ACTIVITIES TO THE BOARD OF DIRECTORS ON A QUARTERLY BASIS.
Conflict of interest policy Form 990, Part VI, Section B, Line 12c ANNUALLY, EACH OFFICER, DIRECTOR AND KEY EMPLOYEE SIGNS AN ACKNOWLEDGEMENT AND DISCLOSURE FORM ATTESTING THAT THEY HAVE READ THE CONFLICT OF INTEREST POLICY AND AGREEING TO COMPLY FULLY WITH ITS TERMS AND CONDITIONS DURING THEIR SERVICES WITH CHAPTERS HEALTH SYSTEM, INC. THEY FURTHER AGREE THAT IF, AT ANY TIME SUBSEQUENT TO THE SUBMISSION OF THE DISCLOSURE FORM, THEY BECOME AWARE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST OR THE INFORMATION PREVIOUSLY SUBMITTED BECOMES INACCURATE OR INCOMPLETE, THEY WILL PROMPTLY NOTIFY THE CHS BOARD OF DIRECTORS OR THE PRESIDENT AND CEO OF CHAPTERS HEALTH SYSTEM, INC. DETERMINATION OF AND REMEDIES FOR CONFLICTS OF INTEREST 1. DISCLOSURE. 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 DIRECTORS (AND MEMBERS OF COMMITTEES) CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE DISCLOSURE SHALL BE MADE AS SOON AS PRACTICABLE FOLLOWING THE REALIZATION BY THE INTERESTED PERSON THAT AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST EXISTS. ORDINARILY, DISCLOSURES BY INTERESTED PERSONS SHOULD BE TO THE CHAIRPERSON OF THE BOARD. WHEN AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST BECOMES APPARENT IN THE COURSE OF A BOARD MEETING (OR COMMITTEE MEETING), THE INTERESTED PERSON SHALL IMMEDIATELY DISCLOSE HIS OR HER FINANCIAL INTEREST AND RELATED MATERIAL FACTS TO THE PRESIDING DIRECTOR OR OFFICER AT SUCH MEETING. 2. DETERMINING WHETHER A CONFLICT OF INTEREST EXISTS. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, THE INTERESTED PERSON SHALL LEAVE THE 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. 3.PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST. (A) AN INTERESTED PERSON WHO HAS A CONFLICT OF INTEREST MAY MAKE A PRESENTATION AT THE BOARD (OR COMMITTEE) MEETING, BUT AFTER SUCH PRESENTATION, HE OR SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULT IN THE CONFLICT OF INTEREST. THE INTERESTED PERSON WHO HAS A CONFLICT OF INTEREST WILL NOT BE COUNTED AS PRESENT FOR DETERMINING A MAJORITY WITH RESPECT TO THE VOTE ON THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE CONFLICT OF INTEREST. (B) THE CHAIRPERSON OF THE BOARD (OR COMMITTEE) SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. (C) AFTER EXERCISING DUE DILIGENCE, THE BOARD (OR COMMITTEE) SHALL DETERMINE WHETHER CHAPTERS HEALTH SYSTEM CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR BUSINESS ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. (D)IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD (OR COMMITTEE) SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS (OR COMMITTEE MEMBERS) WHETHER THE TRANSACTION OR ARRANGEMENT IS IN CHS'S BEST INTEREST AND FOR ITS OWN BENEFIT AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO CHS AND SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATION. VIOLATIONS OF THE CONFLICTS OF INTEREST POLICY (A) IF THE BOARD (OR COMMITTEE) HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE INTERESTED PERSON OF THE BASIS FOR SUCH BELIEF AND AFFORD THE INTERESTED PERSON AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. (B) IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED UNDER THE CIRCUMSTANCES, THE BOARD (OR COMMITTEE) DETERMINES THAT THE INTERESTED PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE SUCH ACTION AS IT DETERMINES TO BE APPROPRIATE, INCLUDING CORRECTIVE AND DISCIPLINARY ACTION. RECORD OF PROCEEDINGS THE MINUTES OF THE BOARD (AND EACH COMMITTEE) SHALL CONTAIN: 1. THE NAME OF EACH PERSON WHO DISCLOSED OR OTHERWISE WAS FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S (OR COMMITTEE'S) DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED. 2. THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSION, INCLUDING ANY ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH. PERIODIC REVIEWS TO ENSURE THAT CHS OPERATES IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES AND THAT IT DOES NOT ENGAGE IN ACTIVITIES THAT COULD JEOPARDIZE ITS STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAX, PERIODIC REVIEWS SHALL BE CONDUCTED. CHS MAY, BUT NEED NOT, USE AN OUTSIDE ADVISOR TO CONDUCT A PERIODIC REVIEW. THE PERIODIC REVIEW SHALL INCLUDE, AT A MINIMUM, THE FOLLOWING SUBJECTS: 1. WHETHER COMPENSATION ARRANGEMENTS AND BENEFITS ARE REASONABLE AND ARE THE RESULTS OF ARM'S-LENGTH BARGAINING. 2. WHETHER AGREEMENTS TO PROVIDE HEALTH CARE AND AGREEMENTS WITH OTHER HEALTH CARE PROVIDERS, EMPLOYEES AND THIRD PARTY PAYERS FURTHER CHS'S CHARITABLE PURPOSES AND DO NOT RESULT IN PRIVATE INUREMENT OR IMPERMISSIBLE PRIVATE BENEFIT.
Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a THE ORGANIZATION ENGAGED AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST IN ESTABLISHING A COMPENSATION CHARTER THAT DETAILS THE ORGANIZATION'S PROCEDURES FOR SETTING COMPENSATION OF THE CEO AND ALL OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. THE COMPENSATION CHARTER ESTABLISHED THE COMPENSATION COMMITTEE, THE INDEPENDENT BODY RESPONSIBLE FOR ESTABLISHING THE COMPENSATION OF THE CEO AND ALL OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. THE COMPENSATION COMMITTEE RELIES ON A RECENT COMPENSATION STUDY PERFORMED BY AN INDEPENDENT COMPENSATION CONSULTANT, WHICH IS DONE ON AN ANNUAL BASIS, THAT PROVIDES COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS AND REPORTS ITS ACTIVITIES TO THE BOARD OF DIRECTORS AT THE NEXT REGULARLY SCHEDULED MEETING. THE COMPENSATION COMMITTEE ADEQUATELY DOCUMENTS ITS COMPENSATION DETERMINATIONS IN THE MEETING MINUTES ON A TIMELY BASIS.
Process used to establish compensation of other officers/key employees Form 990, Part VI, Section B, Line 15b SEE NARRATIVE FOR PART VI, LINE 15A
Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 THE ORGANIZATION'S ARTICLES OF INCORPORATION ARE FILED WITH AND VIEWABLE BY THE PUBLIC AT THE OFFICIAL WEBSITE OF THE FLORIDA DEPARTMENT OF STATE, DIVISION OF CORPORATIONS. THE ORGANIZATION'S BYLAWS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. UNAUDITED FINANCIAL STATEMENTS OF THE ORGANIZATION ARE FILED AND VIEWABLE BY THE PUBLIC AT THE OFFICIAL WEBSITE OF THE STATE OF FLORIDA, DIVISION OF CONSUMER SERVICES. THE ORGANIZATION IS REQUIRED TO FILE ITS AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND OTHER FINANCIAL INFORMATION WITH ITS ANNUAL MEDICARE COST REPORT. THIS INFORMATION IS SUBJECT TO A PUBLIC RECORDS REQUEST. IN ADDITION, THE ORGANIZATION REPORTS ITS FINANCIAL PERFORMANCE EACH YEAR IN ITS ANNUAL REPORT, COPIES OF WHICH ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A GEORGE H. WALLACE, H. DARRELL WHITE, KATHY L. FERNANDEZ, RONALD S. SCHONWETTER, ANDREW LUTTON, BRIAN HINTON, JAMES T. JOINER, REX YENTES, DAVID O'NEIL AND STANLEY L. PIOTROWSKI DEVOTE APPROXIMATELY 2 HOURS A WEEK TO GOOD SHEPHERD HOSPICE, INC., A RELATED TAX-EXEMPT ORGANIZATION. GEORGE H. WALLACE, H. DARRELL WHITE, KATHY L. FERNANDEZ, RONALD S. SCHONWETTER, ANDREW LUTTON, GENE FOGARTY, WILLIAM BECKER, JR., HERB BELL, DAVID O'NEIL, KRISTIN E. DIMEO, R. FENN GILES, JR. AND VICKI MARSEE DEVOTE APPROXIMATELY 2 HOURS A WEEK TO LIFEPATH HOSPICE, INC., A RELATED TAX-EXEMPT ORGANIZATION. GEORGE H. WALLACE, H. DARRELL WHITE, KATHY L. FERNANDEZ, RONALD S. SCHONWETTER, ANDREW LUTTON AND DAVID O'NEIL DEVOTE APPROXIMATELY 1 HOUR A WEEK TO THE JUDGE ALVA CARVER FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. GEORGE H. WALLACE, H. DARRELL WHITE, KATHY L. FERNANDEZ, RONALD S. SCHONWETTER, ANDREW LUTTON AND DAVID O'NEIL DEVOTE APPROXIMATELY 2 HOURS A WEEK TO CHAPTERS HEALTH SENIOR INDEPENDENCE, INC., A RELATED TAX-EXEMPT ORGANIZATION.
Other changes in net assets or fund balances Form 990, Part XI, Line 5 NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - -1528847; CHANGE IN VALUE OF SPLIT INTEREST AGREEMENT - -383694; CHANGE IN CASH SURRENDER VALUE - 3988; TRANSFER TO AFFILIATES - -2000000;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID: 11000230
Software Version: v2011.1.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
CHAPTERS HEALTH SYSTEM INC
 
Employer identification number

59-2264957
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity







(1) CHAPTERS HEALTH PALLIATIVE CARE LLC
12973 TELECOM PARKWAY STE 100
TEMPLE TERRACE,FL33637
20-5620723 		PALLIATIVE FL 389,214 0 NA
 
(2) CHAPTERS HEALTH PHARMACY LLC
12973 TELECOM PARKWAY STE 100
TEMPLE TERRACE,FL33637
20-8607458 		PHARMACY FL 8,819,646 660,367 NA
 
(3) CHAPTERS HEALTH STAFFING LLC
12973 TELECOM PARKWAY STE 100
TEMPLE TERRACE,FL33637
26-4146328 		STAFFING FL 1,901,619 0 NA
 






Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) LIFEPATH HOSPICE INC

12973 TELECOM PARKWAY STE 100

TEMPLE TERRACE,FL33637
20-5276870 		HOSPICE CARE FL 501(C)(3) 9 NA
 
Yes
 
(2) GOOD SHEPHERD HOSPICE INC

12973 TELECOM PARKWAY STE 100

TEMPLE TERRACE,FL33637
20-5276923 		HOSPICE CARE FL 501(C)(3) 9 NA
 
Yes
 
(3) THE JUDGE ALVA CARVER FOUNDATION INC

12973 TELECOM PARKWAY STE 100

TEMPLE TERRACE,FL33637
20-0187631 		SUPPORT FL 501(C)(3) N/A NA
 
Yes
 
(4) CHAPTERS HEALTH SENIOR INDEPENDENCE INC

12973 TELECOM PARKWAY STE 100

TEMPLE TERRACE,FL33637
27-5158323 		LONG-TERM CARE FL 501(C)(3) 9 NA
 
Yes
 






For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership












Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) LIFEPATH HOSPICE INC

 A 1,540,787 FMV
(2) GOOD SHEPHERD HOSPICE INC

 A 845,716 FMV
(3) LIFEPATH HOSPICE INC

 K 454,892 FMV
(4) GOOD SHEPHERD HOSPICE INC

 K 242,312 FMV
(5) LIFEPATH HOSPICE INC

 N 4,282,322 FMV
(6) GOOD SHEPHERD HOSPICE INC

 N 2,626,216 FMV
(7) LIFEPATH HOSPICE INC

 P 28,208,677 FMV
(8) GOOD SHEPHERD HOSPICE INC

 P 14,281,010 FMV
(9) CHAPTERS HEALTH SENIOR INDEPENDENCE INC

 R 2,000,000 FMV
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


Software ID: 11000230
Software Version: v2011.1.0