Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
GOOD SHEPHERD REHABILITATION NETWORK
Employer identification number
23-2216041
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
6,422,146
7,917,385
3,576,315
4,688,896
3,468,259
26,073,001
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..
6,422,146
7,917,385
3,576,315
4,688,896
3,468,259
26,073,001
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.
26,073,001
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
6,422,146
7,917,385
3,576,315
4,688,896
3,468,259
26,073,001
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
4,991,806
7,228,768
6,483,150
4,783,360
5,506,148
28,993,232
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
277,503
210,099
487,602
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
5,405
4,970
1,280,505
1,428,321
2,719,201
11
Total support (Add lines 7 through 10).
58,273,036
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
200,429,979
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
44.740 %
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
48.010 %
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUE CAFE REVENUE PROFESSIONAL SVC FEES EXPENSE REIMBURSEMENT MEDICAL RECORDS
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
GOOD SHEPHERD REHABILITATION NETWORK
Employer identification number
23-2216041
Identifier
Return Reference
Explanation
FORM 990, PART V, LINE 2:
THE SALARY AND BENEFIT EXPENSES REPORTED ON FORM 990, PART IX, AND THE EMPLOYEE INFORMATION REPORTED ON FORM 990, PART VII, ARE THE GOOD SHEPHERD REHABILITATION NETWORK'S ("GSRN") ALLOCATED PAYROLL COSTS BASED ON TIME SPENT. ALL INDIVIDUALS WORKING AT GSRN ARE EMPLOYEES OF THE GOOD SHEPHERD REHABILITATION HOSPITAL ("GSRH") AND ARE REPORTED ON ITS FORM W-3 UNDER EIN: 23-1371947. GSRH IS AN AFFILIATED TAX-EXEMPT ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A
TWO-THIRDS OF THE ORGANIZATION'S TRUSTEES SHALL BE ELECTED BY THE SYNOD COUNCIL OF THE NORTHEASTERN PENNSYLVANIA SYNOD OF THE EVANGELICAL CHURCH IN AMERICA.
FORM 990, PART VI, SECTION A, LINE 7B
THE ORGANIZATION'S BYLAWS MAY BE ALTERED, AMENDED, OR REPEALED BY THE BOARD. IN ADDITION, THE AMENDMENT SHALL BE APPROVED BY THE SYNOD COUNCIL OF THE NORTHEASTERN PENNSYLVANIA SYNOD OF THE EVANGELICAL CHURCH IN AMERICA BEFORE TAKING EFFECT.
FORM 990, PART VI, SECTION B, LINE 11
THE IRS FORM 990 IS PREPARED USING INFORMATION SOLICITED FROM OFFICERS, DIRECTORS, TRUSTEES, BOARD COMMITTEE MEMBERS, AND MANAGEMENT. THIS GROUP OF INDIVIDUALS IS PROVIDED A DRAFT RETURN BEFORE THE FINAL RETURN IS FILED. QUESTIONS, COMMENTS, AND ADDITIONAL INFORMATION PROVIDED BY THIS GROUP ARE INCORPORATED INTO THE FINAL RETURN. THE FINAL RETURN IS REVIEWED AT A COMMITTEE LEVEL OF THE BOARD PRIOR TO IT BEING FILED.
FORM 990, PART VI, SECTION B, LINE 12C
THERE IS A SYSTEMATIC PROCESS COORDINATED THROUGH THE GOVERNANCE COMMITTEE WHERE THE CONFLICT OF INTEREST STATEMENTS COMPLETED ANNUALLY BY BOARD MEMBERS AND SENIOR LEADERSHIP TEAM MEMBERS ARE REVIEWED BY THE GOVERNANCE COMMITTEE. WHENEVER THE COMMITTEE FEELS THE CONFLICT STATEMENT IS EITHER INCOMPLETE OR FEELS SOMETHING MAY BE MISSING, THE COMMITTEE WILL ASK MANAGEMENT TO PURSUE FURTHER DUE DILIGENCE. WHEN A BOARD MEMBER DOES HAVE AN INHERENT CONFLICT, THE TRUSTEE IS ASKED TO EITHER ABSTAIN FROM VOTING OR EXCUSE HIMSELF FROM THE ROOM DURING THE DISCUSSION AND VOTING.
FORM 990, PART VI, SECTION B, LINE 15
THE GOOD SHEPHERD REHABILITATION NETWORK BOARD DELEGATES RESPONSIBILITY FOR FOLLOWING ALL LEGAL AND REGULATORY REQUIREMENTS AFFECTING EXECUTIVE COMPENSATION TO THE HUMAN RESOURCES/EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD. THIS COMMITTEE IS CHARGED WITH ADMINISTRATION OF COMPENSATION PRACTICES FOR OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. THIS COMMITTEE SELECTED AND USES AN INDEPENDENT CONSULTING FIRM SPECIALIZING IN HEALTHCARE EXECUTIVE COMPENSATION MATTERS AND USES COMPARABLE COMPETITIVE MARKET DATA IN THEIR ANALYSIS. THE SERVICES OF AN INDEPENDENT COMPENSATION CONSULTANT (IHS) WERE UTILIZED AND THEIR LATEST REPORT TO THE HUMAN RESOURCE COMPENSATION COMMITTEE WAS DATED AUGUST 30, 2011. COMMITTEE MEETINGS ARE HELD ON AN ONGOING BASIS AND ARE DOCUMENTED IN DETAIL.
FORM 990, PART VI, SECTION C, LINE 19
FINANCIAL STATEMENTS ARE PUBLISHED TO THE ORGANIZATION'S WEBSITE AT LEAST ANNUALLY. THE GOVERNING DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST.
FORM 990, PART VII, SECTION A:
SARA T. GAMMON, DANIEL C. CONFALONE, PHILLIP R. BRYANT, ANTHONY R. BONGIOVANNI, AND SAMUEL A. MIRANDA, JR. ARE OFFICERS/KEY EMPLOYEES FOR ALL 7 ENTITIES WITHIN THE GOOD SHEPHERD REHABILITATION NETWORK. THEY EACH DEVOTE APPROXIMATELY 60 HOURS PER WEEK TO THE ENTIRE GROUP OF ENTITIES. THE AVERAGE HOURS LISTED IN COLUMN (B) FOR EACH INDIVIDUAL REPRESENTS THE APPROXIMATE PORTION OF 60 HOURS DEVOTED TO THE GOOD SHEPHERD REHABILITATION NETWORK PER WEEK. THE COMPENSATION AND BENEFIT INFORMATION REPORTED IN COLUMNS (D) AND (F) REPRESENTS WHAT EACH INDIVIDUAL EARNS FOR THEIR TIME SPENT ON THE ENTIRE GROUP OF 7 ENTITIES. INFORMATION FOR THE TOP FIVE HIGHEST COMPENSATED EMPLOYEES IS REPORTED IN THE SAME MANNER, AS THESE INDIVIDUALS ALSO DEVOTE APPROXIMATELY 60 HOURS PER WEEK TO THE ENTIRE GROUP OF ENTITIES. THE BOARD MEMBERS ALSO DEVOTE TIME TO FIVE OTHER ORGANIZATIONS IN THE GROUP. TOTAL TIME SPENT BY BOARD MEMBERS RANGES FROM .75 HOURS PER WEEK TO 3.25 HOURS PER WEEK. THE AVERAGE HOURS LISTED IN COLUMN (B) FOR EACH BOARD MEMBER REPRESENTS THE APPROXIMATE PORTION OF HOURS DEVOTED TO THE GOOD SHEPHERD REHABILITATION NETWORK PER WEEK.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 26,408,701. INCOME ON INVESTMENT IN UNCONSOLIDATED SUBSIDIARY 6,764,521. INEFFECTIVENESS OF DERIVATIVE FINANCIAL INSTRUMENT 616,905. CHANGE IN FAIR VALUE OF DERIVATIVE FINANCIAL INSTRUMENTS 93,257. PENSION LIABILITY ADJUSTMENT - UNCONSOLIDATED SUBSIDIARY 369,660. OTHER CHANGES IN UNRESTRICTED NET ASSETS 541,782. OTHER CHANGES IN TEMPORARILY RESTRICTED NET ASSETS -195,361. CHANGE IN VALUE OF SPLIT-INTEREST AGREEMENTS 952,373. VALUATION GAIN, BENEFICIAL INTEREST IN PERPETUAL TRUSTS 1,454,099. REDUCTION IN EQUITY TO REPORT HEALTH NETWORK LABS REVENUE -316,815. TOTAL TO FORM 990, PART XI, LINE 5: 36,689,122.
FORM 990, PART XI, LINE 2C:
THE PROCESSES USED BY THE COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE ORGANIZATION'S FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.