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
2011
Open to Public Inspection
Name of the organization
QUARRY HILL
Employer identification number
01-0213976
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) 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
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
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—2010.
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—2011.
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—2010.
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) 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.") .
211,985
15,270
170,621
20,408
14,100
432,384
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......
10,646,692
12,072,511
10,073,155
10,576,001
10,275,109
53,643,468
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.
10,858,677
12,087,781
10,243,776
10,596,409
10,289,209
54,075,852
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.)
54,075,852
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...
10,858,677
12,087,781
10,243,776
10,596,409
10,289,209
54,075,852
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,494,516
149,312
374,622
123,489
2,141,939
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
1,494,516
149,312
374,622
123,489
2,141,939
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.).
12,353,193
12,237,093
10,618,398
10,596,409
10,412,698
56,217,791
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 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
96.190 %
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
93.740 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
4.000 %
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
6.000 %
19a
33 1/3% support tests—2011.
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—2010.
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) 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
Schedule A (Form 990 or 990-EZ) 2011
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
2011
Open to Public Inspection
Name of the organization
QUARRY HILL
Employer identification number
01-0213976
Identifier
Return Reference
Explanation
CLASSES OF MEMBERS OR STOCKHOLDERS
FORM 990, PAGE 6, PART VI, LINE 6
PEN BAY HEALTHCARE (PBHC) IS THE SOLE MEMBER OF QUARRY HILL. MAINEHEALTH (EIN 01-0431680), AS THE SOLE MEMBER OF PBHC, HAS THE RIGHT TO APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BODY OF PBHC AND ITS SUBSIDIARIES.
ELECTION OF MEMBERS AND THEIR RIGHTS
FORM 990, PAGE 6, PART VI, LINE 7A
THE SOLE MEMBER, PEN BAY HEALTHCARE MAY ELECT THE BOARD OF DIRECTORS FROM A SLATE OF NOMINEES SUBMITTED BY THE CORPORATION. THE OFFICERS ARE ELECTED BY THE BOARD OF TRUSTEES.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS
FORM 990, PAGE 6, PART VI, LINE 7B
DECISIONS OF THE GOVERNING BODY SUCH AS BUDGETS, BUSINESS STRATEGIES, SIGNIFICANT FINANCIAL COMMITMENTS, AMENDMENTS TO THE ARTICLES OF INCORPORATION, AND ELECTION OF THE PRESIDENT/CEO AMONG OTHER DECISIONS, ARE SUBJECT TO APPROVAL BY PEN BAY HEALTHCARE & MAINEHEALTH.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990
FORM 990, PAGE 6, PART VI, LINE 11B
THE FORM 990 IS MADE AVAILABLE TO THE FULL BOARD. A FINAL DETAILED REVIEW OF THE FORM 990 IS PERFORMED BY THE CHIEF FINANCIAL OFFICER BEFORE SIGNING AND PRIOR TO FILING.
ENFORCEMENT OF CONFLICTS POLICY
FORM 990, PAGE 6, PART VI, LINE 12C
AT THE BEGINNING OF BOARD SERVICE, MEMBERS ARE REQUIRED TO DOCUMENT ANY CONFLICT OF INTEREST THAT MAY EXIST. THEY ARE REQUIRED TO REPORT ANY ADDITIONAL CONFLICTS THAT MAY ARISE. BOARD MEMBER CONFLICT OF INTEREST FORMS ARE UPDATED AND REVIEWED ANNUALLY.
COMPENSATION PROCESS FOR TOP OFFICIAL
FORM 990, PAGE 6, PART VI, LINE 15A
QUARRY HILL BOARD OF DIRECTORS ARE RESPONSIBLE FOR AN ANNUAL EVALUATION OF THE PRESIDENT/CEO AND THE OTHER KEY ADMINISTRATIVE EMPLOYEES OF THE ORGANIZATION. FOR THOSE KEY ADMINISTRATIVE EMPLOYEES THAT ARE SHARED WITH PBHC, COMPENSATION IS EVALUATED BY THE PBHC GOVERNANCE COMMITTEE AND APPROVED BY THE ORGANIZATION'S BOARD OF DIRECTORS.
COMPENSATION PROCESS FOR OFFICERS
FORM 990, PAGE 6, PART VI, LINE 15B
THE MEMBER IS RESPONSIBLE FOR AN ANNUAL EVALUATION OF THE PRESIDENT/CEO AND THE OTHER KEY ADMINISTRATIVE EMPLOYEES OF THE ORGANIZATION. COMPENSATION IS EVALUATED BY THE COMPENSATION COMMITTEE APPOINTED BY THE MEMBER, AND THE ORGANIZATION'S BOARD OF TRUSTEES MUST APPROVE OF THE COMPENSATION. IN ADDITION, THE ORGANIZATION UTILIZES THE SERVICES OF AN INDEPENDENT COMPENSATION CONSULTING FIRM AND INDUSTRY SURVEY.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION
FORM 990, PAGE 6, PART VI, LINE 19
DOCUMENTS THAT ARE REQUIRED TO BE OPEN FOR THE PUBLIC INSPECTION ARE MADE AVAILABLE UPON REQUEST.
ADDITIONAL INFORMATION
FORM 990, PART VII
COLUMN B - AVERAGE HOURS PER WEEK AT RELATED ORGANIZATIONS JOEL LAFLEUR WAS A PHYSICIAN AT PENOBSCOT BAY MEDICAL CENTER AND SPENT THE MAJORITY OF HIS TIME AT THAT ORGANIZATION.
OTHER CHANGES IN NET ASSETS EXPLANATION
FORM 990, PART XI, LINE 5
OTHER CHANGES IN NET ASSETS INCLUDE: 312,710 - INCREASE IN MARKET VALUE OF INVESTMENTS 30,370 - GAIN ON SALE OF INVESTMENTS 20,332 - INVESTMENT INCOME (3,522) - MISC. FEES 359,890 - TOTAL OTHER CHANGES IN NET ASSETS
ADDITIONAL INFORMATION
FORM 990, PART XII
A-133 AUDIT - THE ORGANIZATION DID NOT HAVE A SEPARATE A-133 AUDIT. IT WAS PART OF THE CONSOLIDATED A-133 AUDIT OF ITS PARENT COMPANY, PEN BAY HEALTHCARE (EIN 22-2494475).
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.