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
St Francis Hospital - Poughkeepsie
Employer identification number
14-1338503
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.") .
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
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
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
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
St Francis Hospital - Poughkeepsie
Employer identification number
14-1338503
Identifier
Return Reference
Explanation
Governing Body and Managemnet
FORM 990, PART VI, SECTION A
Line 6: St. Francis Hospital has a single Member, Hastings Health Systems, Inc. Line 7A: Hastings Health System, Inc. as the sole Member of the Corporation, shall elect qualified persons to the Board of Trustees at its Annual meeting in accordance with the provisions of the organization's By-Laws. Line 7b: Hastings Health System, Inc. as the sole Member of the Corporation, shall consider the Annual Report of the Corporation at its Annual Meeting, to be submitted and verified by the President and the Treasurer or a majority of the Trustees. The following powers are reserved exclusively to the Member, and no attempted exercise of any such powers by anyone other than the Member shall be valid or of any force or effect whatsoever: 1. To change the philosophy, mission, and purpose of the corporation; 2. To adopt and/or amend the Certificate of Incorporation; 3. To adopt and/or amend Bylaws, 4. To elect the Board of Trustees and to remove Board members with or without cause; 5. To appoint the President and Chief Executive Officer of the organization; 6. To approve the purchase, sale, lease, mortgage or real property; to approve the purchase, sale, or gift of capital assets; 7. To approve the merger, consolidation, or affiliation of the corporation with another corporation, organization, or program; 8. To approve the dissolution of the corporation and disposition of assets. Line 8: Minutes of each Board meeting shall be taken and disseminated to each Board member as soon as possible after the conclusion of the meeting. Minutes of all meetings of the Board of Trustees, the Executive Committee, or other Board Committees shall reflect all business conducted, including findings, conclusions and recommendations.
Policies
FORM 990, PART VI, SECTION B
Line 11: The Form 990 is presented annually to the Audit and Compliance Committee for review, comment and approval. The presentation includes discussion of the compilation process, current year disclosures, overview of relevant schedules, compliance review, education regarding future changes to the form, and recommendations going forward. The Board approves the Form 990 for filing with the Internal Revenue Service. Line 12: All members of the Hospital's Board of Trustees, as well as all officers and employees must annually file a Conflict of Interest Disclosure Statement with the Hospital's Compliance Officer, who shall keep a confidential file of these Statements and consult with outside counsel, as necessary, concerning any potential problems or possible conflicts of interest. The Compliance Officer will review any disclosure (including Board members and other personnel covered by this policy), consult with counsel as necessary, and determine if such financial interest or outside relationship creates a conflict of interest, is improper, or creates the appearance of a conflict of interest or of improper conduct. The Compliance Officer will also review the information to determine if additional disclosures or other action is necessary. Full disclosure and recommendations will then be made to the Audit and Compliance Committee of the Board of Trustees as to the appropriate course of conduct or corrective action for the Hospital and for the personnel involved. Once a final decision is made on how to proceed, the personnel will be instructed as to the course of action decided upon. Line 15: The Executive Committee serves as the Compensation Committee for the President and CEO including an annual evaluation of the President and CEO. The Committee utilizes survey data to determine comparability for compensation. Compensation of other Officers and Key Employees is determined by the CEO, with consultation and recommendations from the Executive Committee. Survey data is utilized in conjunction with the standard Hospital annual employee appraisal process. Compensation decisions and reports are contemporaneously documented in the minutes of the meeting of the Committee when the decisions are made.
PUBLIC DISCLOSURE
FORM 990, PART VI, SECTION C
Line 19: The organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request as deemed appropriate. General information regarding governance, compliance, and financial reporting is made available to the public on the Hospital's website, through annual community benefit reports, and annual publication of the St. Francis Magazine.
FINANCIAL STATEMENTS AND REPORTING
FORM 990, PART XI
Line 2c: The Audit and Compliance Committee has the responsibility for the oversight of the audit of the annual financial statements, and the selection of an independent auditor. Line 3A: The Hospital did not meet the federal award criteria required to undergo an audit as set forth in the Single Audit Act of OMB Circular A-133. Entity wide financial statements audited in accordance with Government Auditing Standards (GAS) have been completed.
Form 990, Part VI, Line 2
Board of Trustees member, George T. Whalen III, and Board of Trustees member, George T. Whalen, Jr., have a family relationship. Board of Trustees member, George T. Whalen III, and Board of Trustees member, ALlan B. Rappleyea, have a family relationship. Board of Trustees Member, Michael Gartland, and Board of Trustees Member, Allan B. Rappleyea, have a business relationship. Board of Trustees Member, John J. Cina, and Board of Trustees Members, George T. Whalen, JR, Roger Fazzone, and Kelley Redl-Hardisty, have a business relationship. Board of Trustees Member, George Whalen III, and Board of Trustees Member, E. Richard O'Shea, have a business relationship.
Form 990, Part X, Line 24
Part IX Total Expenditures Telephone 163,278 18,142 Postage and shipping 267,387 29,709 Equipment rental 546,737 60,748 Printing & publications 164,999 18,333 Utilities 1,633,338 181,482 Purchased Services 9,839,572 1,093,285 Other Direct Expenses 131,233 14,581 Bad Debt Expense 9,905,698 1,100,633 Licenses, dues, 295,191 32,799 --------------------------------------------------------------- Total 22,947,436 2,549,715 Form 990, Part XI, Line 5 Other changes in Net Assets or fund Balances: Donated Services - $3,870 Net Assets Released from Restriction and other below the line adjustments to the Financial Statements- $1,220,459 Unrealized Gains on Investment - $(1,193,124) Net Loss of Pre School Reported on Separate Form 990 - $(697,863) Losses on Investments in Joint Ventures - $(191,195) ---------------------------------------------------------------------- Total Changes in Fund Balance - $(857,853)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.