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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
EMA HEALTH SERVICES INC
Employer identification number
52-1234495
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 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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
If the organization did not check a 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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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......
582,945
813,252
1,091,370
1,058,152
1,046,834
4,592,553
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.
582,945
813,252
1,091,370
1,058,152
1,046,834
4,592,553
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
4,592,553
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
582,945
813,252
1,091,370
1,058,152
1,046,834
4,592,553
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.)
..
101
18,351
18,452
13
Total support. (Add lines 9, 10c, 11, and 12.)..
582,945
813,252
1,091,370
1,058,253
1,065,185
4,611,005
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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
99.600 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.990 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
EMA HEALTH SERVICES INC
Employer identification number
52-1234495
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 3
EMA HEALTH SERVICES IS GOVERNED BY THE BOARD OF DIRECTORS FOR EPISCOPAL MINISTRIES TO THE AGING, INC (EIN: 52-1710891).
FORM 990, PART VI, SECTION A, LINE 6
EPISCOPAL MINISTRIES TO THE AGING, INC IS THE SOLE MEMBER OF EMA HEALTH SERVICES, INC.
FORM 990, PART VI, SECTION A, LINE 7A
EPISCOPAL MINISTRIES TO THE AGING, INC, THE SOLE MEMBER OF EMA HEALTH SERVICES, INC, APPOINTS ALL DIRECTORS, EXCEPT FOR THE PRESIDENT, WHO SHALL BE AN EX-OFFICIO MEMBER OF THE BOARD.
FORM 990, PART VI, SECTION A, LINE 7B
THE FOLLOWING MUST BE APPROVED BY THE SOLE MEMBER: 1) CHANGING OF THE PHILOSOPHY, OBJECTIVES, OR PURPOSE OF THE CORPORATION. 2) AMENDING OF THE BY-LAWS OR ARTICLES OF INCORPORATION OF THE CORPORATION. 3) DISSOLUTION OR LIQUIDATION OF THE CORPORATION. 4) ELECTION OR REMOVAL OF ANY MEMBER OF THE BOARD OF DIRECTORS. 5) MERGING OR CONSOLIDATION OF THE CORPORATION. 6) APPOINTMENT OR REMOVAL OF THE PRESIDENT. 7) CREATION OF ANY SUBSIDIARY ORGANIZATION OR AFFILIATE OF THE CORPORATION WITH ANY OTHER ENTITY FOR THE PURPOSE OF THE JOINT CONDUCT OF BUSINESS OR OTHER PROGRAMS. 8) CONVEYANCE OF GRANT MORTGAGES, TRUST DEEDS OR CREATION OF OTHER LIENS ON ANY REAL PROPERTY ASSETS, OTHER THAN CONVEYANCES OR LIENS IN FAVOR OF ANY PUBLIC OR QUASI-PUBLIC AUTHORITY FOR ACCESS, UTILITIES, ROAD WIDENING AND SIMILAR FUNCTIONS WHICH DO NOT MATERIALLY IMPAIR THE USE OR VALUE OF THE BALANCE OF THE PROPERTY. 9) CONVEYANCE OF ANY OTHER ASSETS OF THE CORPORATION WHOSE FAIR MARKET VALUE EXCEEDS $25,000. 10) INCURRING ANY INDEBTEDNESS OR SERIES OF INDEBTEDNESS, EITHER OF WHICH EXCEEDS $25,000 OR TO GUARANTEE ANY INDEBTEDNESS OR SERIES OF INDEBTEDNESS, EITHER OF WHICH EXCEEDS $25,000. 11) TO APPROVE THE ANNUAL OPERATING BUDGET AND ANNUAL CAPITAL BUDGET AND ANY CHANGE IN EXCESS OF $50,000 THERETO. 12) APPROVAL OF THE STRATEGIC PLAN OF THE CORPORATION AND ANY AMENDMENT THERETO. 13) EXERCISING OF ANY POWERS MENTIONED ABOVE, OTHER THAN #10, THE CORPORATION MAY HAVE AS A MEMBER OR STOCKHOLDER OF ANOTHER CORPORATION OR PARTICIPANT IN ANY LLC, PARTNERSHIP, JOINT VENTURE OR OTHER ENTITY.
FORM 990, PART VI, SECTION B, LINE 11
THE PROCESS TO REVIEW THE FORM 990 IS AS FOLLOWS: 1) THE FINANCE STAFF REVIEWS THE RETURN FOR ACCURACY AND COMPLETENESS. 2) THE RETURN IS PRESENTED TO THE FINANCE COMMITTEE OF THE EMA BOARD OF TRUSTEES FOR THEIR REVIEW AND APPROVAL. 3) ONCE APPROVED BY THE FINANCE COMMITTEE, THE 990 IS RELEASED TO THE ENTIRE BOARD OF TRUSTEES FOR APPROVAL PRIOR TO THE RETURN BEING FILED.
FORM 990, PART VI, SECTION B, LINE 12C
CONFLICT OF INTEREST DISCLOSURES ARE DISTRIBUTED TO MEMBERS OF THE SENIOR LEADERSHIP TEAM IN JANUARY EACH YEAR. THE REMAINING MANAGEMENT STAFF AND TRUSTEE MEMBERS RECEIVE FORMS IN EARLY JUNE. THE COMPLETED FORMS ARE RETURNED TO HUMAN RESOURCES. A REPORT IS PREPARED SHOWING ALL CONFLICT OF INTEREST DISCLOSURES. THIS REPORT IS PRESENTED AT THE JULY MEETING OF THE AUDIT COMMITTEE. IF A CONFLICT OF INTEREST IS DETERMINED TO EXIST, THOSE WITH WHOM THERE IS A CONFLICT ABSTAIN FROM BEING INVOLVED IN DISCUSSIONS AND/OR DECISIONS REGARDING THE CONFLICT.
FORM 990, PART VI, SECTION B, LINE 15
THE PRESIDENT/CEO'S PERFORMANCE IS REVIEWED ANNUALLY BY THE EXECUTIVE COMMITTEE. THE PRESIDENT/CEO PREPARES A COMPREHENSIVE REPORT SHOWING THE RESULTS OF HIS/HER WORK DURING THE PAST YEAR AND GOALS FOR THE COMING YEAR. THIS REPORT IS REVIEWED BY THE EXECUTIVE COMMITTEE WHICH THEN DETERMINES THE ONGOING COMPENSATION FOR THE PRESIDENT/CEO. THE COMMITTEE GIVES THIS INFORMATION TO THE CFO WHO THEN SENDS IT TO VP OF HUMAN RESOURCES FOR PROCESSING. IN THE CASE OF A NEW CEO, A SEARCH FIRM IS USED TO NEGOTIATE SALARY AND BENEFITS DIRECTLY WITH THE CANDIDATE. THE SALARY IS NEGOTIATED TAKING INTO CONSIDERATION COMPARABLE SALARIES IN THE INDUSTRY TO DETERMINE A COMPENSATION PACKAGE WITHIN FAIR MARKET RANGE. THE PROCESS IS ALSO DOCUMENTED IN MINUTES DURING AN EXECUTIVE SESSION. COMPENSATION FOR THE EXECUTIVE DIRECTOR AND OTHER KEY EMPLOYEES IS DETERMINED BY THE CEO USING SIMILAR METHODS. SENIOR MANAGEMENT POSITIONS ARE PAID ACCORDING TO RESPONSIBILITY IN THE COMPANY, EXPERIENCE, CREDENTIALS, AND MANAGEMENT AND LEADERSHIP SKILLS.
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.
FORM 990, PART IX, LINE 11G
CONSULTING FEES: PROGRAM SERVICE EXPENSES 175,309. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 175,309. LABORATORY FEES : PROGRAM SERVICE EXPENSES 57. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 57. X-RAY FEES : PROGRAM SERVICE EXPENSES 839. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 839. MAINTENANCE CONTRACTS : PROGRAM SERVICE EXPENSES 7,500. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,500.
FORM 990, PAGE 5, PART V, LINE 2A
EMA HEALTH SERVICES, INC. IS AN AFFILIATE IN A GROUP OF WHICH EPISCOPAL MINISTRIES TO THE AGING, INC. (EIN 52-1710891) IS CONSIDERED A COMMON PAY AGENT FOR W-2 REPORTING. EPISCOPAL MINISTRIES TO THE AGING, INC. REPORTS ALL EMPLOYEES ON ITS FORM W-3, HOWEVER, EACH AFFILIATE HAS EMPLOYEES ALLOCATED TO THAT ENTITY. PER IRS INSTRUCTIONS, EMPLOYEES LISTED ON PART V, LINE 2A ARE THOSE WHO HAVE BEEN DEEMED TO BE EMPLOYEES OF THIS ORGANIZATION. EMA HEALTH SERVICES, INC. DOES NOT, HOWEVER, REPORT THESE EMPLOYEES ON A SEPARATE W-3 UNDER ITS OWN EIN.
FORM 990, PAGE 5, PART VI, LINE 1A
EMA HEALTH SERVICES, INC. IS AN AFFILIATE IN A GROUP OF WHICH EPISCOPAL MINISTRIES TO THE AGING, INC. (EIN 52-1710891) IS CONSIDERED THE PARENT. EMA, INC., AS PART OF ITS MANAGEMENT FUNCTIONS FOR THE GROUP, ISSUES ALL 1099 INFORMATION FORMS UNDER ITS EIN. EMA HEALTH SERVICES, INC. IS THEN ALLOCATED APPROPRIATE AMOUNTS FOR PROFESSIONAL SERVICES WHICH ARE THEN REPORTED ON PART IX OF THE FORM 990.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.