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
ST JOSEPH'S HOSPITAL OF TAMPA FOUNDATION INC
Employer identification number
59-1100828
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)
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
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
(A)
ST JOSEPH'S HOSPITAL
590774199
501(C)(3)
Yes
1,626,661
Total
1,626,661
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......
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
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
ST JOSEPH'S HOSPITAL OF TAMPA FOUNDATION INC
Employer identification number
59-1100828
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 2
ELAINE SHIMBERG, CHAIRMAN, AND KAREN SHIMBERG KELLY, TRUSTEE - FAMILY RELATIONSHIP
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF THE ST. JOSEPH'S HOSPITAL OF TAMPA FOUNDATION, INC. IS ST. JOSEPH'S HEALTH CARE CENTER, INC.
FORM 990, PART VI, SECTION A, LINE 7A
(A) THE PRESIDENT OF THE CORPORATION SHALL SERVE AS AN EX-OFFICIO TRUSTEE OF THE CORPORATION. (B) ALL OTHER TRUSTEES SHALL BE APPOINTED (THE "APPOINTED TRUSTEES") BY THE BOARD OF TRUSTEES OF THE CORPORATE MEMBER AT AN ANNUAL MEETING OF SAID BOARD PURSUANT TO THE FOLLOWING PROCEDURE: (I) THE NOMINATING COMMITTEE SHALL IDENTIFY POTENTIAL TRUSTEES, PRESENT THE NAMES TO THE TRUSTEES, INTERVIEW THOSE CANDIDATES, CONSULT WITH THE TRUSTEES AND MAKE RECOMMENDATIONS TO THE BOARD OF TRUSTEES OF THE CORPORATE MEMBER. (II) THE BOARD OF TRUSTEES OF THE CORPORATE MEMBER SHALL REVIEW THE RECOMMENDATIONS OF THE NOMINATING COMMITTEE AND EITHER APPOINT THE NEW TRUSTEES OR REQUEST ADDITIONAL RECOMMENDATIONS FROM THE NOMINATING COMMITTEE.
FORM 990, PART VI, SECTION A, LINE 7B
THE FOLLOWING POWERS ARE RESERVED TO THE BOARD OF DIRECTORS OF THE CORPORATE MEMBER: (I) APPROVE THE AMENDMENT OR RESTATEMENT OF THE ARTICLES OF INCORPORATION OF THE CORPORATION, IN WHOLE OR IN PART, AND RECOMMEND THE SAME TO CHE FOR ADOPTION. (II) APPROVE THE AMENDMENT OR RESTATEMENT OF KEY BYLAWS PROVISIONS (AS DEFINED IN THE BYLAWS) OF THE CORPORATION, IN WHOLE OR IN PART, AND RECOMMEND THE SAME TO CHE FOR ADOPTION. (III) APPROVE THE AMENDMENT OR RESTATEMENT OF NON-KEY BYLAWS PROVISIONS OF THIS CORPORATION, IN WHOLE OR IN PART. (IV) APPOINT AND REMOVE TRUSTEES OF THE CORPORATION, WITH OR WITHOUT CAUSE. (V) APPROVE THE OFFICIAL INTERPRETATION OF THE PHILOSOPHY AND MISSION OF THE CORPORATION. (VI) APPROVE THE STRATEGIC PLAN OF THE CORPORATION (VII) APPROVE THE ANNUAL OPERATING PLAN AND BUDGET FOR OF THE CORPORATION. (VIII) APPROVE SIGNIFICANT FINANCIAL TRANSACTIONS (AS DEFINED IN THE BYLAWS) AND SIGNIFICANT BUDGET VARIANCES OF THE CORPORATION, AND RECOMMEND THE SAME TO CHE FOR ADOPTION AND AUTHORIZATION. (IX) APPROVE THE ESTABLISHMENT OR DISSOLUTION OF ORGANIZATIONAL RELATIONSHIPS BY THE CORPORATION, INCLUDING WITHOUT LIMITATION, SUBSIDIARY CORPORATIONS, AND SIGNIFICANT PARTNERSHIPS, JOINT VENTURES AND MERGERS AS DEFINED BY THE CHE GOVERNANCE DOCUMENTS, AND RECOMMEND THE SAME TO CHE FOR ADOPTION AND AUTHORIZATION.
FORM 990, PART VI, SECTION B, LINE 11
PRIOR TO FILING, THE 990 FOR THE FOUNDATION EXCLUDING SCHEDULE B WAS MADE AVAILABLE TO ALL TRUSTEES.
FORM 990, PART VI, SECTION B, LINE 12C
ST. JOSEPH'S HOSPITAL OF TAMPA FOUNDATION HAS TWO SEPARATE CONFLICT OF INTEREST PROCEDURES; ONE THAT RELATES TO BOARD MEMBERS AND ANOTHER THAT RELATES TO NON-BOARD MEMBER EMPLOYEES. BOTH GROUPS ARE REQUIRED ON AN ANNUAL BASIS TO COMPLETE, SIGN AND FILE AN ANNUAL DISCLOSURE STATEMENT DETAILING EXISTING OR POTENTIAL CONFLICTS OF INTERESTS. FOR BOARD MEMBERS, THE REVIEW OF CONFLICTS OR POTENTIAL CONFLICTS OCCURS AT THE BOARD OR COMMITTEE LEVEL AFTER EXCUSING THE MEMBER WITH THE CONFLICT. SHOULD IT BE DETERMINED THAT A BOARD MEMBER HAS AN ACTUAL CONFLICT, HE WOULD BE EXCLUDED FROM CONSIDERATION BY THE BOARD AS TO WHAT ACTION IT WILL TAKE. FOR EMPLOYEES, THE REVIEW OF CONFLICTS OF INTEREST OR POTENTIAL CONFLICTS GOES BY THE BAYCARE'S CONFLICT OF INTEREST DETERMINATION COMMITTEE. THIS COMMITTEE CONSISTS OF BAYCARE CHIEF COMPLIANCE OFFICER, THE CORPORATE RESPONSIBILITY OFFICERS, AND THE BAYCARE VICE PRESIDENT OF TEAM RESOURCES. THIS COMMITTEE SHALL DETERMINE IF AN ACTUAL CONFLICT EXISTS AND ANY ACTION REQUIRED TO ADDRESS THE CONFLICT OF INTEREST SITUATION.
FORM 990, PART VI, SECTION B, LINE 15
THE PROCESS OF DETERMINING THE COMPENSATION OF THE PRESIDENT IS CONDUCTED THROUGH ST. JOSEPH'S HOSPITAL AND ITS PARENT BAYCARE. AN INDEPENDENT COMPENSATION COMMITTEE, APPOINTED BY THE BOARD OF DIRECTORS, PROVIDES OVERSIGHT FOR THE ORGANIZATION'S EXECUTIVE COMPENSATION PROGRAM, REVIEWS AND APPROVES COMPENSATION AND BENEFITS FOR ALL "DISQUALIFIED PERSONS" SUBJECT TO THE INTERMEDIATE SANCTIONS REGULATIONS ISSUED UNDER SECTION 4958 OF THE INTERNAL REVENUE CODE (INCLUDING THE CHIEF EXECUTIVE OFFICER, CHIEF ADMINISTRATIVE OFFICER & CFO, OTHER SYSTEM AND ENTITY EXECUTIVES, AND OTHER DISQUALIFIED PERSONS AS DEFINED IN THE INTERMEDIATE SANCTIONS REGULATIONS (I.E. VOTING MEMBERS OF THE GOVERNING BODY, FAMILY MEMBERS, FORMER OFFICERS)), AND ESTABLISH THE COMPENSATION PHILOSOPHY FOR ALL OTHER EXECUTIVES. THIS COMMITTEE ENGAGES COMPENSATION CONSULTANTS TO ASSIST THEM IN REVIEW OF EXECUTIVE COMPENSATION IN RELATION TO MARKET STANDARDS FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. THE ORGANIZATION KEEPS CONTEMPORANEOUS MINUTES OF THE COMPENSATION COMMITTEES MEETINGS AND DECISIONS. EXTERNAL CONSULTANTS REVIEW COMPENSATION EVERY OTHER YEAR. THE LAST REVIEW OCCURRED IN 2013 BUT THE COMPENSATION COMMITTEE REGULARLY MONITORS COMPENSATION AND ALL OTHER PROCEDURES ARE FOLLOWED ANNUALLY. THE HOSPITAL'S PRESIDENT AND A BOARD COMMITTEE EVALUATES THE PERFORMANCE OF THE FOUNDATION PRESIDENT BASED ON PERFORMANCE GOALS.
FORM 990, PART VI, SECTION C, LINE 19
THE FOUNDATION PROVIDES COPIES OF ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND AUDITED FINANCIAL STATEMENTS TO THE PUBLIC UPON REQUEST.
FORM 990, PART XII, LINE 2C
THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.