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
2012
Open to Public Inspection
Name of the organization
THE HOSPICE OF MARTIN AND ST LUCIE INC
Employer identification number
59-2171740
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
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—2011.
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—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
254,551
1,234,859
388,839
1,878,249
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......
23,305,261
18,628,491
18,796,285
19,299,805
17,084,730
97,114,572
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
23,305,261
18,628,491
19,050,836
20,534,664
17,473,569
98,992,821
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
0
0
0
0
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
0
0
0
0
0
c
Add lines 7a and 7b..
0
0
0
0
0
0
8
Public support (Subtract line 7c from line 6.)
98,992,821
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
23,305,261
18,628,491
19,050,836
20,534,664
17,473,569
98,992,821
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
7,073
7,242
12,603
13,382
11,458
51,758
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
7,073
7,242
12,603
13,382
11,458
51,758
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
765,175
817,059
772,109
0
817,757
3,172,100
13
Total support. (Add lines 9, 10c, 11, and 12.)..
24,077,509
19,452,792
19,835,548
20,548,046
18,302,784
102,216,679
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 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
96.840 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
96.880 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
0.050 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
0.050 %
19a
33 1/3% support tests—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to 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
OTHER INCOME, SCHEDULE A, PART III, LINE 12, DESCRIPTION - THRIFT SHOP REVENUE, COLUMN A - 765175, COLUMN B - 817059, COLUMN C - 772109, COLUMN D - 0, COLUMN E - 814602, COLUMN F - 3168945; DESCRIPTION - OTHER INCOME, COLUMN A - 0, COLUMN B - 0, COLUMN C - 0, COLUMN D - 0, COLUMN E - 3155, COLUMN F - 3155;,
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
12000266
Software Version:
v2012.1.0
-
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
2012
Open to Public Inspection
Name of the organization
THE HOSPICE OF MARTIN AND ST LUCIE INC
Employer identification number
59-2171740
Identifier
Return Reference
Explanation
ORGANIZATION'S MISSION
FORM 990, PART III, LINE 1
(CONTINUED FROM PART III) HOSPICE RECOGNIZES DYING AS A NORMAL PROCESS. HOSPICE EXISTS IN THE HOPE AND BELIEF THAT THROUGH APPROPRIATE CARE AND THE PROMOTION OF A CARING COMMUNITY, SENSITIVE TO THEIR NEEDS, PATIENTS AND FAMILIES MAY BE FREE TO ATTAIN A DEGREE OF MENTAL AND SPIRITUAL PREPARATION FOR DEATH THAT IS SATISFACTORY TO THEM.
Delegate broad authority to a committee
Form 990, Part VI, Section A, Line 1a
THE CHAIRMAN (JAMES PIERSON), VICE CHAIRMAN (ANDREW PASSERI), SECRETARY (JORDAN FIELDS), TREASURER (MICHAEL BROWN) AND PAST CHAIRMAN (WILLIAM MOORE) SERVE ON THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. THE EXECUTIVE COMMITTEE HAS THE AUTHORITY TO ACT FOR THE BOARD OF DIRECTORS BETWEEN REGULAR MEETINGS OF THE BOARD. THE COMMITTEE MAKES A FULL REPORT OF ALL BUSINESS TRANSACTED BY THE COMMITTEE TO THE BOARD FOR ITS APPROVAL.
MICHAEL BROWN, SR. AND RICHARD LYNCH - BUSINESS RELATIONSHIP
Significant changes to organizational documents
Form 990, Part VI, Section A, Line 4
THE ORGANIZATION AMENDED ITS BYLAWS IN OCTOBER 2012 TO CREATE TERM LIMITS FOR THE BOARD MEMBERS. THERE WILL BE THREE CLASSES OF BOARD MEMBERS, THE FIRST SET WILL BE TRUSTEES SERVING ONE YEAR, THE SECOND SET WILL BE TRUSTEES SERVING TWO YEARS AND THE THIRD SET WILL BE TRUSTEES SERVING THREE YEARS. THIS WILL RESULT IN OVERLAPPING BOARD TERMS SO THAT NEW MEMBERS JOIN AS OTHERS ARE TERMED OUT.
Classes of members or stockholders
Form 990, Part VI, Section A, Line 6
THE SOLE MEMBER OF THIS CORPORATION IS HEALTH AND PALLIATIVE SERVICES OF THE TREASURE COAST, INC., A FLORIDA NOT FOR PROFIT CORPORATION. MEMBERSHIP IN THIS CORPORATION IS NOT TRANSFERABLE OR ASSIGNABLE. THE AFFAIRS OF THIS CORPORATION SHALL BE MANAGED BY ITS BOARD OF DIRECTORS, WHICH SHALL POSSESS ALL THE POWERS OF CORPORATE DIRECTORS UNDER THE LAWS OF THE STATE OF FLORIDA. ALL DIRECTORS SHALL BE APPOINTED BY THE BOARD OF DIRECTORS OF HEALTH AND PALLIATIVE SERVICES OF THE TREASURE COAST, INC., WHICH IS THE SOLE MEMBER OF HOSPICE OF MARTIN & ST. LUCIE, INC.
Members or stockholders electing members of governing body
Form 990, Part VI, Section A, Line 7a
THE AFFAIRS OF THIS CORPORATION SHALL BE MANAGED BY ITS BOARD OF DIRECTORS, WHICH SHALL POSSESS ALL THE POWERS OF CORPORATE DIRECTORS UNDER THE LAWS OF THE STATE OF FLORIDA. ALL DIRECTORS SHALL BE APPOINTED BY THE BOARD OF DIRECTORS OF HEALTH AND PALLIATIVE SERVICES OF THE TREASURE COAST, INC., WHICH IS THE SOLE MEMBER OF HOSPICE OF MARTIN & ST. LUCIE, INC.
Decisions requiring approval by members or stockholders
Form 990, Part VI, Section A, Line 7b
HEALTH AND PALLIATIVE SERVICES OF THE TREASURE COAST, INC, WHICH IS THE SOLE MEMBER OF HOSPICE OF MARTIN & ST. LUCIE, INC., CAN AUTHORIZE ANY OFFICER OR OFFICERS OR AGENT OR AGENTS OF HOSPICE OF MARTIN & ST. LUCIE, INC., TO ENTER INTO ANY CONTRACT OR EXECUTE AND DELIVER ANY INSTRUMENT IN THE NAME OF AND ON BEHALF OF HOSPICE OF MARTIN & ST. LUCIE, INC., AND SUCH AUTHORITY MAY BE GENERAL OR CONFINED TO SPECIFIC INSTANCES.
Review of form 990 by governing body
Form 990, Part VI, Section B, Line 11b
THE FORM 990 IS PREPARED BY THE TREASURE COAST HOSPICE ACCOUNTING DEPARTMENT WITH THE HELP OF AN INDEPENDENT ACCOUNTING FIRM. MANAGEMENT AND THE INDEPENDENT ACCOUNTING FIRM PRESENTS THE FORM 990 TO THE BOARD TO EXPLAIN THE KEY POINTS. THE BOARD MEMBERS THEN VOTE TO APPROVE THE SUBMISSION OF THE FORM 990.
Conflict of interest policy
Form 990, Part VI, Section B, Line 12c
ANNUALLY EACH BOARD MEMBER IS GIVEN THE CONFLICT OF INTEREST POLICY AND THE CEO EXPLAINS THE POLICY IN DETAIL PRIOR TO BOARD MEMBER SIGNATURE. ALL VENDORS RECEIVE AND MUST SIGN A FORM DISCLOSING ANY RELATED PARTIES INVOLVED PRIOR TO DOING BUSINESS WITH THE ORGANIZATION. ANYONE WITH A CONFLICT OF INTEREST IS PROHIBITED FROM VOTING ON MATTERS RELATED TO THE CONFLICT.
COMPENSATION OF THE TOP MANAGEMENT OFFICIAL
FORM 990, PART VI, LINE 15A
THE BOARD'S EXECUTIVE COMMITTEE WHICH INCLUDES THE CHAIRMAN RECEIVES A COMPARABLE STUDY OF ALL HOSPICES IN THE STATE OF FLORIDA. THE STUDY COMPARES SEVERAL KEY ASPECTS OF THE HOSPICES SUCH AS REVENUE, ADMISSIONS, ASSETS AND SALARIES OF TOP MANAGEMENT, (EX. CEO'S, CFO'S, COO'S, CIO'S, ETC.) WHICH ARE DRAWN FROM THE MEDICARE COST REPORTS. AVERAGES ARE PRODUCED WITH LOW, MEAN, MEDIAN AND HIGH AND COMPARISONS ARE MADE TO WHERE THE ORGANIZATION RANKS. THE BOARD'S EXECUTIVE COMMITTEE DECIDES ON THE CEO'S PAY AND BENEFITS AND REVIEWS RECOMMENDATIONS BY THE CEO ON OTHER TOP EXECUTIVES AT THE ORGANIZATION. THE PROCESS IS DOCUMENTED IN COMMITTEE MINUTES. THIS PROCESS IS UNDERTAKEN ANNUALLY AND WAS LAST DONE IN 2013.
COMPENSATION OF OTHER OFFICERS
FORM 990, PART VI, LINE 15B
THE CEO RECEIVES A COMPARABLE STUDY OF ALL HOSPICES IN THE STATE OF FLORIDA. THE STUDY COMPARES SEVERAL KEY ASPECTS OF THE HOSPICES SUCH AS REVENUE, ADMISSIONS, ASSETS AND SALARIES OF TOP MANAGEMENT WHICH ARE DRAWN FROM THE MEDICARE COST REPORTS. AVERAGES ARE PRODUCED WITH LOW, MEAN, MEDIAN AND HIGH AND COMPARISONS ARE MADE TO WHERE THE ORGANIZATION RANKS. THE CEO DECIDES ON THE KEY EMPLOYEES PAY AND BENEFITS AND REVIEWS RECOMMENDATIONS BY THE CEO ON OTHER TOP EXECUTIVES AT THE ORGANIZATION. THIS PROCESS IS UNDERTAKEN ANNUALLY AND WAS LAST DONE IN 2013.
Governing documents, conflict of interest policy and financial statements available to the public
Form 990, Part VI, Section C, Line 19
ALL DOCUMENTS ARE ON SITE EITHER IN THE CEO OFFICE OR IN THE DIRECTOR OF ACCOUNTING OFFICE. UPON REQUEST, COPIES ARE SHOWN, MAILED, FAXED OR EMAILED TO THE INQUIRER.
Other changes in net assets or fund balances
Form 990 , Part XI, Line 9
TRANSFER OF NET ASSETS TO AFFILIATES - -3000000;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.