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
Hospice of the Comforter Inc
Employer identification number
59-2935928
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.") .
1,480,041
1,724,982
1,223,974
700,579
304,264
5,433,840
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......
45,157,978
45,397,275
37,387,983
30,525,878
24,664,907
183,134,021
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.
46,638,019
47,122,257
38,611,957
31,226,457
24,969,171
188,567,861
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.)
188,567,861
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...
46,638,019
47,122,257
38,611,957
31,226,457
24,969,171
188,567,861
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
115,831
298,216
417,558
62,349
893,954
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
115,831
298,216
417,558
62,349
893,954
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.)
..
10,000
10,000
13
Total support. (Add lines 9, 10c, 11, and 12.)..
46,753,850
47,420,473
39,029,515
31,298,806
24,969,171
189,471,815
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
99.520 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.420 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.470 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.490 %
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
Hospice of the Comforter Inc
Employer identification number
59-2935928
Return Reference
Explanation
Form 990, Part VI, Section A, line 3
Effective May 1, 2012, Hospice of the Comforter, Inc. (the filing organization) entered into a Management Services Agreement with Adventist Health System Sunbelt Healthcare Corporation (AHSSHC). AHSSHC is the parent organization of a system of tax-exempt hospitals and other health care provider organizations that operate 44 hospitals in 10 states. AHSSHC is exempt from federal income tax under Internal Revenue Code Section 501(c)(3). Under the Management Services Agreement (the Agreement) with AHSSHC, the Board of Directors of the filing organization retains full responsibility and authority for and ultimate control of the Hospice operations conducted by the filing organization. Managerial services provided by AHSSHC included oversight with respect to the following functions: Personnel administration, including recruitment, hiring, training, promoting, directing and terminating personnel; Procurement, including the acquisition of food and beverage items, supplies, devices, furniture, and medical equipment; Health Information Management; Maintenance and Security; Contracting for services and consulting services; Implementation and maintenance of accounting functions; Development of operational and capital budgets; Billing and collection of receivables and remittances of payables; Patient safety and quality systems; Marketing; Regulatory compliance; Banking relationships; and Spiritual ministries.
Form 990, Part VI, Section A, line 6
Hospice of the Comforter, Inc. (the filing organization) has one member. The sole member of the filing organization is The Comforter Health Care Group, Inc. (CHCG). CHCG is a Florida, not-for-profit corporation that is exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). There are no other classes of membership in the filing organization.
Form 990, Part VI, Section A, line 7a
The sole member of the filing organization is The Comforter Health Care Group, Inc. (CHCG). The Board of Directors of the filing organization are appointed by the sole member, CHCG, who has the right to elect, appoint, or remove any member of the Board of Directors of the filing organization.
Form 990, Part VI, Section A, line 7b
CHCG, as the sole member of the filing organization, has certain reserved powers as set forth in the Bylaws of the filing organization. These reserved powers include the following: a) To adopt, amend, restate, and repeal the Articles of Incorporation or Bylaws of the filing organization, and the Medical Staff Bylaws; b) To elect, appoint, or remove members of the filing organization's Board of Directors; and c) Appoint the President of the filing organization.
Form 990, Part VI, Section B, line 11
The filing organization's current year Form 990 was reviewed by the CEO and by the CFO prior to its filing with the IRS. The review conducted by the CEO and the CFO did not include the review of any supporting workpapers that were used in preparation of the current year Form 990, but did include a review of the entire Form 990 and all supporting schedules.
Form 990, Part VI, Section B, line 12c
The Conflict of Interest Policy of the filing organization applies to members of its Board of Directors, its principal officers, and its employees. In connection with any actual or possible conflict of interests, any member of the Board of Directors, any principal officer or employee of the filing organization must disclose the existence of any financial interest with the filing organization. Subsequent to any disclosure of any financial interest/arrangement and all material facts, and after discussion with the relevant individual, the Board of Directors (excluding any Board member who may be the discloser of the possible conflict of interest) or committee with board delegated powers shall discuss, analyze, and vote upon the potential financial interest/arrangement to determine if a conflict of interest exists. Annually, the members of the Board of Director and executive staff of the filing organization must provide written disclosure of all professional or personal relationships or interests, direct or indirect; that might present a conflict of interest. Such annual statements are kept on file at the filing organization.
Form 990, Part VI, Section B, line 15b
The current year compensation for the organization's COO, CFO, CIO, Chief Medical Officer, Associate Medical Directors, and Physicians were set by members of the Board of Directors, none of whom have a conflict of interest with respect to the compensation arrangement being considered. The CEO provides guidance and recommendations to the executive committee for each of the positions other than their own. The CEO is not present as the board deliberates and determines the final recommendations for all components of executive compensation.
Form 990, Part VI, Section C, line 19
The filing organization's governing documents, conflict of interest policy and financial statements are available upon request.
Form 990, Part IX, line 11g
Contracted Labor: Program service expenses 333,039. Management and general expenses 47,088. Fundraising expenses 0. Total expenses 380,127. Payments to Healthcare Professionals: Program service expenses 203,029. Management and general expenses 0. Fundraising expenses 0. Total expenses 203,029. Contracted Services: Program service expenses 0. Management and general expenses 182,143. Fundraising expenses 0. Total expenses 182,143. Ambulance Services: Program service expenses 209,349. Management and general expenses 0. Fundraising expenses 0. Total expenses 209,349. Transcription: Program service expenses 10,491. Management and general expenses 0. Fundraising expenses 0. Total expenses 10,491. Therapy Services: Program service expenses 12,615. Management and general expenses 0. Fundraising expenses 0. Total expenses 12,615. Triage Services: Program service expenses 246,621. Management and general expenses 0. Fundraising expenses 0. Total expenses 246,621.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.