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
COMMUNITY HOSPICE OF TEXAS
Employer identification number
75-2653292
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.") .
318,944
754,191
525,162
781,449
496,460
2,876,206
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......
31,836,913
31,724,359
32,455,196
36,894,644
30,819,022
163,730,134
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.
32,155,857
32,478,550
32,980,358
37,676,093
31,315,482
166,606,340
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
400,000
100,000
0
110,737
610,737
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
400,000
100,000
0
110,737
610,737
8
Public support (Subtract line 7c from line 6.)
165,995,603
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...
32,155,857
32,478,550
32,980,358
37,676,093
31,315,482
166,606,340
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
174,120
369,636
365,730
429,683
454,934
1,794,103
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
174,120
369,636
365,730
429,683
454,934
1,794,103
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.)
..
15,208
11,737
16,765
19,878
6,171
69,759
13
Total support. (Add lines 9, 10c, 11, and 12.)..
32,345,185
32,859,923
33,362,853
38,125,654
31,776,587
168,470,202
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
98.530 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
98.600 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.060 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
1.040 %
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:
13000248
Software Version:
2013v3.1
-
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
COMMUNITY HOSPICE OF TEXAS
Employer identification number
75-2653292
Return Reference
Explanation
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders
COMMUNITY HOSPICE OF TEXAS HAS FOUR MEMBERS, EACH WITH A 25% INTEREST: 1) TEXAS HEALTH HUGULEY HOSPITAL FORT WORTH SOUTH (A MEMBER OF TEXAS HEALTH RESOURCES 2) TEXAS HEALTH HARRIS METHODIST HOSPITAL FORT WORTH (A MEMBER OF TEXAS HEALTH RESOURCES) 3) PROVIDENCE HEALTHCARE NETWORK (A MEMBER OF ASCENSION HEALTH) 4) TEXAS HEALTH ARLINGTON MEMORIAL HOSPITAL (A MEMBER OF TEXAS HEALTH RESOURCES)
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body
THE FOUR MEMBERS OF COMMUNITY HOSPICE OF TEXAS MAY EACH APPOINT ONE VOTING MEMBER TO THE BOARD OF DIRECTORS.
Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders
THE FOLLOWING ACTIONS REQUIRE THE AFFIRMATIVE VOTE OF A MAJORITY OF THE FOUR MEMBERS: A) THE ADOPTION OF CAPITAL AND OPERATING BUDGETS; AND B) THE INCURRENCE OF ANY UNBUDGETED DEBT
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
THE FORM 990 IS REVIEWED BY THE ORGANIZATIONS CEO AND CFO BEFORE IT IS SIGNED AND SUBMITTED TO THE IRS. THE BOARD WILL RECEIVE A COPY OF THE 2013 990 PRIOR TO FILING WITH THE IRS.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
ALL STAFF AND BOARD MEMBERS ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY. THE BOARD REGULARLY MEETS AND DURING THOSE MEETINGS IS WHEN A DISCLOSURE OF A CONFLICT OF INTEREST IS REQUIRED.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
COMPARATIVE DATA, SUCH AS CURRENT SALARY SURVEYS, ARE USED IN DETERMINING THE COMPENSATION OF THE TOP OFFICERS. THE BOARD APPROVES THE COMPENSATION AND DOCUMENTATION IS CONTAINED IN THE MINUTES OF THE BOARD. THIS APPROVAL PROCESS LAST OCCURRED DURING 2013.
FORM 990, PART VI, LINE 15B, PROCESS USED TO DETERMINE COMPENSATION FOR OTHER OFFICERS
COMPARATIVE DATA, SUCH AS CURRENT SALARY SURVEYS, ARE USED IN DETERMINING THE COMPENSATION OF THE TOP OFFICERS. THE BOARD APPROVES THE COMPENSATION AND DOCUMENTATION IS CONTAINED IN THE MINUTES OF THE BOARD. COMPENSATION WAS APPROVED IN 2013 BY THE BOARD AND THE CEO IS INVOLVED IN APPROVING THE COMPENSATION FOR THE COO AND CFO ON JANUARY 30, 2013 ANDREA GREEN PRESENTED A MULTI-VIEW SALARY SURVEY FOR THE COO AND CFO. THE BOARD APPROVED THE INCREASES. BECAUSE THE CEO IS INVOLVED IN THE DECISION OF DETERMINING COMPENSATION FOR THE OTHER OFFICERS, THIS QUESTION NEEDED TO BE MARKED 'NO' SINCE THE CEO IS NOT INDEPENDENT.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.