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
VNA Home Health & Hospice
Employer identification number
01-0246804
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.") .
193,460
137,681
176,221
165,406
99,564
772,332
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......
10,215,270
11,146,527
11,068,613
13,141,397
15,403,155
60,974,962
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.
10,408,730
11,284,208
11,244,834
13,306,803
15,502,719
61,747,294
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
5,000
5,000
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..
5,000
5,000
8
Public support (Subtract line 7c from line 6.)
61,742,294
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...
10,408,730
11,284,208
11,244,834
13,306,803
15,502,719
61,747,294
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
100,789
91,832
107,866
87,205
14,838
402,530
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
100,789
91,832
107,866
87,205
14,838
402,530
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.)..
10,509,519
11,376,040
11,352,700
13,394,008
15,517,557
62,149,824
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
99.340 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.100 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.650 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.880 %
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
VNA Home Health & Hospice
Employer identification number
01-0246804
Return Reference
Explanation
Form 990, Part VI, Section A, line 4
On October 4, 2013, Eastern Maine Healthcare Systems (EMHS) became the sole corporate member of the Association. EMHS is the parent company in an integrated health care delivery system that provides a broad range of health care and related services to nine Northern and Eastern Maine counties through subsidiary and affiliated corporations. Effective with the change in control, the Association adopted a September fiscal year-end to coincide with the year-end of EMHS. The transaction will be accounted for as an acquisition in accordance with Accounting Standards Update No. 2010-07, Not-for-Profit Entities: Mergers and Acquisitions, which requires the assets and liabilities of the Association be accounted for at fair value as of the date of acquisition, which was agreed to be effective October 1, 2013. All assets and liabilities under the control of the Association were revalued to fair value as of the acquisition date, resulting in unrestricted net assets of $13,794,504. Prior to October 4, 2013, the Associations sole member was Mercy Health System of Maine, as part of the Catholic Health East Health Care System.
Form 990, Part VI, Section A, line 6
There shall be two Members of the Corporation. The Class A Member of the Corporation shall be Mercy Health System of Maine, a Maine nonprofit corporation. The Class B Member of the Corporation shall be Eastern Maine Healthcare Systems, a Maine nonprofit corporation (sometimes referred to in these Bylaws as the Class B Member or EMHS). The Class A Member and the Class B Member are referred to herein collectively as the Members.
Form 990, Part VI, Section A, line 7a
The sole power and right of the Class A Member shall be to receive such reports from the management and Board of Directors of the Corporation from time to time as the Class A Member may reasonably request. The Class A Member shall have no right to vote on any matter that shall come before the Corporation.
Form 990, Part VI, Section A, line 7b
All rights of members under the laws of the State of Maine to vote or otherwise take action with respect to the Corporation are reserved exclusively to the Class B Member. The Class B Member shall act on any matters brought to it by the Board of Directors of the Corporation as set forth in this Article II, Article X or otherwise, and shall exercise such other powers as may be conferred on the Class B Member by law, the Articles of Incorporation, or by these Bylaws. The Class B Member (acting independently) and the Corporation (subject to Class B Member board approval) shall have the power and authority to authorize the following actions described as Joint Initiatory Powers. Any exercise of Joint Initiatory Powers shall further the goal of developing and strengthening patient care services within the EMHS System for the benefit of patients within the Corporations service area, and such powers shall be exercised only after reasonable consultation between The Class B Member and the Corporation. Action initiated through the Class B Members exercise of its Joint Initiatory Powers is subject to the right of the Corporation, upon a two-thirds vote of the full Board of Directors, to trigger the formal review function of the EMHS Council of Chairs, as described in the EMHS Bylaws and Council of Chairs committee charter. Action initiated through the Corporations exercise of its Joint Initiatory Powers is subject to the Class B Members board approval or, if authorized through delegation by the Class B Members board, EMHS CEO approval. The Joint Initiatory Powers are as follows: i. Amendments to the Corporations Articles of Incorporation or Bylaws; ii. Change in legal form of organization of the Corporation; iii. Election of the Directors of the Corporation; iv. Action concerning the Corporations operating budget and capital expenditures; v. The Corporations acquisition of assets or assumption of liabilities of a third party; vi. Transfer of 5% or more of the assets of the Corporation; vii. Financing transactions concerning the Corporation; viii. Merger, consolidation, sale, lease, mortgage, pledge or other disposition of all or substantially all assets of the Corporation; ix. Add or revise a health care service of the Corporation; x. Discontinue or close a health care service of the Corporation; xi. Action concerning the Corporations component of EMHS Strategic Plan; xii. Action concerning the Corporations participation in key strategic affiliations with third parties not affiliated with EMHS; and xiii. Dissolution of the Corporation.
Form 990, Part VI, Section B, line 11
Director of Finance reviews the 990 prior to the CEO signing it, then it is distributed to Board of Directors.
Form 990, Part VI, Section B, line 12c
Through annual reveiw by quality manager.
Form 990, Part VI, Section B, line 15
Semiannual State Comparative Market Analysis
Form 990, Part VI, Section C, line 19
UPON REQUEST
Form 990, Part XI, line 9:
All assets and liabilities were revalued to FMV at 10/1/14 acquisition 113,632.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.