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
Thomas Jefferson University Hospitals Inc
Employer identification number
23-2829095
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.") .
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
Thomas Jefferson University Hospitals Inc
Employer identification number
23-2829095
Return Reference
Explanation
FORM 990, PART VI, LINE 2
THE FOLLOWING TRUSTEES HAVE BUSINESS RELATIONSHIPS, NOT INVOLVING ANY TRANSACTIONS WITH TJUH: ROBERT ADELSON, WILLIAM LANDMAN, AND IRA BRIND MICHAEL HELLER AND MARK ALDERMAN MICHAEL HELLER AND DAVID BINSWANGER MICHAEL HELLER AND WILLIAM LANDMAN CHRISTOPHER KNEIZYS AND RICHARD RILEY R. RICHARD WILLIAMS AND IRA BRIND R. RICHARD WILLIAMS AND WILLIAM LANDMAN FORM 990, PART VI, LINE 4 On June 30, 2014, TJUH System separated from Jefferson Health System and affiliated with TJU to form a new affiliated group, hereafter referred to as the University, to enhance their tripartite mission of education, research and patient care. All TJUH System trustees joined the TJU board of trustees. TJU became the sole member of TJUH System, and TJUH System became the sole member of Jefferson University Physicians.
FORM 990, PART VI, LINES 6 & 7
TJUH SYSTEM IS THE SOLE MEMBER OF TJUH. THE BOARD OF TRUSTEES OF TJUH SHALL BE THOSE PERSONS WHO SERVE FROM TIME TO TIME ON THE TJUH SYSTEM BOARD. TJUH SYSTEM RECOMMENDS INDIVIDUALS FOR APPOINTMENT TO ITS BOARD OF TRUSTEES TO ITS SOLE MEMBER, TJU. TJU ELECTS MEMBERS TO THE TJUH SYSTEM BOARD OF TRUSTEES WHO AUTOMATICALLY BECOME MEMBERS OF THE TJUH BOARD OF TRUSTEES FOR RESOLUTION.
FORM 990, PART VI, LINE 11B
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM IN CONJUNCTION WITH TJUH FINANCE PERSONNEL AND IS REVIEWED INTERNALLY BY MANAGEMENT OF TJUH. IT IS THEN PRESENTED TO THE AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND FINAL APPROVAL BEFORE FILING. FORM 990, PART VI, LINE 12C ANNUAL CONFLICT OF INTEREST STATEMENTS ARE COMPLETED BY THE BOARD OF TRUSTEES, SENIOR MANAGEMENT, AND KEY REPRESENTATIVES OF TJUH. ALL CONFLICTS ARE REFERRED TO THE CORPORATE COMPLIANCE OFFICER FOR RESOLUTION. THE CHAIRMAN OF THE BOARD AND THE PRESIDENT OF TJUH ARE RESPONSIBLE FOR MONITORING THE CONDUCT OF AND DISCLOSURE BY KEY REPRESENTATIVES AND THEY IDENTIFY, ADDRESS, AND/OR RESOLVE ACTUAL OR POTENTIAL CONFLICTS IN CONSULTATION WITH LEGAL COUNSEL AND/OR THE CORPORATE COMPLIANCE OFFICER. IF DEEMED NECESSARY OR ADVISABLE, INDIVIDUAL CASES MAY BE REFERRED TO THE FULL BOARD OR A COMMITTEE THEREOF FOR RESOLUTION.
FORM 990, PART VI, LINE 15
The process for determining compensation of the officers and key employees of TJUH uses several external market survey data providers such as Mercer Sullivan Cotter, and Olney Associates. The salaries in the surveys are anonymous and contain several other participating organizations in healthcare. The TJU Board hires and determines the base and incentive compensation for the President of TJUH. (In his role as President for TJUH System). While presidents are not officers or employees of the TJU legal entity itself, they do report to the TJU CEO. TJUH formulates market data sheets by sharing the 25th, 50th, and 75th percentiles. For compensation, TJUH targets the 50th percentile of the market. However lower and higher percentiles may be used depending upon a candidate's depth of experience. TJUH also targets organizations such as teaching hospitals, those from northeastern U.S.A., and those with revenue greater than one billion dollars as a gauge for determining compensation ranges.
FORM 990, PART VI, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART VII, SECTION B - INDEPENDENT CONTRACTORS TJUH and TJU have maintained a close academic affiliation. Services provided by TJU to TJUH include physician and non-physician personnel and other support services necessary to preserve and maintain the tertiary care capacity of TJUH. TJU also provides office and clinical space, as well as administrative, finance, human resources, information technology, maintenance, security, education, temporary staffing and other ancillary services to TJUH. Expenses charged for these services aggregated $221,560,000 for the year ended June 30, 2014. Form 990, Part XI, Line 9 - Other Changes in Net Assets or Fund Balances INCREASE IN PENSION LIABILITY (22,642,985) CHANGE IN NONCONTROLLING INTEREST IN JOINT VENTURE 204,269 TEMPORARILY RESTRICTED UNREALIZED GAINS 2,490,037 CHANGE IN ASSETS HELD BY AFFILIATED FOUNDATION 774,353 DONATED CAPITAL RECEIVED 2,634,527 NET ASSETS RELEASED FROM RESTRICTION - PURCHSE OF P,P&E - UNRESTRICTED 250,636 NET ASSETS RELEASED FROM RESTRICTION - PURCHASE OF P,P&E - TEMPORARILY RESTRICTED (260,636) PERM. RESTRICTED UNREALIZED GAIN ON EXTERNALLY HELD TRUSTS 174,360 INVESTMENT IN FIVE POINTE (POST MERGER) 66,122,320 RECEIVABLE FROM ORIGINAL JHS CONTRIBUTION (POST MERGER) 5,000,000 ------------- TOTAL $ 54,746,881 =============
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.