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
WESTERN CONNECTICUT HOME CARE INC
Employer identification number
06-0655138
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.") .
277,761
316,411
242,522
298,357
448,093
1,583,144
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......
4,760,099
4,096,402
4,443,205
5,279,360
6,974,045
25,553,111
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.
5,037,860
4,412,813
4,685,727
5,577,717
7,422,138
27,136,255
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.)
27,136,255
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...
5,037,860
4,412,813
4,685,727
5,577,717
7,422,138
27,136,255
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
25,001
24,190
17,458
21,314
24,066
112,029
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
25,001
24,190
17,458
21,314
24,066
112,029
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.)..
5,062,861
4,437,003
4,703,185
5,599,031
7,446,204
27,248,284
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
99.590 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.530 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.410 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.470 %
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
WESTERN CONNECTICUT HOME CARE INC
Employer identification number
06-0655138
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 4
ON 1/1/2014 WESTERN CONNECTICUT HEALTH NETWORK (WCHN) BECAME THE SOLE CORPORATE MEMBER OF NORWALK HEALTH SERVICES CORPORATION, AND A CORPORATE AFFILIATION WAS COMPLETED.
FORM 990, PART VI, SECTION A, LINE 6
THE ORGANIZATION IS A MEMBERSHIP ORGANIZATION, WITH ITS SOLE MEMBER BEING WESTERN CONNECTICUT HEALTH NETWORK.
FORM 990, PART VI, SECTION A, LINE 7A
WESTERN CONNECTICUT HEALTH NETWORK MUST APPROVE THE ORGANIZATION'S BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B
CERTAIN DECISIONS OF THE BOARD OF DIRECTORS ARE SUBJECT TO APPROVAL BY WESTERN CONNECTICUT HEALTH NETWORK, THE SOLE MEMBER OF WESTERN CONNECTICUT HOME CARE, INC. THESE DECISIONS INCLUDE: (1) WESTERN CONNECTICUT HOME CARE'S ANNUAL OPERATING AND CAPITAL BUDGET, (2) PROPOSED ANNUAL FUNDRAISING PROGRAMS, (3) PROPOSED SIGNIFICANT PROGRAMS AND EXPENDITURES, (4) PURCHASE OR SALE OF SIGNIFICANT CAPITAL OR OPERATING ASSETS, (5) ACQUISITION OF INDEBTEDNESS FOR BORROWED MONEY, (6) ELECTION OR REMOVAL OF A MEMBER OF THE BOARD OF DIRECTORS, (7) DEVELOPMENT, IMPLEMENTATION, REVIEW, AND MONITORING OF INVESTMENT POLICY, (8) SETTING THE MAXIMUM AND MINIMUM NUMBER OF THE BOARD OF DIRECTORS, (9) REPLACEMENT OF A DIRECTOR DUE TO DEATH, RESIGNATION, OR OTHERWISE, AND (10) ANY OTHER MATTERS ON WHICH MEMBERS ARE ENTITLED TO VOTE UNDER THE NONSTOCK CORPORATION ACT OF THE STATE OF CONNECTICUT.
FORM 990, PART VI, SECTION B, LINE 11
THE ORGANIZATION'S AUDIT FIRM PREPARES THE IRS FORM 990 FROM INFORMATION PROVIDED BY THE ORGANIZATION. A DRAFT COPY IS REVIEWED AND APPROVED BY MANAGEMENT. THE DRAFT IS THEN FORWARDED TO THE FINANCE COMMITTEE FOR THEIR REVIEW AND INPUT, IF ANY. THE DRAFT IS THEN PRESENTED TO THE COMPLETE BOARD OF DIRECTORS FOR THEIR REVIEW AND INPUT, IF ANY. THE FINAL COPY IS THEN FILED WITH THE INTERNAL REVENUE SERVICE. STEVEN ROSENBERG, CFO, WILL REVIEW THE 990 PRIOR TO IT BEING SENT TO THE IRS. A PRELIMINARY 990, IS PRESENTED TO THE AUDIT COMMITTEE IN JUNE, WHO REVIEWS IT ON BEHALF OF THE BOARD. E&Y IS ON HAND TO REVIEW THE 990 WITH THE AUDIT COMMITTEE AND ANSWER ANY QUESTIONS. PRIOR TO THE 990 BEING FILED WITH THE IRS, THE BOARD WILL RECEIVE A FULL AND ACCURATE COPY ON A SECURED WEBSITE FOR THEIR REVIEW.
FORM 990, PART VI, SECTION B, LINE 12C
ANNUALLY, ALL MEMBERS OF THE BOARD OF DIRECTORS ARE REQUIRED TO READ THE CONFLICT OF INTEREST POLICY STATEMENT, DISCLOSE ANY CONFLICTS OF INTEREST, AND SIGN.
FORM 990, PART VI, SECTION B, LINE 15
15A. COMPENSATION OF CEO: IN ORDER TO ACHIEVE ITS MISSION AND ITS OVERALL PERFORMANCE OBJECTIVES, WESTERN CONNECTICUT HEALTH NETWORK, INC. EMPLOYS A PERFORMANCE-BASED TOTAL COMPENSATION PROGRAM FOR ITS SENIOR EXECUTIVES THAT IS MARKET COMPETITIVE, COMPLIANT WITH REGULATORY GUIDELINES, AND REPRESENTATIVE OF BEST PRACTICES. ELIGIBLE EXECUTIVES ARE GENERALLY DIRECT REPORTS OF THE CEO ALONG WITH OTHER EXECUTIVES DESIGNATED BY THE CEO. TO MEET WESTERN CONNECTICUT HEALTH NETWORK INC.'S TOTAL COMPENSATION OBJECTIVES FOR EXECUTIVES, THE FOLLOWING SURVEY SOURCES ARE USED FOR COMPARISON PURPOSES: - BLEND OF NATIONAL CONFIDENTIAL SOURCE, IHS, AND HAY GROUP POINTS HEALTHCARE DATA (WHERE DATA AVAILABLE), PLUS 15% GEOGRAPHICAL DIFFERENTIAL. TITLE MATCH DATA CUTS SELECTED BASED ON REVENUE SIZE. - FOR PHYSICIAN EXECUTIVES, SURVEYS COVERING PHYSICIAN COMPENSATION IN ACCREDITED MEDICAL SCHOOLS (AAMC) ARE USED IN COMBINATION WITH PROPRIETARY SURVEYS COMPILED BY NATIONALLY KNOWN CONSULTING FIRM, SULLIVAN COTTER AND THE MEDICAL GROUP MANAGEMENT ASSOCIATION (MGMA). WESTERN CONNECTICUT HEALTH NETWORK, INC. TARGETS CASH COMPENSATION AT MARKET COMPETITIVE LEVELS. BASE SALARY PLUS SHORT-TERM (ANNUAL) INCENTIVE AWARDS (TOTAL CASH) APPROXIMATE MARKET COMPETITIVE LEVELS FOR TOTAL CASH COMPENSATION. EXECUTIVE PERFORMANCE IS EXPECTED TO MEET OR EXCEED PREDETERMINED OPERATIONAL AND FINANCIAL METRICS. OTHER FACTORS, SUCH AS COMPETITIVE MARKET FORCES, JOB PERFORMANCE, UNIQUE QUALIFICATIONS, AND/OR INDIVIDUAL JOB RESPONSIBILITIES ARE ALSO CONSIDERED IN WESTERN CONNECTICUT HEALTH NETWORK, INC.'S EXECUTIVE COMPENSATION DECISIONS. ROLES OF THE COMMITTEE ON GOVERNANCE AND KEY EXECUTIVES IN THE EXECUTIVE COMPENSATION PROCESS: - THE COMMITTEE ON GOVERNANCE IN CONSULTATION WITH THE CEO AND THE SVP HR SELECTS THE OUTSIDE COMPENSATION CONSULTANTS. THE CURRENT CONSULTANT IS THE HAY GROUP, WHOSE PURPOSE IS TO PROVIDE A VALID INDEPENDENT ASSESSMENT OF THE RELEVANT MARKET RATES AND PAY PRACTICES FOR HEALTHCARE EXECUTIVES, PHYSICIAN EXECUTIVES AND FOR PHYSICIANS IN GENERAL. - THE COMPENSATION CONSULTING FIRM COMPILES APPROPRIATE MARKET DATA, JOB EVALUATION AND RANKING INFORMATION FOR ALL EXECUTIVES AND PHYSICIANS OF THE ORGANIZATION, EXCLUDING THE CEO, AND WILL SUPPLY THIS MATERIAL TO THE CEO AND SVP HR FOR REVIEW AND AGREEMENT. ONCE THE REPORT IS FINAL, IT WILL BE SUPPLIED TO THE COMMITTEE ON GOVERNANCE FOR THEIR CONSIDERATION AND ACCEPTANCE. - THE COMMITTEE ON GOVERNANCE DETERMINES THE CEO'S SALARY BASED ON OVERALL PERFORMANCE AND MARKET DATA SUPPLIED BY THE OUTSIDE MARKET CONSULTANT. THE LAST EXECUTIVE COMPENSATION EVALUATION BY AN OUTSIDE CONSULTANT WAS DONE IN THE FALL OF 2014. 15B. COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES: COMPENSATION REVIEW AND APPROVAL PROCESS IS IDENTICAL TO THE PROCESS FOR THE CEO AND EXECUTIVES NOTED IN 15A ABOVE.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. INFORMATION IS MAINTAINED BY THE MANAGEMENT OF THE ORGANIZATION.
FORM 990, PART IX, LINE 11G
OTHER SERVICE FEES: PROGRAM SERVICE EXPENSES 796,792. MANAGEMENT AND GENERAL EXPENSES 304,504. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,101,296.
FORM 990, PART XI, LINE 2C:
THE OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS HAS NOT CHANGED FROM THE PRIOR YEAR. THE SELECTION OF AN INDEPENDENT ACCOUNTANT NO LONGER REQUIRES THE FORMAL APPROVAL OF WESTERN CONNECTICUT HOME NETWORK.
OTHER INFORMATION
THE TAXPAYER'S FORM 5471 FILING REQUIREMENTS HAVE BEEN OR WILL BE SATISFIED BY DANBURY HOSPITAL, 24 HOSPITAL AVENUE, DANBURY, CONNECTICUT, 06810, EIN: 06-0646597, THE MAJORITY SHAREHOLDER OF WESTERN CONNECTICUT HEALTHCARE INSURANCE CO., LTD. DANBURY HOSPITAL HAS FILED OR WILL FILE THE FORM 5471 AND THE APPLICABLE SCHEDULES WITH THE IRS SERVICE CENTER, PHILADELPHIA, PA.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.