Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
HACKENSACK UNIVERSITY MEDICAL CENTER |
221487576 | 03 | No | 0 | 0 | |
Total 1
|
0 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| CORE FORM, PART VI, SECTION A; QUESTIONS 6 & 7 | HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC") IS THE SOLE MEMBER OF THIS ORGANIZATION WHICH EXISTS THROUGH A PHYSICIAN NOMINEE AGREEMENT DUE TO STATE OF NEW JERSEY CORPORATE PRACTICE OF MEDICINE PROHIBITIONS. HACKENSACKUMC HAS THE ULTIMATE AUTHORITY AND RIGHT TO ELECT THE MEMBERS OF THIS ORGANIZATION'S BOARD OF TRUSTEES AND HAS CERTAIN RESERVED POWERS AS DEFINED IN THIS ORGANIZATION'S BYLAWS. |
| CORE FORM, PART VI, SECTION A; QUESTION 11B | THE ORGANIZATION IS AN AFFILIATE WITHIN HACKENSACK UNIVERSITY HEALTH NETWORK, INC. ("NETWORK"); A TAX-EXEMPT INTEGRATED HEALTHCARE DELIVERY SYSTEM ("SYSTEM"), WHICH INCLUDES HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC"). THE ORGANIZATION'S FEDERAL FORM 990 WAS PROVIDED TO EACH VOTING MEMBER OF ITS GOVERNING BODY, ITS BOARD OF TRUSTEES, PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE ("IRS"). THE ORGANIZATION'S BOARD OF TRUSTEES HAS ASSUMED THE RESPONSIBILITY TO OVERSEE, REVIEW AND APPROVE THE FEDERAL FORM 990, INCLUDING THE PREPARATION, REVIEW AND FILING PROCESS. AS PART OF THE TAX RETURN PREPARATION PROCESS THE ORGANIZATION HIRED A PROFESSIONAL CPA FIRM WITH EXPERIENCE AND EXPERTISE IN BOTH HEALTHCARE AND NOT-FOR-PROFIT TAX RETURN PREPARATION TO PREPARE THE FEDERAL FORM 990. THE CPA FIRM'S TAX PROFESSIONALS WORKED CLOSELY WITH HACKENSACKUMC'S FINANCE PERSONNEL AND INTERNAL WORKING GROUP (WHICH INCLUDED, BUT WAS NOT LIMITED TO, THE CHIEF FINANCIAL OFFICER, CONTROLLER, ACCOUNTING MANAGER AND CHIEF COMPLIANCE OFFICER) TO OBTAIN THE INFORMATION NEEDED IN ORDER TO PREPARE A COMPLETE AND ACCURATE TAX RETURN. THE CPA FIRM PREPARED A DRAFT FEDERAL FORM 990 AND FURNISHED IT TO THE ORGANIZATION'S FINANCE PERSONNEL AND INTERNAL WORKING GROUP FOR THEIR REVIEW. HACKENSACKUMC'S FINANCE PERSONNEL AND INTERNAL WORKING GROUP REVIEWED THE DRAFT FEDERAL FORM 990 AND DISCUSSED QUESTIONS AND COMMENTS WITH THE CPA FIRM. REVISIONS WERE MADE TO THE DRAFT FEDERAL FORM 990 WHERE NECESSARY AND A FINAL DRAFT WAS FURNISHED BY THE CPA FIRM TO THE HACKENSACKUMC'S FINANCE PERSONNEL AND INTERNAL WORKING GROUP FOR FINAL REVIEW AND APPROVAL PRIOR TO FILING WITH THE IRS. |
| CORE FORM, PART VI, SECTION B; QUESTION 12 | THE ORGANIZATION IS AN AFFILIATE WITHIN HACKENSACK UNIVERSITY HEALTH NETWORK, INC. ("NETWORK"); A TAX-EXEMPT INTEGRATED HEALTHCARE DELIVERY SYSTEM ("SYSTEM"), WHICH INCLUDES HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC"). THE NETWORK AND THIS ORGANIZATION REGULARLY MONITOR AND ENFORCE COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICY. ANNUALLY ALL MEMBERS OF THE BOARD OF TRUSTEES, OFFICERS AND SENIOR MANAGEMENT PERSONNEL ARE REQUIRED TO REVIEW THE EXISTING CONFLICT OF INTEREST POLICY AND COMPLETE A QUESTIONNAIRE. THE COMPLETED QUESTIONNAIRES ARE RETURNED TO HACKENSACKUMC'S CHIEF COMPLIANCE OFFICER FOR REVIEW. THEREAFTER THE CHIEF COMPLIANCE OFFICER PREPARES A SUMMARY OF THE COMPLETED QUESTIONNAIRES WHICH CONTAINS INFORMATION DISCLOSED ON AN INDIVIDUAL BY INDIVIDUAL BASIS. THE CHIEF COMPLIANCE OFFICER THEN PRESENTS THIS SUMMARY TO HACKENSACKUMC'S GOVERNANCE COMMITTEE FOR ITS REVIEW AND DISCUSSION. |
| CORE FORM, PART VI, SECTION B; QUESTION 15 | THE ORGANIZATION IS AN AFFILIATE WITHIN HACKENSACK UNIVERSITY HEALTH NETWORK, INC. ("NETWORK"); A TAX-EXEMPT INTEGRATED HEALTHCARE DELIVERY SYSTEM ("SYSTEM"), WHICH INCLUDES HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC"). THE NETWORK IS THE TAX-EXEMPT PARENT OF THE SYSTEM. THE NETWORK'S BOARD OF TRUSTEES HAS AN EXECUTIVE COMPENSATION COMMITTEE ("COMMITTEE"). THE COMMITTEE HAS ADOPTED A WRITTEN EXECUTIVE COMPENSATION PHILOSOPHY WHICH IT FOLLOWS WHEN IT REVIEWS AND APPROVES OF THE COMPENSATION AND BENEFITS OF THE SYSTEM'S SENIOR MANAGEMENT, INCLUDING, BUT NOT LIMITED TO, DIRECTORS OF THIS ORGANIZATION. THE COMMITTEE REVIEWS THE "TOTAL COMPENSATION" OF THE INDIVIDUALS WHICH IS INTENDED TO INCLUDE BOTH CURRENT AND DEFERRED COMPENSATION AND ALL EMPLOYEE BENEFITS, BOTH QUALIFIED AND NON-QUALIFIED. THE COMMITTEE CONDUCTS ITS REVIEW AND APPROVAL PROCESS AT LEAST ANNUALLY OVER SEVERAL MEETINGS, AND APPROVES ONLY "TOTAL COMPENSATION" THAT THE COMMITTEE HAS CONCLUDED DOES NOT EXCEED WHAT THE COMMITTEE CONSIDERS TO BE REASONABLE COMPENSATION. THE COMMITTEE STRUCTURES AND CONDUCTS ITS REVIEW AND APPROVAL PROCESS SO AS TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER THE INTERMEDIATE SANCTIONS RULES OF FEDERAL INCOME TAX LAW. THIS REVIEW AND APPROVAL PROCESS APPLIES TO ALL FORMS OF COMPENSATION AND BENEFITS PROVIDED TO ALL MEMBERS OF THE SENIOR MANAGEMENT TEAM. THE THREE FACTORS WHICH MUST BE SATISFIED IN ORDER TO RECEIVE THE REBUTTABLE PRESUMPTION OF REASONABLENESS ARE THE FOLLOWING: 1. THE COMPENSATION ARRANGEMENT IS APPROVED IN ADVANCE BY AN "AUTHORIZED BODY" OF THE APPLICABLE TAX-EXEMPT ORGANIZATION WHICH IS COMPOSED ENTIRELY OF INDIVIDUALS WHO DO NOT HAVE A "CONFLICT OF INTEREST" WITH RESPECT TO THE COMPENSATION ARRANGEMENT; 2. THE AUTHORIZED BODY OBTAINED AND RELIED UPON "APPROPRIATE DATA AS TO COMPARABILITY" PRIOR TO MAKING ITS DETERMINATION; AND 3. THE AUTHORIZED BODY "ADEQUATELY DOCUMENTED THE BASIS FOR ITS DETERMINATION" CONCURRENTLY WITH MAKING THAT DETERMINATION. THE COMMITTEE IS COMPRISED OF MEMBERS OF THE BOARD OF TRUSTEES, EACH OF WHOM IS "DISINTERESTED" AS DEFINED BY THE IRS IN ITS REGULATIONS DESCRIBING THIS STANDARD. THE COMMITTEE RELIED UPON APPROPRIATE COMPARABLE DATA; SPECIFICALLY THE COMMITTEE OBTAINED A WRITTEN COMPENSATION STUDY FROM AN INDEPENDENT FIRM WHICH SPECIALIZES IN THE REVIEW OF HOSPITAL AND HEALTHCARE SYSTEM EXECUTIVE COMPENSATION AND BENEFITS THROUGHOUT THE UNITED STATES. THIS DETAILED STUDY USES COMPARABLE GEOGRAPHIC AND DEMOGRAPHIC MARKET DATA FOR TAX-EXEMPT HOSPITALS AND HEALTHCARE SYSTEMS OF A SIMILAR LEVEL OF NET ANNUAL OPERATING REVENUE IN THE SAME GEOGRAPHIC REGION. NO DATA FROM ANY FOR-PROFIT ENTITIES IS USED. THE COMMITTEE ADEQUATELY DOCUMENTED ITS BASIS FOR ITS DETERMINATION THROUGH THE TIMELY PREPARATION OF WRITTEN MINUTES OF THE COMPENSATION COMMITTEE MEETINGS DURING WHICH THE EXECUTIVE COMPENSATION AND BENEFITS WAS REVIEWED AND SUBSEQUENTLY APPROVED. THE REVIEW AND APPROVAL PROCESS USED BY THE COMMITTEE, INCLUDING ALL ACTIONS DESIGNED TO QUALIFY FOR THE REBUTTABLE PRESUMPTION OF REASONABLENESS, IS APPLIED TO ALL MEMBERS OF THE SENIOR MANAGEMENT TEAM OF THE SYSTEM, WHETHER OR NOT THEY WOULD BE CONSIDERED 'DISQUALIFIED PERSONS' UNDER THE INTERMEDIATE SANCTIONS RULES. IN ADDITION TO RELYING ON MARKET DATA, THE COMMITTEE APPLIES A WIDE RANGE OF BUSINESS JUDGMENT FACTORS INCLUDING, BUT NOT LIMITED TO, INDIVIDUAL PERFORMANCE, INDIVIDUAL EXPERIENCE, RECRUITMENT AND RETENTION FACTORS, AND THE UNIQUE DEMANDS OF PARTICULAR POSITIONS. |
| CORE FORM, PART VI, SECTION C; QUESTION 19 | THE ORGANIZATION'S FILED CERTIFICATE OF INCORPORATION AND ANY AMENDMENTS CAN BE OBTAINED AND REVIEWED THROUGH THE STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY. |
| CORE FORM, PART VII, SECTION A | THE ORGANIZATION IS AN AFFILIATE WITHIN HACKENSACK UNIVERSITY HEALTH NETWORK, INC. ("NETWORK"); A TAX-EXEMPT INTEGRATED HEALTHCARE DELIVERY SYSTEM ("SYSTEM"), WHICH INCLUDES HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC"). THE SYSTEM INCLUDES BOTH FOR-PROFIT AND NOT-FOR-PROFIT ORGANIZATIONS. THIS ORGANIZATION'S SOLE VOTING MEMBER, IHOR S. SAWCZUK, M.D., LISTED ON CORE FORM, PART VII AND SCHEDULE J OF THIS FORM 990 IS THE EXECUTIVE VICE PRESIDENT/CHIEF MEDICAL OFFICER EMPLOYED BY HACKENSACKUMC AND NOMINEE OWNER OF THIS ORGANIZATION DUE TO CORPORATE PRACTICE OF MEDICINE PROHIBITIONS. THE HOURS REFLECTED FOR DR. SAWCZUK REPRESENT THE ESTIMATED HOURS DEVOTED PER WEEK ON BEHALF OF THE SYSTEM; NOT SOLELY THIS ORGANIZATION. |
| CORE FORM, PART VII AND SCHEDULE J | PART VII AND SCHEDULE J REFLECT AN OFFICER AND BOARD MEMBER RECEIVING COMPENSATION AND BENEFITS FROM A RELATED ORGANIZATION. PLEASE NOTE THIS REMUNERATION WAS FOR SERVICES RENDERED AS A FULL-TIME EMPLOYEE OF THE RELATED ORGANIZATION AND NOT FOR SERVICES RENDERED AS AN OFFICER OR VOTING MEMBER OF THIS ORGANIZATION'S BOARD OF TRUSTEES. |
| CORE FORM, PART XII; QUESTION 2 | THE ORGANIZATION IS AN AFFILIATE WITHIN HACKENSACK UNIVERSITY HEALTH NETWORK, INC. ("NETWORK"); A TAX-EXEMPT INTEGRATED HEALTHCARE DELIVERY SYSTEM ("SYSTEM"), WHICH INCLUDES HACKENSACK UNIVERSITY MEDICAL CENTER ("HACKENSACKUMC"). AN INDEPENDENT BIG FOUR CPA FIRM PREPARED AUDITED CONSOLIDATED FINANCIAL STATEMENTS FOR THE NETWORK AND ITS SUBSIDIARIES AND CONTROLLED ENTITIES, FOR THE YEARS ENDED DECEMBER 31, 2014 AND 2013, RESPECTIVELY. THE INDEPENDENT CPA FIRM ISSUED AN UNQUALIFIED OPINION WITH RESPECT TO THESE AUDITED CONSOLIDATED FINANCIAL STATEMENTS EACH YEAR. THE NETWORK'S AUDIT AND CORPORATE COMPLIANCE COMMITTEE HAS ASSUMED RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT OF THE HACKENSACK UNIVERSITY HEALTH NETWORK AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT AUDITOR. |
| Software ID: | |
| Software Version: |