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)
ST JOSEPH'S HOSPITAL HEALTH CENTER |
150532254 | 3 | Yes | 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. |
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| 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 |
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| Return Reference | Explanation |
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| 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 |
|---|---|
| FORM 990, PART III, LINE 2 | IN SEPTEMBER 2014, THE MEDICAL PC MADE A STRATEGIC DECISION TO HIRE A BREAST SURGEON SPECIALIZING IN BREAST DISEASE AND TREATMENT TO FURTHER DEVELOP THEIR CURRENT BREAST CARE PROGRAM TO BETTER SERVE THESE PATIENTS. THE MISSION OF THE BREAST CARE PROGRAM IS TO PROVIDE AN ORGANIZED, COMPREHENSIVE, MULTIDISCIPLINARY TEAM APPROACH TO BREAST CARE TO IMPROVE CLINICAL AND PSYCHOLOGICAL OUTCOMES FOR ALL PATIENTS. THE PROGRAM INCLUDES A HIGHLY SKILLED TEAM OF PHYSICIANS LEAD BY DR. KORT AND NURSE NAVIGATORS TO GUIDE AND SUPPORT EACH PATIENT THROUGH THE TREATMENT AND SURVIVORSHIP PROCESS. THE MULTISPECIALTY ENSURES COORDINATION OF CARE BETWEEN SURGERY, RADIOLOGY, PATHOLOGY, MEDICAL AND RADIATION ONCOLOGY. |
| FORM 990, PART III, LINE 3 | IN PRIOR YEARS AND PRIOR TO MARCH OF 2014, THE MEDICAL PC HAD A GYN PRACTICE. THE PRACTICE WAS SET UP TO PROVIDE GYNECOLOGY SERVICES TO THE COMMUNITY. IN 2014, THE MEDICAL PC DETERMINED THAT THE DEMAND FOR THE SERVICES OF THE PROVIDERS IN THE PRACTICE WERE NOT ENOUGH TO SUPPORT THE COST OF THE PRACTICE. THE FOUR PROVIDERS EMPLOYED BY THE PRACTICE LEFT TO PURSUE WORK IN OTHER INDEPENDENT PRACTICES. |
| FORM 990, PART VI, SECTION A, LINE 1 | ST. JOSEPH'S MEDICAL, P.C. IS A NEW YORK STATE PROFESSIONAL SERVICES CORPORATION WHICH IS A TAX EXEMPT CAPTIVE P.C. THE SOLE SHAREHOLDER, SANDRA M. SULIK, M.D. IS THE VICE PRESIDENT FOR MEDICAL AFFAIRS OF ST. JOSEPH'S HOSPITAL HEALTH CENTER, A SECTION 501(C)(3), 431 BED ACUTE CARE HOSPITAL. PURSUANT TO ST. JOSEPH'S MEDICAL, P.C.'S BY-LAWS, THE BOARD OF TRUSTEES OF THE HOSPITAL IS REQUIRED TO APPOINT A PRIMARY CARE OVERSIGHT AND COMPENSATION ADVISORY COMMITTEE ("ADVISORY COMMITTEE") TO MAKE RECOMMENDATIONS TO THE CORPORATION'S BOARD OF DIRECTORS ON THE FOLLOWING ISSUES: (1) IMPLEMENTING AND EVALUATING COMPENSATION USING NATIONAL SURVEYS FOR ALL PHYSICIAN-EMPLOYEES; (2) IMPLEMENTING AND EVALUATING THE CORPORATION'S BUDGET; (3) PROVISION OF MANAGEMENT, ADMINISTRATIVE AND BILLING SERVICES; (4) ESTABLISHMENT OF ADDITIONAL PRACTICE LOCATIONS; (5) LEVEL AND QUALITY OF COMMUNITY SERVICES PROVIDED BY PHYSICIAN-EMPLOYEES; (6) DECISIONS INVOLVING COST EFFICIENT OPERATIONS; (7) LONG-RANGE PLANNING; AND (8) ACTIONS REQUIRED FOR THE CORPORATION TO OPERATE IN A MANNER CONSISTENT WITH ITS CHARITABLE PURPOSES AND TO OBTAIN AND MAINTAIN ITS TAX-EXEMPT STATUS PURSUANT TO INTERNAL REVENUE CODE SECTION 501(C)(3). THE CURRENT MEMBERS OF THE ADVISORY COMMITTEE OF ST. JOSEPH'S MEDICAL, P.C. ARE SISTER MARY OBRIST, OSF, JOHN MARSHALL, LOWELL SEIFTER, MEREDITH PRICE AND SANDRA SULIK, M.D., PRESIDENT. THE ADVISORY COMMITTEE MEMBERS WERE APPOINTED BY THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES OF ST. JOSEPH'S HOSPITAL HEALTH CENTER. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE PRESIDENT OF THE ORGANIZATION IS THE SOLE SHAREHOLDER AND DIRECTOR. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE BY LAWS PROVIDE THAT DR. SULIK AS THE SOLE SHAREHOLDER HAS THE POWER TO APPOINT THE SOLE DIRECTOR OF THE CORPORATION. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE PC, ACCORDING TO ITS BYLAWS, HAS AN OVERSIGHT COMMITTEE THAT IS APPOINTED BY THE HOSPITAL'S BOARD OF TRUSTEES. THE MATTERS THAT THE COMMITTEE IS TO PROVIDE OVERSIGHT ON ARE SPECIFIED IN THE BYLAWS. |
| FORM 990, PART VI, SECTION B, LINE 11 | A COPY OF THE 990 IS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW PRIOR TO ITS SUBMISSION. |
| FORM 990, PART VI, SECTION B, LINE 12C | CONSISTENT WITH THE HOSPITAL BYLAWS WHICH REQUIRES A DUTY TO DISCLOSE, ON AN ANNUAL BASIS AT A DEFINED TIME, ALL BOARD OF TRUSTEES ARE GIVEN THE CONFLICT OF INTEREST POLICY AND FORM TO REVIEW AND COMPLETE. THE PRESIDENT OF THE BOARD OF TRUSTEES TRACKS THE SUBMISSION PROCESS TO ENSURE THAT ALL FORMS ARE COMPLETED AND SUBMITTED. THE INFORMATION FROM THE CONFLICT OF INTEREST STATEMENTS ARE REVIEWED AT A SUBSEQUENT BOARD MEETING. ANY NEW INDIVIDUALS APPOINTED AS A TRUSTEE WILL COMPLETE THIS REVIEW AND SUBMISSION PROCESS AFTER THEY HAVE BEEN CONFIRMED. THE INTERESTED PERSON IS REQUIRED TO LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF AND VOTE ON THE TRANSACTION OR ARRANGEMENT THAT RESULTS FROM THE CONFLICT OF INTEREST. THE BOARD OF TRUSTEE MEETING MINUTES REFLECT WHENEVER A BOARD MEMBER ABSTAINS FROM VOTING. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION'S BY-LAWS ESTABLISHES A COMPENSATION ADVISORY COMMITTEE TO IMPLEMENT AND EVALUATE THE COMPENSATION. THE COMMITTEE IS RESPONSIBLE FOR ENSURING THAT THE EXECUTIVE COMPENSATION PROGRAM IS APPROPRIATE AND THAT ITS COMPENSATION AND BENEFITS ARE REASONABLE. |
| FORM 990, PART VI, SECTION C, LINE 19 | ST. JOSEPH'S MEDICAL, P.C. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR THE FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. |
| FORM 990, PART XI, LINE 9: | EQUITY TRANSFER 15,551,193. |
| FORM 990, PART XII, LINE 2C: | THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
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