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)
SVMC |
222563241 | Yes | 0 | 0 | ||
| (B)
SVHC |
030179435 | Yes | 0 | 0 | ||
| (C)
MAHC |
030279740 | Yes | 0 | 0 | ||
| (D)
SVHCA |
222563243 | Yes | 0 | 0 | ||
Total 4
|
||||||
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 |
|---|---|
| SCHEDULE A, PART I, LINE 11I | ORGANIZATIONS SUPPORTED: THE COMPLETE NAMES OF THE ORGANIZATIONS SUPPORTED ARE AS FOLLOWS: (A) SOUTHWESTERN VERMONT MEDICAL CENTER (B) SOUTHWESTERN VERMONT HEALTH CARE CORPORATION (C) MOUNT ANTHONY HOUSING CORPORATION (D) SOUTHWESTERN VERMONT HEALTHCARE AUXILIARY |
| SCHEDULE A, PART IV, SECTION B, LINE 1 | SVHC IS THE SOLE MEMBER OF THE SVHC FOUNDATION. SVHC'S PRESIDENT/CEO SERVES ON THE FOUNDATION BOARD EX OFFICIO WITH VOTE AND SVHC'S CFO SERVES ON THE FOUNDATION BOARD EX OFFICIO WITHOUT VOTE. TWO MEMBERS OF SVHC'S BOARD OF TRUSTEES ALSO SERVE AS DIRECTORS OF THE FOUNDATION. ALL DIRECTORS OF THE FOUNDATION ARE NOMINATED AND ELECTED BY THE FOUNDATION, SUBJECT TO RATIFICATION BY SVHC. |
| 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 4A | PROGRAM SERVICE ACCOMPLISHMENTS: AT SVHC, STAFF WORKING DIRECTLY WITH PATIENTS IDENTIFY A PATIENT'S NEED AND FILL OUT A RESTRICTED GIFT CHECK REQUEST FORM TO PAY FOR SOMETHING THAT THE STAFF MEMBER BELIEVES THE PATIENT IS UNABLE TO PAY FOR HIMSELF. NEED IS DETERMINED BY THE STAFF MEMBER'S CONVERSATIONS WITH THE PATIENT AS WELL AS OBSERVATION AND KNOWLEDGE OF THE PATIENT'S LIVING CONDITIONS AND SITUATION. THE CHECK REQUEST IS APPROVED AND SIGNED BY THE STAFF MEMBER'S SUPERVISOR AND SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT. IN THE CANCER CENTER, STAFF MEMBERS ARE ENCOURAGED TO REPORT ANY PATIENT NEED THEY IDENTIFY TO THE CANCER CENTER DIRECTOR, NURSE MANAGER, PHYSICIAN, OR SOCIAL SERVICES. IF THE PATIENT'S NEED IS FOR AN "EMOTIONAL BOOST," SUCH AS A MASSAGE OR OTHER SUCH SERVICE, THE PATIENT IS ELIGIBLE BY VIRTUE OF HIS/HER CANCER DIAGNOSIS. IF THE PATIENT'S NEED IS FOR FINANCIAL ASSISTANCE WITH RENT, UTILITIES, PRESCRIPTIONS, ETC., HE/SHE IS REFERRED TO SOCIAL SERVICES. SOCIAL SERVICES DETERMINES FINANCIAL NEED BY TALKING WITH THE PATIENT TO FIND OUT THEIR CURRENT SITUATION. SOCIAL SERVICES LOOKS FOR OTHER FINANCIAL RESOURCES IN THE COMMUNITY WITH WHICH TO HELP THE PATIENT AND CONSIDERS THE HEALTH SYSTEM'S PATIENT RESOURCE FUNDS. ASSISTANCE IS GENERALLY CONSIDERED TO BE A ONE-TIME, EMERGENCY STOP-GAP AID, AND NOT SOMETHING THAT WILL BE ONGOING. ONCE NEED HAS BEEN DETERMINED, THE NURSE MANAGER, THE CHIEF RADIATION THERAPIST OR SOCIAL SERVICES COMPLETES THE RESTRICTED GIFT CHECK REQUEST FORM AND OBTAINS APPROVAL FROM THE DIRECTOR OF THE CANCER CENTER. THE CHECK REQUEST FORM IS THEN SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT. THE SVMC PATIENT RESOURCE FUND IS MAINLY USED BY SOCIAL SERVICES TO HELP NON-CANCER PATIENTS WITH THE SAME SORTS OF NEEDS THAT THE OTHER TWO FUNDS ARE USED FOR. CHECK REQUESTS TO ACCESS THIS FUND WOULD BE FILLED OUT BY A SOCIAL SERVICES STAFF MEMBER, APPROVED BY THE HEAD OF SOCIAL SERVICES AND SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT. |
| FORM 990, PART VI, SECTION A, LINE 2 | BUSINESS RELATIONSHIPS: THOMAS DEE, MICHAEL BRADY, MARNY KRAUSE, AND STEPHEN D MAJETICH SHARE A BUSINESS RELATIONSHIP AS THEY ARE ALL ON THE BOARD OF SOUTHWESTERN VERMONT HEALTHCARE ENTERPRISES, A RELATED TAXABLE ORGANIZATION. ORION HOWARD, MD, IS EMPLOYED BY DARTMOUTH-HITCHCOCK AND WORKS AT SVMC. |
| FORM 990, PART VI, SECTION A, LINES 6, 7A & 7B | CLASSES OF MEMBERS OR STOCKHOLDERS: THE SOLE MEMBER OF THE CORPORATION SHALL BE THE SOUTHWESTERN VERMONT HEALTH CARE CORPORATION ("SVHC"), A NONPROFIT CORPORATION, ACTING THROUGH ITS BOARD OF DIRECTORS (THE "SVHC BOARD"). THE MEMBER SHALL TAKE ACTION BY RESOLUTION DULY ADOPTED BY THE SVHC BOARD OR BY EXECUTION OF A WRITTEN CONSENT, AUTHORIZED BY THE SVHC BOARD AND EXECUTED BY A PERSON SO AUTHORIZED. THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED AND CONDUCTED BY A BOARD OF DIRECTORS (THE "BOARD"), SUBJECT TO THE AUTHORITY AND DIRECTION OF THE SVHC BOARD. THE SVHC BOARD SHALL HAVE ULTIMATE RESPONSIBILITY TO ASSURE THAT THE POLICIES AND ACTIVITIES OF THE CORPORATION ARE COORDINATED WITH THOSE OF ITS AFFILIATED CORPORATIONS IN ORDER TO ACHIEVE A HIGHLY EFFICIENT, PATIENT-FOCUSED, INTEGRATED SYSTEM OF HEALTH CARE DELIVERY. ACCORDINGLY, ANY CORPORATE ACTION OF THE CORPORATION AUTHORIZED BY THE SVHC BOARD SHALL BE DEEMED TO BE AUTHORIZED AND DIRECTED BY THE BOARD. IN THE ABSENCE OF ANY CONTRARY DIRECTION FROM SVHC BOARD, THE BOARD MAY TAKE ACTION WITH RESPECT TO THE AFFAIRS OF THE CORPORATION IN ACCORDANCE WITH THESE BYLAWS, PROVIDED HOWEVER, THAT THE BOARD MAY NOT TAKE ACTION WITH RESPECT TO ANY OF THE FOLLOWING MATTERS WITHOUT AUTHORIZATION OF THE SVHC BOARD: ANNUAL OPERATING BUDGETS; CAPITAL BUDGETS; CERTIFICATE OF NEED APPLICATIONS; ANY CONTRACT OR AGREEMENT WHICH IS OF A SUBSTANTIAL NATURE OR WHICH IS NOT INCLUDED IN APPROVED OPERATING OR CAPITAL BUDGETS; ANY VOLUNTARY DISSOLUTION, MERGER, OR CONSOLIDATION OF THE CORPORATION OR THE SALE OR TRANSFER OF ALL OR SUB-CREATION, ACQUISITION, DISSOLUTION, MERGER OR CONSOLIDATION OF ANY SUBSIDIARY OR AFFILIATE OR AUXILIARY CORPORATION; ANY AMENDMENTS TO THE BYLAWS, ARTICLES OF INCORPORATION OF THE CORPORATION; THE STRATEGIC AND MASTER FACILITIES PLANS; AND APPOINTMENT OF CHIEF EXECUTIVE OFFICER. |
| FORM 990, PART VI, SECTION B, LINE 11B | PROCESS TO REVIEW THE FORM 990: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE DRAFT 990 IS THEN REVIEWED BY MANAGEMENT AND ACCOUNTING. AFTER ALL SUGGESTED CHANGES FROM MANAGEMENT ARE MADE, THE UPDATED DRAFT FORM 990 IS THE PRESENTED TO THE FINANCE COMMITTEE. AFTER ANY FINAL CHANGES ARE MADE, THE FORM 990 IS PRESENTED TO THE FULL BOARD OF DIRECTORS BEFORE FILING WITH THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY: OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY DISCLOSE INTEREST WHICH COULD RESULT IN CONFLICTS. THE COMPLIANCE OFFICER MAINTAINS RECORDS ON THE COMPLETION OF THE CONFLICT OF INTEREST FORMS, ANY POTENTIAL CONFLICTS ARE DISCUSSED AT THE AUDIT AND COMPLIANCE MEETING AFTER WHICH RECOMMENDATIONS ARE BROUGHT BEFORE THE FULL BOARD FOR A VOTE. IN THE CASE OF A POTENTIAL CONFLICT OF INTEREST, THE BOARD MEMBER ABSTAINS FROM ALL DISCUSSION AND CONSIDERATION OF THE ITEM THAT PRESENTS THE POTENTIAL CONFLICT. |
| FORM 990, PART VI, SECTION B, LINES 15A & 15B | COMPENSATION REVIEW: THE ORGANIZATION'S CEO POSITION IS PAID BY SOUTHWESTERN VERMONT MEDICAL CENTER (SVMC). THE PROCESS SVMC USES TO DETERMINE CEO COMPENSATION IS AS FOLLOWS: THE BOARD ENGAGES AN OUTSIDE CONSULTING FIRM TO REVIEW COMPARABLE CEO SALARY DATA AND USES NATIONAL PROFESSIONAL ORGANIZATION SURVEY DATA IN THE DETERMINATION OF THE CEO'S SALARY AND BENEFITS. IN ADDITION, THE BOARD ENGAGES AN OUTSIDE CONSULTING FIRM AND ALSO USES NATIONAL PROFESSIONAL ORGANIZATION SURVEY DATA TO REVIEW THE WAGE DATA OF OTHER OFFICERS AND KEY EMPLOYEES. THE PROCESS BEGINS WITH A REQUEST TO OUR COMPENSATION CONSULTANT MIKE MACIEKOWICH OF ASTRON SOLUTIONS TO PERFORM A MARKET ANALYSIS OF THE CEO POSITION. THIS REPORT IS USED AS THE BASIS FOR STRUCTURING COMPENSATION FOR THE CEO DURING THE NEXT CONTRACT PERIOD. USING THE RESULTS OF THE MARKET ANALYSIS WITH INPUT FROM OUR CEO, THE COMPENSATION OFFER FOR THE NEXT CONTRACT PERIOD IS DEVELOPED AND INCORPORATED INTO THE CONTRACT. THE COMPENSATION IS THEN DISCUSSED BY THE GOVERNANCE COMMITTEE OF THE BOARD WITH MIKE MACIEKOWICH IN ATTENDANCE OR ON THE PHONE. IF MIKE MACIEKOWICH IS IN AGREEMENT HE WILL PROVIDE A WRITTEN LETTER CONFIRMING HIS AGREEMENT. |
| FORM 990, PART VI, SECTION C, LINE 19 | DOCUMENT DISCLOSURE: SVHC FOUNDATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART VII, SECTION A | BOARD MEMBER COMPENSATION: NO TRUSTEE RECEIVES COMPENSATION FOR THEIR SERVICES AS A TRUSTEE OF THE BOARD. THOMAS DEE IS COMPENSATED AS THE CEO OF THE SOUTHWESTERN VERMONT HEALTHCARE SYSTEM. STEPHEN MAJETICH IS COMPENSATED AS CFO OF SOUTHWESTERN VERMONT HEALTHCARE SYSTEM. |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS: $ (280,659) TRANSFER FROM AFFILIATES (54,756) CHANGE IN BENEFICIAL INTEREST IN TRUST ------------ $ (335,415) |
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| Software Version: |