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 (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 | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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 | ||||
| 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 2015 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-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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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 I, LINE 1 | DESCRIPTION OF ORGANIZATION MISSION: THE HOSPITAL COMMITTEE FOR THE LIVERMORE-PLEASANTON AREAS, DBA STANFORD HEALTH CARE - VALLEYCARE ("SHC-VC") IS A CALIFORNIA NOT-FOR-PROFIT CORPORATION THAT PROVIDES BOTH INPATIENT AND OUTPATIENT HEALTHCARE SERVICES. |
| FORM 990, PART VI, SECTION A, LINE 2 | THE FOLLOWING INDIVIDUALS ARE EMPLOYEES OF STANFORD HEALTH CARE: DANIEL MORISSETTE JENNIFER VARGAS JAMES HEREFORD AMIR DAN RUBIN DOUGLAS GUNDERSON BENJIE M LOANZON DAVID CONNOR THE FOLLOWING INDIVIDUALS ARE EMPLOYEES OF STANFORD UNIVERSITY: RAJNEESH BEHAL MARK CULLEN LLOYD B. MINOR MD THE FOLLOWING INDIVIDUALS ARE BOARD MEMBERS AT STANFORD HEALTH CARE: JOHN GOLDMAN LLOYD B. MINOR MD KAYE FOSTER-CHEEK THE FOLLOWING INDIVIDUALS ARE BOARD MEMBERS AT STANFORD PET-CT LLC: AMIR DAN RUBIN JAMES HEREFORD LLOYD B. MINOR MD THE FOLLOWING INDIVIDUALS ARE BOARD MEMBERS AT SUMIT HOLDING INTERNATIONAL, LLC: AMIR DAN RUBIN DANIEL MORISSETTE THE FOLLOWING INDIVIDUALS ARE BOARD MEMBERS AT SUMIT INSURANCE COMPANY, LTD.: AMIR DAN RUBIN DANIEL MORISSETTE THE FOLLOWING INDIVIDUALS ARE CLASS A SUBSCRIBER VOTING MEMBERS AT THE PROFESSIONAL EXCHANGE ASSURANCE COMPANY: AMIR DAN RUBIN DANIEL MORISSETTE |
| FORM 990, PART VI, SECTION A, LINE 6 | STANFORD HEALTH CARE IS THE SOLE MEMBER OF SHC-VC. |
| FORM 990, PART VI, SECTION A, LINE 7A | STANFORD HEALTH CARE, AS THE SOLE MEMBER OF SHC-VC, APPOINTS ALL CLASS "B" DIRECTORS, AND APPROVES THE SHC-VC BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE SOLE MEMBER, STANFORD HEALTH CARE, APPROVES THE APPOINTMENT OF CLASS "A" DIRECTORS TO THE SHC-VC BOARD OF DIRECTORS. THE MEMBER SHALL HAVE ALL POWER AND AUTHORITY CONFERRED UPON IT BY THE ARTICLES OF INCORPORATION OF THE CORPORATION AND THESE BYLAWS AND UPON MEMBERS BY LAW. THE FOLLOWING POWERS SHALL BE RESERVED TO THE MEMBER: (A) APPOINTMENT AND REMOVAL OF ALL SENIOR LEADERSHIP AND ENGAGEMENT OF STANFORD UNIVERSITY TO PROVIDE LEGAL AND INTERNAL AUDIT SERVICES TO THE CORPORATION; (B) SELECTION OF THE AUDITORS OF THE CORPORATION; (C) AMENDMENT OF THESE BYLAWS, EXCEPT AS PROVIDED IN ARTICLE X; (D) APPROVAL OF THE INCURRENCE OF DEBT BY THE CORPORATION OTHER THAN DEBT PROVIDED FOR IN AN APPROVED CAPITAL BUDGET APPROVED BY THE MEMBER; (E) APPROVAL OF OPERATING AND CAPITAL BUDGETS OF THE CORPORATION; AND (F) APPROVAL OF STRATEGIC PLANS THAT HAVE BEEN DEVELOPED BY MANAGEMENT AND SUBMITTED FOR APPROVAL TO THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE FINANCE DEPARTMENT REVIEWS THE FORM 990 FOR ACCURACY, WITH INPUT FROM COMMUNITY BENEFITS DEPARTMENT PRIMARILY FOR SCHEDULE H. PRIOR TO FILING THE RETURN WITH THE INTERNAL REVENUE SERVICE, A COMPLETE COPY OF THE FORM 990 IS SENT ELECTRONICALLY TO EACH MEMBER OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. THE CFO REVIEWS THE FORM 990 WITH THE AUDIT COMMITTEE AND INVITES QUESTIONS. FOLLOWING THIS REVIEW, A FULL COPY OF THE FINAL RETURN IS PROVIDED TO EACH MEMBER OF THE BOARD OF DIRECTORS PRIOR TO FILING. ONCE THESE STEPS ARE COMPLETE, THE RETURN IS FILED WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C | OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO COMPLETE AN INITIAL CONFLICT-OF-INTEREST DISCLOSURE STATEMENT ("DISCLOSURE STATEMENT") WITHIN 30 DAYS OF BEGINNING SERVICE AT SHC-VC. ADDITIONALLY, AN UPDATED DISCLOSURE STATEMENT IS REQUIRED THEREAFTER ON AN ANNUAL BASIS. FURTHERMORE, OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO UPDATE THEIR DISCLOSURE STATEMENT WITHIN TEN (10) BUSINESS DAYS OF A MATERIAL CHANGE IN THEIR SITUATIONS THAT MAY CREATE AN ACTUAL OR PERCEIVED CONFLICT-OF-INTEREST. A DISCLOSURE THAT APPEARS TO BE A CONFLICT WILL BE RESOLVED BY A MUTUAL AGREEABLE PLAN WITH THE VICE PRESIDENT OF HUMAN RESOURCES THAT OUTLINES THE STEPS THE OFFICER, DIRECTOR OR KEY EMPLOYEE MUST TAKE TO RECTIFY THE CONFLICT. IN MATTERS THAT ARE UNCLEAR OR QUESTIONABLE, THE OFFICE OF CHIEF COMPLIANCE OFFICER WILL BE CONSULTED FOR A RULING. IF FURTHER INQUIRY IS NECESSARY THE OFFICE OF THE GENERAL COUNSEL WILL DETERMINE THE APPROPRIATE COURSE OF ACTION. |
| FORM 990, PART VI, SECTION B, LINE 15A & B | SHC-VC UTILIZES THE SERVICES OF TOWER WATSON FOR COMPENSATION BENCHMARKING, ANALYSIS, AND REPORTING. THE BOARD OF DIRECTORS HAS A COMPENSATION SUB-COMMITTEE WHO REVIEW THE RESULTS OF THE COMPENSATION REVIEW AND IS ASSURED THAT TOTAL COMPENSATION IS CONSISTENT WITH THE MARKET. THIS PROCESS WAS LAST PERFORMED IN 2016. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING/ORGANIZING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND AUDITED FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS OR FUND BALANCES: EQUITY TRANSFER - $3,088,731 ADDITIONAL TEMPORARY RESTRICTED NET ASSETS - $556,956 NET ASSET FUNDING ADJUSTMENT - $6,899 TOTAL - $3,652,586 |
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