Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 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 |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) 2015 | (b) 2016 | (c) 2017 | (d) 2018 | (e) 2019 | (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) |
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| 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): |
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| 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 2019 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-2019 |
(iii) Distributable Amount for 2019 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2019 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2019: | ||||
| a From 2014....... | ||||
| b From 2015....... | ||||
| c From 2016....... | ||||
| d From 2017....... | ||||
| e From 2018....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2019 distributable amount | ||||
|
i
Carryover from 2014 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2019 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2019 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2020. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2015..... | ||||
| b Excess from 2016..... | ||||
| c Excess from 2017..... | ||||
| d Excess from 2018..... | ||||
| e Excess from 2019..... | ||||
| 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.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 1 | ORGANIZATION'S MISSION: THE PURPOSE OF THE ORGANIZATION IS ALSO TO PROMOTE AND SUPPORT THE DEVELOPMENT AND MAINTENANCE OF A HIGHLY EFFICIENT, PATIENT-FOCUSED, INTEGRATED HEALTHCARE DELIVERY SYSTEM. |
| FORM 990, PART III, LINE 2 | ADDITIONAL PROGRAM SERVICE ACTIVITIES: ON FEBRUARY 5, 2018, THE CORPORATION ACQUIRED HOOSICK FALLS HEALTH CENTER, INC., D/B/A THE CENTER FOR NURSING AND REHABILITATION AT HOOSICK FALLS (CNR), A NOT-FOR-PROFIT SKILLED NURSING FACILITY THAT PROVIDES LONG-TERM CARE SERVICES IN THE HOOSICK FALLS AND RENSSELAER COUNTY COMMUNITIES. THE CORPORATION EXPECTS THE ACQUISITION WILL ALLOW IT TO PROVIDE MORE COMPREHENSIVE HEALTH CARE SERVICES IN ITS CURRENT SERVICE AREA AND ACHIEVE COST SAVINGS THROUGH ELIMINATION OF CERTAIN DUPLICATIVE ADMINISTRATIVE AND OTHER FUNCTIONS. THE ACQUISITION WAS ACCOMPLISHED BY SVHC-HOOSICK FALLS, LLC, BECOMING THE SOLE MEMBER OF CNR. |
| FORM 990, PART VI, SECTION A, LINE 4 | 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: THE ORGANIZATION'S BOARD OF DIRECTORS IS THE SAME AS THE BOARD OF DIRECTORS OF SOUTHWESTERN VERMONT HEALTHCARE ENTERPRISES, A RELATED TAXABLE ORGANIZATION. THOMAS DEE, ERIC SEYFERTH, MD, AND STEPHEN MAJETICH HAVE A BUSINESS RELATIONSHIP AS THEY ARE EMPLOYED BY A RELATED ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 3 | MANAGEMENT DUTIES: DARTMOUTH-HITCHCOCK MEDICAL CENTER MANAGES OUR PHYSICIANS. AS PART OF THIS ARRANGEMENT, THE SYSTEM'S CMO IS AN EMPLOYEE OF DARTMOUTH-HITCHCOCK AND PERFORMS CERTAIN MANAGEMENT FUNCTIONS. |
| FORM 990, PART VI, SECTION B, LINE 11B | FORM 990 REVIEW PROCESS: 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 THEN 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 ON INTEREST POLICY: OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY DISCLOSE INTERESTS 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 AND THEN 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. 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: THE ORGANIZATION 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. ERIC SEYFERTH, MD, RECEIVES COMPENSATION AS A PHYSICIAN. THOMAS DEE IS COMPENSATED AS THE CEO OF THE SOUTHWESTERN VERMONT HEALTHCARE SYSTEM. |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS: $ 707,326 CHANGE IN INVESTMENT IN HOOSICK FALLS HEALTH CENTER 42,665 DEFINED BENEFIT PENSION COSTS (239,710) TRANSFER TO AFFILIATES ---------- $ 510,281 |
| Software ID: | |
| Software Version: |