TY 2019 Form 990

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) Scott P La rue...................................................................... PRESIDENT/CEO of archcare	1.0 ................. 37.0	X				0	1,246,121	338,444
(2) Frank A Calamari...................................................................... President/Executive Director	37.0 ................. 0.0		X			767,223	0	39,083
(3) DEVMANI JAITLY MD...................................................................... ATTENDING PHYSICIAN	37.0 ................. 0.0				X	649,861	0	43,358
(4) Michael J Brescia MD...................................................................... Executive Medical Director	37.0 ................. 0.0		X			567,891	0	35,560
(5) Andrew V Greco...................................................................... VICE PRESIDENT & cfo	37.0 ................. 0.0		X			490,902	0	59,043
(6) Christoper Comfort MD...................................................................... COO (AS OF 07/2019)	37.0 ................. 0.0		X			455,883	0	46,058
(7) SREENIVASA PATIBANDLA...................................................................... STAFF PHYSICIAN	37.0 ................. 0.0				X	407,552	0	28,000
(8) ROBERT BRESCIA MD...................................................................... DIR., PALLIATIVE CARE INST.	37.0 ................. 0.0				X	396,809	0	35,560
(9) GAIL CHRZANOWSKI MD...................................................................... ATTENDING PHYSICIAN	37.0 ................. 0.0				X	341,868	0	38,488
(10) RACHELLE PARKER MD...................................................................... DIRECTPR INPATIENT SERVICES	37.0 ................. 0.0				X	317,912	0	38,488
(11) NANCY D'AGOSTINO RN...................................................................... VP OF COMMUNITY PATIENT SVCS	37.0 ................. 0.0			X		268,598	0	48,930
(12) Margaret pelkowski...................................................................... vp for patient care service	37.0 ................. 0.0			X		230,049	0	33,566
(13) ROBERT SIEGEL MD...................................................................... MEDICAL DIRECTOR(AS OF 7/2019)	37.0 ................. 0.0		X			138,487	0	31,042
(14) Thomas J Fahey Jr MD...................................................................... Chairman of Board	2.0 ................. 1.0	X	X			0	0	0
(15) Anne Cote Taylor...................................................................... secretary	1.0 ................. 0.0	X	X			0	0	0
(16) Edward D Heben...................................................................... Treasurer	1.0 ................. 0.5	X	X			0	0	0
(17) JOHN A DECINA...................................................................... Vice-Chairman	0.5 ................. 0.5	X	X			0	0	0

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)
(18) Rev Eric P Cruz MDIV........................................................................ Director	1.0 .......................0.0	X
(19) Rena M Murtha RN........................................................................ Director	1.0 .......................0.0	X
(20) Amit Sikdar........................................................................ Director	0.5 .......................0.0	X
(21) Joseph L Demarzo........................................................................ Director	1.0 .......................0.0	X
(22) Joseph A Tarantino........................................................................ Director	1.0 .......................0.5	X
(23) CARLOS HERNANDEZ........................................................................ DIRECTOR	0.5 .......................1.0	X
(24) MARYANN JULIA POPIEL........................................................................ DIRECTOR	1.0 .......................0.5	X
(25) Thomas G Ferrara........................................................................ Director	0.5 .......................0.0	X
(26) dr marc prager........................................................................ Director	0.5 .......................0.0	X
(27) james harden........................................................................ director	0.5 .......................0.0	X
(28) john p bertsch........................................................................ Director Emeritus (Non-Voting)	0.5 .......................0.0	X
(29) Steven J Golub........................................................................ Director emeritus (non-voting)	0.5 .......................1.0	X
(30) Manfred Altstadt........................................................................ Director Emeritus (Non-Voting)	0.5 .......................0.5	X
(31) Terence Gallagher........................................................................ Director Emeritus (Non-Voting)	0.5 .......................0.5	X
(32) DANIEL S GURRELL MD........................................................................ DIRECTOR (AS OF 7/2019)	1.0 .......................0.0	X

(A) Name and business address	(B) Description of services	(C) Compensation
NAVIN HAFTY ASSOCIATES LLP, 1900 WEST PARK DRIVE SUITE 1800 WESTBROUGH,MA01581	IT CONSULTING	3,644,179
HVAC INC, 681 GRAND BLVD SUITE 7 DEER PARK,NY11729	COGEN INSTALLATION	1,707,500
MEDICAL INFORMATION TECHNOLOGY, MEDITECH CIRCLE WESTWOOD,MA02090	IT SERVICES	1,144,466
EMPIRE GENERAL CONTRACTING, 74 MAIN STREET TUCKAHOE,NY10707	PHARMACY RENOVATION	1,117,260
CERNER HEALTH SERVICES, PO BOX 959167 ST LOUIS,MO63195	IT SERVICES	600,824
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 38

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2019

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

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.

Section B. Total Support

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

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2018. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2019. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2018. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

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.)

Section B. Total Support

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.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2018. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990 or 990-EZ) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2019

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2019

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	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

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2019

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

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.
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)
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.
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.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
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.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization CALVARY HOSPITAL INC

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization CALVARY HOSPITAL INC		Employer identification number 13-1740274

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization CALVARY HOSPITAL INC			Employer identification number 13-1740274
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2019

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2016	(b) 2017	(c) 2018	(d) 2019	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2019

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Yes

22,000

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Yes

43,709

Total. Add lines 1c through 1i ....................................................................................................

65,709

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures (see instructions) .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, PART II-B, LINE 1i, LOBBYING ACTIVITIES	Calvary Hospital engages two individuals to directly lobby congress and other governmental agencies on its behalf. The total amount paid to these external consultants in calendar year 2019 is $22,000. Calvary Hospital incurs indirect lobbying expenditures from its membership in various healthcare associations. The $43,709 reported on Schedule C, Part II-B, Line 1(I) includes the portion of its membership dues attributable to lobbying endeavors that the hospital pays to the following membership associations: - The Hospital Association of New York State (HANYS) - The Greater New York Hospital Association (GNYHA)

Return Reference

Explanation

Schedule C, PART II-B, LINE 1i, LOBBYING ACTIVITIES

Calvary Hospital engages two individuals to directly lobby congress and other governmental agencies on its behalf. The total amount paid to these external consultants in calendar year 2019 is $22,000. Calvary Hospital incurs indirect lobbying expenditures from its membership in various healthcare associations. The $43,709 reported on Schedule C, Part II-B, Line 1(I) includes the portion of its membership dues attributable to lobbying endeavors that the hospital pays to the following membership associations: - The Hospital Association of New York State (HANYS) - The Greater New York Hospital Association (GNYHA)

Schedule C (Form 990 or 990EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2019

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....	29,283,900	30,643,900	26,805,300	25,378,200	27,742,000
b	Contributions ...	3,309,900	1,807,200	1,725,600	1,723,700	2,037,500
c	Net investment earnings, gains, and losses	5,215,300	-1,112,700	4,295,000	1,787,400	-1,396,800
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...	1,941,800	2,054,500	2,182,000	2,084,000	3,004,500
f	Administrative expenses ....
g	End of year balance ......	35,867,300	29,283,900	30,643,900	26,805,300	25,378,200

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

5.000 %

Term endowment SchDMd Bullet

95.000 %

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	538,000		538,000
b	Buildings ....	37,763,200	29,941,939	7,821,261
c	Leasehold improvements
d	Equipment ....	70,557,000	56,382,052	14,174,948
e	Other .....	4,402,200	3,849,809	552,391
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				23,086,600

Schedule D (Form 990) 2019

Page 3

Part VII

InvestmentsOther Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	0

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1)ASSETS OF CALVARY FUND	23,873,900	F
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)	23,873,900

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes	0
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	50,963,100
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2019

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	134,138,200
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	1,726,500
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	1,070,500
e	Add lines 2a through 2d .....................			2e	2,797,000
3	Subtract line 2e from line 1..................			3	131,341,200
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................			4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	131,341,200

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1	131,862,700
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3	131,862,700
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5	131,862,700

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference

Explanation

Schedule D, Part X - FIN 48:

The hospital follows guidance that clarifies the accounting for uncertainty in tax positions taken or expected to be taken in a tax return, including issues relating to financial statement recognition and measurement. This guidance provides that the tax effects from an uncertain tax position can only be recognized in the financial statements if the position is "more-likely-than-not" to be sustained if the position were to be challenged by a taxing authority. The assessment of the tax position is based solely on the technical merits of the position, without regard to the likelihood that the tax position may be challenged. The hospital is exempt from federal income tax under IRC section 501(c)(3), though it is subject to tax on income unrelated to its exempt purpose, unless that income is otherwise excluded by the IRS. The hospital has processes presently in place to ensure the maintenance of its tax-exempt status; to identify and report unrelated income; to determine its filing and tax obligations in jurisdictions for which it was nexus; and to identify and evaluate other matters that may be considered tax positions. The Hospital has determined that there are no material uncertain tax positions that require recognition or disclosure in the financial statements. Schedule D, Part IV - Escrow and Custodial Arrangements: The Hospital maintains custodial accounts for its patients and various auxiliary groups. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN BENEFICIAL INTEREST IN NET PENSION RELATED ADJUSTMENT .......................($3,828,100) ASSETS OF CALVARY FUND, INC. .....................$4,904,400 RECLASS OF GRANT TO AFFILIATE........................($5,800) TOTAL TO SCHEDULE D, PART XI, LINE 2D ............$1,070,500

Schedule D (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 0 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	429,753		429,753	0 %
b	Medicaid (from Worksheet 3, column a) . . . . .	9,246,734	10,593,810	0
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	9,676,487	10,593,810	0	0 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .
k	Total. Add lines 7d and 7j .	9,676,487	10,593,810	0	0 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(c) Total community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	15	1,027,978	0.950 %
4	Environmental improvements
5	Leadership development and training for community members	1	2,000	0.010 %
6	Coalition building
7	Community health improvement advocacy	5	18,293	0.020 %
8	Workforce development
9	Other	2	18,380	0.020 %
10	Total	23	1,066,651	1.000 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

3,386,578

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

42,028,200

Enter Medicare allowable costs of care relating to payments on line 5.....

51,622,206

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-9,594,006

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2019

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?2Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)			Other (describe)	Facility reporting group
1	CALVARY HOSPITAL INC 1740 EASTCHESTER ROAD BRONX,NY10461 CALVARYHOSPITAL.ORG	X	EXTENDED NEOPLASTIC DISEASE CARE	A
2	CALVARY HOSPITAL INC (BROOKLYN CAMP 1740 EASTCHESTER ROAD BRONX,NY11220 CALVARYHOSPITAL.ORG	X	EXTENDED NEOPLASTIC DISEASE CARE	A

Schedule H (Form 990) 2019

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	CALVARY HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 19

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): CALVARYHOSPITAL.ORG

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): CALVARYHOSPITAL.ORG

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	CALVARY HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 0.%
and FPG family income limit for eligibility for discounted care of 300.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

CALVARYHOSPITAL.ORG

The FAP application form was widely available on a website (list url):

CALVARYHOSPITAL.ORG

A plain language summary of the FAP was widely available on a website (list url):
CALVARYHOSPITAL.ORG

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	CALVARY HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	CALVARY HOSPITAL INC
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2019

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation

Schedule H (Form 990) 2019

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
PART I, LINE 3C:	CALVARY HOSPITAL INC. USES THE FEDERAL POVERTY GUIDELINES (FPG) TO DETERMINE ELIGIBILITY FOR DISCOUNTED CARE TO LOW-INCOME PATIENTS. Form 990, Schedule H, part I, Line 6a & 6b Calvary Hospital completed its most recent full Community Benefit Report/Community Health Needs Assessment in December of 2019. This Report is posted on Calvary hospital's website. Calvary routinely receives input from all hospitals and health systems in its catchment area; through its Palliative Care Institute, Calvary works directly with the Medical Schools in the New York area, NYC EMS services and the National Cancer Institute. The totality of this input enables Calvary to produce a thorough and targeted community service plan each year.
PART I, LINE 7:	Calvary Hospital is unique in the healthcare environment in that it provides services to a very specific set of patients: the terminally ill. Patients in-hospital care at Calvary if they have been diagnosed with advanced cancer and other terminal illnesses, which have not responded to curative treatments and require continuous supervision by a medical team. They have severe symptoms related to their illness, such as infections, complex wound care needs, nausea, severe weight loss, pain, or confusion, or due to the severity of their symptoms, care at home is not possible. FROM ITS INCEPTION IN 1899, CALVARY HOSPITAL HAS BEEN FAITHFULLY DEVOTED TO PROVIDING PALLIATIVE CARE TO ADULT PATIENTS IN THE ADVANCED STAGES OF CANCER, AND OTHER LIFE-LIMITING ILLNESSES ADDRESSING THE SYMPTOMS OF THE DISEASE, NOT ITS CURE. A VOLUNTARY, NOT-FOR-PROFIT HOSPITAL, OPERATED IN CONNECTION WITH THE ARCHDIOCESE OF NEW YORK, CALVARY CONTINUES TO EMBODY THIS TRADITION OF CARING THROUGH THE SERVICES AND PROGRAMS OFFERED BY AND THROUGH THE DEDICATION AND CONCERN SHOWN BY ITS STAFF MEMBERS. THE HOSPITAL WILL CONTINUE TO BE FAITHFUL TO THIS TRADITION THROUGH A TWOFOLD COMMITMENT. CALVARY WILL STRIVE PRIMARILY TO EXPAND ITS PROGRAMS AND SERVICES TO MEET THE EMERGING PHYSICAL, PSYCHOSOCIAL, AND SPIRITUAL NEEDS OF BOTH PATIENTS AND FAMILIES THROUGH THE PROVISION OF ACUTE INPATIENT, CALVARY @ HOME (HomeCare, HOSPICE @ HOME), AND A BROOKLYN CAMPUS. IN ADDITION, THROUGH THE PALLIATIVE CARE INSTITUTE, THE HOSPITAL ENDEAVORS TO TRANSMIT TO OTHER HEALTH CARE PROFESSIONALS, THROUGH RESEARCH AND EDUCATION, THE KNOWLEDGE AND COMPETENCE WHICH IT HAS DEVELOPED IN THE CARE OF ADULT PATIENTS WITH ADVANCED CANCER AND OTHER LIFE LIMITING ILLNESSES. THROUGH THIS TWOFOLD COMMITMENT, CALVARY HOSPITAL WILL DEEPEN AND STRENGTHEN THE PHILOSOPHY OF COMPASSIONATE CARE WHICH HAS BEEN THE CORNERSTONE OF ITS PROGRAM OF SERVICE, AND WILL OFFER TO THOSE IN OUR EXPANDED COMMUNITY AND OTHERS, A TRADITION OF SUCCESSFUL EXPERIENCE IN THE CARE OF THE ADVANCED CANCER PATIENT. CALVARY HOSPITAL IS THE ONLY FULLY ACCREDITED EXTENDED NEOPLASTIC DISEASE CARE HOSPITAL PROVIDING PALLIATIVE CARE FOR ADVANCED CANCER PATIENTS IN THE UNITED STATES. WITH 225 BEDS IN THE BRONX AND BROOKLYN AND 1,228 EMPLOYEES, CALVARY SERVES MORE THAN 5,399 PATIENTS ANNUALLY AT HOME. CALVARY PROVIDES PALLIATIVE CARE, WHICH IS THE ACTIVE TREATMENT OF THE SYMPTOMS, NOT THE CURE OF THE DISEASE, IN ORDER TO MAKE OUR PATIENTS AS COMFORTABLE AS POSSIBLE. CALVARY'S PROGRAMS INCLUDE INPATIENT CARE CASE MANAGEMENT, CALVARY @ HOME, AND SUPPORT PROGRAMS FOR FAMILIES AND FRIENDS. AS CALVARY APPROACHES THE FUTURE WITH A SENSE OF HOPE AND PROMISE, CALVARY IS EVER MINDFUL OF THE LEGACY OF OUR FOUNDERS, THE WOMEN OF CALVARY, TO PROVIDE COMPREHENSIVE CARE WHILE RECOGNIZING THE INDIVIDUALITY AND DIGNITY OF EVERY PATIENT. AT THE SAME TIME, CALVARY WILL CONTINUE TO DEVELOP NEW PROGRAMS AND SERVICES TO MEET THE NEEDS OF TODAY'S WORLD. Accordingly, Calvary Hospital is not suited to providing the type of community benefits that other traditional hospitals provide. Calvary reports in Part VII the value of any Medicaid services it provides as well as financial assistance costs. TO arrive at the charity care amounts reported in Part VII, CALVARY UTILIZES NET REALIZABLE VALUE OF THE SERVICES RENDERED. This reporting is consistent to what is presented in Calvarys Cost report with the New York State Department of Health. Form 990, Schedule H, PART II, COMMUNITY BUILDING ACTIVITIES: CALVARY HOSPITAL MAKES A NUMBER OF DIFFERENT SUPPORT GROUPS AVAILABLE TO THE COMMUNITY. THESE SUPPORT GROUPS ARE ADVERTISED ON CALVARY HOSPITAL'S WEBSITE, WWW.CALVARYHOSPITAL.ORG, ON ITS CALENDAR OF EVENTS. In addition, the Hospital publishes "CALVARY IN TOUCH", A BI-MONTHLY NEWSLETTER ABOUT BEREAVEMENT ISSUES that is AVAILABLE THROUGH THE HOSPITAL'S WEBSITE AND IS CIRCULATED IN HARD COPY BY MAIL. CALVARY HOSPITAL PROVIDES BEREAVEMENT SUPPORT FOR ADULTS WHO HAVE LOST LOVED ONES AT CALVARY HOSPITAL OR CALVARY@HOME, AND THOSE FROM THE COMMUNITY AT LARGE WHO HAVE LOST SOMEONE BECAUSE OF ILLNESS, ACCIDENTS VIOLENCE, OR ANY OTHER CAUSE. GROUPS ARE OFFERED IN THE BRONX, BROOKLYN and manhattan. THE HOSPITAL Also OFFERS AGE-APPROPRIATE SUPPORT GROUPS FOR CHILDREN, AGES 6 THROUGH 11, AND FOR ADOLESCENTS, AGES 12 TO 18, AND FOR YOUNG ADULTS, AGES 18 TO 25. THESE COMMUNITY SUPPORT GROUPS INCLUDE BUT ARE NOT LIMITED TO: - SUPPORT GROUPS FOR BEREAVED PARENTS - MINDFULNESS AND MOVEMENT THROUGH GRIEF GROUP - PRECIOUS MOMENTS SUPPORT GROUP FOR CHILDREN AGES 6 TO 9 - TWEEN BEREAVEMENT GROUPS FOR TWEENS AGES 10 TO 12 -TEEN BEREAVEMENT GROUPS FOR TEENS AGES 13-17 - Young adults ages 18-25 - DEATH OF A SPOUSE/PARTNER BEREAVEMENT GROUPS - DEATH OF A PARENT BEREAVEMENT GROUPS - MEN ONLY GROUP - PSYCHOTHERAPY GROUP - CAMP COMPASS DAY CAMP FOR BEREAVED CHILDREN OPEN TO ALL CHILDREN WHO HAVE ATTENDED OTHER GROUPS ARE FREE OF CHARGE, AND ARE LED BY CALVARY HOSPITAL STAFF AND STAFF HIRED JUST FOR THIS WEEK LONG EVENT. CALVARY HOSPITAL ALSO MAKES AVAILABLE A NUMBER OF DIFFERENT WELLNESS ACTIVITIES TO THE COMMUNITY. THESE WELLNESS ACTIVITIES INCLUDE BUT ARE NOT LIMITED TO YOGA, zumba, MASSAGE THERAPY, staff drumming CLASSES, RECREATIONAL THERAPY AND PET THERAPY AND A FACILITY DOG ON STAFF. CALVARY HOSPITAL'S THERAPEUTIC RECREATION AND "MUSIC THERAPY PROGRAMS WERE CREATED TO GIVE PATIENTS A SENSE OF ACCOMPLISHMENT AND TO RELIEVE THE SUFFERING OF OUR PATIENTS AND THEIR FAMILIES. THERAPEUTIC RECREATION ACTIVITIES INCLUDES DRAWING, SCULPTURE, AND CERAMICS PROJECTS; HORTICULTURE; A GAMES AND DISCUSSION HOUR; AND HOLIDAY PARTIES. MUSIC THERAPY OFTEN HELPS SOOTHE PATIENTS AND HELPS THEM FOCUS ON LIFE. OUR BOARD CERTIFIED MUSIC THERAPISTS USE MUSIC THERAPY INTERVENTIONS TO SOOTHE PATIENTS, RELIEVE ANXIETY, REMINISCE, AND EASE PAIN AND SUFFERING. MUSIC THERAPY INTERVENTIONS MAY ALSO PROVIDE RELEASE IN THE LAST HOURS OR MOMENTS OF LIFE. PATIENTS RECEIVING MUSIC THERAPY SOMETIMES WRITE SONGS ASSISTED BY THE MUSIC THERAPISTS TO LEAVE FOR LOVED ONES, OR FIND OTHER WAYS TO OPEN THEIR HEARTS THROUGH MUSIC. OUR CLINICIANS REPORT THAT IN SOME CASES, THE ONLY TIME A PATIENT LAUGHS OR SMILES IS DURING A MUSIC THERAPY SESSION. WE ALSO FIND THAT MUSIC THERAPY IS AVAILABLE AT BOTH INPATIENT LOCATIONS AND IS ALSO ONE OF THE SERVICES WE OFFER THROUGH CALVARY@HOME. IN KEEPING WITH OUR MISSION TO SHARE OUR KNOWLEDGE AND EXPERIENCE WITH OTHERS, CALVARY OFFERS INTERNSHIP PROGRAMS IN THE FOLLOWING AREAS: SOCIAL WORK, bereavement, PALLIATIVE CARE AND MUSIC THERAPY, WHICH IS RECOGNIZED AS A NATIONAL CLINICAL TRAINING SITE BY THE AMERICAN MUSIC THERAPY ASSOCIATION. THROUGH ITS EDDIE HIGGINS SCHOLARSHIP PROGRAM, CALVARY HOSPITAL PROVIDES LEADERSHIP DEVELOPMENT AND TRAINING. THE EDDIE HIGGINS SCHOLARSHIP IS NAMED AFTER A CHERISHED MEMBER OF THE CALVARY FAMILY WHO CAME TO THE HOSPITAL AS A YOUNG BOY. EDDIE WAS HOSPITALIZED INTERMITTENTLY FOR 15 YEARS AT CALVARY UNTIL HIS DEATH IN 1982 AT THE AGE OF 29. EDDIE IS REMEMBERED FOR HIS LOVE OF GOD AND HIS REMARKABLE COURAGE DESPITE HIS ILLNESS. CALVARY HAS GIVEN THE ANNUAL SCHOLARSHIP SINCE 1985. CALVARY ALSO HOSTS AN ANNUAL MENTORS THROUGH MOuRNING WORKSHOP, FREE OF CHARGE, FOR SCHOOL PROFESSIONALS TO EDUCATE THEM ON THE GRIEF PROCESS OF CHILDREN. ALSO OFFERED IS A 11 WEEK ANNUAL COURSE THAT WE CHARGE $50/SESSION, which is offered in the Bronx and Brooklyn. Form 990, Part III, Line 4 - Bad Debt Footnote The Hospital's bad debt footnote is reported thusly in its audited financial statements: The Hospital recognizes patient service revenue associated with services provided to patients who have third-party payor coverage on the basis of contractual rates for the services rendered. For uninsured patients that do not qualify for charity care, the Hospital recognizes revenue on the basis of its standard rates for services provided (or on the basis of discounted rates, if negotiated or provided by policy). On the basis of historical experience, a significant portion of the Hospital's uninsured patients will be unable or unwilling to pay for the services provided. Thus, the Hospital records a significant provision for uncollectible accounts receivable related to uninsured patients in the period the services are provided. The Hospital also records a provision for uncollectible accounts to cover the estimated write-offs resulting from insured patients whose benefits are subsequently determined to have been exhausted during their hospitalization or whose coverage is denied by the insurer. insurer.
PART III, LINE 2:	The methodology that Calvary Hospital employs to estimate its bad debt expense is captured in its audited financial statements. The footnote is reproduced below: Accounts receivable are reduced by an allowance for uncollectible accounts receivable. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for uncollectible accounts receivable and provision for uncollectible accounts receivable. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for uncollectible accounts receivable. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for uncollectible accounts and a provision for uncollectible accounts receivable, if necessary. For receivables associated with self-pay patients, the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for uncollectible accounts receivable. Part III, Line 5: Calvary Hospital does not traditionally treat the shortfall on its Medicare reimbursement as charity care and does not report it as such in its audited financial statements. PART III, LINE 7: CALVARY HOSPITAL INC. HAS REPORTED A SHORTFALL IN PART III SECTION B LINE 7. THE EXPENSES, REVENUES AND SHORTFALL REPORTED IN PART III LINES 5-7 WERE DEVELOPED FROM THE 2019 CALVARY HOSPITAL, INC. COST REPORTS FILED WITH THE NYS DOH AND NATIONAL GOVERNMENT SERVICES (MEDICARE INTERMEDIARY).
PART III, LINE 9B:	CALVARY HOSPITAL, INC.'S FINANCIAL ASSISTANCE POLICY CONTAINS PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR FINANCIAL ASSISTANCE. CALVARY HOSPITAL'S COLLECTION POLICY IS THAT ALL REASONABLE EFFORTS WILL BE MADE BY PATIENT ACCOUNTS REPRESENTATIVES TO OBTAIN PAYMENT AND TO SETTLE PATIENT ACCOUNTS RECEIVABLE ON A CONSISTENT BASIS. THE PATIENT ACCOUNTING SYSTEM WILL BEAR ENTRIES OF SUCH ATTEMPTS, INCLUDING THE DATE AND THE REPRESENTATIVE'S INITIALS. ACCOUNTS RESISTING SETTLEMENT MAY BE REFERRED TO A COLLECTION AGENCY. Form 990, Schedule H, Part V, SECTION B, LINE 11: Calvary Hospital assessed the needs of the community through the lenses of the specialized services it is equipped to provide. The Joint Commissions Steering Committee and Quality Committees of the Board of Directors are responsible for evaluating the data and prioritizing the needs. Calvary Hospital used secondary and qualitative data to determine three top health issues based on capacity, resources, competencies, and needs specific to the populations it serves. All needs are a priority with palliative care services being the most significant need. These issues are within the hospitals scope, competency and resources to impact in a meaningful manner. Calvary Hospitals end of life palliative care is the worlds most comprehensive. For more than a century, it has been treating not only the physical pain, but has also been providing enormous emotional relief, to both the patient and the family. Calvary eliminates the stress and anxiety at a time when people are most vulnerable. The hospital identified three primary significant needs within its Community Needs Assessment: 1. Palliative Care Services 2. Bereavement Services 3. Palliative Care Provider Education The Hospitals Community Needs Assessment provides tremendous detail as to how the Hospital addresses these needs. Please refer to the Hospitals website at https://www.calvaryhospital.org/wp-content/uploads/2019/11/CH_CHNA_Brochur e_FINAL-11-12-19-1.pdf Form 990, Schedule H, PART V, SECTION B, LINE 22D: The maximum amount that Calvary Hospital will charge FAP-eligible patients is 15% OF GROSS CHARGES; this reflects an amount that is BELOW OUR LOWEST PAYOR.
PART VI, LINE 2:	CALVARY HOSPITAL IS THE ONLY FULLY ACCREDITED EXTENDED NEOPLASTIC DISEASE CARE HOSPITAL PROVIDING PALLIATIVE CARE FOR ADULT PATIENTS with advanced cancer and other life-limiting illnesses IN THE UNITED STATES. CalvaryCare may be obtained at our 200-bed Bronx campus or 25-bed Brooklyn campus. Through Calvary@Home, our care is also provided each day in hundreds of private homes, nursing and assisted living facilities in New York City, Westchester, Nassau, and Rockland counties. When home hospice patients are in need of short-term inpatient care, we can seamlessly transfer them to the Dawn Greene Hospice at Mary Manning Walsh Home in Manhattan and the Ozanam Hall of Queens Nursing Home. Calvary treats patients both inpatient and at-home through the Calvary @ home program. CALVARY HOSPITAL USES A VARIETY OF METHODS AND SERVICES TO GATHER COMMUNITY INPUT TO ASSESS THE NEEDS OF THE COMMUNITY, AND TO ASSURE INPUT IN THE COMMUNITY SERVICE PLAN. SOME OF THESE METHODS ARE: A. COMMUNITY OUTREACH SERVICES: COMMUNITY OUTREACH SERVICES FUNCTIONS AS A LIAISON WITH THE COMMUNITY, REFERRERS, PHYSICIANS, PATIENTS, AND FAMILIES AND FACILITATES ADMISSION TO CALVARY. THE DEPARTMENT OUTREACHES THROUGH THE TRI-STATE REGION AND EDUCATES THE HEALTH CARE AND PATIENT COMMUNITIES AS TO THE CONTINUUM OF SERVICES CALVARY PROVIDES (INPATIENT, Calvary @ Home). THROUGH ON-SITE VISITS, PUBLIC PRESENTATIONS AND PARTICIPATION IN COMMUNITY AND PROVIDER ACTIVITIES, THE OUTREACH STAFF CONTINUALLY ASSESSES THE NEEDS OF THE COMMUNITY. the bereavement department also facilitates a community outreach to educate mental health agencies and schools about grief and bereavement as well as provide support to agencies that are experiencing a death in their community B. PROFESSIONAL ADVISORY BOARD: THE PROFESSIONAL ADVISORY BOARD WAS ESTABLISHED IN 1992 TO OBTAIN INPUT FROM THE COMMUNITY. THE ADVISORY BOARD MEETS AT LEAST ANNUALLY AND IS COMPRISED OF PHYSICIANS, NURSES, AND SOCIAL WORKERS, REPRESENTING HOSPITALS, AND HOME CARE AGENCIES, AS WELL AS THE COMMUNITY. THIS GROUP HAS CONTRIBUTED A VARIETY OF IDEAS FOR ENHANCING SERVICES TO THE COMMUNITY. C. COMMUNITY PLANNING BOARD: EACH YEAR THE HOSPITAL INVITES THE HEALTH COMMITTEE OF COMMUNITY PLANNING BOARD *11 TO VISIT THE HOSPITAL. D. OUTREACH REPRESENTATION (OPEN HOUSE) FOR HEALTH CARE PROFESSIONALS: COMMUNITY OUTREACH HOSTS OPEN HOUSES AT BOTH THE BRONX AND BROOKLYN LOCATIONS TO PROVIDE INFORMATION TO AND RECEIVE INFORMATION FROM ITS REFERRERS. CALVARY HOSPITAL, INC. ALSO HAS PUBLIC PARTICIPATION IN THE EXTENDED. COMMUNITY THROUGH PARTICIPATION IN: - GREATER NEW YORK HOSPITAL ASSOCIATION - HOSPITAL ASSOCIATION OF NEW YORK STATE - AMERICAN HOSPITAL ASSOCIATION - NEW YORK CITY DEPARTMENT OF HEALTH - NEW YORK STATE DEPARTMENT OF HEALTH - CATHOLIC HEALTHCARE ASSOCIATION - CMS THROUGH ONGOING PARTICIPATION IN THE GROUPS ABOVE, CALVARY HOSPITAL CONTINUALLY MONITORS THE TRENDS IN THE HEALTHCARE NEEDS OF THE LARGER COMMUNITY. ALTHOUGH THE NATURE OF ITS SERVICES IS LIMITED BY ITS SPECIALIZED MISSION, CALVARY HAS IDENTIFIED A VARIETY OF ACTIVITIES TO PARTICIPATE IN IMPROVING THE HEALTH OF ITS EXTENDED COMMUNITY.
PART VI, LINE 3:	EACH PERSON REQUESTING CALVARY'S SERVICES MUST BE MADE AWARE OF CALVARY'S UNCOMPENSATED (FREE) SERVICES OR DISCOUNTED SERVICES PROGRAM AS FOLLOWS: 1. DISTRIBUTE AN INDIVIDUAL NOTICE TO EACH PERSON WHO IS SEEKING SERVICES ON BEHALF OF HIMSELF OR ANOTHER. THIS NOTICE IS PASSED TO THE INDIVIDUAL USUALLY AT THE POINT OF ADMISSION OR REGISTRATION WHEN FINANCIAL ARRANGEMENTS ARE BEING DISCUSSED. THE "NOTICE OF AVAILABILITY OF UNCOMPENSATED (FREE) SERVICES OR DISCOUNTED SERVICES" IS UPDATED ANNUALLY. 2. POST SIGNS PROVIDED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES CONSPICUOUSLY IN THE ADMITTING OFFICE, BUSINESS OFFICE, and Calvary @ Home AREAS. THE SIGNS ARE posted IN ENGLISH, SPANISH and russian. ADDITIONALLY, CALVARY HAS ACCESS TO A LANGUAGE TELEPHONE SERVICE and video service THAT ADDS over 240 ADDITIONAL LANGUAGES TO ENGLISH AND SPANISH.
PART VI, LINE 4:	CALVARY HOSPITAL'S MAIN CAMPUS IS LOCATED IN THE BRONX, NY. THE BRONX IS CONSIDERED THE PRIMARY COMMUNITY FOR THE PURPOSES OF PUBLIC HEALTH PLANNING, AND 45% OF ITS EMPLOYEES RESIDE IN THE PRIMARY SERVICE AREA. IN ADDITION, AS A TERTIARY REFERRAL CENTER FOR ADVANCED DISEASE, CALVARY HOSPITAL SERVES THE ENTIRE TRI-STATE REGION. THE SECONDARY SERVICE IS DETERMINED BASED ON CURRENT REFERRAL PATTERNS. THE PRIMARY REFERRAL SOURCES FOR ADMISSIONS CONTINUE TO BE THE ACUTE CARE HOSPITALS. CURRENTLY 58.7% OF ADMISSIONS ARE REFERRED BY HOSPITALS LOCATED WITHIN THE BOROUGHS OF NEW YORK CITY, ROCKLAND, AND WESTCHESTER COUNTIES, LONG ISLAND, AND THE STATES OF NEW JERSEY AND CONNECTICUT. OTHER REFERRAL SOURCES ARE CALVARY @ Home AND OTHER HOME CARE AND HOSPICE AGENCIES, FAMILIES, PHYSICIANS, NURSING HOMES, AND COMMUNITY AGENCIES. IN 2001, CALVARY EXPANDED ITS SERVICES WITH THE OPENING OF CALVARY'S BROOKLYN CAMPUS, AT NYU LANGONE HOSPITAL - BROOKLYN. in 2014, Calvary @ Home established the Dawn Greene hospice at Mary Manning Walsh Home in Manhattan. In 2016, Calvary @ home began providing Calvary @ Home services to patients residing at the Ozanam Hall of Queens Nursing Home in Queens, New York.
PART VI, LINE 7	LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT: NY

Schedule H (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
CALVARY HOSPITAL INC

Employer identification number
13-1740274

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient

that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC section (if applicable)	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of noncash assistance	(h) Purpose of grant or assistance
(1) CALVARY HOLDING COMPANY INC 1740 EASTCHESTER ROAD BRONX,NY10461	06-1531426	501(C)(3)	5,800				GENERAL SUPPORT

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2019

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

(a) Type of grant or assistance	(b) Number of recipients	(c) Amount of cash grant	(d) Amount of noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.

Return Reference	Explanation
PART II	Calvary Hospital does not typically make grants to other organizations; however, in 2019, the Hospital made a grant of $5,800 to its parent organization, Calvary Holding Company, Inc. to reimburse it for expenses incurred on behalf of the hospital. The Hospital does not monitor the use of these grant funds as the issuance of the grant is solely to reimburse expenses already incurred.

Schedule I (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .........

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ..

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2019

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Michael J Brescia MD Executive Medical Director	(i) (ii)	422,987 ------------- 0	54,272 ------------- 0	90,632 ------------- 0	28,000 ------------- 0	7,560 ------------- 0	603,451 ------------- 0	23,445 ------------- 0
2Frank A Calamari President/Executive Director	(i) (ii)	512,689 ------------- 0	67,673 ------------- 0	186,861 ------------- 0	28,000 ------------- 0	11,083 ------------- 0	806,306 ------------- 0	73,198 ------------- 0
3Andrew V Greco VICE PRESIDENT & cfo	(i) (ii)	303,651 ------------- 0	39,367 ------------- 0	147,884 ------------- 0	28,000 ------------- 0	31,043 ------------- 0	549,945 ------------- 0	15,886 ------------- 0
4Scott P La rue PRESIDENT/CEO of archcare	(i) (ii)	0 ------------- 868,515	0 ------------- 255,814	0 ------------- 121,792	0 ------------- 312,660	0 ------------- 25,784	0 ------------- 1,584,565	0 ------------- 255,814
5Christoper Comfort MD COO (AS OF 07/2019)	(i) (ii)	375,689 ------------- 0	43,238 ------------- 0	36,956 ------------- 0	28,000 ------------- 0	18,058 ------------- 0	501,941 ------------- 0	0 ------------- 0
6Margaret pelkowski vp for patient care service	(i) (ii)	224,224 ------------- 0	0 ------------- 0	5,825 ------------- 0	23,077 ------------- 0	10,489 ------------- 0	263,615 ------------- 0	0 ------------- 0
7NANCY D'AGOSTINO RN VP OF COMMUNITY PATIENT SVCS	(i) (ii)	254,342 ------------- 0	0 ------------- 0	14,256 ------------- 0	27,462 ------------- 0	21,468 ------------- 0	317,528 ------------- 0	0 ------------- 0
8SREENIVASA PATIBANDLA MD STAFF PHYSICIAN	(i) (ii)	208,045 ------------- 0	0 ------------- 0	199,507 ------------- 0	28,000 ------------- 0	0 ------------- 0	435,552 ------------- 0	0 ------------- 0
9ROBERT BRESCIA MD DIR., PALLIATIVE CARE INST.	(i) (ii)	328,362 ------------- 0	43,240 ------------- 0	25,207 ------------- 0	28,000 ------------- 0	7,560 ------------- 0	432,369 ------------- 0	0 ------------- 0
10DEVMANI JAITLY MD ATTENDING PHYSICIAN	(i) (ii)	247,745 ------------- 0	0 ------------- 0	402,116 ------------- 0	28,000 ------------- 0	15,358 ------------- 0	693,219 ------------- 0	0 ------------- 0
11GAIL CHRZANOWSKI MD ATTENDING PHYSICIAN	(i) (ii)	316,997 ------------- 0	0 ------------- 0	24,871 ------------- 0	28,000 ------------- 0	10,488 ------------- 0	380,356 ------------- 0	0 ------------- 0
12ROBERT SIEGEL MD MEDICAL DIRECTOR(AS OF 7/2019)	(i) (ii)	132,692 ------------- 0	0 ------------- 0	5,795 ------------- 0	0 ------------- 0	31,042 ------------- 0	169,529 ------------- 0	0 ------------- 0
13RACHELLE PARKER MD DIRECTPR INPATIENT SERVICES	(i) (ii)	279,724 ------------- 0	0 ------------- 0	38,188 ------------- 0	28,000 ------------- 0	10,488 ------------- 0	356,400 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation
PART I, LINE 1A	EFFECTIVE JUNE 1, 1998, THE HOSPITAL ESTABLISHED THE CALVARY HOSPITAL SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) TO PROVIDE PENSION BENEFITS FOR WAGES EARNED BY CERTAIN PHYSICIANS AND SENIOR EXECUTIVE STAFF WITH COMPENSATION IN EXCESS OF THE IRS LIMITS AND ALSO ESTABLISHED THE CALVARY HOSPITAL KEY EMPLOYEE SHARE OPTION PLAN(KEYSOP) TO PROVIDE ADDITIONAL AND ALTERNATIVE FORMS OF COMPENSATION TO KEY EMPLOYEES. PRIOR TO 2002, THE HOSPITAL UTILIZED THE KEYSOP TO FUND THE SERP. AS A RESULT OF THE IRS 457 REGULATIONS WHICH WERE ISSUED DURING 2002, THE UTILIZATION OF THE KEYSOP TO FUND THE SERP BECAME UNFEASIBLE. AFTER CONSIDERATION OF VARIOUS REPLACEMENT OPTIONS, IN 2003, CALVARY HOSPITAL CHOSE THE TAX GROSS-UP OPTION, WHEREBY, INDIVIDUAL PARTICIPANTS' DEFERRALS WOULD BE GROSSED-UP TO DUPLICATE THE BENEFITS HE WOULD RECEIVE IN A TAX-DEFERRED ARRANGEMENT AND PAID THEM OUT DIRECTLY TO THE PARTICIPANTS. THE FOLLOWING EXECUTIVES RECEIVED TAX GROSS-UP PAYMENTS IN 2019 IN ORDER TO DUPLICATE A TAX DEFERRED VEHICLE: (THE AMOUNTS WERE CALCULATED BY FRANK J. WALTERS ASSOCIATES, INC. UTILIZING EXPECTED TAX RATES TO CALCULATE THE NET AMOUNTS.) Andrew Greco, chief financial officer, received a gross-up for taxes on his SERP distribution and for dependent tuition reimbursement. The tax gross-up is reported in Schedule J, Part II, column (b)(iii). THE ORGANIZATION PROVIDED SOCIAL CLUB DUES IN 2019 FOR FRANK CALAMARI AND THE DUES WERE INCLUDED AS TAXABLE COMPENSATION.
PART I, LINE 4B	THE FOLLOWING CALVARY HOSPITAL OFFICERS PARTICIPATE IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN AND RECEIVED THE FOLLOWING DISTRIBUTIONS(WHICH ARE INCLUDED IN COLUMN (B)(III) OTHER REPORTABLE COMPENSATION: FRANK CALAMARI - $73,198.00 MICHAEL BRESCIA - 23,445.00 Andrew Greco- $15,886.00 Scott P. La Rue participated in a supplemental nonqualified retirement plan. Catholic Health Care System D/B/A Archcare distributed $121,792 to Scott in his 2019 W-2.
PART I, LINE 7	Calvary Hospital engaged the services of an independent compensation consulting firm that specializes in healthcare executive compensation to design its executive incentive compensation plan. As part of the Plan, the Calvary Executive Team develops a number of strategic goals that executives must meet to participate in the incentive program; these goals are then reviewed and approved annually by the Compensation Committee of the Board. At year end, Calvarys CEO presents the results from the previous year in terms of which goals were achieved by the Executive Team. The Compensation Committee of the Board then convenes with independent compensation consulting firm to determine and approve the bonuses that are distributed to each executive.

Schedule J (Form 990) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 6:	Pursuant to Calvary Hospitals bylaws, Catholic Health Care System ("archcare") is its sole corporate member.
FORM 990, PART VI, SECTION A, LINE 7A:	Calvary Hospital is a full participating member of Catholic Health Care System ("archcare"), a health care delivery system in New York State. The Calvary Hospital bylaws reserve certain rights to Catholic Health System as the sole member. One of those rights, in Article IV, is the power to appoint and remove board members (as well as the Chairman of the Board).
FORM 990, PART VI, SECTION A, LINE 7B:	Providence Health Services is the sole member of Catholic Health Care System ("Archcare"), which is, in turn, sole member of Calvary Hospital. Providence is the sponsor of Calvary Hospital (and its related entities) and as such has been reserved certain powers in Calvary Hospitals bylaws, exercised in conjunction with recommendations made by Calvary Health Care System (as sole corporate member). These powers are as follows: 1. Right to amend bylaws; 2. Right to change Calvary Hospitals mission; 3. Right to approve any merger, joint venture, or dissolution of the Fund; 4. Approval with respect to certain real property transactions exceeding $400,000; 5. Approval of any leases expected to exceed a period of 9 years; 6. Approval of the Fund entering into any debt instruments in an amount greater than $400,000; 7. Approval on the disposition of any significant historical artifacts. As noted above, the sole member, Catholic Health Care System has been reserved the right to make recommendations to Providence about any of the above actions.
FORM 990, PART VI, SECTION B, LINE 11:	THE 2019 FORM 990 OF CALVARY HOSPITAL WAS PREPARED BY Grant Thornton LLP WITH THE ASSISTANCE OF CALVARY ACCOUNTING PERSONNEL. THE DRAFT FORM 990 WAS REVIEWED BY Grant Thornton LLP, THE DIRECTOR OF FINANCE AND the CFO OF CALVARY HOSPITAL BEFORE DISTRIBUTION OF THE FULL VERSION OF THE FINAL DRAFT TO THE board. A COPY OF THE FORM 990 DRAFT WAS PROVIDED TO EACH MEMBER OF THE CALVARY HOSPITAL BOARD OF DIRECTORS ON OCTOBER 27,2020 PRIOR TO ITS FILING WITH THE INTERNAL REVENUE SERVICE IN ELECTRONIC FORMAT.
FORM 990, PART VI, SECTION B, LINE 12C:	EACH OFFICER, DIRECTOR, TRUSTEE AND KEY EMPLOYEE IS REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST THAT ARISE BY VIRTUE OF THEIR EMPLOYMENT AND POSITION WITH CALVARY HOSPITAL OR CALVARY FUND. CALVARY MONITORS COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICY THROUGH AN ANNUAL QUESTIONNAIRE SUBMITTED TO THESE INDIVIDUALS. POTENTIAL CONFLICTS ARE INVESTIGATED IMMEDIATELY AND, IF ANY ARE UNCOVERED, THERE ARE POLICIES IN PLACE TO ENSURE THAT THOSE INDIVIDUALS RECUSE THEMSELVES FROM PARTICIPATING in any decision making related to such conflict.
FORM 990, PART VI, SECTION B, LINE 15:	CALVARY HOSPITAL, INC. UNDERTAKES A RIGOROUS PROCESS TO ENSURE THAT THE EXECUTIVE COMPENSATION IT PAYS TO ITS TOP MANAGEMENT OFFICIALS AND ALL OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION IS REASONABLE. IN RELEVANT PART, THE BOARD OF DIRECTORS HAS ESTABLISHED A COMPENSATION COMMITTEE COMPRISED OF INDEPENDENT PERSONS THAT HAVE NO PERSONAL INTEREST IN THE PROPOSED COMPENSATION ARRANGEMENT. THE BOARD OF DIRECTORS USES AN INDEPENDENT COMPENSATION CONSULTANT TO HELP ADVISE ON THE APPROPRIATE COMPENSATION LEVELS FOR THE AFOREMENTIONED INDIVIDUALS. THAT COMPENSATION CONSULTANT WILL USE COMPARABILITY OR BENCHMARKLNG DATA (BASED ON INDUSTRY SURVEYS) THAT DOCUMENTS THE COMPENSATION OF PERSONS HOLDING SIMILAR PERSONS IN SIMILAR ORGANIZATIONS. The Hospital commissioned its most recent independent compensation study in February of 2020. ONCE THE COMPENSATION CONSULTANT HAS MADE ITS RECOMMENDATIONS, THE CALVARY COMPENSATION COMMITTEE MUST APPROVE THE COMPENSATION, WITHOUT INPUT OR VOTING PARTICIPATION BY THE PERSON WHOSE COMPENSATION IS BEING APPROVED OR BY ANY OTHER INDIVIDUAL WITH A CONFLICT OF INTEREST. THE FINAL DETERMINATION IS THEN DOCUMENTED IN COMMITTEE MINUTES. THOSE MINUTES WILL CONTAIN THE TERMS OF THE PROPOSED COMPENSATION, THE DECISIONS OF THOSE INDIVIDUALS WHO VOTED ON THE COMPENSATION, AND THE COMPARABILITY DATA THAT WAS RELIED UPON.
FORM 990, PART VI, SECTION C, LINE 19:	CALVARY HOSPITAL MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC BY RETAINING A COPY AT THE ADDRESS LISTED ON PAGE 1 OF THIS RETURN. ANY INDIVIDUAL REQUESTING A COPY OF THESE DOCUMENTS IS PROVIDED THAT COPY ON THE SAME BUSINESS DAY. THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND AUDITED FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST AND AT MANAGEMENT'S DISCRETION.
FORM 990, PART XI, LINE 9, CHANGES IN NET ASSETS:	CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF CALVARY FUND, INC............$4,904,400 Pension related adjustment....................$(3,828,100) TOTAL TO FORM 990, PART XI, LINE 9............$ 1,076,300

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

CALVARY HOSPITAL INC

Employer identification number

13-1740274

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) End-of-year assets	(f) Direct controlling entity
(1) CALVARY PALLIATIVE CARE NETWORK LLC 1740 EASTCHESTER ROAD Bronx,NY10461	HEALTHCARE	NY	0	CHC
(2) CALVARY NETWORK INDep PRACTICE ASSN 1740 EAsTCHESTER ROAD Bronx,NY10461	HEALTHCARE	NY	0	CPCN
(3) CALVARY NETWORK MANAGEMENT SERVICES LLC 1740 EASTCHESTER ROAD Bronx,NY10461	HEALTHCARE	NY	0	CHC

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)CALVARY FUND INC 1740 EASTCHESTER ROAD Bronx,NY10461 13-3259649	FUNDRAISING	NY	501(C)(3)	12A	CHC		No
(2)CALVARY HOLDING COMPANY 1740 EASTCHESTER ROAD Bronx,NY10461 06-1531426	MANAGEMENT	NY	501(C)(3)	12A	archcare		No
(3)ARCHCARE 155 EAST 56TH STREET FLOOR 2 NEW YORK,NY10022 13-3896624	management	NY	501(C)(3)	1	NA		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2019

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

Yes

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

Yes

e Loans or loan guarantees by related organization(s) ............................

Yes

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

Yes

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

Yes

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2019

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2019

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. (see instructions).

Return Reference	Explanation
Part I, Line 1 & 3, Column (f):	CHC - Calvary Holding Company Part I, Line 2, Column (f): CPCN - Calvary Palliative Care Network, Inc.
Part II, Line 2, Column (f):	CHCS - Catholic Health Care System

Schedule R (Form 990) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: CALVARY HOSPITAL IS A FULLY ACCREDITED EXTENDED NEOPLASTIC DISEASE CARE HOSPITAL PROVIDING PALLIATIVE CARE FOR TERMINALLY ILL CANCER PATIENTS IN THE UNITED STATES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	15
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	1,228
6	Total number of volunteers (estimate if necessary) .............	6	111
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	5,753,800	8,858,100
9	Program service revenue (Part VIII, line 2g) .........	113,396,200	119,818,700
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,940,700	1,921,600
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	800,900	742,800
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	121,891,600	131,341,200
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	5,100	5,800
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	88,834,701	92,955,802
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	33,677,399	38,901,098
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	122,517,200	131,862,700
19	Revenue less expenses. Subtract line 18 from line 12.......	-625,600	-521,500
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	100,681,800	102,670,200
21	Total liabilities (Part X, line 26).............	71,929,700	71,636,800
22	Net assets or fund balances. Subtract line 21 from line 20.....	28,752,100	31,033,400

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 87,336,239 including grants of $ 5,800 ) (Revenue $ 88,765,400 )
	Terminally ill CANCER CARE INPATIENT - CALVARY SERVES ABOUT 23.4% OF ALL INDIVIDUALS WHO DIE OF CANCER IN THE NEW YORK METROPOLITAN AREA EACH YEAR. PATIENTS ARE REFERRED TO CALVARY FROM EVERY MAJOR HOSPITAL AND MEDICAL CENTER IN NEW YORK CITY. IN 2019, CALVARY CARED FOR MORE THAN 5,826 PATIENTS AND FAMILIES AS INPATIENTS IN OUR 200-BED BRONX CAMPUS AND OUR 25-BED SATELLITE AT NYU LANGONE HOSPITAL IN BROOKLYN. THE AVERAGE LENGTH OF INPATIENT STAY IS 26.4 DAYS.

4b	(Code: ) (Expenses $ 26,718,864 including grants of $ ) (Revenue $ 31,011,100 )
	CALVARY HOSPITAL HOSPICE IS A MEDICARE-CERTIFIED HOSPICE PROGRAM, WHICH PROVIDES AN INTERDISCIPLINARY CARE TEAM FOR PATIENTS WITH A TERMINAL PROGNOSIS FOR ALL END-STAGE DISEASES. CALVARY HOSPITAL HOSPICE EMBRACES AND IMPLEMENTS THE BASIC ASSUMPTIONS OF THE HOSPICE CONCEPT, INCLUDING THE FOLLOWING: - HOSPICE PROVIDES PALLIATIVE MEDICAL CARE, TREATING THE PHYSICAL, EMOTIONAL AND SPIRITUAL PAIN OF THE PATIENT AND FAMILY. - HOSPICE TREATS THE PATIENT AND LOVED ONES TOGETHER AS A WHOLE UNIT OF CARE AND OFFERS BEREAVEMENT COUNSELING FOR SURVIVING CAREGIVERS AFTER THE PATIENT'S DEATH. - HOSPICE PATIENTS REMAIN IN THE FAMILIAR, COMFORTING SURROUNDINGS OF HOME, WHETHER IT'S A PRIVATE RESIDENCE, NURSING HOME, HOSPITAL OR AN ASSISTED LIVING FACILITY. - HOSPICE CARE PROVIDES THE FOLLOWING FOUR LEVELS OF CARE: ROUTINE CARE, GENERAL INPATIENT CARE (IF NEEDED), CONTINUOUS CARE (DURING A CRISIS), AND RESPITE CARE.HOSPICE SERVICES - NURSING CARE, AS NECESSARY TO MAINTAIN THE PATIENT AT HOME - 24 HOURS A DAY, 7 DAYS A WEEK ON-CALL NURSE PHYSICIAN SERVICES - MEDICAL SOCIAL SERVICES - PASTORAL CARE - COUNSELING SERVICES - NUTRITIONAL COUNSELING - SHORT-TERM INPATIENT AND RESPITE CARE - MEDICAL SUPPLIES RELATED TO TERMINALLY ILL - PERSONAL CARE PROVIDED BY CERTIFIED HOME HEALTH AIDES - THERAPIES (E.G., PHYSICAL, OCCUPATIONAL AND SPEECH) - MEDICATIONS FOR SYMPTOM MANAGEMENT AND PAIN CONTROL RELATED TO THE TERMINALLY ILL - BEREAVEMENT COUNSELING FOR FAMILY MEMBERS - VOLUNTEER SERVICES

4c	(Code: ) (Expenses $ 972,897 including grants of $ ) (Revenue $ 42,200 )
	CALVARY'S HOME HEALTH AGENCY SERVES PATIENTS IN THE BRONX, QUEENS, NORTHERN MANHATTAN, AND SOUTHERN WESTCHESTER COUNTY. CALVARY OFFERS HOME CARE TO PATIENTS WITH ALL DIAGNOSES. MOST PATIENTS RETURN TO PRE-ILLNESS FUNCTION AND ARE DISCHARGED TO SELF-CARE WITHIN SIX TO EIGHT WEEKS. ALL OF OUR PATIENTS WHO WE CARE FOR AT HOME GET THE SAME LEVEL OF HIGH-QUALITY AND UNIQUE "CALVARY CARE" AS ALL OF OUR INPATIENTS.THE FOLLOWING SERVICES ARE AVAILABLE TO PATIENTS AND THEIR FAMILIES THROUGH CALVARY'S CERTIFIED HOME HEALTH AGENCY: NURSING SERVICES - OUR COMMUNITY HEALTH NURSES PROVIDE NURSING VISITS TO PATIENTS IN THEIR HOMES. - SPECIALIZED NURSING IS AVAILABLE SUCH AS ENTEROSTOMAL THERAPY. - 24-HOUR TELEPHONE ACCESS TO RN (REGISTERED NURSE) ON-CALL.HOME HEALTH AIDE - PROVIDES ASSISTANCE WITH PERSONAL CARE AND OTHER ACTIVITIES RELATED TO HEALTH CARE. NUTRITIONAL SERVICES - CALVARY'S DIETITIANS ARE AVAILABLE BY PHONE TO HELP IN PLANNING THERAPEUTIC NUTRITIONAL MANAGEMENT.THERAPY SERVICES - PHYSICAL THERAPY- OCCUPATIONAL THERAPY - SPEECH THERAPYMEDICAL CARE - CALVARY HOME CARE STAFF WILL WORK CLOSELY WITH THE PATIENT'S OWN PHYSICIAN TO MEET HOME HEALTH NEEDS. - OUR STAFF HAS EXTENSIVE KNOWLEDGE OF PAIN MANAGEMENT.MEDICAL SOCIAL WORK A FULL RANGE OF SOCIAL WORK SERVICES ARE AVAILABLE TO HELP PATIENTS AND FAMILIES COPE WITH THE PROBLEMS OF ILLNESS. - ASSISTANCE IN MEDICAID APPLICATION - ASSISTANCE IN LONG-TERM PLANNINGREFERRING PATIENTS - REFERRALS MAY BE MADE BY PATIENTS FAMILY MEMBERS, FRIENDS, HOSPITALS, CLINICS, PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS AND COMMUNITY AGENCIES. - PART OF THE CALVARY CONTINUUM FACILITATE ADMISSION TO INPATIENT CARE FOR SYMPTOM MANAGEMENT - REFERRAL TO OUTPATIENT AND WOUND CARE CLINICS - PROVIDE INFORMATION ON CALVARY PROGRAMS INCLUDING BEREAVEMENT SUPPORT

4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses115,028,000

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	5,033,035	1,246,121	815,620

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	5,005,000
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	3,853,100

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		8,858,100

		Business Code
2a	PATIENT SERVICE REVENUE	900099	119,818,700	119,818,700
b
c
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		119,818,700

3 Investment income (including dividends, interest, and othersimilar amounts) ......			429,200			429,200
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		47,500	6a
b	Less: rental expenses			6b
c	Rental income or (loss)	0	47,500	6c
d	Net rental income or (loss).......			47,500
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	6,900	15,587,400	7a
b	Less: cost or other basis and sales expenses		14,101,900	7b
c	Gain or (loss)	6,900	1,485,500	7c
d	Net gain or (loss).........			1,492,400			1,492,400
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a	0
b	Less: direct expenses ...		8b	0
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a	0
b	Less: direct expenses ...		9b	0
c	Net income or (loss) from gaming activities..			0
10a	Gross sales of inventory, less returns and allowances ..
			10a	0
b	Less: cost of goods sold ..		10b	0
c	Net income or (loss) from sales of inventory..			0
Business Code			Miscellaneous Revenue
11a	PARKING LOT REVENUE		812930	249,400			249,400
b	CAFETERIA		900099	158,100			158,100
c	RELATED PARTY REIMBURSEMENTS		900099	144,200	144,200
d	All other revenue ....			143,600			143,600
e	Total. Add lines 11a–11d ......			695,300
12	Total revenue. See instructions.....			131,341,200	119,962,900		2,472,700

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	5,800	5,800
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........	0
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............	0
4	Benefits paid to or for members .......	0
5	Compensation of current officers, directors, trustees, and key employees ...........	3,212,489	1,354,296	1,858,193
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........	0
7	Other salaries and wages........	65,812,869	62,661,336	3,151,533
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	3,251,313	3,019,612	231,701
9	Other employee benefits .......	15,805,430	14,679,074	1,126,356
10	Payroll taxes ...........	4,873,701	4,526,382	347,319
11	Fees for services (non-employees):
a	Management ......	1,894,718		1,894,718
b	Legal .........	480,362		480,362
c	Accounting ...........	345,688		345,688
d	Lobbying ...........	65,709		65,709
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	10,831,426	10,831,426
12	Advertising and promotion ....	1,339,527	668,249	671,278
13	Office expenses .......	2,460,693	1,227,564	1,233,129
14	Information technology ......	294,173	146,754	147,419
15	Royalties ..	0
16	Occupancy ...........	2,447,028	1,690,773	756,255
17	Travel ............	271,111	135,249	135,862
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	70,764	35,287	35,477
20	Interest ...........	242,100	242,100
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	6,407,142	6,033,565	373,577
23	Insurance ...	846,324		846,324
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	PHARMACEUTICALS	4,793,825	4,793,825
b	MAINTENANCE AND REPAIRS	1,496,388	746,502	749,886
c	FOOD EXPENSE	1,048,056	522,843	525,213
d	LEASES	413,839	389,710	24,129
e	All other expenses	3,152,225	1,317,653	1,834,572
25	Total functional expenses. Add lines 1 through 24e	131,862,700	115,028,000	16,834,700	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			21,600	1	5,600
2	Savings and temporary cash investments .........			2,039,300	2	65,000
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			27,791,100	4	31,358,100
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
				0	6	0
7	Notes and loans receivable, net ...........			0	7	0
8	Inventories for sale or use ............			201,100	8	578,238
9	Prepaid expenses and deferred charges ......			664,000	9	773,262
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	113,260,400
b	Less: accumulated depreciation	10b	90,173,800	20,948,300	10c	23,086,600
11	Investments—publicly traded securities .			22,253,100	11	14,502,100
12	Investments—other securities. See Part IV, line 11 .....			10,679,500	12	7,570,400
13	Investments—program-related. See Part IV, line 11 ..			15,860,400	13	23,873,900
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			223,400	15	857,000
16	Total assets. Add lines 1 through 15 (must equal line 33)...			100,681,800	16	102,670,200

17	Accounts payable and accrued expenses .....	17,975,700	17	17,962,500
18	Grants payable ...	0	18	0
19	Deferred revenue .........	0	19	0
20	Tax-exempt bond liabilities .........	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D	126,200	21	0
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
		0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	1,833,300	23	1,711,200
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	1,000,000
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	51,994,500	25	50,963,100
26	Total liabilities. Add lines 17 through 25..	71,929,700	26	71,636,800

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	-531,800	27	-4,833,900
28	Net assets with donor restrictions ...........	29,283,900	28	35,867,300
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	28,752,100	32	31,033,400
33	Total liabilities and net assets/fund balances ........	100,681,800	33	102,670,200