Form990
Department of the TreasuryInternal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
A For the 2019 calendar year, or tax year beginning 07-01-2019 , and ending 06-30-2020
BCheck if applicable:
CName of organization
Alice Peck Day Memorial Hospital
 
 
Doing business as
 
 
Number and street (or P.O. box if mail is not delivered to street address)
10 Alice Peck Day Drive
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Lebanon, NH03766
D Employer identification number

02-0222791
E Telephone number

G Gross receipts $ 73,081,604
F Name and address of principal officer:
Susan E Mooney MD MS
10 Alice Peck Day Drive
Lebanon,NH03766
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.alicepeckday.org
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:  
L Year of formation: 1943
M State of legal domicile: NH
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: To improve the health and wellbeing of our community
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 18
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 11
5 Total number of individuals employed in calendar year 2019 (Part V, line 2a) ...... 5 668
6 Total number of volunteers (estimate if necessary) ............. 6 72
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a -2,104
b Net unrelated business taxable income from Form 990-T, line 39 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 682,127 617,929
9 Program service revenue (Part VIII, line 2g) ......... 73,224,665 65,607,874
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 1,015,717 95,641
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -13,498 6,760,160
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 74,909,011 73,081,604
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 220,565 109,193
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 43,750,730 43,787,912
16a Professional fundraising fees (Part IX, column (A), line 11e) .....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet178,760    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 32,013,891 27,435,157
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 75,985,186 71,332,262
19 Revenue less expenses. Subtract line 18 from line 12....... -1,076,175 1,749,342
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 76,398,452 106,122,575
21 Total liabilities (Part X, line 26)............. 47,949,645 75,713,869
22 Net assets or fund balances. Subtract line 21 from line 20..... 28,448,807 30,408,706
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
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Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2019)
Form 990 (2019)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: To improve the health and wellbeing of our community
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? .....................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ...........................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 67,416,201 including grants of $ 109,193 ) (Revenue $ 72,350,229 )
Alice Peck Day Memorial Hospital is a community-based critical access hospital operating in Lebanon, NH. The Hospital began as a small cottage hospital in 1932. From its humble beginnings, Alice Peck Day has continually demonstrated its commitment to provide patient-focused health care services which improve the quality of life within its community and promote wellness for all. Alice Peck Day Memorial Hospital is a charitable health care organization which is dedicated to serving its community. This commitment includes granting credit to patients, substantially all of whom are local residents. The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than the established rates. Collections are not pursued for amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy, the established costs of the services and supplies provided, and equivalent service statistics. For the fiscal year ended June 30, 2020, charity care at a cost of $399,882 was provided to eligible patients. Estimated costs incurred in excess of payment for inpatient and outpatient services for Medicaid patients in fiscal year ended June 30, 2020 were $2,150,499. In addition to the charity care services described above, the Hospital provided a number of other services for which little or no payment was received. These included: the Upper Valley Smiles dental program of free oral health education, screenings, and preventive treatment offered to low-income children in ten local elementary schools; Elder Friends, a program matching volunteers one-on-one with isolated, home-bound seniors; Lebanon Lunch Friends, which provides free lunches to eligible local children who no longer have access to free or reduced-price meals at school during the summer; the Tobacco 21 initiative, which involved forming a community coalition to consider supporting a City of Lebanon ordinance that restricts tobacco and e-cigarette sales to individuals 21 years and older; the creation of a public access trail from one of the Hospital parking lots to the Mascoma River Greenway, and Community Care News, a web-based initiative focused on providing helpful tips to improve health and wellbeing during the pandemic. As a local hospital, Alice Peck Day works closely with community organizations to address community needs. Organizations that were beneficiaries of hospital staff time, meeting space, cash and/or materials included: Alcoholics Anonymous, American Red Cross, Good Neighbor Health Clinic, Headrest, Lebanon Chamber of Commerce, Lebanon Department of Recreation, Ottauquechee School, Upper Valley Business Alliance, Upper Valley Medtech Collaborative, and Upper Valley Public Health Council. In certain instances, assistance was provided to the community for which no value can be placed. Alice Peck Day Memorial Hospital considers caring for our community a special responsibility that we are honored to fulfill.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet67,416,201
Form 990 (2019)
Form 990 (2019)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I.............
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part IIClick to see attachment.........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part III..
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I.........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II....
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII......................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States? .....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I(see instructions) ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....Click to see attachment
21
Yes
 
Form 990 (2019)
Form 990 (2019)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........Click to see attachment
22
Yes
 
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............
24c
 
No
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I ....
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or 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? If "Yes," complete Schedule L, Part II...........
26
 
No
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part III.........................
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................
28a
 
No
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....
28b
 
No
c
A 35% controlled entity of one or more individuals and/or organizations described in lines 28a or 28b? If "Yes," complete Schedule L, Part IV.....................
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2.............
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable ..
1a
120
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
Form 990 (2019)
Form 990 (2019)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
668
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided? .....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see instructions and file Form 4720, Schedule N.
15
 
No
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
No
Form 990 (2019)
Form 990 (2019)
Page 6
Part VI
Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
1a
18
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
11
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .......................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the states with which a copy of this Form 990 is required to be filedMediumBullet
NH
18
Section 6104 requires an organization to make its Form 1023 (or 1024-A if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletTodd Roberts10 Alice Peck Day Drive   Lebanon,NH03766 (603) 448-3121
Form 990 (2019)
Form 990 (2019)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

See instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(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) 		(D)
Reportable compensation from the organization (W-2/1099-MISC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) Brett C Peltzer
 
Trustee, Treasurer
 2.0
.................
0 		X   X       0 0 0
(2) Greg W Lange
 
Trustee, Chair
 2.0
.................
0 		X   X       0 0 0
(3) Marisa D Devlin
 
Trustee, Vice Chair
 2.0
.................
0 		X   X       0 0 0
(4) Michael F Long
 
Trustee, Secretary
 2.0
.................
0 		X   X       0 0 0
(5) SUSAN MOONEY MD MS FACOG
 
TRUSTEE/PRESIDENT/CEO APD
 52.0
.................
8.0 		X   X       407,198 0 29,195
(6) Anne D MacEwan
 
Trustee (end 12/19)
 0.5
.................
0.5 		X           0 0 0
(7) Brenan Riehl
 
Trustee
 2.0
.................
0 		X           0 0 0
(8) Charles J Wheelan
 
Trustee
 0.5
.................
0 		X           0 0 0
(9) Clayton R Adams
 
Trustee
 0.5
.................
0 		X           0 0 0
(10) GEORGE T BLIKE MD
 
Trustee
 0.5
.................
41.0 		X           0 474,747 64,154
(11) Jennifer Sage Schiffman
 
Trustee
 0.5
.................
0 		X           0 0 0
(12) John L Scherding
 
Trustee
 0.5
.................
2.0 		X           0 0 0
(13) JOHN P HOUDE MD
 
TRUSTEE/EX-OFFICIO/SURGEON
 40.0
.................
0 		X           520,397 0 29,208
(14) Kyle Fisher
 
Trustee (as of 1/20)
 0.5
.................
0.5 		X           0 0 0
(15) Mary M Oseid MHCDS
 
Trustee
 1.0
.................
41.0 		X           0 315,102 60,061
(16) Patrick F Jordan III MBA
 
Trustee
 0.5
.................
56.5 		X           0 770,233 64,134
(17) Rebecca W Holcombe
 
Trustee (end 1/20)
 0.5
.................
0 		X           0 0 0
Form 990 (2019)
Form 990 (2019)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(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) 		(D)
Reportable compensation from the organization (W-2/1099-MISC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) Sara L Kobylenski
 
Trustee
 0.5
.......................2.0 		X           0 0 0
(19) SCOTT W RODI MD
 
Trustee
 0.5
.......................40.0 		X           0 426,376 60,408
(20) Tina E Naimie CPA
 
Trustee
 1.0
.......................41.0 		X           0 284,775 23,176
(21) Christopher Fallon
 
Interim CFO (end 12/19)
 45.0
.......................5.0 		    X       268,679 0 0
(22) TODD ROBERTS
 
VP Finance (as of 1/20)
 48.0
.......................2.0 		    X       134,764 0 25,975
(23) DALE C VIDAL MD MS
 
Executive Director MSC
 40.0
.......................0 		      X     527,075 0 29,208
(24) JEAN TEN HAKEN MSN RN CENP
 
CNO/COO
 40.0
.......................0 		      X     230,130 0 11,363
(25) BRIAN LOMBARDO MD
 
PHYSICIAN
 40.0
.......................0 		        X   266,186 0 26,221
(26) DEBORAH GLAZER MD
 
PHYSICIAN
 40.0
.......................0 		        X   272,750 0 5,473
(27) DIANE RILEY MD CAQSH
 
Ortho Surgeon Hand Specialist
 40.0
.......................0 		        X   442,413 0 23,784
(28) ERIN MCNEELY MD
 
PHYSICIAN
 40.0
.......................0 		        X   274,705 0 28,658
(29) IVAN TOMEK MD
 
General Orthopedic Surgeon
 40.0
.......................0 		        X   563,705 0 26,443
(30) Brenda L Blair
 
Former VP & COO
 30.0
.......................0 		          X 130,969 140,648 14,590
(31) Kathryn M Vargo MD
 
Former Officer
 30.0
.......................0 		          X 106,703 0 30,217
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 4,145,674 2,411,881 552,268
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet45
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Conifer Revenue Cycle Solutions LLC

PO Box 655025
Dallas,TX75265 		Revenue Management Services 3,293,628
Upper Valley Neurology

106 Hanover Street
Lebanon,NH03766 		Physician Services 2,920,861
The Chappelle Group LLC

7500 Greenway Center Drive
Suite 480
Greenbelt,MD20770 		Revenue cycle/ financial services 1,821,882
American Healthcare Services Associates

PO Box 945
Traverse,MI49685 		Staffing 1,637,214
EmCare Physician Services Inc

7032 Collection Center Drive
Chicago,IL60693 		Physician Services 922,066
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet11
Form 990 (2019)
Form 990 (2019)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, GrantAmt and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues..1b  
c Fundraising events..1c  
d Related organizations1d 78,503
e Government grants (contributions)1e 43,503
f All other contributions, gifts, grants, and similar amounts not included above1f 495,923
g Noncash contributions included in lines 1a - 1f:$ 1g 37,824
h Total. Add lines 1a-1f.......MediumBullet 617,929
Program Service RevenueAmt Business Code
2a Patient Services 622110 65,495,587 65,495,587    
b Nutritional Services 722210 112,287 112,287    
c
d
e
f All other program service revenue. 0 0 0 0
g Total. Add lines 2a–2f .....MediumBullet 65,607,874
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 301,037   -2,104 303,141
4 Income from investment of tax-exempt bond proceedsMediumBullet        
5 Royalties...........MediumBullet        
(ii) Personal (i) Real
6a Gross rents   17,805 6a
b Less: rental expenses     6b
c Rental income or (loss) 0 17,805 6c
d Net rental income or (loss).......MediumBullet 17,805     17,805
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory -205,396   7a
b Less: cost or other basis and sales expenses     7b
c Gain or (loss) -205,396 0 7c
d Net gain or (loss).........MediumBullet -205,396     -205,396
8a Gross income from fundraising events (not including $   of contributions reported on line 1c). See Part IV, line 18 ....
8a  
b Less: direct expenses ... 8b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a  
b Less: direct expenses ... 9b  
c Net income or (loss) from gaming activities..MediumBullet        
10a Gross sales of inventory, less
returns and allowances ..
10a  
b Less: cost of goods sold .. 10b  
c Net income or (loss) from sales of inventory..MediumBullet        
Business Code Miscellaneous Revenue
11a STIMULUS FUNDING 622110 6,136,728 6,136,728    
b PURCHASE REBATES AND DISCOUNTS 900099 202,579 202,579    
c MISCELLANEOUS 900099 403,048 403,048    
d All other revenue .... 0 0 0 0
e Total. Add lines 11a–11d ...... MediumBullet 6,742,355
12 Total revenue. See instructions.....MediumBullet 73,081,604 72,350,229 -2,104 115,550
Form 990 (2019)
Form 990 (2019)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising
expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 86,748 86,748
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ........... 22,445 22,445
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............    
4 Benefits paid to or for members .......    
5 Compensation of current officers, directors, trustees, and key employees ........... 2,567,815 835,153 1,710,615 22,047
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........        
7 Other salaries and wages........ 35,310,484 34,962,230 255,221 93,033
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 650,061 626,908 21,275 1,878
9 Other employee benefits ....... 3,578,469 3,567,847 1,188 9,434
10 Payroll taxes ........... 1,681,083 1,606,379 69,733 4,971
11 Fees for services (non-employees):        
a Management ......        
b Legal ......... 3,840   3,840  
c Accounting ...........        
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) 5,339,711 5,072,726 250,966 16,019
12 Advertising and promotion .... 16,231   16,231  
13 Office expenses ....... 1,199,768 223,157 973,012 3,599
14 Information technology ...... 539,986 512,987 25,379 1,620
15 Royalties ..        
16 Occupancy ........... 1,812,706 1,722,071 85,197 5,438
17 Travel ............ 34,585 32,855 1,626 104
18 Payments of travel or entertainment expenses for any federal, state, or local public officials .        
19 Conferences, conventions, and meetings ....        
20 Interest ........... 905,791 860,502 42,572 2,717
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .. 3,360,423 3,192,402 157,940 10,081
23 Insurance ... 253,493 240,819 11,914 760
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 Drugs/medical supplies 8,389,767 8,389,767    
b New Hampshire MET 3,225,836 3,225,836    
c Repairs/maintenance 1,744,073 1,656,870 81,971 5,232
d STAFF DUES , LICENSES AND EDUCATION 252,748 240,111 11,879 758
e All other expenses 356,199 338,388 16,742 1,069
25 Total functional expenses. Add lines 1 through 24e 71,332,262 67,416,201 3,737,301 178,760
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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2019)
Form 990 (2019)
Page 11
Part X
Balance Sheet
Check if Schedule O contains a response or note to any line in this Part IX..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ........ 2,159 1 15,725,480
2 Savings and temporary cash investments ......... 7,063,489 2 10,425,917
3 Pledges and grants receivable, net ...... 120,009 3 120,009
4 Accounts receivable, net ............. 7,282,615 4 8,642,305
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 ...........   7 10,749,298
8 Inventories for sale or use ............ 735,346 8 444,769
9 Prepaid expenses and deferred charges ...... 205,316 9 441,331
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 75,035,599
b Less: accumulated depreciation 10b 36,656,712 30,923,643 10c 38,378,887
11 Investments—publicly traded securities . 17,948,875 11 13,069,164
12 Investments—other securities. See Part IV, line 11 ..... 9,805,137 12  
13 Investments—program-related. See Part IV, line 11 .. 0 13  
14 Intangible assets ...............   14 5,216,933
15 Other assets. See Part IV, line 11 ........... 2,311,863 15 2,908,482
16 Total assets. Add lines 1 through 15 (must equal line 33)... 76,398,452 16 106,122,575
Liabilities 17 Accounts payable and accrued expenses ..... 8,405,326 17 6,815,774
18 Grants payable ...   18  
19 Deferred revenue ......... 33,082 19 11,854,938
20 Tax-exempt bond liabilities ......... 25,740,604 20 25,160,000
21 Escrow or custodial account liability. Complete Part IV of Schedule D   21  
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 .. 248,731 23 11,660
24 Unsecured notes and loans payable to unrelated third parties ..   24  
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 13,521,902 25 31,871,497
26 Total liabilities. Add lines 17 through 25.. 47,949,645 26 75,713,869
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions .......... 27,652,645 27 29,463,607
28 Net assets with donor restrictions ........... 796,162 28 945,099
Organizations that do not follow FASB ASC 958, check here MediumBullet 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 ........... 28,448,807 32 30,408,706
33 Total liabilities and net assets/fund balances ........ 76,398,452 33 106,122,575
Form 990 (2019)
Form 990 (2019)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
73,081,604
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
71,332,262
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
1,749,342
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
28,448,807
5
Net unrealized gains (losses) on investments ...............
5
-8,756
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
219,313
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
30,408,706
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII.............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2019)
Form 990 (2019)
Additional Data


Software ID: 19010655
Software Version: 2019v5.0
Form 990, Special Condition Description:
Special Condition Description
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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
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.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total
 
   
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

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) right arrow (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) right arrow (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  
12
12
 
13
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
14
14
 
15
15
 
16a
b
17a
b
18
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

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) right arrow (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) right arrow (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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2019

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
No
1
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.
1
 
 
2
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).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.
3a
 
 
b
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.
3b
 
 
c
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.
3c
 
 
4a
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.
4a
 
 
b
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.
4b
 
 
c
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.
4c
 
 
5a
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).
5a
 
 
b
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?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
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.
6
 
 
7
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) .
7
 
 
8
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).
8
 
 
9a
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.
9a
 
 
b
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.
9b
 
 
c
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.
9c
 
 
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
 
 
b
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

Schedule A (Form 990 or 990-EZ) 2019
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
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
 
 
b
A family member of a person described in (a) above?
11b
 
 
c
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
No
1
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.
1
 
 
2
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.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
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).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
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?
1
 
 
2
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).
2
 
 
3
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.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer (a) and (b) below.
Yes
No
a
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.
2a
 
 
b
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.
2b
 
 
3
Parent of Supported Organizations. Answer (a) and (b) below.
a
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.
3a
 
 
b
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.
3b
 
 
Schedule A (Form 990 or 990-EZ) 2019

Schedule A (Form 990 or 990-EZ) 2019
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
Section A - Adjusted Net Income (A) Prior Year (B) Current Year
(optional)
1 Net short-term capital gain 1    
2 Recoveries of prior-year distributions 2    
3 Other gross income (see instructions) 3    
4 Add lines 1 through 3 4    
5 Depreciation and depletion 5    
6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6    
7 Other expenses (see instructions) 7    
8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8    
Section B - Minimum Asset Amount (A) Prior Year (B) Current Year
(optional)
1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): 1
a Average monthly value of securities 1a    
b Average monthly cash balances 1b    
c Fair market value of other non-exempt-use assets 1c    
d Total (add lines 1a, 1b, and 1c) 1d    
e Discount claimed for blockage or other factors
(explain in detail in Part VI):  
2 Acquisition indebtedness applicable to non-exempt use assets 2    
3 Subtract line 2 from line 1d 3    
4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 4    
5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5    
6 Multiply line 5 by .035 6    
7 Recoveries of prior-year distributions 7    
8 Minimum Asset Amount (add line 7 to line 6) 8    
Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1  
2 Enter 85% of line 1 2  
3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3  
4 Enter greater of line 2 or line 3 4  
5 Income tax imposed in prior year 5  
6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6  
7
Schedule A (Form 990 or 990-EZ) 2019

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: 19010655
Software Version: 2019v5.0
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors

Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Name of the organization
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ






Form 990-PF




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
Special Rules
......... 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
Alice Peck Day Memorial Hospital
  		Employer identification number
02-0222791
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


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(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
Alice Peck Day Memorial Hospital
  		Employer identification number

02-0222791
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
Alice Peck Day Memorial Hospital
  		Employer identification number

02-0222791
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 $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a)
No. from Part I		 (b) Purpose of gift (c) Use 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 (c) Use 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 (c) Use 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 (c) Use 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: 19010655
Software Version: 2019v5.0
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 BulletGo 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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

2
Political campaign activity expenditures (see instructions) ....................................................................SchCMd Bullet
$  
3
Volunteer hours for political campaign activities (see instructions) ..................................................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 ................................SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 .......................SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................
4a
Was a correction made? ......................................................................................................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b...........SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ...................................................................
5
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

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 Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(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? ...................................................................................................................

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


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
1
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:
a
Volunteers? ...........................................................................................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........
 
No
c
Media advertisements? ...................................................................................................
 
No
 
d
Mailings to members, legislators, or the public? .............................................................................
 
No
 
e
Publications, or published or broadcast statements? ...........................................................
 
No
 
f
Grants to other organizations for lobbying purposes? ..........................................................
Yes
 
11,918
g
Direct contact with legislators, their staffs, government officials, or a legislative body? .......................
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................
 
No
 
i
Other activities? ...................................................................................................................
Yes
 
5,000
j
Total. Add lines 1c through 1i ....................................................................................................
16,918
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 ...........................................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ...............................................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................
3
 
 
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."
1
Dues, assessments and similar amounts from members ......................................................................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).
a
Current year .............................................................................................................................
2a
 
b
Carryover from last year ............................................................................................................
2b
 
c
Total ...........................................................................................................................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ......................................................................................................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) .........................................
5
 
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 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY ALICE PECK DAY MEMORIAL HOSPITAL WAS A MEMBER OF THE AMERICAN HOSPITAL ASSOCIATION AND THE NEW HAMPSHIRE HOSPITAL ASSOCIATION IN THE FISCAL YEAR ENDED JUNE 30, 2020. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS WAS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF ALICE PECK DAY MEMORIAL HOSPITAL AND THE OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. THE TOTAL DUES PAID BY THE HOSPITAL TO THESE ORGANIZATIONS, AND THE PORTION THAT WAS AVAILABLE FOR LOBBYING ARE DETAILED BELOW. AMERICAN HOSPITAL ASSOCIATION-TOTAL DUES $44,555 AMOUNT OF DUES AVAILABLE FOR LOBBYING $8,488 NEW HAMPSHIRE HOSPITAL ASSOCIATION-TOTAL DUES $14,708 AMOUNT OF DUES AVAILABLE FOR LOBBYING $3,430 ALSO, THE HOSPITAL BELONGS TO THE 10 MILE CRITICAL ACCESS HOSPITAL (CAH) COALTION WHICH ENGAGED STRATEGIC HEALTH RESOURCES (SHR) FOR PURPOSES OF FURTHERING LOBBYING EFFORTS WITH REGARDS TO ATTEMPT TO ELIMINATE CAH STATUS. THE CEO PARTICIPATES IN PERIODIC TELEPHONE CALLS WITH THIS GROUP IN ATTEMPTS TO KEEP THE ISSUE OF RURAL HEALTHCARE AND THE KEY ROLE THAT CAHS PLAY IN RURAL HEALTHCARE IN FRONT OF THE VARIOUS LEGISLATIVE DELEGATIONS.
Schedule C (Form 990 or 990EZ) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............
6
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet $  
8
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)? .............................
9
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.
1a
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.
b
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 $  
2
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:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
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

Schedule D (Form 990) 2019
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?...
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
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  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...
b
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 .... 97,000 219,295 33,539 31,051 30,268
b Contributions ...     185,756 2,488  
c Net investment earnings, gains, and losses         1,577
d Grants or scholarships ...          
e Other expenditures for facilities
and programs ... 		  122,295     794
f Administrative expenses ....          
g End of year balance ...... 97,000 97,000 219,295 33,539 31,051
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet100 %
c
Term endowment SchDMd Bullet0 %
The percentages on lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) Unrelated organizations .................
3a(i)
 
No
(ii) Related organizations .................
3a(ii)
Yes
 
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
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 .....   4,600,000 4,600,000
b Buildings ....   17,875,061 11,884,251 5,990,810
c Leasehold improvements   212,775 212,775 0
d Equipment ....   31,489,273 22,110,740 9,378,533
e Other .....   20,858,490 2,448,946 18,409,544
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 38,378,887
Schedule D (Form 990) 2019

Schedule D (Form 990) 2019
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
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.)...........Small Bullet  
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  
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 31,871,497
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

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  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains (losses) on investments .... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1.................. 3  
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  
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  
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  
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  
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 V, Line 4 Intended uses of endowment funds The Organization uses the income from its endowment funds in support of its operations.
Schedule D (Form 990) 2019


Additional Data


Software ID: 19010655
Software Version: 2019v5.0




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet 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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
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.
3
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.
a
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:
3a
Yes
 
b
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: . . . . . . . .
3b
Yes
 
%
c
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.
4
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"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
 
No
c
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? . . . . . . . . . . . . .
5c
 
 
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (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) . . . 		    399,882   399,882 0.56 %
b Medicaid (from Worksheet 3, column a) . . . . .     8,586,132 6,435,633 2,150,499 3.01 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .         0 0 %
d Total Financial Assistance and Means-Tested Government Programs . . . . . 0 0 8,986,014 6,435,633 2,550,381 3.58 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     247,571 24,945 222,626 0.31 %
f Health professions education (from Worksheet 5) . . .     8,000   8,000 0.01 %
g Subsidized health services (from Worksheet 6) . . . .     18,474,625 14,311,070 4,163,555 5.84 %
h Research (from Worksheet 7) .         0 0 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . . 24   40,420   40,420 0.06 %
j Total. Other Benefits . . 24 0 18,770,616 14,336,015 4,434,601 6.22 %
k Total. Add lines 7d and 7j . 24 0 27,756,630 20,771,648 6,984,982 9.79 %
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) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing     7,715   7,715 0.01 %
2 Economic development         0 0 %
3 Community support     30,048   30,048 0.04 %
4 Environmental improvements         0 0 %
5 Leadership development and
training for community members		         0 0 %
6 Coalition building         0 0 %
7 Community health improvement advocacy     22,834   22,834 0.03 %
8 Workforce development         0 0 %
9 Other         0 0 %
10 Total 0 0 60,597 0 60,597 0.08 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
0
3
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. ......
3
0
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
19,578,901
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
22,091,824
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-2,512,923
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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 .........................

9b

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
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?1Name, 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) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Alice Peck Day Memorial Hospital
10 Alice Peck Day Drive
Lebanon,NH03766
www.alicepeckday.org
00016 		X X     X   X   Physician Clinics  
2  
  		                   
Schedule H (Form 990) 2019
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)
Alice Peck Day Memorial Hospital
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): 		1
Yes No
Community Health Needs Assessment
1 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?........................ 1   No
2 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............... 2   No
3 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...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 18
5 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 ................. 5 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.................................. 6a Yes  
b 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. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 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. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 19
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): www.alicpeckday.org/about/apd/reports/
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 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   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c 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
Schedule H (Form 990) 2019
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Alice Peck Day Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 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):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
www.alicepeckday.org/patients/financial_services
b
ww.alicepeckday.org/patients/financial_services
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 6
Part VFacility Information (continued)

Billing and Collections
Alice Peck Day Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 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?.................................. 17 Yes  
18 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:
a
b
c
d
e
f
19 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?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 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):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 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?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2019
Schedule H (Form 990) 2019
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Alice Peck Day Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 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.
a
b
c
d
23 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? ............................... 23   No
If "Yes," explain in Section C.
24 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? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2019
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, Part V, Section B, Line 5 Facility , 1 Facility , 1 - Alice Peck Day Memorial Hospital. With a shared Hospital Service Area, Alice Peck Day Memorial Hospital collaborated with Dartmouth-Hitchcock in conducting the fiscal year 2019 Community Health Needs Assessment. Technical expertise was provided by the New Hampshire Community Health Institute, the NH affiliate of JSI, a nation-wide public health management consulting and research organization. Methods employed in the assessment included surveys of community residents made available online and paper surveys placed in numerous locations throughout the region (completed by 2,100 individuals), a direct email survey of key stakeholders and community leaders representing multiple community sectors; a set of community discussion groups; compilation of results from assessment activities focused specifically on behavioral health needs and gaps; and a review of available population demographics and health status indicators. All information collection activities and analyses sought to focus assessment activities on vulnerable and disproportionately served populations in the region including populations that could experience limited access to health-related services or resources due to income, age, disability, and social or physical isolation. Enhanced efforts were made to understand the needs of these populations through targeted surveys and community conversations including facilitated surveys and discussions at community suppers, a regional free clinic, homeless programs, and other community settings serving economically vulnerable residents. The data gathered in the FY2019 CHNA is part of a continual process for considering progress and emerging community needs informed by dialogue with community members, leaders, and experience.
Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - Alice Peck Day Memorial Hospital. ALICE PECK DAY MEMORIAL HOSPITAL PARTNERED WITH MARY HITCHCOCK MEMORIAL HOSPITAL TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT. APDMH ALSO PARTNERED WITH NEIGHBORING HOSPITALS AND ORGANIZATIONS INCLUDING DARTMOUTH HITCHCOCK MEDICAL CENTER, NEW LONDON HOSPITAL,VALLEY REGIONAL HOSPITAL, MOUNT ASCUTNEY HOSPITAL AND VISITING NURSE & HOSPICE OF VT and NH.
Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - Alice Peck Day Memorial Hospital. Technical assistance for the Hospital's 2018 CHNA was provided by the New Hampshire Community Health Institute
Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - ALICE PECK DAY MEMORIAL HOSITAL. Alice Peck Day Memorial Hospital's (APDMH) Community Health Implementation Plan, approved by the governing board in November of 2019, is a three-year document that provides a detailed set of strategies for addressing our region's top health needs. Based on the most recent Community Health Needs Assessment (CHNA), affordable health care and health insurance were the top needs identified. APDMH offers affordable care to our under- and uninsured patients through our Financial Assistance programs, in addition to offering Marketplace Health Insurance counseling during Open Enrollment and Medicaid enrollment assistance. We also provide in-kind donation of space to the Good Neighbor Health Clinic, the Upper Valley's free medical clinic. Additional top health needs include: mental health, substance misuse and addiction, child abuse or neglect, cost of prescription drugs, availability of primary care services, domestic violence, and senior health care services. We work in partnership with local and state organizations and agencies to address these concerns. We offer mental health services through our Behavioral Health Specialist; participate in the region's Integrated Delivery Network to enhance behavioral health capacity, and created an Emergency Department Rapid Referral Program through partnership with West Central Behavioral Health. In the Clinic, we provide Medication Assisted Treatment to patients with substance use disorders, and in the community we led an advocacy initiative aimed at increasing the minimum age to 21 for tobacco sales in Lebanon, NH. We participate in a regional initiative called "Strong Families, Strong Starts" to help strengthen child development and address childhood trauma. We provide vouchers for emergency prescription assistance and one-on-one help applying for prescription assistance programs offered through drug companies. In our clinics, we screen for child abuse and domestic violence and refer patients for treatment. Lastly, we offer our Senior Care Team's home-based primary care program for the elderly in the local community; provide the Elder Friends program, which matches those referred by the Senior Care team with a volunteer for companionship; and host an educational/networking forum focused on the elderly called Elder Forum. These initiatives and ongoing efforts continue to address several of the most pressing community needs as identified in our community needs assessment.
Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - Alice Peck Day Mememorial Hospital:. Alice Peck Day Memorial Hospital offers financial assistance to patients demonstrating need. In making the need determination, APD participates with and honors the founding principles and guidelines of the New Hampshire Health Access Network (NHHAN).Accordingly, decisions regarding the granting of financial assistance will be based primarily on a patient and their household income and assets. There will be minimal consideration of expenses except when they identify areas for further investigation or incomplete or inaccurate information. The value of a patient's principal residence is not considered in qualifying a patient for in-house assistance. APD requires exhaustion of other payment methodologies, including but not limited to, worker's compensation, veterans benefits, Medicaid, liability insurance, victims of crime, and COBRA. When applicable, proof of determination may be required prior to consideration for financial assistance.
Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - Alice Peck Day Memorial Hospital. THE FINANCIAL ASSISTANCE POLICY, APPLICAION AND PLAIN LANGUAGE SUMMARY ARE AVAILABLE ON THE HOSPITAL'S WEBSITE. APDMH prints and distributes its financial assistance application in Spanish when requested.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2019
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?7
Name and address Type of Facility (describe)
1 Neurosurgery Services at APD (NSAPD)
106 Hanover Street
Lebanon,NH03766 		Neurosurgery Physician Clinic
2 RAM Center for Community Care
10 Alice Peck Day Drive
Lebanon,NH03766 		Primary Care Physician Clinic
3 APD Orthopaedic Clinic
10 Alice Peck Day Drive
Lebanon,NH03766 		Orthopaedic Physician Clinic
4 Women's Care Center
10 Alice Peck Day Drive
Lebanon,NH03766 		OB/GYN Physician Clinic
5 General Surgery Clinic
10 Alice Peck Day Drive
Lebanon,NH03766 		General Surgery Clinic
6 Pain Management Clinic
10 Alice Peck Day Drive
Lebanon,NH03766 		Pain Management Clinic
7 Occupational Health Services
10 Alice Peck Day Drive
Lebanon,NH03766 		Occupational Health Physician Clinic
8
9
10
Schedule H (Form 990) 2019
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
Schedule H, Part I, Line 3c OTHER FACTORS USED IN DETERMINING ELIGIBILITY OTHER THAN FPG APD USES THE FPG GUIDELINES IN DETERMINING THE INITIAL LEVEL OF FINANCIAL ASSISTANCE PROVIDED. IN ADDITION, APD ALLOWS FOR CATASTROPHIC ASSISTANCE CONSIDERATION BASED ON A CALCULATION OF 10% OF TWO YEARS INCOME PLUS 10% OF AMOUNT OVER SHELTERED ASSETS. IF THE PROJECTED OR CURRENT SELF-PAY BALANCE IS GREATER THAN THIS CALCULATION, THE SELF-PAY BALANCE IS REDUCED TO THE SUM OF 10% OF TWO YEARS INCOME PLUS 10% OF ASSETS. EACH HOUSEHOLD IS ALLOWED CERTAIN SHELTERED ASSETS WHICH ARE NOT USED WHEN CALCULATING HOUSEHOLD INCOME OR ASSETS SAVINGS IS SHELTERED UP TO 100% OF FPL BASED ON FAMILY SIZE, EQUITY IN PRIMARY RESIDENCE UP TO $200,000 UP TO 55 AND $250,000 FOR AGED 55 AND OLDER, AND A RETIREMENT SHELTER OF UP TO $100,000 IN RETIREMENT ASSETS AS LONG AS IT IS EMPLOYER BASED CONTRIBUTIONS IF WORKING OR IRA IF SELF-EMPLOYED. IF A PATIENT IS RETIRED, PRIOR RETIREMENT ACCOUNTS WOULD BE INCLUDED AS A SHELTERED ASSET.
Schedule H, Part I, Line 7 SUBSIDIZED HEALTH SERVICE COSTS APD has several hospital clinical services and hospital-owned physician practices. Per instructions for IRS Form 990, Schedule H, Worksheet 6, organizations may include any applicable physician practice that the Hospital subsidizes (i.e., operates at a loss) in the completing of Schedule H. Therefore, the Hospital has included the following hospital clinical services and hospital-owned physician practices that operate at a loss (i.e., are subsidized by the Hospital) and the associated costs of these practices: a. Primary Care b. Women's Care c. Orthopedics d. Occupational Health e. Sleep Lab The above-listed hospital clinical services and hospital-owned physician practices have a community benefit (i.e. aggregate loss or subsidy from the Hospital) of approximately $4.16 million. In addition, the community benefit does not take into account bad debts, charity care, or contractual adjustments. Thus, this community benefit of approximately $4.16 million is a conservative figure that reconciles to the community benefit information reported on IRS Form 990, Schedule H, Part I, Line 7g, Column e.
Schedule H, Part II Community Building Activities Alice Peck Day actively promotes community-based leadership development. Staff members participate in the Lebanon Chamber of Commerce, Mascoma Savings Bank Board of Directors, Foundation for Healthy Communities, the Rural Health Coalition, and the Advocacy Task Force. As an active member of the community, APD works to be proactive concerning disaster readiness. Staff have participated in onsite training for disaster preparedness as well as off-site training with other regional hospitals. Collaborative efforts include all hazard regional training, emergency response training, and a regional mass casualty response program to help facilitate cooperative efforts if such needs arise.
Schedule H, Part III, Line 8 EXTENT ANY SHORTFALL FROM LINE 7 Form 990, Schedule H instructions and guidance contain a template (Worksheet 2) that may be used to determine the overall cost to charge ratio that could be applied throughout Schedule H in order to convert charges to cost. Where applicable, the Hospital has utilized Worksheet 2 for various calculations. The only areas where Worksheet 2 was not utilized for Part III, Line 8 was Schedule H, Worksheet B, Line 2 & 6, Medicare Allowable Costs and Payments Related to Subsidized Health Services. The Hospital utilized the Medicare cost report for estimated cost and payment for these services. The Hospital believes that its hospital clinical services, hospital-owned physician practices, emergency room and inpatient psychiatric units listed above should all be considered community benefits. These services, facilities, and programs provide a benefit to community members, and are both offered and subsidized by the Hospital. Medicare shortfall is reported to the State of New Hampshire in the Community Benefits Report, under Section 4, Unreimbursed Costs, Government-Sponsored Health Care. In prior years, the State of New Hampshire used MET dollars to service the general fund of the State. However, recently the State has used these dollars to directly fund medical and other related budgetary goals. As a result of this change in the State's appropriation of these funds, the net MET/DSH impact is considered a healthcare-related expenditure by the Hospital.
Schedule H, Part V, Section B, Line 16 WEBPAGE LOCATION 16a-c Financial Assistance Policy, Financial Assistance Policy Application, and Plain Language Summary can be found at: https://www.alicepeckday.org/patients/financial_services
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount AS A RESULT OF NEW ACCOUNTING GUIDANCE, BAD DEBT IS NO LONGER AN EXPENSE, BUT IS INCLUDED AS A REDUCTION IN NET PATIENT REVENUE.
Schedule H, Part III, Line 3 Bad Debt Expense Methodology FOR FINANCIAL STATEMENT PURPOSES, THE HOSPITAL HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE. THE AMOUNT REPORTED ON PART III, LINE 3 IS THE ESTIMATED COST OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY ON A GROSS BASIS.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote APDMH FILES A CONSOLIDATED AUDITED FINANCIAL STATEMENT WITH DARTMOUTH-HITCHCOCK HEALTH AND ITS SUBSIDIARIES. APDMH PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER THEIR FINANCIAL ASSISTANCE POLICIES WITHOUT CHARGE OR AT AMOUNTS LESS THAN THEIR ESTABLISHED RATES. BECAUSE MHMH DOES NOT ANTICIPATE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. APDMH GRANTS CREDIT WITHOUT COLLATERAL TO PATIENTS. MOST ARE LOCAL RESIDENTS AND ARE INSURED UNDER THIRD-PARTY ARRANGEMENTS. FOR FINANCIAL STATEMENT PURPOSES, DARTMOUTH HITCHCOCK HEALTH HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance Our bad debts collection policy applies to all patient accounts in a consistent manner. The policy specifically indicates that, after a second statement is sent with no payment received, a patient accounts representative will contact the patient by phone to determine if a financial assistance application or payment plan is appropriate. This is completed to avoid further escalation of past due account(s) if the patient may qualify for full or partial relief under the charity care policy. If the application is successful, then the qualifying balance or balances are classified as charity care and no longer pursued for collections. Once a patient balance is classified as charity care, it is not subject to collection activities. Alice Peck Day is committed to helping our patients obtain quality healthcare, regardless of ability to pay. Our financial assistance programs encourage and enable our patients to make healthcare decisions free of financial barriers. We educate ourpatients about our programs and provide assistance prior to their receiving services, at registration for services, and during our billing process to ensure that any and all patients in need of assistance are provided with the help they qualify for under APD programs. Brochures and signs are placed in high traffic areas such as the ER and registration. Our staff is trained to identify patients during registration, provide information, and offer assistance in completing the necessary forms. During our billing process, calls are made to patients with outstanding balances. APD staff work with patients to identify problems they are facing in dealing with outstanding balances. Patients are notified again of the many types of financial assistance available for which they may qualify. Programs are explained and assistance is offered, if needed, in completing the applications. Due to this multi-level approach and staff that is trained to identify clients who may need financial assistance, very few qualifying patients reach the point of bad debt. Our collection policies and procedures, in conjunction with our small size, allow our organization to place great emphasis on helping all patients who may be in need to apply for, and obtain, the appropriate level of financial assistance.
Schedule H, Part V, Section B, Line 16a FAP website - Alice Peck Day Memorial Hospital: Line 16a URL: www.alicepeckday.org/patients/financial_services;
Schedule H, Part V, Section B, Line 16b FAP Application website - Alice Peck Day Memorial Hospital: Line 16b URL: ww.alicepeckday.org/patients/financial_services;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website - Alice Peck Day Memorial Hospital: Line 16c URL: ww.alicepeckday.org/patients/financial_services;
Schedule H, Part VI, Line 2 Needs assessment Every three years, APDMH conducts a Community Health Needs Assessment (CHNA). We partner with Dartmouth-Hitchcock Health member organizations and other healthcare institutions to identify top community health needs in our region. The assessment includes a community survey, discussion groups, conversations with key stakeholders, analysis of population demographics, and health status indicators. All information-collection activities and analyses sought to focus assessment activities on vulnerable and disproportionately-served populations in the region including populations that could experience limited access to healthrelated services or resources due to income, age, disability, and social or physical isolation. Enhanced efforts were made to understand the needs of these populations through targeted surveys and community conversations including facilitated surveys and discussions at community suppers, a regional free clinic, homeless programs, and other community settings serving economically-vulnerable residents. The CHNA allows APDMH to strategically allocate resources to best meet community needs and improve community health.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance Alice Peck Day believes that quality health care should be available to all, regardless of ability to pay. Our financial assistance programs and staff are dedicated to helping people obtain the care they need. We reach out to our patients in many different ways to ensure that they are aware that help is available and to help guide them through the process. Brochures and signage are posted in high traffic areas such as the emergency room, registration, and the lobby. Registration staff are trained to identify patients who may be in need of financial assistance. Once identified, staff notify the patient that APD has various forms of financial assistance and explain that assistance is available for anyone who might require help or guidance in completing any necessary paperwork. In addition to the above, our billing staff are trained to help identify and offer assistance to anyone who might require financial assistance. Patients with outstanding claims are contacted by our credit coordinator who works with them to clear up balances through the variety of programs we offer. Assistance is also provided in applying for federal/state programs to those who qualify. Specially trained staff guide applicants through the process to ensure forms are filled out correctly, all required documentation is attached, and the applicants understand what they can expect to happen along the way.
Schedule H, Part VI, Line 4 Community information Alice Peck Day Memorial Hospital is part of the Lebanon Health Care service area. The Lebanon service area comprises cities and towns in New Hampshire and Vermont. APD's service area in NH comprises 15 towns in addition to the city of Lebanon, including Canaan, Cornish, Croydon, Dorchester, Enfield, Grafton, Grantham, Hanover, Lyme, Newport, Orange, Orford, Piermont, Plainfield, and Warren. Vermont towns include East Thetford, Fairlee, Hartford, Hartland, North Hartland, North Thetford, Norwich, Post Mills, Quechee, Sharon, South Strafford, Strafford, Thetford, Thetford Center, Vershire, West Vershire, West Fairlee, West Hartford, White River Junction and Woodstock. Demographics: Age: According to the 2016 American Community Survey, the population of the APD Service Area is slightly older on average than the New Hampshire and Vermont populations. 17.5% of the service area is over age 65, compared with 15.8% in New Hampshire and 17% in Vermont. Income and poverty: 11.5% of children in the hospital service area live at or below 100% FPL, with 25.7% living below 200% FPL. Education: A higher proportion of the hospital service area (94.4%) have earned at least a high school diploma or equivalent compared to New Hampshire (92.6%) and Vermont (91.9%) overall. Language: The percent of the hospital service area, ages 5 or higher, who report speaking English "less than very well" is 0.8%, compared with a statewide rate of 1.5% in New Hampshire and 0.7% in Vermont.
Schedule H, Part VI, Line 5 Promotion of community health APDMH's Community Health Department is well known in the region for Upper Valley Smiles, a unique school-based oral health program for low-income elementary school children enrolled in ten schools across the Upper Valley. The APDMH dental team visits each school annually, providing classroom oral health education, dental screenings, fluoride varnish, sealants and (in NH only) decay-stopping fluoride treatments and interim therapeutic restorations, all at little or no cost to parents. During Fiscal Year 2020, the Upper Valley Smiles program was only able to provide services during the Fall of 2019. The risk of coronavirus transmission prevented us from being able to safety access the schools and provide services during the COVID 19 pandemic. APDMH also started a new program in 2019 known as FitScripts. The FitScripts program aims to get patients exercising more and leading healthier lifestyles. FitScripts allows our primary care providers to write referrals for their patients age 16 or older, who are living with one or more chronic conditions, and for whom the cost of a gym membership has been a barrier. APDMH partnered with the Carter Community Building Association (CCBA) in Lebanon, New Hampshire, and the Upper Valley Aquatic Center (UVAC) in White River Junction, Vermont, to offer this program. APDMH pays for the gym memberships and other associated costs. There is no cost to our patients. This program was temporarily paused at the start of the pandemic due to UVAC and CCBA closures, but the program has resumed under each facilities' revised operating procedures.
Schedule H, Part VI, Line 6 Affiliated health care system Alice Peck Day Memorial Hospital is a critical access hospital located in Lebanon, NH. APDMH IS a member of the Dartmouth-Hitchcock Health System (D-HH)WHICH INCLUDES MARY HITCHCOCK MEMORIAL HOSPITAL, DARTMOUTH-HITCHCOCK CLINIC, AND OTHER RELATED ORGANIZATIONS WHOSE PRIMARY MISSION IS HEALTH CARE. MARY HITCHCOCK MEMORIAL HOSPITAL (MHMH) IN LEBANON IS NEW HAMPSHIRE'S LARGEST HOSPITAL. IN FISCAL YEAR 2020 MHMH HAD 396 LICENSED INPATIENT BEDS. THE DARTMOUTH-HITCHCOCK CLINIC (DHC) IS A MULTI-SPECIALTY PHYSICIAN PRACTICE WITH A NETWORK OF PROVIDERS ACROSS NEW HAMPSHIRE AND VERMONT. WHILE DHC'S MAIN OFFICES ARE LOCATED IN LEBANON, THE CLINIC ALSO HAS MULTI-SPECIALTY PRACTICES IN MANCHESTER, NASHUA, CONCORD, AND KEENE, NH AREAS AS WELL AS BENNINGTON, VT. IN ADDITION, THE CLINIC PROVIDES PRIMARY CARE IN RURAL COMMUNITIES IN VERMONT AND NORTHERN NEW HAMPSHIRE. THE HOSPITAL AND CLINIC OPERATE JOINTLY THROUGH INTERLOCKING DIRECTORATES, STRATEGIC PLANNING AND MANAGEMENT AND SHARE IDENTICAL MISSIONS. THE MEDICAL SCHOOL, WHICH WORKS CLOSELY WITH THE HOSPITAL AND CLINIC, IS FOCUSED ON MEDICAL EDUCATION AND RESEARCH.
Schedule H, Part VI, Line 7 State filing of community benefit report NH
Schedule H (Form 990) 2019
Additional Data


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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
Alice Peck Day Memorial Hospital
 
Employer identification number
02-0222791
Part I
General Information on Grants and Assistance
1
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? ........................
2
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) NEW HAMPSHIRE HOSPITAL ASSOCIATION
125 AIRPORT ROAD
CONCORD,NH03301 		02-6012527 501(C)(6) 86,748       FUNDING TO ENHANCE AND SUPPORT THE PERFORMANCE OF NEW HAMPSHIRE-BASED HOSPITALS
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
0
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
1
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2019

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) Tuition Assistance 9 22,445   Book  
(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
Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. APD provides support for selected community organizations that address needs identified in the Community Health Needs Assessment and are part of APD's Community Health Improvement plan. The annual amount to be contributed by APD to organizations is approved annually through the annual budget process. APD receives and reviews each year the organization's published annual reports and also maintains informal contacts throughout the year to monitor the organization's operations and services. Additionally, the Hospital provides tuition reimbursement for some health professional employees. The employees must have been employed by the Hospital or a related entity for at least one year and be in good standing.
Schedule I (Form 990) 2019



Additional Data


Software ID: 19010655
Software Version: 2019v5.0


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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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 .........
1b
 
 
2
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? ..
2
 
 
3
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.
4
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:
a
Receive a severance payment or change-of-control payment? .............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ....................
5a
 
No
b
Any related organization? .......................
5b
 
No
If "Yes," on line 5a or 5b, describe in Part III.
6
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:
a
The organization? ..................
6a
 
No
b
Any related organization? ......................
6b
 
No
If "Yes," on line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2019

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
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1Brenda L Blair
 
Former VP & COO 		(i)

(ii)		 125,642
-------------
131,293 		5,000
-------------
8,908 		327
-------------
447 		0
-------------
7,769 		2,886
-------------
3,935 		133,855
-------------
152,352 		0
-------------
0
2SUSAN MOONEY MD MS FACOG
 
TRUSTEE/PRESIDENT/CEO APD 		(i)

(ii)		 323,707
-------------
0 		0
-------------
0 		83,491
-------------
0 		5,600
-------------
0 		23,595
-------------
0 		436,393
-------------
0 		0
-------------
0
3Patrick F Jordan III MBA
 
Trustee 		(i)

(ii)		 0
-------------
654,825 		0
-------------
80,400 		0
-------------
35,008 		0
-------------
21,355 		0
-------------
42,779 		0
-------------
834,367 		0
-------------
0
4JOHN P HOUDE MD
 
TRUSTEE/EX-OFFICIO/SURGEON 		(i)

(ii)		 519,623
-------------
0 		0
-------------
0 		774
-------------
0 		5,600
-------------
0 		23,608
-------------
0 		549,605
-------------
0 		0
-------------
0
5GEORGE T BLIKE MD
 
Trustee 		(i)

(ii)		 0
-------------
433,049 		0
-------------
0 		0
-------------
41,698 		0
-------------
26,955 		0
-------------
37,199 		0
-------------
538,901 		0
-------------
0
6SCOTT W RODI MD
 
Trustee 		(i)

(ii)		 0
-------------
398,343 		0
-------------
0 		0
-------------
28,033 		0
-------------
26,955 		0
-------------
33,453 		0
-------------
486,784 		0
-------------
0
7Mary M Oseid MHCDS
 
Trustee 		(i)

(ii)		 0
-------------
294,667 		0
-------------
0 		0
-------------
20,435 		0
-------------
26,955 		0
-------------
33,106 		0
-------------
375,163 		0
-------------
0
8Tina E Naimie CPA
 
Trustee 		(i)

(ii)		 0
-------------
273,632 		0
-------------
0 		0
-------------
11,143 		0
-------------
21,355 		0
-------------
1,821 		0
-------------
307,951 		0
-------------
0
9Kathryn M Vargo MD
 
Former Officer 		(i)

(ii)		 104,591
-------------
0 		0
-------------
0 		2,112
-------------
0 		0
-------------
0 		30,217
-------------
0 		136,920
-------------
0 		0
-------------
0
10Christopher Fallon
 
Interim CFO (end 12/19) 		(i)

(ii)		 268,679
-------------
0 		0
-------------
0 		0
-------------
0 		0
-------------
0 		0
-------------
0 		268,679
-------------
0 		0
-------------
0
11TODD ROBERTS
 
VP Finance (as of 1/20) 		(i)

(ii)		 130,264
-------------
0 		4,500
-------------
0 		0
-------------
0 		2,880
-------------
0 		23,095
-------------
0 		160,739
-------------
0 		0
-------------
0
12DALE C VIDAL MD MS
 
Executive Director MSC 		(i)

(ii)		 497,999
-------------
0 		16,878
-------------
0 		12,198
-------------
0 		5,600
-------------
0 		23,608
-------------
0 		556,283
-------------
0 		0
-------------
0
13JEAN TEN HAKEN MSN RN CENP
 
CNO/COO 		(i)

(ii)		 217,486
-------------
0 		11,878
-------------
0 		766
-------------
0 		2,593
-------------
0 		8,770
-------------
0 		241,493
-------------
0 		0
-------------
0
14IVAN TOMEK MD
 
General Orthopedic Surgeon 		(i)

(ii)		 526,791
-------------
0 		17,500
-------------
0 		19,414
-------------
0 		5,600
-------------
0 		20,843
-------------
0 		590,148
-------------
0 		0
-------------
0
15DIANE RILEY MD CAQSH
 
Ortho Surgeon Hand Specialist 		(i)

(ii)		 441,639
-------------
0 		0
-------------
0 		774
-------------
0 		5,600
-------------
0 		18,184
-------------
0 		466,197
-------------
0 		0
-------------
0
16ERIN MCNEELY MD
 
PHYSICIAN 		(i)

(ii)		 253,250
-------------
0 		0
-------------
0 		21,455
-------------
0 		5,600
-------------
0 		23,058
-------------
0 		303,363
-------------
0 		0
-------------
0
17BRIAN LOMBARDO MD
 
PHYSICIAN 		(i)

(ii)		 219,422
-------------
0 		0
-------------
0 		46,764
-------------
0 		3,357
-------------
0 		22,864
-------------
0 		292,407
-------------
0 		0
-------------
0
18DEBORAH GLAZER MD
 
PHYSICIAN 		(i)

(ii)		 190,441
-------------
0 		0
-------------
0 		82,309
-------------
0 		3,948
-------------
0 		1,525
-------------
0 		278,223
-------------
0 		0
-------------
0
Schedule J (Form 990) 2019

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
Schedule J, Part II Form 990, Part VII Section A Former Officer Compensation Brenda Blair, Mary Hitchcock Memorial Hospital's VP Total Rewards, and former APD Memorial Hospital's VP and Chief Medical Officer transitioned from APDMH to MHMH in May 2019. Blair's 2019 calendar year compensation includes earnings both from her employment at APDMH and MHMH. Because Blair was reported as an Officer on APD's 990 in fiscal year 2019, earnings from MHMH in excess of $100,000 are reported on Form 990 Part VII, and Schedule J, Part II according to IRS instructions.
Schedule J, Part II Form 990 Part VII Section A, Former Officer Compensation Kathryn Vargo, APD Staff Physician served as Medical Staff President in fiscal 2019 and was reported as an officer on the fiscal 2019 Form 990. Vargo stepped down as Medical Staff President and continued to serve APD as Staff Physician in fiscal 2020. However, because Vargo was reported as an officer on the filing organization's 2019 Forms 990, and in accordance with IRS Instructions for Form 990, Vargo's 2019 calendar year compensation has been reported on this year's Form 990, Part VII, and Schedule J, Part II.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan Dartmouth Hitchcock Clinic (DHC) and Mary Hitchcock Memorial Hospital (MHMH) sponsor a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable DHC and MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen to new participants in 1998. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. THE FOLLOWING INDIVIDUALS HAVE A SPLIT DOLLAR LIFE PLAN ARRANGEMENT:MARY OSEID $39,402
Schedule J (Form 990) 2019

Additional Data


Software ID: 19010655
Software Version: 2019v5.0

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

Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2019
Open to Public
Inspection
Name of the organization
Alice Peck Day Memorial Hospital
 
Employer identification number
02-0222791
Part Ⅰ
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer		 (i) Pool
financing
Yes No Yes No Yes No
A NH Health and Education Facilities Aurhority
  		02-0279866 000000000 08-15-2018 25,865,000 Refund bond issued 11/30/2010   X   X   X
Part Ⅱ
Proceeds
A B C D
1 Amount of bonds retired .................. 705,000      
2 Amount of bonds legally defeased ..............        
3 Total proceeds of issue .................. 25,865,000      
4 Gross proceeds in reserve funds .............        
5 Capitalized interest from proceeds .............        
6 Proceeds in refunding escrows ...............        
7 Issuance costs from proceeds ............... 289,249      
8 Credit enhancement from proceeds .............        
9 Working capital expenditures from proceeds .............        
10 Capital expenditures from proceeds .............        
11 Other spent proceeds ............. 25,575,751      
12 Other unspent proceeds .............        
13 Year of substantial completion ............. 2018
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue of tax-exempt
bonds (or, if issued prior to 2018, a current refunding issue)? ........ 		X              
15 Were the bonds issued as part of an advance refunding issue of taxable
bonds (or, if issued prior to 2018, an advance refunding issue)? ........ 		  X            
16 Has the final allocation of proceeds been made? .......... X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .................. X              
Part Ⅲ
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............   X            
2 Are there any lease arrangements that may result in private business use of bond-financed property? ............... X              
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2019

Schedule K (Form 990) 2019
Page 2
Part Ⅲ
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? ............. X              
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? X              
c Are there any research agreements that may result in private business use of bond-financed property? .............   X            
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....SchKMediumBullet 0 %      
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government ......... SchKMediumBullet 0 %      
6 Total of lines 4 and 5 ............. 0 %      
7 Does the bond issue meet the private security or payment test? ...   X            
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............   X            
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..        
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............                
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2? ........ 		X              
Part Ⅳ
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...   X            
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? ....... X              
b Exception to rebate? ........   X            
c No rebate due? .........   X            
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate
computation was performed ......
3 Is the bond issue a variable rate issue? ..... X              
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X            
b Name of provider ..........  
  		 
  		 
  		 
 
c Term of hedge .........        
d Was the hedge superintegrated? ......                
e Was the hedge terminated? ........                
Schedule K (Form 990) 2019

Schedule K (Form 990) 2019
Page 3
Part Ⅳ
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?   X            
b Name of provider ..........  
  		 
  		 
  		 
 
c Term of GIC .........        
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........                
6 Were any gross proceeds invested beyond an available temporary period?   X            
7 Has the organization established written procedures to monitor the requirements of section 148? ... X              
Part Ⅴ
Procedures To Undertake Corrective Action
--------------------------------------------------------------------------------------------------------------- A B C D
Yes No Yes No Yes No Yes No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations? X              
Part Ⅵ
Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).
Return Reference Explanation
Schedule K (Form 990) 2019

Additional Data


Software ID: 19010655
Software Version: 2019v5.0

SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
Right pointing arrow large imageGo to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2019
Open to Public Inspection
Name of the organization
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 1 25,830 Market value
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ...        
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( GIFT CERTIFICATES ) X 4 310 Market value
26 Other Right pointing arrow large image ( PERSONAL PROTECTIVE SUPPLIES ) X 4,000 11,684 Market value
27 Other Right pointing arrow large image ( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement
29
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that it must hold for at least three years from the date of the initial contribution, and which isn't required to be used for exempt purposes for the entire holding period? ...................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any nonstandard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization didn't report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) (2019)
Schedule M (Form 990) (2019)
Page 2
Part IISupplemental Information. Provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Return Reference Explanation
Schedule M, Part I Explanations of reporting method for number of contributions Securities - Publicly traded - THE ORGANIZATION REPORTS THE NUMBER OF INDIVIDUAL ITEMS RECEIVED DURING THE FISCAL YEAR. Other - GIFT CERTIFICATES NUMBER OF ITEMS RECEIVED Other - PERSONAL PROTECTIVE SUPPLIES NUMBER OF ITEMS RECEIVED
Schedule M (Form 990) (2019)

Additional Data


Software ID: 19010655
Software Version: 2019v5.0
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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
Return Reference Explanation
Form 990, Part V, Line 1a NUMBER OF EMPLOYEES FOR ADMINISTRATIVE PURPOSES, ALICE PECK DAY MEMORIAL HOSPITAL MANAGES ALICE PECK DAY LIFE CENTER, INC.'S PAYROLL PROCESSING AND REPORTING. INCLUDED IN THE NUMBER OF EMPLOYEES REPORTED ARE 148 APD LIFECARE EMPLOYEES.
Form 990, Part VI, Line 1a Delegate broad authority to a committee The Executive Committee of the Board consists of all board officers, all of whom are members of the board. The committee has the power to transact all regular business of the Corporation during the period between the meetings of the Board, subject to the powers reserved to the Member and any limitations imposed by the Board.
Form 990, Part VI, Line 6 Classes of members or stockholders The Membership of the corporation shall consist of Dartmouth-Hitchcock health (D-HH) as the sole member.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body The Member will retain the reserved power to appoint without limitation one-third of the Trustees (which appointees, before final appointment by Member, will be discussed with the Board Chair and other Trustees selected by the Chair for their input). The D-H/D-HH CEO or designee will serve on the Board ex officio, with full voting rights, and will count toward the one-third membership appointed by Member.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders DARTMOUTH-HITCHCOCK HEALTH (D-HH) IS THE SOLE CORPORATE MEMBER OF Alice Peck Day Memorial Hospital. D-HH HAS SPECIFIC AUTHORITY AND RESERVED POWERS, INCLUDING the power to: * Initiate and/or approve or disapprove all material governance, programmatic and financial decisions of the APD board of trustees; * Appoint without limitation one-third of the APD board of trustee members; * Ratify the two-thirds membership of the APD Board of trustees members which APD board of trustees has the right to nominate; * Remove by a vote of two-thirds any APD trustee; * Approve borrowings and dispositions of material assets; * Approve any key strategic relationships between APD and other organization; * Initiate and approve all operating and capital budgets and strategic plans; * Approve all policies relating to academic and research programs and affiliations; * Allocate the non-donor restricted assets and resources of APD and D-HH as appropriate to serve the overall best interest of the D-HH System; * Except as limited by the affiliation agreements, to appoint, evaluate the performance of, and terminate the APD CEO; * Approve any proposed amendment or repeal of the Articles of Agreement or Bylaws; * Approve the dissolution or liquidation of APD, following such approval by the APD Board of Trustees.
Form 990, Part VI, Line 11b Review of form 990 by governing body Prior to filing, the completed form 990 is made available to the Finance Committee on a secure website. The Chair of the Finance Committee advises the Finance Committee members to review the Form 990 for content and raise any issues with Board Leadership or Management. The Chair of the Finance Committee then advises the Chair of the Board and the full Board that Form 990 is available for their review to enable a detailed and conscientious review by the full Board. All questions and concerns are addressed by the Chief Executive Officer and are incorporated into the Form 990 as deemed appropriate. Management files the final Form 990 with the Internal Revenue Service as required after the above review is concluded.
Form 990, Part VI, Line 12c Conflict of interest policy ALICE PECK DAY HOSPITAL IS A MEMBER OF THE Dartmouth Hitchcock Health (D-HH) Compliance Advisory Group which provides oversight for audit and compliance matters related to the D-HH System. D-HH COMPLIANCE AND AUDIT SERVICES REQUIRES ANNUAL DISCLOSURE OF ANY POTENTIAL CONFLICTS OF INTEREST and CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS, TRUSTEES, AND KEY EMPLOYEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS OR OTHERWISE PERCEIVED CONFLICTS ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION-MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS, IN FACT, FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION.
Form 990, Part VI, Line 15a Process to establish compensation of top management official The Human Resources Committee of the Alice Peck Day Memorial Hospital Board of Trustees is responsible for determining the compensation of the Chief Executive Officer/President. The Chief Administrative Officer or her designee provides compensation data of comparable organizations with approximately the same size staff and spending in a location of similar size. The committee determines the appropriate compensation and approves an amount that is then communicated to Human Resources for adjustment. Dartmouth-Hitchcock Health reviews the compensation of the CEO/President in addition to the process described above.
Form 990, Part VI, Line 15b Process to establish compensation of other employees The CEO/President is responsible for reviewing the performance of senior management staff. The information is brought to the Human Resource Committee of the Board of Trustees along with a recommendation for the salary of each individual. The compensation is determined through a variety of analysis of salary data and performance. Individual salary increases are then based on overall performance, within budgeted increases for the organization. The Human Resources committee approves the base compensation and salary increase amount.
Form 990, Part VI, Line 19 Required documents available to the public The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request.
Form 990, Part VII, Section A, Line 1a, Column (D) CHIEF EXECUTIVE Dr. Susan E. Mooney is a practicing physician in addition to being the chief executive officer. The majority of her time is spent in executive matters while a minor amount of time spent as a physician.
Form 990, Part XI, Line 9 Other changes in net assets or fund balances Net assets transferred from affiliates - 219313;
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: 19010655
Software Version: 2019v5.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach 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
Alice Peck Day Memorial Hospital
 
Employer identification number

02-0222791
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)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










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?
Yes No
(1)Alice Peck Day Lifecare Center Inc
10 Alice Peck Day Drive

Lebanon,NH03766
02-0479094 		Independent & Assisted Living NH 501(c)(3) 10 APD Memorial Hospital
 
Yes
 
(2)Dartmouth-Hitchcock Health
One Medical Center Drive

Lebanon,NH03756
26-4812335 		Parent Organization NH 501(c)(3) 7 NA
 
 
No
(3)Dartmouth-Hitchcock Clinic
One Medical Center Drive

Lebanon,NH03756
22-2519596 		Physician Services NH 501(c)(3) 10 D-HH
 
 
No
(4)Mary Hitchcock Memorial Hospital
One Medical Center Drive

Lebanon,NH03756
02-0222140 		Hospital NH 501(c)(3) 3 D-HH
 
 
No
(5)The New London Hospital Association Inc
273 County Road

New London,NH03257
02-0222171 		Hospital NH 501(c)(3) 3 D-HH
 
 
No
(6)Windsor Hospital Corporation
289 Country Road

Windsor,VT05089
03-0183721 		Hospital VT 501(c)(3) 3 D-HH
 
 
No
(7)Cheshire Medical Center
580 Court Street

Keene,NH03431
02-0354549 		Hospital NH 501(c)(3) 3 D-HH
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2019
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



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(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?



 		(k)
Percentage
ownership
Yes No 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
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) HITCHCOCK HEALTH CONNECT

ONE MEDICAL CENTER DRIVE
LEBANON,NH03756
80-0908979 		TELEHEALTH DE NA
  		C Corporation 0 0     No
(2) IMAGINE CARE

ONE MEDICAL CENTER DRIVE
LEBANON,NH03756
81-3105071 		SOFTWARE TECH NH NA
  		C Corporation 0 0     No










Schedule R (Form 990) 2019
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
No
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 .....................
1a
Yes
 
b Gift, grant, or capital contribution to related organization(s) ............................
1b
 
No
c Gift, grant, or capital contribution from related organization(s) ............................
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) ............................
1d
Yes
 
e Loans or loan guarantees by related organization(s) ............................
1e
 
No
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
 
No
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
Yes
 
r Other transfer of cash or property to related organization(s) ............................
1r
 
No
s Other transfer of cash or property from related organization(s) ............................
1s
Yes
 
2
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
(1) Alice Peck Day Lifecare Center

 A 43,469 FMV
(2) Alice Peck Day Lifecare Center

 D 480,548 FMV
(3) ALICE PECK DAY LIFECARE CENTER

 Q 5,195,417 FMV



Schedule R (Form 990) 2019
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) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(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? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2019
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
Schedule R (Form 990) 2019

Additional Data


Software ID: 19010655
Software Version: 2019v5.0