Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year
(or fiscal year beginning in)
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(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) .. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 524,793 | 56,490 | 57,271 | 72,983 | 21,472 | 733,009 |
| 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 | 9,093,442 | 9,429,702 | 9,898,691 | 10,430,007 | 10,356,578 | 49,208,420 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | 0 | |||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | 0 | |||||
| 6 | Total. Add lines 1 through 5 | 9,618,235 | 9,486,192 | 9,955,962 | 10,502,990 | 10,378,050 | 49,941,429 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 0 | 0 | 0 | 6,000 | 0 | 6,000 |
| 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. | 424,366 | 0 | 0 | 0 | 0 | 424,366 |
| c | Add lines 7a and 7b.. | 424,366 | 0 | 0 | 6,000 | 0 | 430,366 |
| 8 | Public support. (Subtract line 7c from line 6.) | 49,511,063 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2018 | (b) 2019 | (c) 2020 | (d) 2021 | (e) 2022 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 9,618,235 | 9,486,192 | 9,955,962 | 10,502,990 | 10,378,050 | 49,941,429 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 94,495 | 6,473 | 2,405 | 4,131 | 14,332 | 121,836 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 94,495 | 6,473 | 2,405 | 4,131 | 14,332 | 121,836 |
| 11 | Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | 0 | 0 | 0 | 0 | 0 | 0 |
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 9,712,730 | 9,492,665 | 9,958,367 | 10,507,121 | 10,392,382 | 50,063,265 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
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| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 0.015 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 0.035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2022 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2022 |
(iii) Distributable Amount for 2022 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2022 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2022 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2022: | ||||
| a From 2017....... | ||||
| b From 2018....... | ||||
| c From 2019....... | ||||
| d From 2020....... | ||||
| e From 2021....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2022 distributable amount | ||||
|
i
Carryover from 2017 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2022 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2022 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2022, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2022. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2023. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2018..... | ||||
| b Excess from 2019..... | ||||
| c Excess from 2020..... | ||||
| d Excess from 2021..... | ||||
| e Excess from 2022..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | 22016089 |
| Software Version: | 2022v5.0 |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part V, Line 2a EMPLOYEE SERVICES AGREEMENT | On March 1, 2016 Allice Peck Day Memorial Hospital (APDMH) and Alice Peck Day Lifecare (APD Lifecare) entered into two employee services agreements: an Administrative Services Agreement, and an Employee Lease Program. According to the Administrative Services Agreement, APDMH employees provide a variety of administrative services to APD Lifecare. According to the Employee Lease Program, licensed professional services including skilled nurses are employed by APDMH and leased to APD Lifecare. In both cases, APDMH is responsible for all wages, employment taxes, workers compensation and fringe benefits. APDMH bills APD Lifecare according to an agreed upon schedule of fees. |
| Form 990, Part VI, Line 15 Compensation process for the top management official and other officers | The Human Resources Committee of the Alice Peck Day Memorial Hospital Board of Trustees is responsible for determining the compensation of the Executive Director. 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, the sole corporate member of Alice Peck Day Memorial Hospital, reviews the compensation of the Executive Director in addition to the process described above. |
| Form 990, Part VI, Line 1a Delegate broad authority to a committee | The Executive Committee of the Board consists of all Board Officers and the APD Memorial Hospital President and CEO, all of whom are voting members of the Board. The Committee has the power to transact all regular business requiring action of the Board 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 | Alice Peck Day Memorial Hospital, an affiliate of Dartmouth-Hitchcock Health (D-HH) is the sole member of the corporation. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | The Governance Committee of Alice Peck Day Memorial Hospital (the Member) shall submit its list of nominations to the Organization's Board Chair no later than 30-days before the Member's annual meeting. The Board Chair of Alice Peck Day Lifecare must approve or disapprove the list within ten days. Any disapproved nomination will be replaced by another nomination by the Member's Governance Committee. The Board of Trustees of the Member will approve the slate of Member-nominated Trustees. The residence councils of the respective residential facilities shall submit a slate of three nominees to the Governance Committee of the Member who shall then nominate one Resident Trustee from each facility. Any vacancies of the Board of Trustees shall be filled by the Member upon nomination of the Member's Governance Committee as noted above. |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | Alice Peck Day Memorial Hospital (the Member) will retain the following reserved powers over the Organization, which, will be exercised by the Member's Board of Trustees, subject to the reserved powers of Dartmouth-Hitchcock Health (D-HH) which is the sole corporate Member of Alice Peck Day Memorial Hospital. 1.) To initiate and/or approve or disapprove all material governance decisions of the Organization's Board of Trustees; 2.) To appoint the Organization's Board of Trustees up to fifteen members, as nominated by the Member's Governance Committee; 3.) To remove, by a vote of two-thirds of the Member's Board of Trustees, any of the Organization's trustees if the Member determines that such removal is warranted and after prior consultation with the Organization's Chair; 4.) To approve of borrowings and dispositions of material assets of the Organization and to initiate the refinancing and restructuring of existing indebtedness; 5.) To approve any key strategic relationships between the Organization and another organization; 6.) To initiate and/or approve all operating and capital budgets; 7. ) To allocate non-donor restricted assets and resources of the Organization as deemed appropriate and after consultation with the Organization's Board of Trustees; 8.) To approve any proposed amendments or repeal of the Organization's Articles of Agreement or Bylaws; and, 9.) To approve the dissolution or liquidation of the Organization. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | Management provides a notice that the completed Form 990 is available to the Finance Committee prior to filing. Management advises the Finance Committee that the completed Form 990 is available on a secure website that requires an assigned user name and password. The Chair of the Finance Committee advises the Financial Committee members to review the Form 990 for content and raise any issues with Board Leadership or Management. The Chair of the Finance Committee advises the Chair of the Board and the full Board that the Form 990 is available for review. That notice is in advance of the filing deadline to enable a detailed and conscientious review by the 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 | APD Lifecare has a multi-faceted conflict of interest policy. Members of the Board of Trustees complete conflict of interest questionnaires on an annual basis and any new members complete the questionnaire upon joining the Board. As part of our ongoing monitoring process, our Executive Assistant reviews all Board questionnaires and disclosures to identify any potential conflicts before they arise. In addition, our Executive Assistant attends all Board meetings to ensure that if any conflicts arise, they are handled appropriately. If such conflicts arise, the Organization complies with the New Hampshire and federal requirements for disclosures of such events. The Organization is committed to conducting its business in a manner that is both ethical and legal. As part of this commitment, a standard of conduct form is required of all employees of the organization. This is reviewed with all employees upon hire and on an annual basis thereafter. The standard of conduct covers conflict of interest and other vital matters to ensure all business activity is conducted in a manner that is consistent with the highest standards of honesty, integrity, and fairness. |
| 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 IX, Line 11g Other Fees | Contracted Employees - Total Expense: 5462029, Program Service Expense: 4949208, Management and General Expenses: 512821, Fundraising Expenses: ; Temporary Staff - Total Expense: 141927, Program Service Expense: 141927, Management and General Expenses: , Fundraising Expenses: ; |
| Software ID: | 22016089 |
| Software Version: | 2022v5.0 |