2017-08-09T07:43:05-05:00 2016-09-30 135381590 BDO USA LLP TWO INTERNATIONAL PLACE BOSTON MA 02210 990 2015-10-01 043318952 ANNA JAQUES COMMUNITY HEALTH FOUNDATION ANNA 9784631000 25 HIGHLAND AVE NEWBURYPORT MA 01950 KEVIN KILDAY VP/CFO 9784631000 2017-07-20 1 JEFFREY T ROGERS P01074284 6177427788 2015 2021-01-29 14:40:06Z MARK GOLDSTEIN 25 HIGHLAND AVE NEWBURYPORT MA 01950 1950753 0 X WWW.AJH.ORG X 1996 MA ANNA JAQUES COMMUNITY HEALTH FOUNDATION PROVIDES SUPPORT TO ANNA JAQUES HOSPITAL, A TAX EXEMPT HOSPITAL DESCRIBED IN SECTION 170(B)(1)(A)(III). 26 23 0 23 0 0 1980446 1209823 0 0 958616 651077 -9091 1676 2929971 1862576 1859192 2054458 0 0 348441 428557 0 0 475037 109400 125776 2317033 2608791 612938 -746215 19657160 19481317 943485 808426 18713675 18672891 ANNA JAQUES COMMUNITY HEALTH FOUNDATION PROVIDES SUPPORT TO ANNA JAQUES HOSPITAL, A TAX EXEMPT HOSPITAL. 0 0 2054458 2054458 THE MISSION OF AJCHF IS TO PROVIDE SUPPORT TO ANNA JAQUES HOSPITAL. THE GRANTS REPRESENT DONATIONS WHICH WERE RELEASED TO THE HOSPITAL, EITHER BECAUSE THEY WERE UNRESTRICTED DONATIONS, OR BECAUSE THEY WERE RESTRICTED DONATIONS FOR WHICH THE DONORS' RESTRICTIONS HAD BEEN SATISFIED. 2054458 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 X 26 23 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X THE ORGANIZATION 9784631000 25 HIGHLAND AVE NEWBURYPORT MA 01950 MARK GOLDSTEIN PRESIDENT/CEO 5.00 55.00 X X 0 610294 143933 KEVIN KILDAY VP/CFO 5.00 55.00 X X 0 313946 38305 SARAH GNERRE VP/EXECUTIVE DIRECTOR 50.00 X X 0 175083 32123 TREY BYRNES DIRECTOR 5.00 X 0 0 0 RALPH CASTAGNA DIRECTOR 5.00 X 0 0 0 PATRICIA MANSFIELD DIRECTOR 5.00 X 0 0 0 KARI BERNARD DIRECTOR 5.00 X 0 0 0 LUIS FERNANDEZ DIRECTOR 5.00 X 0 0 0 JESSICA AMOROSINO MD DIRECTOR 5.00 X 0 0 0 KATHY CONNORS DIRECTOR 5.00 X 0 0 0 JEFFREY NAHAS DIRECTOR 5.00 X 0 0 0 JOAN MILLER DIRECTOR 5.00 X 0 0 0 KEVIN GASIOROWSKI DIRECTOR 5.00 X 0 0 0 MATT KHATIB DIRECTOR 5.00 X 0 0 0 VANIA O'CONNOR DIRECTOR 5.00 X 0 0 0 CHRIS SULLIVAN DIRECTOR 5.00 X 0 0 0 KRISTIN TALLMAN OD DIRECTOR 5.00 X 0 0 0 MARY WILLIAMSON DIRECTOR 5.00 X 0 0 0 JAY IANNINI DIRECTOR 5.00 X 0 0 0 CHRISTOPHER JOHNSTON DIRECTOR 5.00 X 0 0 0 LISA PURINTON DIRECTOR 5.00 X 0 0 0 TODD BALTICH DIRECTOR 5.00 X 0 0 0 KATHY BECHTEL DIRECTOR 5.00 X 0 0 0 MELISSA FOLEY DIRECTOR 5.00 X 0 0 0 KIM FOULKES DIRECTOR 5.00 X 0 0 0 JULIE GANONG DIRECTOR 5.00 X 0 0 0 DELIA O'CONNOR PRESIDENT/CEO THROUGH 12/31/14 0.00 X 0 180673 500 0 1279996 214861 0 1 1 0 0 135873 1073950 1209823 363482 363482 336713 49118 287595 287595 287595 40735 135873 39059 1676 1676 1862576 0 0 652753 2054458 2054458 175083 47272 127811 167876 167876 64046 11893 52153 21552 3521 18031 15000 15000 17749 17749 80214 80214 11203 11203 1360 1360 DUES 250 250 2608791 2054458 79296 475037 75727 181717 1169531 750381 16827 16304 18395075 18532915 19657160 19481317 26284 21357 917201 787069 943485 808426 X 5598711 6138522 7808454 7071640 5306510 5462729 18713675 18672891 19657160 19481317 -746215 705431 0 X 0 1 X 1 0 X X 1 ANNA JAQUES HOSPITAL 042104338 3 1 2054458 0 1 2054458 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13706652 1029573 796286 7827 13932112 14520243 -477873 330000 5718 13706652 13990828 87359 1163509 701569 19884 14520243 13644734 1721740 1348884 26762 13990828 11817347 1829717 2330 13644734 0.44000 0.14200 0.41800 0 0 0 DUE TO AFFILIATES 787069 787069 X PART V, LINE 4: THE AMOUNTS IN PART V, COLUMN (B) ARE NOT THE SAME VALUES AS THE SEPTEMBER 30, 2015 TAX RETURN AS THE AMOUNTS ON THE FILED RETURN WERE INCORRECT. THE VALUES HAVE BEEN REVISED TO THE CORRECT AMOUNTS FOR THE SEPTEMBER 30, 2016 TAX RETURN. PART X, LINE 2: THERE IS NO FIN48 (ASC 740) FOOTNOTE IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART V LINE 4 AJCHF MAINTAINS MULTIPLE ENDOWMENTS WITH DIFFERENT PURPOSES. THE MAJORITY HAVE A PERMANENTLY RESTRICTED CORPUS, WITH THE INCOME AVAILABLE TO SUPPORT THE OPERATIONS OF ANNA JAQUES HOSPITAL. THE INCOME FROM OTHER ENDOWMENTS IS AVAILABLE TO FUND HEALTHCARE EDUCATION FOR AJH EMPLOYEES OR FOR SCHOLARSHIPS TO AREA HIGH SCHOOL STUDENTS WHO WISH TO PURSUE A HEALTH CARE RELATED DEGREE PROGRAM. THE ENTITIES WHICH USE THE ENDOWMENT FUNDS ARE THE PARENT (SRHS), THE HOSPITAL (AJH), THE FOUNDATION (AJCHF) AND THE PHYSICIAN GROUP (SAGP). THEY ARE TAX EXEMPT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE IRS CODE AND, ACCORDINGLY, ARE EXEMPT FROM FEDERAL AND STATE CORPORATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. GOLF TOURNAMENT 176608 135873 40735 9215 26500 3344 176608 135873 40735 9215 26500 3344 39059 1676 1 ANNA JAQUES HOSPITAL 25 HIGHLAND AVE NEWBURYPORT MA 01950 042104338 501C3 2054458 FMV GENERAL ASSISTANCE 1 0 PART I, LINE 2: DONATIONS ARE TRACKED BY DONOR RESTRICTION (FOR EXAMPLE, A DONATION TO FUND THE PURCHASE OF A PARTICULAR PIECE OF CAPITAL EQUIPMENT). DONATIONS ARE NOT RELEASED TO THE HOSPITAL UNTIL THE SPECIFIC RESTRICTION HAS BEEN MET. UNRESTRICTED DONATIONS ARE TRANSFERRED PERIODICALLY TO ASSIST WITH GENERAL SUPPORT. ALL GRANTS ARE MADE TO ANNA JAQUES HOSPITAL,CHF'S SOLE MEMBER, A RELATED 501(C)(3) ORGANIZATION. 0 1 0 0 0 1 1 0 0 MARK GOLDSTEIN PRESIDENT/CEO 0 518749 0 91545 0 0 0 113090 0 30843 0 754227 0 0 KEVIN KILDAY VP/CFO 0 267388 0 46558 0 0 0 7135 0 31170 0 352251 0 0 SARAH GNERRE VP/EXECUTIVE DIRECTOR 0 160144 0 14939 0 0 0 11928 0 20195 0 207206 0 0 DELIA O'CONNOR PRESIDENT/CEO THROUGH 12/31/14 0 180673 0 0 0 0 0 100 0 400 0 181173 0 154072 PART I, LINE 3 THIS ORGANIZATION DOES NOT ESTABLISH COMPENSATION FOR THE CEO AND OTHER SENIOR EXECUTIVES. THE BOARD OF THE PARENT (SRHS) PERFORMS THAT FUNCTION AND DOES USE A COMPENSATION COMMITTEE, INDEPENDENT CONSULTANT, AND COMPENSATION SURVEYS TO ESTABLISH COMPENSATION LEVELS AND DOES REQUIRE APPROVAL BY THE COMPENSATION COMMITTEE BEFORE PAYMENTS ARE MADE. PART I, LINE 4B DELIA O'CONNOR RETIRED AS CEO EFFECTIVE DECEMBER 31, 2014 AND IS NOW RECEIVING RETIREMENT DISTRIBUTIONS FROM SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS. IN CALENDAR YEAR 2015 THE AMOUNT OF THESE PAYMENTS WAS $173,918. MARK GOLDSTEIN PARTICIPATES IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN FUNDED BY A SPLIT DOLLAR LIFE INSURANCE POLICY. THE 2015 PREMIUM FOR THIS PLAN WAS $85,000. PART I, LINE 6 MARK GOLDSTEIN, KEVIN KILDAY AND SARAH GNERRE'S BONUS PAYMENTS WERE CONTINGENT ON THE ORGANIZATIONS IN THE SYSTEM MEETING SEVERAL TARGETS, INCLUDING THE TARGETED EARNINGS OF THE ORGANIZATIONS. THE AMOUNTS PAID WERE $91,545, $46,558 AND $14,939 RESPECTIVELY. FORM 990, PART VI, SECTION A, LINE 6 ANNA JAQUES HOSPITAL IS THE SOLE MEMBER OF AJCHF. FORM 990, PART VI, SECTION A, LINE 7A THE AJH BOARD ELECTS THE AJCHF BOARD. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL BY THE AJH BOARD IS REQUIRED FOR THE ADOPTION OF ANNUAL OPERATING AND CAPITAL BUDGETS; FOR THE MERGER OR CONSOLIDATION OF THE ORGANIZATION WITH ANY OTHER CORPORATION; FOR THE FORMATION OR DISSOLUTION OF THE SUBSIDIARIES OF THE CORPORATION; AND FOR A DECISION TO CONDUCT ANY FUND-RAISING ACTIVITIES. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PREPARED BY STAFF, REVIEWED BY AN OUTSIDE ACCOUNTING FIRM AND BY THE CEO AND CFO. ONCE APPROVED, A COPY OF THE 990 IS AVAILABLE TO THE BOARD FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF TRUSTEES AND SENIOR EXECUTIVES REVIEW THE CONFLICT OF INTEREST POLICY ANNUALLY AND COMPLETE A SURVEY ABOUT POSSIBLE CONFLICTS OF INTEREST. THEIR ANSWERS ARE REVIEWED BY THE CHAIRPERSON TO DETERMINE IF CONFLICTS EXIST. IF THERE IS A CONFLICT OF INTEREST ON A PARTICULAR ISSUE, THE CHAIRPERSON REQUESTS THAT THE INDIVIDUAL ABSTAIN FROM VOTING AT THAT TIME. THE CHAIRPERSON OR SECRETARY MONITORS SURVEYS TO ENSURE COMPLIANCE. FORM 990, PART VI, SECTION B, LINE 15 TOTAL COMPENSATION OF THE SENIOR EXECUTIVE TEAM IS REVIEWED ANNUALLY BY AN INDEPENDENT COMMITTEE OF THE PARENT'S (SRHS) BOARD. THE COMMITTEE USES DATA RECEIVED FROM AN INDEPENDENT COMPENSATION CONSULTING FIRM TO DETERMINE THE FAIRNESS AND COMPARABILITY OF THE COMPENSATION, AND DECIDES WHETHER ANY CHANGES ARE TO BE MADE. IN ADDITION, THE COMMITTEE AGREES ON BENCHMARKS FOR EXECUTIVE BONUSES AT THE START OF EACH YEAR, AND REVIEWS PROGRESS AT THE CONCLUSION OF THE YEAR TO DETERMINE WHAT BONUSES ARE PAYABLE. BONUSES ARE INCLUDED IN TOTAL COMPENSATION DURING THE SALARY REVIEW MENTIONED ABOVE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, THE CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. ANNA JAQUES HOSPITAL 25 HIGHLAND AVE NEWBURYPORT MA 01950 042104338 HOSPITAL MA 501(C)(3) LINE 3 0 SEACOAST REGIONAL HEALTH SYSTEMS 25 HIGHLAND AVE NEWBURYPORT MA 01950 222814214 FUNCTIONALLY INTEGRATED SUPPORTING ORG MA 501(C)(3) LINE 11B, II 0 SEACOAST AFFILIATED GROUP PRACTICE 25 HIGHLAND AVE NEWBURYPORT MA 01950 043485648 PHYSICIAN GROUP MA 501(C)(3) LINE 9 0 SEACOAST REGIONAL MRI 25 HIGHLAND AVE NEWBURYPORT MA 01950 320443663 HEALTHCARE SERVICES MA 501(C)(3) LINE 9 0 GREATER NEWBURYPORT MANAGEMENT SERVICES ORG 25 HIGHLAND AVE NEWBURYPORT MA 01950 161744477 MANAGEMENT SERVICES MA C 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 ANNA JAQUES HOSPITAL B 2054458 FMV ANNA JAQUES HOSPITAL L 1211499 FMV ANNA JAQUES HOSPITAL P 554334 FMV