2016-08-03T13:05:22-05:00 2015-09-30 135381590 BDO USA LLP 200 PORTLAND STREET BOSTON MA 02114 990 2014-10-01 043318952 ANNA JAQUES COMMUNITY HEALTH FOUNDATION ANNA 9784631000 25 HIGHLAND AVE NEWBURYPORT MA 01950 KEVIN KILDAY VP/CFO 9784631000 2016-08-02 1 JEFFREY T ROGERS P01074284 6177427788 2014 2016-12-15 16:53:06Z KEVIN KILDAY 25 HIGHLAND AVE NEWBURYPORT MA 01950 3029124 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). 27 23 0 23 0 0 850242 1980446 0 0 795213 958616 14512 -9091 1659967 2929971 1975377 1859192 0 0 345659 348441 0 0 383715 89755 109400 2410791 2317033 -750824 612938 20808937 19657160 1102235 943485 19706702 18713675 ANNA JAQUES COMMUNITY HEALTH FOUNDATION PROVIDES SUPPORT TO ANNA JAQUES HOSPITAL, A TAX EXEMPT HOSPITAL DESCRIBED IN SECTION 170(B)(1)(A)(III). 0 0 1859192 1859192 0 THE MISSION OF AJCHF IS TO PROVIDE SUPPORT TO ANNA JAQUES HOSPITAL. THE GRANTS REPRESENT DONATION 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. 1859192 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 1 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 1 1 1 0 0 X 27 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 RALPH CASTAGNA CHAIR, BD OF TTEES 5.00 X 0 0 0 PATRICIA MANSFIELD VICE-CHAIR, BD OF TTEES 5.00 X 0 0 0 TREY BYRNES SECRETARY, BD OF TTEES 5.00 X 0 0 0 GINNY ERAMO TRUSTEE 5.00 X 0 0 0 JESSICA AMOROSINO MD TRUSTEE 5.00 X 0 0 0 TODD BALTICH TRUSTEE 5.00 X 0 0 0 KATHY BECHTEL TRUSTEE 5.00 X 0 0 0 KARI BERNARD TRUSTEE 5.00 X 0 0 0 CRAIG CHILDS TRUSTEE 5.00 X 0 0 0 KATHY CONNORS TRUSTEE 5.00 X 0 0 0 LUIS FERNANDEZ TRUSTEE 5.00 X 0 0 0 MELISSA FOLEY TRUSTEE 5.00 X 0 0 0 KIM FOULKES TRUSTEE 5.00 X 0 0 0 JULIE GANONG TRUSTEE 5.00 X 0 0 0 KEVIN GASIOROWSKI TRUSTEE 5.00 X 0 0 0 MATT KHATIB TRUSTEE 5.00 X 0 0 0 JOAN MILLER TRUSTEE 5.00 X 0 0 0 JEFFREY NAHAS TRUSTEE 5.00 X 0 0 0 VANIA O'CONNOR TRUSTEE 5.00 X 0 0 0 CHRIS SULLIVAN TRUSTEE 5.00 X 0 0 0 KRISTIN TALLMAN OD TRUSTEE 5.00 X 0 0 0 MARY WILLIAMSON TRUSTEE 5.00 X 0 0 0 CHUCK WITHEE TRUSTEE 5.00 X 0 0 0 KEVIN KILDAY VP/CFO EFF 1/1/15 5.00 55.00 X X 0 92574 10063 SARAH GNERRE VP OF DEVELOPMENT 50.00 X 0 168557 29924 DONNA TWOMBLY TTEE/RADIOLOGY MGR 5.00 40.00 X 0 98965 20841 MARK GOLDSTEIN PRES/CEO EFF 1/1/15 5.00 55.00 X X 0 544922 126200 DELIA O'CONNOR PRES/CEO THRU 12/31/14 5.00 55.00 X X 0 761064 47484 0 1666082 234512 0 0 1 0 0 139023 1841423 47144 1980446 267900 267900 740683 49967 690716 690716 690716 40095 139023 49186 -9091 -9091 2929971 0 0 949525 1859192 1859192 181384 48974 132410 102929 102929 46292 6944 39348 17836 1784 16052 15000 15000 21580 21580 69965 174 69791 1605 1605 730 730 DUES 520 0 520 0 2317033 1859192 74126 383715 0 -2 229440 75729 1017841 1169531 0 0 0 0 0 0 0 0 0 0 0 16827 0 0 0 0 19561656 18395075 0 0 0 0 0 0 0 0 20808937 19657160 5263 26284 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1096972 917201 1102235 943485 X 5477337 5598711 8593808 7808454 5635557 5306510 19706702 18713675 20808937 19657160 612938 -1605965 0 X 0 1 X 1 0 X X X 1 ANNA JAQUES HOSPITAL 042104338 3 1 1859192 0 1 1859192 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 14520243 -804600 330000 5718 13379925 13990828 87359 1163509 701569 19884 14520243 13644734 1721740 1348884 26762 13990828 11817347 1829717 2330 13644734 12459268 -622711 19210 11817347 0.40800 0.14400 0.44800 0 0 0 DUE TO AFFILIATES 917201 917201 X 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 PAY FOR UNINSURED PATIENTS' CARE, TO FUND HEALTH CARE 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. PART X, LINE 2: THERE IS NO FIN 48 (ASC 740) FOOTNOTE IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS. PART V IN FISCAL 2015 THE AUDITED FINANCIAL STATEMENTS WERE REVISED OVER THE PRIOR YEARS TO LIST THE BOARD DESIGNATED FUNDS AS A QUASI-ENDOWMENT. FOR THAT REASON, WE HAVE RESTATED THE PRIOR YEARS TO INCLUDE THESE FUNDS IN OUR ENDOWMENT FIGURES. GOLF TOURNAMENT 179118 139023 40095 6385 40692 2109 179118 139023 40095 6385 40692 2109 49186 -9091 1 ANNA JAQUES HOSPITAL 25 HIGHLAND AVE NEWBURYPORT MA 01950 042104338 501C3 1859192 FMV GENERAL ASSISTANCE 1 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 SARAH GNERRE VP OF DEVELOPMENT 0 154574 0 13983 0 0 0 12152 0 17772 0 198481 0 0 MARK GOLDSTEIN PRES/CEO EFF 1/1/15 0 462706 0 82216 0 0 0 98627 0 27573 0 671122 0 0 DELIA O'CONNOR PRES/CEO THRU 12/31/14 0 628907 0 132157 0 0 0 29075 0 18409 0 808548 0 0 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 PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. SHE IS 100% VESTED IN THIS PLAN AND IS ENTITLED TO RECEIVE DISTRIBUTIONS UPON THE TERMINATION OF HER EMPLOYMENT. NO EMPLOYER CONTRIBUTION WAS MADE TO THIS PLAN IN CY 2014. IN ADDITION, DELIA O'CONNOR AND MARK GOLDSTEIN PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN FUNDED BY A SPLIT DOLLAR LIFE INSURANCE POLICY. THE 2014 PREMIUM FOR MARK GOLDSTEIN'S PLAN WAS $70,560. NO PREMIUM WAS PAID FOR DELIA O'CONNOR'S POLICY IN CY 2014. PART I, LINE 6 BOTH DELIA O'CONNOR AND MARK GOLDSTEIN'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 $132,157 AND $82,216 RESPECTIVELY. X 5 33876 FMV X 1 2089 FMV X 1 5113 FMV X SUNGLASSES FOR GOLFERS 1 6066 FMV 0 0 0 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 MEMBERS OF 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 1859192 FMV ANNA JAQUES HOSPITAL L 2979971 FMV ANNA JAQUES HOSPITAL P 457840 FMV