2015-08-11T07:47:26-05:00 2014-09-30 042684828 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2013-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON PRESIDENT/CEO 5089417000 2015-08-11 1 JEFFREY T ROGERS P01074284 6177427788 2013 2016-02-25 16:41:14Z KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 3375980 0 X SIGNATURE-HEALTHCARE.ORG X 1890 MA THE MAINTENANCE OF DONOR RESTRICTED FUNDS FOR BROCKTON HOSPITAL AS WELL AS SOLICITATION OF CONTRIBUTIONS ON BEHALF OF THE HOSPITAL, INCLUDING THE CANCER WALK AND GOLF TOURNAMENT. 18 13 0 125 0 0 334102 211254 0 0 52009 191216 970643 948812 1356754 1351282 0 0 0 0 0 0 35749 101148 522750 492580 568771 528329 669919 828425 681363 60406110 12001468 19698729 679405 40707381 11322063 X THE MISSION OF SIGNATURE HEALTHCARE IS TO BE THE LEADING COMMUNITY BASE HEALTHCARE DELIVERY SYSTEM IN SOUTHEASTERN MASSACHUSETTS PROVIDING THE FULL RANGE OF PRIMARY CARE, SPECIALTY CARE, HOSPITAL CARE AND RELATED ANCILLARY SERVICES ON A COORDINATED BASIS. SIGNATURE HEALTHCARE PHYSICIANS AND SIGNATURE HEALTHCARE BROCKTON HOSPITAL STRIVE TO BE RECOGNIZED AS THE "PROVIDERS OF CHOICE" BY STAFF, PATIENTS, AND THE COMMUNITY. 0 0 110377 745490 THE MAINTENANCE OF DONOR RESTRICTED FUNDS FOR BROCKTON HOSPITAL AS WELL AS SOLICITATION OF CONTRIBUTIONS ON BEHALF OF THE HOSPITAL, INCLUDING THE CANCER WALK AND THE GOLF TOURNAMENT. 110377 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 1 6 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 18 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X X KIM HOLLON 5089417000 680 CENTRE STREET BROCKTON MA 023023395 TIMOTHY J CRUZ TRUSTEE 1.00 X 0 0 0 JOSEPH P DRIER III TRUSTEE 1.00 X 0 0 0 DAVID P FRENETTE TRUSTEE 1.00 X 0 0 0 WALLACE H PECKHAM III TRUSTEE 1.00 X 0 0 0 PATTI ROLAND TRUSTEE 1.00 X 0 0 0 MICHAEL J SULLIVAN TRUSTEE 1.00 X 0 0 0 ROBERT D SULLIVAN TRUSTEE 1.00 X 0 0 0 MARY V WALDRON TRUSTEE 1.00 X 0 0 0 DAVID R WOLOHOJIAN TRUSTEE 1.00 X 0 0 0 KIM N HOLLON CHIEF EXECUTIVE OFFICER 1.00 40.00 X X 0 657424 34399 ROBERT S GREENBERG MD TRUSTEE 1.00 40.00 X 0 271061 20781 DAVID A DRINKWATER MD TRUSTEE 1.00 40.00 X 0 502163 22549 PATRICIA TORTORELLA TRUSTEE 1.00 X 0 0 0 MICHAEL L DERN MD TRUSTEE 1.00 40.00 X 0 589524 19815 JAMES LEARY TRUSTEE 1.00 X 0 0 0 REV CHERYL HARRIS TRUSTEE 1.00 X 0 0 0 EUGENE MARROW TRUSTEE 1.00 X 0 0 0 KEITH S MERLIN TRUSTEE 1.00 40.00 X 0 472530 54904 JAMES PAPADAKOS CHIEF FINANCIAL OFFICER 1.00 40.00 X 0 325452 33715 ROBERT COVETT MD FORMER TRUSTEE 0.00 40.00 X 0 361953 7787 TIMOTHY R LYNCH MD FORMER TRUSTEE 0.00 40.00 X 0 20629 1735 DALE J ELLENBERG FORMER TRUSTEE 0.00 40.00 X 0 251185 25049 KENNETH LAWSON FORMER TRUSTEE 0.00 40.00 X 0 423983 27447 0 3875904 248181 0 1 1 0 0 17780 193474 34298 211254 36101 36101 2598390 1852900 745490 745490 745490 155115 0 155115 155115 155115 375120 17780 171798 203322 203322 1351282 745490 0 394538 101148 101148 FUNDRAISING EXPENSES 421602 421602 ADMINISTRATIVE EXPENSES 147169 110377 36792 669919 110377 36792 522750 117282 37987 270000 221000 1500 8057305 2752405 36718722 5304900 3018896 3340081 20281210 3096000 60406110 12001468 43143 22585 19017896 637690 656820 19698729 679405 X 37424131 7801038 1828169 1983944 1455081 1537081 40707381 11322063 60406110 12001468 X 681363 47969 -30114650 X 0 1 X 1 0 X X 0 0 0 BROCKTON HOSPITAL INC 222472297 3 1 1 1 0 SIGNATURE MEDICAL GROUP INC 043306782 9 1 1 1 30608025 2 30608025 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3742703 274466 4017169 3507330 235373 3742703 3166498 340832 3507330 3335390 -168892 3166498 3187674 147716 3335390 0.84000 0.16000 0 0 957454 957454 3528276 1198880 2329396 2667434 1083323 1584111 387939 366363 21576 516202 103839 412363 5304900 BOARD-DESIGNATED INVESTMENTS 40056 F DONOR-RESTRICTED INVESTMENTS 3300025 F 3340081 SPLIT DOLLAR LIFE INSURANCE POLICY 3096000 3096000 DEFERRED ASSET RETIREMENT OBLIGATION 656820 656820 2985556 1634274 1634274 1351282 0 1351282 2694617 2024698 2024698 669919 0 669919 PART V, LINE 4: THE ORGANIZATION INTENDS TO USE THE FUNDS IN SUPPORT OF BROCKTON HOSPITAL, INC. IN ADDITION, FUNDS ARE SET ASIDE FOR PROGRAMS THAT INCLUDE FREE CARE, MEDICAL EDUCATION, AND THE SCHOOL OF NURSING. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL INCOME FROM AFFILIATES 1,852,900. FUNDRAISING EVENT EXPENSES 171,798. NON-OPERATING ACTIVITIES -282,618. RESTRICTED NET ASSET ACTIVITY -107,806. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 1,852,900. FUNDRAISING EVENT EXPENSES 171,798. X X X X X 1 RIGHTTRACK SOLUTIONS LLC 340 ANAWAN STREET REHOBOTH MA 02769 TRAINING-DATA ENTRY 0 0 0 7500 BLACKBAUD SYSTEMS PO BOX 930256 ATLANTA GA 31193 ANALYSIS OF CONTRIBUTIONS 0 0 0 29332 DJP CONSULTING 10 FAXON STREET NEWPORT RI 02840 GRANT WRITING 0 0 0 12700 FREEDMAN HEALTHCARE LLC 29 CRAFTS STREET NEWTON MA 02458 GRANT CONSULTING 0 0 0 33500 RAFFERTY COMMUNICATIONS 36 COUNTRY ROAD CHESTNUT HILL MA 02458 GRANT WRITING 0 0 0 18116 101148 MA RING OF CHAMPIONS 83722 392 83330 65 392 13812 400 3857 CANCER WALK 189713 6190 183523 244 5506 3656 111983 1 119465 11198 108267 8608 14850 8425 392900 17780 375120 309 14506 32318 400 124265 171798 203322 1 X X X X X 0 1 0 0 0 0 0 0 0 KIM N HOLLON CHIEF EXECUTIVE OFFICER 0 657424 0 0 0 0 0 11475 0 22924 0 691823 0 0 ROBERT S GREENBERG MD TRUSTEE 0 271061 0 0 0 0 0 5100 0 15681 0 291842 0 0 DAVID A DRINKWATER MD TRUSTEE 0 502163 0 0 0 0 0 0 0 22549 0 524712 0 0 MICHAEL L DERN MD TRUSTEE 0 589524 0 0 0 0 0 5100 0 14715 0 609339 0 0 KEITH S MERLIN TRUSTEE 0 472530 0 0 0 0 0 32355 0 22549 0 527434 0 0 JAMES PAPADAKOS CHIEF FINANCIAL OFFICER 0 325452 0 0 0 0 0 8751 0 24964 0 359167 0 0 ROBERT COVETT MD FORMER TRUSTEE 0 361953 0 0 0 0 0 0 0 7787 0 369740 0 0 TIMOTHY R LYNCH MD FORMER TRUSTEE 0 20629 0 0 0 0 0 0 0 1735 0 22364 0 0 DALE J ELLENBERG FORMER TRUSTEE 0 251185 0 0 0 0 0 2500 0 22549 0 276234 0 0 KENNETH LAWSON FORMER TRUSTEE 0 423983 0 0 0 0 0 4898 0 22549 0 451430 0 0 PART I, LINE 4B DURING THE YEAR ENDED 9/30/14 BROCKTON HOSPITAL (A RELATED ORGANIZATION) MADE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CONTRIBUTION FOR TWO EMPLOYEES. CONSISTENT WITH REPORTING REQUIREMENTS FOR IRS FORM 990, THE HOSPITAL REPORTS COMPENSATION AND OTHER PAYMENTS TO EMPLOYEES AND FORMER EMPLOYEES ON A CALENDAR YEAR (FORM W-2) BASIS. CONSEQUENTLY, THE FOLLOWING AMOUNTS ARE REPORTED FOR THE FISCAL YEAR ENDING 9/30/14: JAMES PAPADAKOS - $1,326 KEITH MERLIN - $27,255 NORMAN GOODMAN FMR CEO LOAN RECEIVABLE (SPLIT DOLLAR LIFE INSURANCE POLICY) X 2535000 2535000 0 1 1 2535000 X SUPPLIES 111 32283 FMV X GIFT CARDS 24 2015 FACE VALUE 0 1 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ADDITIONALLY, THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE PUBLIC CHARITIES WEBSITE MAINTAINED BY THE COMMONWEALTH OF MASSACHUSETTS ATTORNEY GENERAL. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER ELECTRONICALLY. IN ADDITION, A BOARD MEETING WAS CONVENED TO REVIEW THE 990 IN ADVANCE OF THE FILING DATE. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE CIRCULATED ON AN ANNUAL BASIS AND ARE SUMMARIZED AND PRESENTED TO THE BOARD FOR REVIEW AND ACTION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR OFFICERS AND KEY EMPLOYEES IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTORS AND ADJUSTMENTS TO COMPENSATION ARE BASED ON PERFORMANCE STANDARDS AND COMPARISON OF COMPENSATION LEVELS TO SIMILAR PROVIDER ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ADDITIONALLY, THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE PUBLIC CHARITIES WEBSITE MAINTAINED BY THE COMMONWEALTH OF MASSACHUSETTS ATTORNEY GENERAL. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY (UNRESTRICTED) 561,000. TRANSFERS TO AFFILIATE -30,608,025. LOSS ON EARLY EXTINQUISHMENT OF DEBT -149,625. PERMANENTLY RESTRICTED GIFTS AND BEQUESTS 82,000. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE STREET BROCKTON MA 02302 320048951 REALTY COMPANY MA 1719120 0 SIGNATURE HEALTHCARE CORPORATION SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE STREET BROCKTON MA 02302 043306782 MEDICAL CARE MA 501C(3) 9 SIGNATURE HEALTHCARE CORPORATION 1 BROCKTON HOSPITAL INC 680 CENTRE STREET BROCKTON MA 02302 222472297 MEDICAL CARE MA 501C(3) 3 SIGNATURE HEALTHCARE CORPORATION 1 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN PRACTICE MA SIGNATURE HEALTHCARE CORPORATION C 6816779 1.00000 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 1 1 BROCKTON HOSPITAL INC O 354973 FMV BROCKTON HOSPITAL INC P 198086 FMV BROCKTON HOSPITAL INC Q 44722 FMV BROCKTON HOSPITAL INC R 150050 FMV BROCKTON HOSPITAL INC I 14751784 FMV BROCKTON HOSPITAL INC J 645000 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES R 3275875 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES S 1153671 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES Q 1342456 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES I 42412598 FMV 110 LIBERTY STREET COMPANY LLC S 2578 FMV 110 LIBERTY STREET COMPANY LLC I 11833422 FMV 110 LIBERTY STREET COMPANY LLC Q 2758227 FMV SIGNATURE MEDICAL GROUP INC I 12607836 FMV SIGNATURE MEDICAL GROUP INC B 73097 FMV SIGNATURE MEDICAL GROUP INC Q 10147 FMV SIGNATURE MEDICAL GROUP INC R 457003 FMV SIGNATURE MEDICAL GROUP INC J 234270 FMV SIGNATURE MEDICAL GROUP INC S 895875 FMV BROCKTON HOSPITAL INC S 5481875 FMV