2014-08-11T10:12:07-05:00 2013-09-30 346565596 Ernst & Young 200 Clarendon St Boston MA 02116 990 2012-10-01 043318952 Anna Jaques Community Health Foundation ANNA 9784631000 25 Highland Ave Newburyport MA 01950 Mark Goldstein 9784631000 2014-08-11 1 Jeanne Schuster P00743154 6172662000 2012 2015-11-30 17:44:51Z Delia O'Connor 25 Highland Ave Newburyport MA 01950 3185102 0 X www.ajh.org X 1996 MA Anna Jaques Community Health Foundation provides support to Anna Jaques Hospital. 23 19 0 18 0 0 1637611 1219449 0 0 1361399 1835778 15597 9578 3014607 3064805 1936478 4021540 0 0 258068 330161 42667 9700 409032 188637 124003 2425850 4485404 588757 -1420599 22185938 21034231 1056900 1179435 21129038 19854796 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 4021540 4021540 1219449 The mission of AJCHF is to provide support to Anna Jaques Hospital. The expenses represent donations which were released to the hospital either because they were unrestricted donations, or because they were restricted donations whose restrictions have been satisfied. 4021540 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 1 0 0 0 0 0 1 1 1 1 0 0 0 0 0 X 23 19 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Kirsten Arnold Director of Finance 9788348256 25 Highland Ave Newburyport MA 01950 Ginny Eramo 5.00 X 0 0 0 Donna Twombly 5.00 40.00 X 0 89112 26564 Mark Goldstein 5.00 55.00 X X 0 511574 119279 Delia O'Connor 5.00 55.00 X X 0 671850 173591 Todd Baltich 5.00 X 0 0 0 Kari Bernard 5.00 X 0 0 0 Cynthia Barry Rubenfeld 5.00 X 0 0 0 Trey Byrnes 5.00 X 0 0 0 Ralph Castagna 5.00 X 0 0 0 Craig Childs 5.00 X 0 0 0 Mary Anne Clancy 5.00 X 0 0 0 Barbara Cullen 5.00 X 0 0 0 Scott Eaton 5.00 X 0 0 0 Cynthia Gompers 5.00 X 0 0 0 Michael Jewell 5.00 X 0 0 0 Leanne Martin 5.00 X 0 0 0 Joan Miller 5.00 X 0 0 0 Susan Kneeland Rumore 5.00 X 0 0 0 Luis Fernandez 5.00 X 0 0 0 Patricia Mansfield 5.00 X 0 0 0 Jeffrey Nahas 5.00 X 0 0 0 Charles Withee 5.00 X 0 0 0 Sarah Gnerre 5.00 50.00 X 157941 0 22201 157941 1272536 341635 1 0 1 0 0 137428 1082021 1219449 328907 328907 1583088 76217 1506871 1506871 1506871 53658 137428 44080 9578 9578 3064805 0 0 1845356 4021540 4021540 157941 31588 126353 119447 119447 44785 4440 40345 7988 2416 5572 15000 15000 9700 9700 530 530 93209 93209 13876 13876 978 978 DUES 410 410 4485404 4021540 54832 409032 365254 190258 3651599 2533916 4672 288 18164413 18309769 22185938 21034231 17560 15070 1039340 1164365 1056900 1179435 X 4134561 4880323 11702924 9518572 5291553 5455901 21129038 19854796 22185938 21034231 -1420599 146357 0 X 0 1 X 1 0 X X X 0 0 0 Anna Jaques Hospital 042104338 3 1 1 1 4021540 1 4021540 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8823165 0 1231727 1341876 0 18107 8694909 7645587 0 1187609 0 0 10031 8823165 8059246 -400480 0 0 13179 7645587 6324578 1844069 99245 10145 8059257 6446549 65285 163961 23295 6324578 0.22000 0.78000 0 0 0 Due to affiliates, net 1043677 Gift annuities payable 120688 1164365 Description of Intended Use of Endowment Funds: Part V, Line 4: CHF 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 (CHF) 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 Sections 501(a) of the Code. Part X Line 2: There is no FIN 48 (ASC 740) footnote in the financial statements. golf tournament 191086 137428 53658 0 0 33391 9533 1156 191086 137428 53658 33391 9533 1156 44080 9578 1 Anna Jaques Hospital 25 Highland Ave Newburyport MA 01950 042104338 501c3 4021540 FMV general assistance 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, 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 501c3 organization. 0 1 0 0 0 1 1 0 0 Mark Goldstein 0 430385 0 81189 0 0 0 96280 0 22999 0 630853 0 0 Delia O'Connor 0 574988 0 96862 0 0 0 158075 0 15516 0 845441 0 0 Sarah Gnerre 144416 0 13525 0 0 0 7264 0 14937 0 180142 0 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 and Mark Goldstein participate in a supplemental non-qualified retirement plan, which is funded by split dollar life insurance policies. The premium applicable to Ms. O'Connor was $130,550 and to Mr. Goldstein was $70,560. In addition, Ms. O'Connor participated in a Rabbi Trust plan. No employer contribution was made to this plan in CY 2012. Part I, Line 6 Mark Goldstein's and Delia O'Connor's bonus payments were contingent on the organizations within the system meeting several targets, including the targeted earnings. The amounts were $96,862 and $81,189 respectively. Form 990, Part VI, Section A, line 6 Anna Jaques Hospital (AJH) is the sole member of AJHCHF. 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 corporations; 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 501c hospital 0 Seacoast Regional Health Systems 25 Highland Ave Newburyport MA 01950 222814214 functionally integrated supporting org MA 501c supporting org 0 Seacoast Affiliated Group Practices 25 Highland Ave Newburyport MA 01950 043485648 physician group MA 501c 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 3908690 funds distributed Anna Jaques Hospital L 1273107 revenues raised Anna Jaques Hospital P 507943 expenses paid Seacoast Affiliated Group Practices B 112850 funds distributed