2014-08-14T14:27:25-05:00 2013-09-30 042684828 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2012-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON 5089417000 2014-08-01 1 ALAN GAROFALO P00744592 6177427788 2012 2015-11-30 17:44:51Z KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 3449250 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. 16 11 0 247 0 0 82322 334102 0 0 125283 52009 968829 970643 1176434 1356754 0 0 0 0 0 0 48556 35749 445654 424818 492580 473374 528329 703060 828425 63801207 60406110 22917426 19698729 40883781 40707381 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 55394 720612 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. 55394 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 3 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 16 11 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 1.00 X 0 0 0 JOSEPH P DRIER III 1.00 X 0 0 0 DAVID P FRENETTE 1.00 X 0 0 0 WALLACE H PECKHAM III 1.00 X 0 0 0 PATTI ROLAND 1.00 X 0 0 0 MICHAEL J SULLIVAN 1.00 X 0 0 0 ROBERT D SULLIVAN 1.00 X 0 0 0 MARY V WALDRON 1.00 X 0 0 0 DAVID R WOLOHOJIAN 1.00 X 0 0 0 KIM N HOLLON 1.00 40.00 X X 0 567243 33950 ROBERT S GREENBERG MD 1.00 40.00 X 0 276562 21948 DAVID A DRINKWATER MD 1.00 40.00 X 0 533077 22325 DALE J ELLENBERG 1.00 X 0 235787 24825 PATRICIA TORTORELLA 1.00 X 0 0 0 MICHAEL L DERN MD 1.00 40.00 X 0 530116 19491 JAMES LEARY 1.00 X 0 0 0 JAMES PAPADAKOS 1.00 40.00 X 0 178992 12330 ROBERT COVETT MD 0.00 40.00 X 0 372242 9369 TIMOTHY R LYNCH MD 1.00 40.00 X 0 282195 22325 0 2976214 166563 0 1 1 0 0 26176 307926 12971 334102 27955 27955 2652000 1931388 720612 720612 720612 24054 0 24054 24054 24054 411139 26176 161108 250031 250031 1356754 720612 0 302040 35749 35749 FUNDRAISING EXPENSES 409905 409905 ADMINISTRATIVE EXPENSES 82675 55394 27281 528329 55394 27281 445654 117428 117282 337000 270000 43866372 7147650 37756477 36718722 3494577 3018896 22095725 20281210 63801207 60406110 31955 43143 22266355 19017896 619116 637690 22917426 19698729 X 38150543 37424131 1278157 1828169 1455081 1455081 40883781 40707381 63801207 60406110 X 828425 264359 -1269184 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 0 2 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3507330 235373 3742703 3166498 340832 3507330 3335390 -168892 3166498 3187674 147716 3335390 3404596 250 -217172 3187674 0.00000 0.87000 0.13000 0 0 2857454 2857454 37403046 5691410 31711636 2667434 998396 1669038 423789 366557 57232 514649 91287 423362 36718722 DUE FROM RELATED PARTY 17546749 SPLIT DOLLAR LIFE INSURANCE POLICY 2535000 DEBT ISSUE COSTS, NET 199461 20281210 DEFERRED ASSET RETIREMENT OBLIGATION 637690 637690 3713609 264359 2092496 2356855 1356754 0 1356754 2620825 2092496 2092496 528329 0 528329 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: 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 EXPENSES 1,931,388. FUNDRAISING EVENT EXPENSES 161,108. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 1,931,388. FUNDRAISING EVENT EXPENSES 161,108. X X X X X 1 RIGHTTRACK SOLUTIONS LLC 340 ANAWAN STREET REHOBOTH MA 02769 TRAINING-DATA ENTRY 0 0 0 5000 BLACKBAUD SYSTEMS PO BOX 930256 ATLANTA GA 31193 ANALYSIS OF CONTRIBUTIONS 0 0 0 30749 35749 MA RING OF CHAMPIONS 93543 331 93212 23 1500 17325 750 3240 CANCER WALK 193792 16255 177537 234 4656 6855 3217 0 94271 1 149980 9590 140390 177 7970 1000 12226 0 7664 437315 26176 411139 434 12626 9355 32768 750 105175 161108 250031 1 X X X X X 0 1 0 0 0 0 0 0 0 KIM N HOLLON 0 567243 0 0 0 0 0 11250 0 22700 0 601193 0 0 ROBERT S GREENBERG MD 0 276562 0 0 0 0 0 5000 0 16948 0 298510 0 0 DAVID A DRINKWATER MD 0 533077 0 0 0 0 0 0 0 22325 0 555402 0 0 DALE J ELLENBERG 0 235787 0 0 0 0 0 2500 0 22325 0 260612 0 0 MICHAEL L DERN MD 0 530116 0 0 0 0 0 5000 0 14491 0 549607 0 0 JAMES PAPADAKOS 0 178992 0 0 0 0 0 0 0 12330 0 191322 0 0 ROBERT COVETT MD 0 372242 0 0 0 0 0 0 0 9369 0 381611 0 0 TIMOTHY R LYNCH MD 0 282195 0 0 0 0 0 0 0 22325 0 304520 0 0 PART I, LINE 4B DURING THE YEAR ENDED 9/30/13 BROCKTON HOSPITAL (A RELATED ORGANIZATION) MADE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CONTRIBUTION FOR THREE 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 9/30/13: JAMES PAPADAKOS - $2,365 NORMAN GOODMAN LOAN RECEIVABLE (SPLIT DOLLAR LIFE INSURANCE POLICY) X 2535000 2535000 0 1 1 2535000 SCHEDULE L, PART II, LOANS TO AND FROM INTERESTED PERSONS: (A) NAME OF PERSON: NORMAN B. GOODMAN(A) PURPOSE OF LOAN: LOAN RECEIVABLE (SPLIT DOLLAR LIFE INSURANCE POLICY)(B) LOAN TO OR FROM ORGANIZATION? = FROM(C) ORIGINAL PRINCIPAL AMOUNT $2,535,000(D) BALANCE DUE $2,535,000(E) LOAN IN DEFAULT? = NO(F) APPROVED BY BOARD OF COMMITTEE? = YES(G) WRITTEN AGREEMENT? = YES X GIFT CARDS 6 520 FACE VALUE X SUPPLIES 43 12451 FMV 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY (UNRESTRICTED) -470,000. TRANSFERS TO AFFILIATE -799,184. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE STREET BROCKTON MA 02302 320048951 REALTY COMPANY MA 1764000 31420007 SIGNATURE HEALTHCARE CORPORATION SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE STREET BROCKTON MA 02302 043306782 MEDICAL CARE MA 501C(3) 3 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 37063083 15272461 1.00000 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 BROCKTON HOSPITAL INC O 22132224 FMV BROCKTON HOSPITAL INC P 81440 FMV BROCKTON HOSPITAL INC Q 1035000 FMV BROCKTON HOSPITAL INC R 6134583 FMV BROCKTON HOSPITAL INC I 645000 FMV BROCKTON HOSPITAL INC N 346946 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES P 24356336 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES R 150000 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES O 2558 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES Q 1167000 FMV 110 LIBERTY STREET COMPANY LLC P 2131046 FMV SIGNATURE MEDICAL GROUP INC I 243000 FMV SIGNATURE MEDICAL GROUP INC P 18329 FMV SIGNATURE MEDICAL GROUP INC O 13800 FMV SIGNATURE MEDICAL GROUP INC Q 100000 FMV SIGNATURE MEDICAL GROUP INC R 220 FMV