2013-05-07T12:16:27-05:00 2012-06-30 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2011-07-01 020519436 Alliance Ambulatory Services ALLI 6036683545 100 McGregor St Manchester NH 03102 Edward L Dudley III 6036683545 2013-05-02 Nicholas E Porto P01310283 2078792100 2011 2016-02-25 16:41:14Z Joseph Pepe MD 100 McGregor St Manchester NH 03102 2878403 0 0928 X www.catholicmedicalcenter.org X 2000 NH To promote and generate healthcare programs for a broad cross-section of the greater Manchester, New Hampshire community 19 14 0 26 0 0 0 0 3130375 2878179 262 224 0 0 3130637 2878403 0 0 0 0 0 0 0 0 0 317432 64 317432 64 2813205 2878339 6535802 6484141 0 0 6535802 6484141 To create and promote healthcare programs in the Manchester New Hampshire, community. 0 0 64 2878179 Revenue from partnership interest in Bedford Ambulatory Surgical Center, LLC 64 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 19 14 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 NH X Edward L Dudley III 6036683545 100 McGregor St Manchester NH 03102 X Adele Boufford Baker 1.00 X 0 0 0 Gary Bouchard PhD 1.00 X 0 0 0 Paul S Boynton 1.00 X 0 0 0 Daryl J Cady 1.00 X 0 0 0 Stephen Camann 1.00 X 0 0 0 Guy D Chapdelaine 1.00 X 0 0 0 William Clutterbuck MD 1.00 X 0 342506 33294 Eleanor Wm Dahar Esq 1.00 X 0 0 0 Jeff Eisenberg 1.00 X 0 0 0 Raef Fahmy DPM 1.00 X 0 116392 2432 Connor J Haugh MD FACC 1.00 X 0 630602 34137 Susan Huard 1.00 X 0 0 0 Suzanna D Majewski 1.00 X 0 0 0 Anne M O'Connor MD 1.00 X 0 0 0 Msgr John P Quinn 1.00 X 0 0 0 Ronald J Rioux 1.00 X 0 0 0 Keith A Stahl MD 1.00 X 0 287041 12440 Rev Gayle Whittemore 1.00 X 0 0 0 Joseph Graham 1.00 X X 0 0 0 Suzanne K Mellon PhD RN 1.00 X X 0 0 0 Jerome Duval 1.00 X X 0 0 0 Margaret-Ann Moran Esq 1.00 X X 0 0 0 Joseph Pepe MD 1.00 X X 0 346001 19545 Alyson Pitman Giles 1.00 X X 0 798551 348357 Edward Dudley III 1.00 X 0 358208 82328 Allen Ericson 1.00 X 0 408870 43671 Raymond Bonito 1.00 X 0 428228 137121 Kevin Kilday 0.00 X 0 124809 0 0 3841208 713325 0 1 1 0 0 Interest in Ambulatory 621990 2878179 2878179 2878179 224 224 2878403 2878179 0 224 64 64 64 64 0 0 211065 161225 6324737 6322916 6535802 6484141 0 0 X 6535802 6484141 6535802 6484141 6535802 6484141 X 2878339 -2930000 X X 0 1 1 X 0 X X X 0 0 0 CMC 020315693 3 1 1 1 0 1 0 0 Investment in Bedford Ambulatory Surgical Care 6322916 F 6322916 Description of Uncertain Tax Positions Under FIN 48: Part X: The Medical Center, PPA, Resources, AAS, Hillcrest, AHS, DMA and St. Peter's Home, Inc. are not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. X X X X X 1 1 0 0 0 0 0 0 0 William Clutterbuck MD 0 342506 0 0 0 0 0 14700 0 18594 0 375800 0 0 Connor J Haugh MD FACC 0 503116 0 127486 0 0 0 14962 0 19175 0 664739 0 0 Keith A Stahl MD 0 279968 0 7073 0 0 0 10071 0 2369 0 299481 0 0 Joseph Pepe MD 0 315300 0 30701 0 0 0 11206 0 8339 0 365546 0 0 Alyson Pitman Giles 0 654209 0 144342 0 0 0 288191 0 60166 0 1146908 0 0 Edward Dudley III 0 328206 0 30002 0 0 0 40013 0 42315 0 440536 0 0 Allen Ericson 0 349070 0 59800 0 0 0 16067 0 27604 0 452541 0 0 Raymond Bonito 0 365021 0 63207 0 0 0 96265 0 40856 0 565349 0 0 Kevin Kilday 0 124809 0 0 0 0 0 0 0 0 0 124809 0 0 Part I, Lines 4a-b Part I, Lines 4a-b: 4A: The following individual received base compensation under a severance agreement from a related organization (Catholic Medical Center). Kevin Kilday $124,809 4B: The following individuals take part in a section 457(f) forfeitable nonqualified deferred compensation plan through Catholic Medical Center (a related organization). The following represents contributions for many years of service. Alyson Pitman Giles: $270,207 Raymond Bonito: $84,065 Allen Ericson: $4,186 Edward Dudley: $40,013 Form 990, Part VI, Section A, line 6 The sole member of Alliance Ambulatory services is CMC Healthcare System. Form 990, Part VI, Section A, line 7a The directors of Alliance Ambulatory Services are appointed by the sole member. Form 990, Part VI, Section A, line 7b The sole member has reserved powers over Alliance Ambulatory Services but does not approve each separate action taken by the Alliance Ambulatory Services board. Form 990, Part VI, Section B, line 11 Form 990 is prepared by the Organization, and is sent to an independent tax accounting firm (Baker, Newman, Noyes) for a thorough and exhaustive review. Upon completion of independent firm review, Form 990 is sent back to the Organization, where the CFO, Controller, and Director of Accounting perform a final in-house review prior to submission to the Board of Directors for final approval. Upon approval from Board, Form 990 is filed with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c Officers are required to complete a conflict of interest policy annually. 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. Form 990, Part VII: Several individuals reported on Form 990, Part VII split their time with related organizations. The following are the average hours per week those respective members spent during the year at related organizations: Joseph Pepe: 50 hrs William Clutterbuck, MD: 40 hrs Connor Haugh, MD: 40 hrs Keith Stahl, MD: 40 hrs Allen Ericson: 50 hrs Edward Dudley, III: 50 hrs Raef Fahmy, DPM: 40 hrs Alyson Pitman Giles: 60 hrs Raymond Bonito: 50 hrs Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net Transfer to Affiliates -2,930,000. Total to Form 990, Part XI, Line 5: -2,930,000. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Alliance Health Services 100 McGregor Street Manchester NH 03102 611508839 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 Catholic Medical Center 100 McGregor Street Manchester NH 03102 020315693 Hospital NH 501(c)(3) Line 3 CMC Healthcare System 0 CMC Healthcare System 100 McGregor Street Manchester NH 03102 010568516 Parent NH 501(c)(3) Line 11b, II N/A 0 CMC Associates 100 McGregor Street Manchester NH 03102 020344786 Gift Shop NH 501(c)(3) Line 11b, II CMC 0 CMC Physician Practice Associates 100 McGregor Street Manchester NH 03102 020460245 Practices NH 501(c)(3) Line 11b, II CMC Healthcare System 0 St Peters Home 100 McGregor Street Manchester NH 03102 020222228 Home NH 501(c)(3) Line 9 CMC Healthcare System 0 Alliance Resources 100 McGregor Street Manchester NH 03102 020398138 Real Estate NH 501(c)(3) Line 11b, II CMC Healthcare System 0 McGregor Steet MOB 100 McGregor Street Manchester NH 03102 134347316 Medical Office Building NH CMC Healthcare System Related 0 0 Doctors' Medical Association 100 McGregor Street Manchester NH 03102 020340690 Medical Office Building NH CMC Healthcare System C Alliance Enterprises 100 McGregor Street Manchester NH 03102 020386795 Real Estate NH CMC Healthcare System C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Bedford Ambulatory Surgical Center LLC 11 Washington Place Bedford NH 03110 020519727 Outpatient surgery NH Related 0 2849692 3726826 0 0 1 0.50000