2013-08-12T06:50:27-05:00 2012-09-30 042684828 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2011-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON 5089417000 2013-07-23 1 ALAN GAROFALO P00744592 6177427788 2011 2016-02-25 16:41:14Z KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 3333897 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 12 0 282 0 0 194997 82322 0 0 395471 125283 1523827 968829 2114295 1176434 0 0 0 0 0 0 20000 48556 386492 557820 424818 577820 473374 1536475 703060 65184942 63801207 25866130 22917426 39318812 40883781 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 58209 741067 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. 58209 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 0 1 6 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 18 12 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 JAMES E LEARY 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 X X 0 490851 28770 DAVID A DRINKWATER 1.00 X 0 505407 16745 TIMOTHY R LYNCH 1.00 X 0 252634 20984 ROBERT J MCMAHAN 1.00 X 0 0 0 PATRICIA TORTORELLA 1.00 X 0 0 0 DALE J ELLENBERG 1.00 X 0 226253 26753 MICHAEL L DERN 1.00 X 0 473981 21771 ROBERT S GREENBERG 1.00 X 0 272975 16544 JAY HOFFMAN 1.00 X 0 0 0 JAMES PAPADAKOS 1.00 X 0 0 0 JULIE WHITE 0.00 X 0 11379 0 ROBERT COVETT MD 0.00 X 0 357686 6908 MARC GREENWALD 0.00 X 0 325570 19654 KEVIN P LEONARD 0.00 X 0 166506 8398 KENNETH LAWSON 0.00 X 0 414240 20572 DEBORAH WILSON 0.00 X 0 315691 5535 0 3813173 192634 0 1 1 0 0 31292 51030 23144 82322 86223 86223 2652000 2000849 651151 651151 651151 39060 0 39060 39060 39060 384376 31292 156614 227762 227762 BLUE CROSS 900099 89916 89916 89916 1176434 741067 0 353045 48556 48556 FUNDRAISING EXPENSES 337936 337936 ADMINISTRATIVE EXPENSES 86882 58209 28673 473374 58209 28673 386492 116426 117428 494500 337000 43850037 6093560 38889502 37756477 8948378 3494577 16736136 22095725 65184942 63801207 78909 31955 25186137 22266355 601084 619116 25866130 22917426 X 36849618 38150543 1014113 1278157 1455081 1455081 39318812 40883781 65184942 63801207 X 703060 861909 X 0 1 1 X 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 3166498 340832 3507330 3335390 -168892 3166498 3187674 147716 3335390 3404596 250 -217172 3187674 0.92000 0.08000 0 0 2857455 2857455 37399257 4751186 32648071 2667436 913468 1753968 423789 350171 73618 502100 78735 423365 37756477 BOARD-DESIGNATED INVESTMENTS 1098338 F DONOR-RESTRICTED INVESTMENTS 2396239 F 3494577 DUE FROM RELATED PARTY 18844704 SPLIT DOLLAR LIFE INSURANCE POLICY 3005000 DEBT ISSUE COSTS, NET 246021 22095725 DEFERRED ASSET RETIREMENT OBLIGATION 619116 619116 1176434 473374 703060 420909 441000 861909 1564969 2790791 1614357 1614357 1176434 0 1176434 2087731 1614357 1614357 473374 0 473374 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 8 - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY (UNRESTRICTED) 441,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,000,849. FUNDRAISING EXPENSES -386,492. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,000,849. FUNDRAISING EXPENSES -386,492. X X X X X 1 SALIENT HEALTH SOLUTIONS 99 SUMMER STREET BOSTON MA 02110 GRANT WRITER 0 0 0 15000 BLACKBAUD SYSTEMS PO BOX 930256 ATLANTA GA 31193 ANALYSIS OF CONTRIBUTIONS 0 0 0 33556 48556 RING OF CHAMPIONS 84983 1123 83860 67 435 1000 15753 400 2577 CANCER WALK 233037 22058 210979 284 3362 6704 3432 0 96481 1 97648 8111 89537 142 6411 0 12648 0 6918 415668 31292 384376 493 10208 7704 31833 400 105976 156614 227762 1 X X X X X X 1 1 0 0 0 0 0 0 0 KIM N HOLLON 0 490851 0 0 0 0 0 9390 0 19380 0 519621 0 0 DAVID A DRINKWATER 0 505407 0 0 0 0 0 0 0 16745 0 522152 0 0 TIMOTHY R LYNCH 0 252634 0 0 0 0 0 0 0 20984 0 273618 0 0 DALE J ELLENBERG 0 226253 0 0 0 0 0 5896 0 20857 0 253006 0 0 MICHAEL L DERN 0 473981 0 0 0 0 0 4900 0 16871 0 495752 0 0 ROBERT S GREENBERG 0 269930 0 0 0 3045 0 4900 0 11644 0 289519 0 0 JULIE WHITE 0 11379 0 0 0 0 0 0 0 0 0 11379 0 0 ROBERT COVETT MD 0 357686 0 0 0 0 0 0 0 6908 0 364594 0 0 MARC GREENWALD 0 325570 0 0 0 0 0 5046 0 14608 0 345224 0 0 KEVIN P LEONARD 0 103508 0 0 0 62998 0 3748 0 4650 0 174904 0 0 KENNETH LAWSON 0 414240 0 0 0 0 0 3827 0 16745 0 434812 0 0 DEBORAH WILSON 0 101506 0 0 0 214185 0 2638 0 2897 0 321226 0 0 PART I, LINES 4A-B THE SENIOR VICE PRESIDENT OF AMBULATORY SERVICES AND PHYSICIAN SERVICES RESIGNED IN JANUARY 2011, AND HAS A SEVERANCE ARRANGEMENT WHICH STATES THAT IN THE EVENT OF TERMINATION WITHOUT CAUSE, THE SENIOR VICE PRESIDENT WOULD RECEIVE BASE SALARY PLUS CONTINUATION OF BENEFITS FOR NINE MONTHS. THE FORMER VICE PRESIDENT RECEIVED SEPARATION PAYMENTS TOTALING $214,185 DURING CALENDAR YEAR 2011. THE FORMER CHIEF FINANCIAL OFFICER RESIGNED FROM BROCKTON HOSPITAL (A RELATED ORGANIZATION) IN MARCH, 2011. PURSUANT TO AN AGREEMENT BETWEEN THE PARTIES, THE FORMER CHIEF FINANCIAL OFFICER RECEIVED CERTAIN SEPARATION PAYMENTS FROM THE HOSPITAL IN CALENDAR YEAR 2011. SEPARATION PAYMENT TO THE FORMER CHIEF FINANCIAL OFFICER MADE IN CALENDAR YEAR 2011 AMOUNTING TO $62,998 ARE REPORTED FOR THE FISCAL YEAR ENDING 9/30/12. DURING THE YEAR ENDED 9/30/12 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 9/30/12: KAREN MURPHY - $6,900 DAVID FISHER - $15,600 NORMAN B GOODMAN LOAN RECEIVABLE (SPLIT DOLLAR LIFE INSURANCE POLICY) X 3005000 3005000 0 1 1 3005000 X GIFT CARDS 3 380 FACE VALUE X SUPPLIES 26 22765 FMV 29 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 5: NET UNREALIZED GAINS ON INVESTMENTS: 420,909. CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY (UNRESTRICTED) 441,000. TOTAL TO FORM 990, PART XI, LINE 5: 861,909. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE STREET BROCKTON MA 02302 320048951 REALTY COMPANY MA 1764000 32322193 SIGNATURE HEALTHCARE CORPORATION SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE STREET BROCKTON MA 02302 043306782 MEDICAL CARE MA 501C(3) 9 SIGNATURE HEALTHCARE CORPORATION 0 BROCKTON HOSPITAL INC 680 CENTRE STREET BROCKTON MA 02302 222472297 MEDICAL CARE MA 501C(3) 3 SIGNATURE HEALTHCARE CORPORATION 0 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN PRACTICE MA SIGNATURE HEALTHCARE CORPORATION C 42986888 13398582 1.00000 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 SIGNATURE MEDICAL GROUP INC I 243000 FMV SIGNATURE MEDICAL GROUP INC P 16158 FMV SIGNATURE MEDICAL GROUP INC B 93672 FMV BROCKTON HOSPITAL INC B 50704 FMV BROCKTON HOSPITAL INC N 296407 FMV BROCKTON HOSPITAL INC O 116078 FMV BROCKTON HOSPITAL INC P 70896 FMV BROCKTON HOSPITAL INC Q 850238 FMV BROCKTON HOSPITAL INC R 120000 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES P 2203373 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES Q 1000000 FMV 110 LIBERTY STREET COMPANY LLC P 1333334 FMV BROCKTON HOSPITAL INC I 645000 FMV SIGNATURE MEDICAL GROUP INC O 7100 FMV SIGNATURE MEDICAL GROUP INC Q 1049790 FMV