2013-11-08T18:58:32-06:00 2012-12-31 861065772 DELOITTE TAX LLP TWO JERICHO PLAZA JERICHO NY 11753 990 2012-01-01 131739922 BLYTHEDALE CHILDREN'S HOSPITAL BLYT 9145927555 95 BRADHURST AVE VALHALLA NY 10595 JOHN CANNING 9145927555 2013-11-06 1 P00743140 5169187000 2013-11-05 2012 2016-02-24 21:20:13Z JOHN CANNING 95 BRADHURST AVE VALHALLA NY 10595 74855128 0 X WWW.BLYTHEDALE.ORG X 1891 NY BLYTHEDALE CHILDREN'S HOSPITAL IS DEDICATED TO IMPROVING THE HEALTH & WELL-BEING OF CHILDREN. BLYTHEDALE IS A LEADER IN THE DIAGNOSIS & TREATMENT OF CHILDREN WITH DISABLING AND COMPLEX MEDICAL CONDITIONS. 36 36 498 280 0 0 6034551 2881226 50726819 59912842 -367130 6919891 4333160 4953924 60727400 74667883 0 0 0 0 37398653 43408667 0 0 741345 16808675 21506607 54207328 64915274 6520072 9752609 195750356 205551901 57873031 57656214 137877325 147895687 X BLYTHEDALE CHILDREN'S HOSPITAL IS DEDICATED TO IMPROVING THE HEALTH AND WELL-BEING OF CHILDREN. WE ACT TO SERVE AS THE PRE-EMINENT SPECIALTY CHILDREN'S HOSPITAL IN THE NORTHEAST. WE SERVE HIGHER ACUITY PATIENTS WITH A VARIETY OF SPECIAL HEALTHCARE NEEDS, THROUGH SUPERB MEDICAL, PSYCHOSOCIAL, TEACHING, RESEARCH AND ADVOCACY PROGRAMS. WE SERVE CHILDREN WITHOUT REGARD TO RELIGION, RACE, OR ABILITY TO PAY. 0 0 36063769 47563777 INPATIENT SERVICES - BLYTHEDALE CHILDREN'S HOSPITAL, FOUNDED IN 1891, IS A LICENSED ACUTE CARE FREE-STANDING CHILDREN'S HOSPITAL THAT SPECIALIZES IN THE CARE OF CHILDREN REQUIRING REHABILITATIVE, RESPIRATORY AND COMPLEX MEDICAL CARE. BLYTHEDALE IS DESIGNATED BY CMS AS A PPS EXEMPT, FREESTANDING CHILDREN'S HOSPITAL. WITHIN BLYTHEDALE CHILDREN'S HOSPITAL, WE PROVIDE A COMPREHENSIVE RANGE OF SERVICES WHICH INCLUDE BUT ARE NOT LIMITED TO GENERAL PEDIATRICS, ADOLESCENT MEDICINE, PEDIATRIC PULMONOLOGY, CHILD NEUROLOGY, PSYCHIATRY, ORTHOPEDICS, PHYSICAL MEDICINE, AND REHABILITATION OF MULTIPLE PEDIATRIC SPECIALTIES (SUCH AS CARDIOLOGY, INFECTIOUS DISEASE, ENT, OPHTHALMOLOGY, ETC.) BLYTHEDALE MAINTAINS A CORE GROUP OF FULL TIME SPECIALTY COVERAGE IN PEDIATRICS, PULMONOLOGY, ADOLESCENT MEDICINE, NEUROLOGY, AND PSYCHIATRY. OTHER SUBSPECIALTY COVERAGE IS MAINTAINED AND UTILIZED AS NEEDED THROUGH A VARIETY OF CONTRACTUAL RELATIONSHIPS WITH THE AREA'S LEADING ACADEMIC MEDICAL CENTERS. BLYTHEDALE ALSO PROVIDES OTHER VITAL CLINICAL SERVICES SUCH AS NURSING, RESPIRATORY THERAPY, PSYCHOLOGY, CHILD LIFE, RESPIRATORY, SPEECH, OCCUPATIONAL AND PHYSICAL THERAPY, THERAPEUTIC RECREATION, SOCIAL WORK AND CASE MANAGEMENT. THE INPATIENT SERVICES ARE PRIMARILY COMPOSED OF 4 MAJOR PROGRAMS, PHYSICAL MEDICINE AND REHABILITATION SERVICES, VENTILATOR WEANING, TRAUMATIC BRAIN INJURY AND MEDICAL THERAPIES FOR COMPLEX AND CHRONIC HEALTH CONDITIONS. THE HOSPITAL OPERATES 86 LICENSED BEDS AND PROVIDED CARE TO OVER 78 INPATIENTS PER DAY ON AVERAGE IN 2012. THE HOSPITAL HAD 548 TOTAL DISCHARGES. OVER 72% OF OUR INPATIENT ADMISSIONS WERE REIMBURSED THROUGH THE MEDICAID PROGRAM (FFS & MANAGED) IN 2012. WHILE 100% OF THE HOSPITALS INPATIENT POPULATION IS REFERRED IN FROM OTHER ACUTE CARE HOSPITALS IN THE REGION, OVER >61% COME DIRECTLY FROM INTENSIVE CARE UNITS (ICU'S). THIS SPEAKS TO THE HIGH ACUITY OF THE PATIENT POPULATION BEING MANAGED AT BLYTHEDALE. IN 2012 OVER 51% OF PATIENTS TREATED WERE BELOW THE AGES OF 5 YEARS. THIS FACT PRESENTS MANY UNIQUE CHALLENGES TO THE DELIVERY OF CARE AS THE HOSPITAL PROVIDES HIGH QUALITY TO BOTH THE PATIENTS AND THE FAMILY. BLYTHEDALE CHILDREN'S HOSPITAL DOESN'T OPERATE PRIMARY CARE CLINICS, OR AN EMERGENCY DEPARTMENT OR OBSTETRICAL SERVICES. THESE SERVICES ARE OFTEN THE PRIMARY DRIVERS OF UNINSURED PATIENTS AT ACUTE CARE HOSPITALS. SECONDLY, CHILDREN, MORE SO THAN ADULTS HAVE GREATER ACCESS TO MEDICAID REIMBURSEMENT AS A PAYER OF LAST RESORT BECAUSE OF STATE CHILD HEALTH PLUS LAWS. THESE TWO FACTORS SIGNIFICANTLY IMPACT THE REPORTED AMOUNT OF CARE CLASSIFIED AS TRUE CHARITY CARE RELATIVE TO FULL SERVICE ACUTE CARE HOSPITALS. 7607044 10757485 DAY HOSPITAL PROGRAM - BLYTHEDALE OFFERS A DAY HOSPITAL PROGRAM FOR THOSE CHILDREN WHO ARE ABLE TO LIVE AT HOME, BUT STILL REQUIRE A LEVEL OF MEDICAL AND REHABILITATIVE CARE THAT CANNOT BE MET BY THEIR SCHOOL OR OUTPATIENT PROGRAM. IN 2012, 65 % OF THE PROGRAM CAME DIRECTLY FROM THE INPATIENT SETTING, 25 % CAME DIRECTLY FROM REFERRALS IN THE COMMUNITY AND 10% THROUGH THE EARLY INTERVENTION/CPSE PROGRAMS. IN 2012, THE PROGRAM SERVED ON AVERAGE OF 99 PATIENTS PER SCHOOL DAY FOR A TOTAL OF 22,608 VISITS. OVER 82% OF THESE PATIENTS WERE REIMBURSED BY THE MEDICAID PROGRAM. THE DAY HOSPITAL PROGRAM PROVIDES A NURTURING ENVIRONMENT WHERE CHILDREN WITH VARIOUS SPECIAL MEDICAL NEEDS CAN RECEIVE DAILY MEDICAL SUPERVISION, NURSING CARE, AND HAVE THEIR NEEDS FOR PHYSICAL, OCCUPATIONAL AND SPEECH THERAPIES MET, ALL WHILE RETURNING HOME AT THE END OF THE DAY. EACH CHILD'S PROGRAM IS INDIVIDUALIZED TO ADDRESS THEIR UNIQUE MEDICAL, PSYCHOLOGICAL AND THERAPEUTIC NEEDS. IN ADDITION, EVERY CHILD IS ASSIGNED A SOCIAL WORKER TO PROVIDE FAMILY SUPPORT AND CASE MANAGEMENT. AS NECESSARY, ONGOING PSYCHOSOCIAL SUPPORT AND COUNSELING, AND CASE MANAGEMENT ARE PROVIDED. SERVICES FOR SCHOOL-AGE CHILDREN ARE PROVIDED IN CONJUNCTION WITH A FULL ACADEMIC PROGRAM UNDER THE AUSPICES OF THE MOUNT PLEASANT-BLYTHEDALE UNION FREE SCHOOL DISTRICT.COMMITTEE ON PRESCHOOL SPECIAL EDUCATION (CPSE PROGRAM) - BLYTHEDALE - CHILDREN'S HOSPITAL PROVIDES EVALUATION AND TREATMENT SERVICES FOR YOUNG CHILDREN BETWEEN THE AGES OF 3 TO 5 YEARS WHO ARE REFERRED THROUGH THEIR LOCAL COMMITTEE ON PRESCHOOL SPECIAL EDUCATION (CPSE). THESE PATIENTS ARE ELIGIBLE FOR ASSESSMENT AT NO COST TO THEIR FAMILIES. THE NEW YORK STATE EDUCATION DEPARTMENT OVERSEES A STATEWIDE PRESCHOOL SPECIAL EDUCATION PROGRAM WITH SCHOOL DISTRICTS, MUNICIPALITIES, APPROVED PROVIDERS, AND PARENTS. EVALUATIONS AND SERVICES ARE PROVIDED TO ELIGIBLE CHILDREN WHO HAVE A DISABILITY THAT AFFECTS THEIR LEARNING. FUNDING FOR EVALUATIONS AND SERVICES IS PROVIDED BY MUNICIPALITIES AND THE STATE. IN 2012, THE PROGRAM SERVED ON AVERAGE OF 16 PATIENTS PER SCHOOL DAY FOR A TOTAL OF 3,265 VISITS. EVALUATION AND TREATMENT PLANNING ARE PERFORMED BY A MULTIDISCIPLINARY TEAM THAT MAY CONSIST OF THERAPISTS, SPECIAL EDUCATION TEACHERS, AUDIOLOGISTS, PHYSIATRISTS (REHABILITATION DOCTORS), NEUROLOGISTS, PSYCHIATRISTS, PSYCHOLOGISTS, SOCIAL WORKERS, NURSES, NUTRITIONISTS, AND OTHER SPECIALTY CONSULTANTS. AT BLYTHEDALE, WE PROVIDE INDIVIDUALIZED RELATED SERVICES TO ELIGIBLE CHILDREN AGE'S THREE TO FIVE THROUGH OUR OUTPATIENT DEPARTMENT. WE SERVE CHILDREN WITH A WIDE RANGE OF NEEDS INCLUDING DIFFICULTIES THAT MAY INTERFERE WITH THEIR LEARNING AND FUNCTIONING IN PRESCHOOL. CHILDREN WITH THE FOLLOWING DIFFICULTIES ARE MOST COMMON IN THE PROGRAM:- DELAYS OR LAGS IN COGNITIVE, LANGUAGE, MOTOR OR SOCIAL EMOTIONAL DEVELOPMENT- CONGENITAL OR ACQUIRED ABNORMALITIES- DIAGNOSED MEDICAL CONDITIONS SUCH AS CEREBRAL PALSY, NEUROMUSCULAR OR OTHER NEUROLOGICAL DISORDERS 2644075 1591580 EARLY INTERVENTION - THE EARLY INTERVENTION PROGRAM IS A STATEWIDE PROGRAM THAT PROVIDES MANY DIFFERENT TYPES OF EARLY INTERVENTION SERVICES TO CHILDREN BETWEEN THE AGES OF BIRTH TO THREE YEARS WITH DEVELOPMENT DELAY OR DIAGNOSED DISABILITIES AND TO THEIR FAMILIES. IN NEW YORK STATE, THE DEPARTMENT OF HEALTH IS THE LEAD STATE AGENCY RESPONSIBLE FOR THE EARLY INTERVENTION PROGRAM. IN 2012, THE PROGRAM SERVED ON AVERAGE OF 18 PATIENTS PER SCHOOL DAY FOR A TOTAL OF 4,569 VISITS. THE HOSPITAL ALSO PROVIDED 3,277 OUTPATIENT THERAPY AND CLINIC VISITS TO PATIENTS IN THE PROGRAM. BLYTHEDALE CHILDREN'S HOSPITAL IS WELL SUITED TO PROVIDE EVALUATION AND TREATMENT SERVICES FOR YOUNG CHILDREN. AS THE REGION'S PREMIERE HOSPITAL OFFERING REHABILITATIVE SERVICES TO CHILDREN, WE HAVE THE LARGEST DEPARTMENTS OF SPEECH THERAPY, OCCUPATIONAL THERAPY AND PHYSICAL THERAPY. THE EXPERTISE OF OUR HIGHLY SKILLED, MULTIDISCIPLINARY STAFF ENABLES US TO PROVIDE COORDINATED, COMPREHENSIVE, INDIVIDUALIZED PROGRAMS FOR THE CHILDREN AND FAMILIES WE SERVE. PARENTS AND STAFF WORK CLOSELY TOGETHER TO DEVELOP GOALS AND IMPATIENT PLANS. EVALUATION AND TREATMENT PLANNING ARE PERFORMED BY A MULTI-DISCIPLINARY TEAM THAT MAY CONSIST OF THERAPISTS, PHYSIATRISTS (REHABILITATION DOCTORS), NEUROLOGISTS, PSYCHIATRISTS, PSYCHOLOGISTS, SPECIAL EDUCATION, TEACHERS, AUDIOLOGISTS, SOCIAL WORKERS, NURSES, NUTRITIONISTS, AND OTHER SPECIALTY CONSULTANTS. WHILE NOT LIMITED TO THE FOLLOWING, THE PROGRAM TREATS A WIDE ARRAY OF ISSUES AND DIAGNOSES: - DELAYS OR LAGS IN REACHING THEIR DEVELOPMENTAL MILESTONES - CONGENITAL OR ACQUIRED ABNORMALITIES SUCH AS VISION OR HEARING IMPAIRMENTS - DIAGNOSED MEDICAL CONDITIONS SUCH AS CEREBRAL PALSY, NEUROMUSCULAR OR OTHER NEUROLOGICAL DISORDERS BLYTHEDALE CHILDREN'S HOSPITAL OFFERS VARIOUS OUTPATIENT THERAPY AND SUB SPECIALTY MEDICAL CLINICS TO SPECIAL NEEDS CHILDREN THROUGHOUT THE REGION. IN 2012 THE HOSPITAL PROVIDED OVER 3,953 ENCOUNTERS TO CHILDREN REQUIRING THESE SERVICES (THESE SERVICES INCLUDE AUDIOLOGY, PHYSIATRY OR REHABILIATION MEDICINE, NEUROLOGY, ORTHOPEDICS, SPINA BIFIDA CLINIC, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, BRACE AND EQUIPMENT MODIFICATION AND FITTING). 3398551 5053314 3398551 5053314 49713439 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 1 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 X 35 0 1 498 1 0 1 BD CJ VI 0 0 0 1 1 0 0 0 0 0 X 36 36 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X JOHN CANNING 9145927555 95 BRADHURST AVE VALHALLA NY 10595 OWEN GUTFREUND 1.00 X 0 0 0 JEANNE SAVITT 1.00 X 0 0 0 TIM EVNIN 1.00 X 0 0 0 DAVID PEDOWITZ 1.00 X 0 0 0 JUDITH GOODHUE 1.00 X 0 0 0 PEGGY EPSTEIN TANNER 1.00 X 0 0 0 ABBEY POPPER 1.00 X 0 0 0 DARREN FOGEL 1.00 X 0 0 0 DAVID OSBORN 1.00 X 0 0 0 EDWARD DAVIDOWITZ 1.00 X 0 0 0 FARREL STARKER 1.00 X 0 0 0 FRANK STERN 1.00 X 0 0 0 HEIDI SCHWARTZ 1.00 X 0 0 0 HOWARD ADLER 1.00 X 0 0 0 JEAN HOFMEIMER BENNETT 1.00 X 0 0 0 JOHN BARKER 1.00 X 0 0 0 JON BURNHAM 1.00 X 0 0 0 JOHN FURTH 1.00 X 0 0 0 HOLOVACH JORDANA 1.00 X 0 0 0 LAURENCE COHEN 1.00 X 0 0 0 LESLIE WEISSMAN 1.00 X 0 0 0 LOUISE GRAYER 1.00 X 0 0 0 LUCY SCHMOLKA 1.00 X 0 0 0 MATTHEW FELDMAN 1.00 X 0 0 0 MERWIN HASKEL 1.00 X 0 0 0 MICHAEL MARGULIES 1.00 X 0 0 0 NANCY PUNDYK 1.00 X 0 0 0 PATRICIA STANLEY 1.00 X 0 0 0 PETER RITTMASTER 1.00 X 0 0 0 PHYLLIS LASHINS 1.00 X 0 0 0 SCOTT KARR 1.00 X 0 0 0 STEVEN SOLOMON 1.00 X 0 0 0 TERRI HERENSTEIN 1.00 X 0 0 0 THOMAS BROCK 1.00 X 0 0 0 WILLIAM CAHN 1.00 X 0 0 0 WILLIAM LEVY 1.00 X 0 0 0 LAWRENCE LEVINE 37.50 X 580757 0 145339 JOHN CANNING 37.50 X 343346 0 61663 JOELLE MAST 37.50 X 289338 0 60230 MAUREEN DESIMONE 37.50 X 276601 0 83342 REGINA KELLY 37.50 X 171740 0 59016 RONALD GALLO 37.50 X 214408 0 57436 JANE MACDONALD 37.50 X 205425 0 33831 ELIZABETH BOWMAN 37.50 X 203284 0 23053 JUDI PEACOCK 37.50 X 175297 0 4159 LOIS ALLEN 37.50 X 180185 0 3324 RONI AMIEL 37.50 X 167920 0 29137 MILICENT MITCHELL 37.50 X 239062 0 66330 BYRON FERNANDEZ 37.50 X 230151 0 30079 LAURA MIRKINSON 37.50 X 219811 0 25536 KATHY SILVERMAN 37.50 X 176084 0 29349 MARY DIDIE 37.50 X 175085 0 63571 3848494 0 775395 64 0 1 0 BOVIS LEND LEASE 200 PARK AVENUE NEW YORK NY 10166 GENERAL CONTRACTORS 6575733 SODEXO INC & AFFILIATES PO BOX 81049 WOBURN MA 018131049 FACILITIES, HOUSEKEEPING AND DIETARY AND 2863225 PAR ENVIRONMENTAL CORP 313 SPOOK ROCK ROAD SUFFERN NY 10901 CONTRACTORS 1187047 FOJP SERVICE CORP PO BOX 10073 UNIONDALE NY 11555 INSURANCE BROKERAGE SERVICES 552310 SSC INC PO BOX 13 BRATTLEBORO VT 053020135 SECURITY 481130 30 790975 2090251 86263 2881226 INPATIENT 900099 47563777 47563777 DAY HOSPITAL 900099 10757485 10757485 EARLY INT / OPD 900099 1591580 1591580 59912842 399411 399411 6520480 0 6520480 6520480 6520480 87855 790975 187245 -99390 -99390 HI TECH REVENUE 900099 1470366 1470366 SCHOOL CONTRACT 900099 875000 875000 OFFSITE THERAPIES 900099 617595 617595 2090353 2090353 5053314 74667883 64966156 0 6820501 3307849 516287 2600551 191011 30331340 27027691 3078994 224655 3640084 3301082 309642 29360 3741150 3227289 477022 36839 2388244 1984367 375823 28054 2525002 1160648 1314003 50351 360528 360528 260734 239490 21244 15826 15826 23525 23525 164619 70590 89005 5024 762110 437372 320840 3898 5239382 4164074 1073241 2067 59598 27933 29041 2624 76414 42815 31922 1677 19564 19564 6174223 3543359 2599279 31585 687187 402720 284467 CONTRACTED LABOR 3100372 2405597 588442 106333 UTILITIES 794079 455719 334298 4062 TAXES & OTHER ASSESSMEN 742846 658605 84241 0 DEBT FINANCE FEES 500598 287291 210746 2561 64915274 49713439 14460490 741345 21846638 20063359 14654507 5591416 1351544 975644 7357080 10139574 257264 269748 534662 513735 94369294 21006781 69640819 73362513 21793485 35177227 52857544 58170392 5456813 1288293 195750356 205551901 5942352 4636299 27000000 26405000 146242 19744 24784437 26595171 57873031 57656214 X 128669885 137764695 5275246 6150300 3929194 3980692 137877325 147895687 195750356 205551901 X 9752609 921052 1965576 -2620875 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 15826 0 0 15826 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: BLYTHEDALE CHILDREN'S HOSPITAL, AS A MEMBER OF STATE-WIDE HOSPITAL ORGANIZATIONS, HAS A PORTION OF ITS DUES USED FOR LOBBYING. IN ADDITION, BLYTHEDALE HAS ENGAGED AN OUTSIDE LOBBYIST TO LOBBY ON ITS BEHALF ON ISSUES RELATING TO THE STATE BUDGET. 9207439 1230427 923951 1230826 10130991 14508992 911024 -687562 5525015 9207439 20617212 430633 1098917 7637770 14508992 19230372 1619160 372366 604686 20617212 28286047 1671350 -2147297 8579728 19230372 0.00000 0.39290 0.60710 1 0 1383879 1383879 45516063 7691855 37824208 40033724 11490574 28543150 2000000 5435628 1824352 5611276 73362513 LIMITED LIABILITY PARTNERSHIP (HEDGE FUNDS) 58170392 C 58170392 ACCRUED PENSION LIABILITY 22297716 DUE TO THIRD PARTY PAYORS 3348248 ASSET RETIREMENT OBLIGATION 121207 MALPRACTICE LIABILITIES 828000 26595171 X 74852626 1230826 1230826 73621800 1046083 1046083 74667883 65102519 187245 187245 64915274 0 64915274 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: TEMPORARILY RESTRICTED NET ASSETS ARE THOSE WHOSE USE BY BLYTHEDALE CHILDREN'S HOSPITAL (THE "HOSPITAL") HAS BEEN LIMITED BY DONORS TO A SPECIFIC PERIOD OR PURPOSE. PERMANENTLY RESTRICTED NET ASSETS HAVE BEEN RESTRICTED BY DONORS TO BE MAINTAINED BY THE HOSPITAL IN PERPETUITY. THE HOSPITAL'S ENDOWMENT CONSISTS OF APPROXIMATELY 20 INDIVIDUAL FUNDS ESTABLISHED FOR A VARIETY OF PURPOSES. THE HOSPITAL BECAME SUBJECT TO NYPMIFA (THE NEW YORK PRUDENT MANAGEMENT OF INSTITUTIONAL FUNDS ACT) WHICH WAS ENACTED IN SEPTEMBER 2010. THE BOARD OF TRUSTEES INTERPRETED NYPMIFA AS (A) REQUIRING THE PRESERVATION OF THE ORIGINAL GIFT AS OF THE GIFT DATE OF THE DONOR-RESTRICTED ENDOWMENT FUNDS ABSENT EXPLICIT DONOR STIPULATIONS TO THE CONTRARY. AS A RESULT OF THIS INTERPRETATION, THE HOSPITAL CLASSIFIES AS PERMANENTLY RESTRICTED NET ASSETS: (A) THE ORIGINAL VALUE OF GIFTS DONATED TO THE PERMANENT ENDOWMENT, (B) THE ORIGINAL VALUE OF SUBSEQUENT GIFTS TO THE PERMANENT ENDOWMENT, AND (C) ACCUMULATIONS OF INCOME ARE ADDED TO THE FUND IN ACCORDANCE WITH THE DIRECTION OF THE APPLICABLE DONOR GIFT INSTRUMENT AT THE TIME THE ACCUMULATION IS ADDED TO THE FUND. THE REMAINING PORTION OF THE DONOR-RESTRICTED ENDOWMENT FUND THAT IS NOT CLASSIFIED IN PERMANENTLY RESTRICTED NET ASSETS IS CLASSIFIED AS TEMPORARILY RESTRICTED UNTIL THOSE AMOUNTS ARE APPROPRIATED FOR EXPENDITURE BY THE ORGANIZATION. IN ACCORDANCE WITH NYPMIFA THE ORGANIZATION CONSIDERS THE FOLLOWING FACTORS IN MAKING A DETERMINATION TO APPROPRIATE OR ACCUMULATE DONOR-RESTRICTED ENDOWMENT FUNDS: (A) THE DURATION AND PRESERVATION OF THE FUND (B) THE PURPOSES OF THE ORGANIZATION AND THE DONOR-RESTRICTED ENDOWMENTFUND (C) GENERAL ECONOMIC CONDITIONS (D) THE POSSIBLE EFFECT OF INFLATION AND DEFLATION (E) THE EXPECTED TOTAL RETURN FROM INCOME AND THE APPRECIATION OFINVESTMENTS (F) OTHER RESOURCES OF THE ORGANIZATION (G) THE INVESTMENT POLICIES OF THE ORGANIZATION TEMPORARILY RESTRICTED NET ASSETS AS OF DECEMBER 31, 2012 AND 2011, ARE AVAILABLE FOR THE FOLLOWING PURPOSES: 2012 2011 PLANT REPLACEMENT $1,147,607 $1,240,131 TEMPORARILY RECTRICTED PORTION OF ENDOWMENT FUND $3,185,006 $2,437,491 MEDICAL EQUIPMENT $87,366 $197,518 OTHER $1,7030,321 $1,400,106 TOTALS $6,150,300 $5,275,246 PERMANENTLY RESTRICTED NET ASSETS AS OF DECEMBER 31, 2012 AND 2011 ARE RESTRICTED TO THE FOLLOWING: 2012 2011 INVESTMENTS TO BE HELD IN PERPETUITY, THE INCOME FROM WHICH IS EXPENDABLE TO SUPPORT HEALTH CARE SERVICES $3,980,629 ___________ $3,932,194 BLYTHEDALE CHILDREN'S HOSPITAL HAS A CHARITABLE REMAINDER TRUST HELD BY TRUSTEES CITIBANK, CALLED THE HENRY STERN TRUST. THE PRINCIPLE IS PERMANENTLY RESTRICTED. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN JUNE 2006, THE FINANCIAL ACCOUNTING STANDARDS BOARD ("FASB") ISSUED ASC 740-10-65, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, WHICH CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RE PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSET RELEASED FROM RESTRICTION 1,230,826. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMP REST CONTRIBUTIONS 1,226,007. PERM REST CONTRIBUTIONS 4,420. REALIZED GAINS ON INVESTMENT 2,899. FUNDRAISING EXPENSE RECLASS -187,245. ROUNDING 2. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSE RECLASS 187,245. PART V, LINE 3A(I): BLYTHEDALE CHILDREN'S HOSPITAL HAS A CHARITABLE REMAINDER TRUST HELD BY TRUSTEES CITIBANK, CALLED THE HENRY STERN TRUST. THE PRINCIPLE IS PERMANENTLY RESTRICTED. CENTRAL AMERICA & THE CARIBBEAN 0 0 INVESTMENTS 50793370 0 0 0 0 0 0 50793370 0 50793370 1 0 1 0 1 0 SPRING EVENT 485593 444463 41130 11660 41130 4800 18746 GOLF EVENT 229840 183115 46725 1530 1200 39890 9340 9701 163397 163397 40400 8848 878830 790975 87855 1530 1200 91950 50470 4800 37295 187245 -99390 1 1 1 X 400.000000000000 1 X 1 1 0 1 1 18627 18627 0.00030 658605 433827 224778 0.00350 0.00000 677232 433827 243405 0.00380 754594 332802 421792 0.00650 497747 82393 415354 0.00640 355638 142032 213606 0.00330 208079 0 208079 0.00320 0.00000 1816058 557227 1258831 0.01940 2493290 991054 1502236 0.02320 0.00000 0.00000 2206526 1119612 1086914 0.01670 0.00000 0.00000 0.00000 0.00000 0.00000 177100 29819 147281 0.00230 2383626 1149431 1234195 0.01900 1 571861 0 0 0 1 1 1 1 BLYTHEDALE CHILDREN'S HOSPITAL

95 BRADHURST AVE VALHALLA NY 10595

WWW.BLYTHEDALE.ORG X X BLYTHEDALE CHILDREN'S HOSPITAL 1 1 1 400.000000000000 1 400.000000000000 1 X 1 1 X X X X X 1 X 1 X X X X 0 X 0 0 PART I, L7 COL(F): BAD DEBTS WILL BE RECORDED AND RECOGNIZED IN THE PERIOD IN WHICH IT IS DETERMINED THE DEBT IS UNCOLLECTIBLE. BAD DEBT IS RECOGNIZED AS THE AMOUNT CONTRACTUALLY OBLIGATED AND RECOGNIZED AS REVENUE FOR WHICH ALL AVENUES OF COLLECTION HAVE BEEN EXHAUSTED. REVENUE IS RECOGNIZED WHEN THE CLAIM HAS (1) PERVASIVE EVIDENCE OF A PAYMENT AGREEMENT / AUTHORIZATION, RATE SHEET OR CONTRACT (2) SERVICES HAVE BEEN RENDERED (3) PRICE IS FIXED AND DETERMINABLE (4) COLLECTABILITY IS REASONABLE ASSURED. BAD DEBT IS RECOGNIZED IF MANAGEMENT IS UNABLE TO COLLECT THE DEBT AFTER THESE CRITERIA HAVE BEEN MET. BAD DEBTS DO NOT INCLUDE CHARITY CARE, COURTESY DISCOUNTS, SELF PAY ALLOWANCES, OR ALLOWANCES FOR OUTPATIENT SERVICES PROVIDED THAT ARE NOT AUTHORIZED. PART II: BLYTHEDALE IS INVOLVED IN NUMEROUS COMMUNITY BUILDING ACTIVITIES WHICH PROMOTE THE HEALTH OF THE COMMUNITIES IT SERVES. NUMEROUS COMMUNITY CONCERNS ARE ADDRESSED, INCLUDING HEALTH IMPROVEMENT (SEE DETAILS UNDER LINE 6 BELOW) AND ACCESS TO CARE. BLYTHEDALE ACTIVELY PARTICIPATES IN THE WESTCHESTER CHILD HEALTH ADVOCACY NETWORK, WHOSE PRINCIPAL GOAL IS TO MAXIMIZE ENROLLMENT OF ELIGIBLE CHILDREN IN NEW YORK STATE'S MEDICAID AND CHILD HEALTH PLUS PROGRAMS. ADDITIONALLY, UNDER THE AEGIS OF THE NEW YORK COALITION OF MEDICALLY FRAGILE CHILDREN, BLYTHEDALE HAS WORKED TO ADVOCATE FOR SERVICES TO SUPPORT FAMILIES CARING FOR MEDICALLY FRAGILE CHILDREN AT HOME. PART III, LINE 4: PROVISION AND ALLOWANCE FOR DOUBTFUL ACCOUNTS - TO PROVIDE FOR ACCOUNTS RECEIVABLE THAT COULD BECOME UNCOLLECTIBLE IN THE FUTURE, THE HOSPITAL ESTABLISHES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS TO REDUCE THE CARRYING VALUE OF SUCH RECEIVABLES TO THEIR ESTIMATED NET REALIZABLE VALUE. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, BLYTHEDALE ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. BLYTHEDALE PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE EXHAUSTED THIRD PARTY BENEFITS RELATIVE TO SERVICES PROVIDED AT THE HOSPITAL AND HAVE NO SECONDARY SOURCE OF COVERAGE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.THE HOSPITAL DID NOT CHANGE ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEAR 2012. THE HOSPITAL MAINTAINED AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IN 2012 AND 2011 RESPECTIVELY IN THE AMOUNTS OF APPROXIMATELY $892,000 AND $876,000. THESE AMOUNTS REPRESENT 1.4% AND 1.7% OF NET PATIENT SERVICES REVENUE RESPECTIVELY. PART III, LINE 8: BLYTHEDALE , AS A CHILDRENS HOSPITAL RECEIVED IMMATERIAL AMOUNTS OF MEDICARE REIMBURSEMENT. IN 2012 THE HOSPITAL FILED A LOW/NO COST UTLIZATION REPORT WITH CMS PART III, LINE 9B: COLLECTION POLICIES ARE THE SAME FOR ALL PATIENTS. ALL PATIENTS HAVING DIFFICULTY PAYING THEIR BILLS ARE DIRECTED TO HOSPITAL STAFF WHO ASSIST THE FAMILY IN COMPLETING A FINANCIAL ASSESSMENT AND TRY TO QUALIFY THE PATIENT FOR ASSISTANCE. ONCE A LEVEL OF FINANCIAL ASSISTANCE IS DETERMINED, THE ACCOUNT BALANCE IS PRORATED FOR CONTRACTUAL ADJUSTMENTS AND THEN PRO RATED TO COST. FROM COSTS, THE LEVEL OF FINANCIAL ASSISTANCE IS THEN APPLIED, ANY REMAINING BALANCE IS COLLECTABLE AS PATIENT RESPONSIBILITY. PATIENTS ARE SCREENED FOR ELIGIBILTY FOR FINANCIAL ASSISTANCE BEFORE COLLECTION PROCEDURE BEGIN. IF AT ANY POINT IN THE COLLECTION PROCESS, DOCUMENTATION IS RECEIVED THAT INDICATES THAT THE PATIENT IS POTENTIALLY ELIGIBLE FOR FINANCIAL ASSISTANCE BUT HAS NOT APPLIED FOR IT, THE ACCOUNT IS REFERRED BACK FOR A FINANCIAL ASSISTANCE REVIEW. BLYTHEDALE DOES NOT PURSUE COLLECTION OF AMOUNTS FROM PATIENTS DETERMINED TO QUALIFY FOR CHARITY CARE. IF A PATIENT HAS REQUESTED AND/OR FILLED OUT A FINANCIAL ASSISTANCE APPLICATION, ALL DEBT COLLECTION ACTIVITIES STOP UNTIL ELIGIBILTY FOR FINANCIAL ASSISTANCE CAN BE DETERMINED. BLYTHEDALE'S POLICY PROVIDES THAT WE WILL NOT REFER ANY ACCOUNTS FOR COLLECTION UNTIL IT IS DETERMINED WHETHER THE INDIVIDUAL IS INSURED AND NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: SINCE THE VAST MAJORITY OF ADMISSIONS TO BLYTHEDALE COME BY REFERRAL FROM OTHER HOSPITALS, PARTICULARLY THE LARGE MEDICAL CENTERS IN THE METROPOLITAN NEW YORK AND HUDSON VALLEY AREA, BLYTHEDALE'S SENSE OF NEED FOR CLINICAL SERVICES LARGELY EMANATES FROM REFERRING HOSPITALS AND THEIR PHYSICIANS. HOWEVER, IN ADDITION TO ITS REFERRAL HOSPITALS, BLYTHEDALE ALSO WORKS CLOSELY WITH A VARIETY OF LOCAL AGENCIES, NOTABLY THE WESTCHESTER, ROCKLAND AND PUTNAM COUNTY DEPARTMENTS OF HEALTH, THE WESTCHESTER CHILD HEALTH ADVOCACY NETWORK AND THE WESTCHESTER SAFE KIDS COALITION, TO IDENTIFY COMMUNITY HEALTH PRIORITIES THAT ARE RELEVANT TO BLYTHEDALE'S MISSION AND SERVICES. PARTICIPANTS IN THESE COALITIONS INCLUDE THE MAJOR CHILD AND ADOLESCENT HEALTH-FOCUSED COMMUNITY-BASED ORGANIZATIONS IN WESTCHESTER. BLYTHEDALE ALSO HAS CLOSE WORKING RELATIONSHIPS WITH MANY OF THE SCHOOL DISTRICTS IN WESTCHESTER COUNTY, THROUGH ITS NUTRITION EDUCATION AND INJURY AND DISEASE PREVENTION ACTIVITIES AND THROUGH ARRANGEMENTS WHEREBY BLYTHEDALE STAFF ARE CONTRACTED TO PROVIDE PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SERVICES TO CHILDREN IN THE SCHOOLS. PART VI, LINE 3: CONSISTENT WITH ITS MISSION AND STATE REQUIREMENTS (NEW YORK STATE PUBLIC HEALTH LAW 2807(K) (9-A), BLYTHEDALE HAS DEVELOPED GUIDELINES THAT DELINEATE THE CIRCUMSTANCES AND PROCEDURES UNDER WHICH FREE OR REDUCED COST CARE IS AVAILABLE. THESE GUIDELINES ARE MADE AVAILABLE TO ALL FAMILIES UPON REGISTRATION, AND HOSPITAL STAFF PROVIDE COUNSELING AS NECESSARY. INTERPRETATION SERVICES ARE AVAILABLE FOR PATIENTS NEEDING INFORMATION IN LANGUAGES OTHER THAN ENGLISH. PATIENTS ARE ALSO NOTIFIED OF BLYTHEDALE'S CHARITY CARE FINANCIAL ASSISTANCE POLICIES THROUGH NOTICES IN ENGLISH AND SPANISH POSTED IN THE HOSPITAL'S LOBBY AND IN PATIENT REGISTRATION AND WAITING AREAS. IN ADDITION, BLYTHEDAL'S PATIENT ASSISTANCE FUNDS HELPS PROVIDE CHILDREN WITH VARIOUS ITEMS (I.E. EQUIPMENT, CLOTHING, ETC.) WHERE FAMILY RESOURCES ARE LIMITED AND INSURANCE DOES NOT COVER. PART VI, LINE 4: AS A SPECIALTY CHILDREN'S HOSPITAL SERVING CHILDREN WITH A BROAD RANGE OF DIAGNOSES, BLYTHEDALE'S SERVICE AREA IS WIDESPREAD, WITH PATIENTS COMING FROM THE ENTIRE SOUTHERN PORTION OF NEW YORK STATE AS WELL AS ADJACENT AREAS OF NEW JERSEY AND CONNECTICUT. THE HOSPITAL IS LOCATED IN A SUBURBAN COUNTY (WESTCHESTER) THAT IS PART OF THE GREATER NEW YORK METROPOLITAN AREA, WHICH HAS AN EXTREMELY DIVERSE POPULATION. THE HOSPITAL'S PATIENT ARE BROADLY REPRESENTATIVE OF THIS POPULATION. PART VI, LINE 5: BLYTHEDALE OFFERS A NUMBER OF COMMUNITY HEALTH IMPROVEMENT PROGRAMS AND SPECIAL PROGRAMS FOR DEVELOPMENT OF THE PEDIATRIC PROFESSIONAL COMMUNITY: NUTRITION EDUCATION: IN A MAJOR INITIATIVE TO HELP REDUCE THE PREVALENCE OF CHILDHOOD OBESITY AND PREVENT ITS LONG-TERM NEGATIVE HEALTH EFFECTS, BLYTHEDALE CHILDREN'S HOSPITAL IS REACHING OUT TO SCHOOL DISTRICTS THROUGHOUT WESTCHESTER COUNTY WITH ITS EAT WELL, BE WELL SCHOOL-BASED NUTRITION EDUCATION PROGRAM. THE EAT WELL, BE WELL PROGRAM, WITH SUPPORT FROM KOHL'S DEPARTMENT STORES, IS DESIGNED TO PROVIDE SCHOOL STAFF AND STUDENTS WITH THE TOOLS NECESSARY TO HELP CHILDREN DEVELOP HEALTHY EATING HABITS THROUGH A COMPREHENSIVE CURRICULUM DEVELOPED BY BLYTHEDALE'S REGISTERED DIETICIANS. IN 2012 THIS PROGRAM REACHED MORE THAN 21,155 STUDENTS IN 38 SCHOOLS THROUGHOUT WESTCHESTER AND PUTNAM, AS WELL AS THEIR PARENTS AND TEACHERS, WITH INFORMATION ON HOW TO MAKE FOOD AND LIFESTYLE CHOICES THAT WILL PROMOTE HEALTHY LIVING FOR A LIFETIME.INJURY PREVENTION: BLYTHEDALE IS COMMITTED TO KEEPING CHILDREN SAFE AND INJURY FREE. IN ORDER TO PROVIDE CHILDREN WITH LESSONS THAT WILL HELP ESTABLISH GOOD SAFETY HABITS, BLYTHEDALE HAS DEVELOPED A SCHOOL-BASED INJURY PROGRAM. WITH THE SUPPORT OF KOHL'S DEPARTMENT STORES, THIS PROGRAM IS DESIGNED TO PROMOTE THE SAFE PRACTICES AND THE CONSISTENT USE OF PROTECTIVE QUIPMENT TO CHILDREN IN THE THIRD, FOURTH AND FIFTH GRADES. IN 2012 THIS PROGRAM REACHED OVER 6,200 CHILDREN. THE INJURY PREVENTION PROGRAM PROVIDES CLASSROOM INSTRUCTIONS TO CHILDREN FROM GRADES K-5. THE THREE AREAS ADDRESSED BY THE PROGRAM ARE: BICYCLE SAFETY, FIRE AND WATER SAFETY. THIS YEAR THE PROGRAM WAS BEEN PRESENTED IN 10 SCHOOLS THROUGHOUT WESTCHESTER, ROCKLAND AND PUNTAM COUNTIES. HOSPITAL STAFF ALSO PARTICIPATED IN SEVERAL HEALTH FAIRS AND SAFETY DAYS. IN ADDITION TO THIS SPECIAL INJURY PREVENTION EDUCATION PROGRAM, BLYTHEDALE HAS FOR MANY YEARS COORDINATED THE WESTCHESTER SAFE KIDS COALITION, THE LOCAL AFFILIATE OF THE NATIONAL SAFE KIDS CAMPAIGN. SAFE KIDS IS DEDICATED TO PREVENTING UNINTENTIONAL CHILDHOOD INJURY FROM ACCIDENTS SUCH AS MOTOR VEHICLE CRASHES, FIRES, DROWNING, POISONING AND FALLS, BY PROMOTING CHANGE IN BEHAVIORS, LAWS AND THE ENVIRONMENT. AS PART OF ITS SAFE KIDS ACTIVITIES, BLYTHEDALE SPONSORS FITTING AND INSTALLATION CHECKS FOR BOTH REGULAR AND SPECIAL-NEED CAR SEATS ON SITE AT THE HOSPITAL. HOSPITAL STAFF ALSO ARE INSTRUCTORS IN CAR SEAT TECHNOLOGIST TRAINING COURSES IN THE LOWER HUDSON VALLEY. CPR TRAINING CENTER: BLYTHEDALE IS A COMMUNITY TRAINING CENTER FOR THE AMERICAN HEART ASSOCIATION, PROVIDING TRAINING IN HEARTSAVER CPR, HEARTSAVER AED AND HEARTSAVER FIRST AID. THOSE TRAINED INCLUDE HEALTH CARE PROFESSIONALS, MEMBER OF LOCAL POLICE AND FIRE DEPARTMENTS, STUDENTS AT AREA SCHOOLS AND STAFF FROM VARIOUS COMMUNITY AGENCIES. BLYTHEDALE ALSO OFFERS PEDIATRIC CPR TRAINING FOR THE COMMUNITY AND HEALTH CARE PROFESSIONALS, AND IS A CERTIFIED PEDIATRIC ADVANCED LIFE SUPPORT TRAINING CENTER. SERVICES TO THE PROFESSIONAL COMMUNITY: BLYTHEDALE ALSO PROVIDES CLINICAL TRAINING FOR SCORES OF PROFESSIONAL STUDENTS IN A WIDE RANGE OF FIELDS, INCLUDING MEDICINE, NURSING, RESPIRATORY THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY AND SOCIAL WORK. BLYTHEDALE ALSO SPONSORS SPECIALIZED COURSES ON PEDIATRIC ISSUES FOR AREA PHYSICAL, OCCUPATIONAL AND SPEECH THERAPISTS. BLYTHEDALE IS THE SPONSOR OF THE REGIONAL CHAPTER OF THE SOCIETY FOR PEDIATRIC NURSING (SPN) WHICH PROMOTES EXCELLENCE IN NURSING CARE OF CHILDREN AND THEIR FAMILIES THROUGH SUPPORT OF ITS MEMBERS' CLINICAL PRACTICE, EDUCATION, RESEARCH AND ADVOCACY. SPN HOSTS BI-ANNUAL CONFERENCES WHICH HAVE COVERED TOPICS RANGING FROM PREVENTING THE SPREAD OF INFECTION TO ETHICS AND LEGAL ISSUES IN PREDIATRIC PRACTICE. X X X X X 1 1 0 0 0 0 0 1 0 LAWRENCE LEVINE 516139 0 51905 0 12713 0 121721 0 23618 0 726096 0 0 0 JOHN CANNING 304250 0 30596 0 8500 0 37487 0 24176 0 405009 0 0 0 JOELLE MAST 280966 0 5600 0 2772 0 36612 0 23618 0 349568 0 0 0 MAUREEN DESIMONE 243400 0 24447 0 8754 0 65407 0 17935 0 359943 0 0 0 REGINA KELLY 161576 0 8000 0 2164 0 34845 0 24171 0 230756 0 0 0 RONALD GALLO 189892 0 13367 0 11149 0 39747 0 17689 0 271844 0 0 0 JANE MACDONALD 189482 0 13338 0 2605 0 22343 0 11488 0 239256 0 0 0 ELIZABETH BOWMAN 189069 0 13309 0 906 0 19294 0 3759 0 226337 0 0 0 JUDI PEACOCK 30288 0 0 0 145009 0 673 0 3486 0 179456 0 0 0 LOIS ALLEN 167443 0 8400 0 4342 0 0 0 3324 0 183509 0 0 0 RONI AMIEL 156192 0 11500 0 228 0 4475 0 24662 0 197057 0 0 0 MILICENT MITCHELL 233572 0 4698 0 792 0 51572 0 14758 0 305392 0 0 0 BYRON FERNANDEZ 226571 0 3400 0 180 0 7961 0 22118 0 260230 0 0 0 LAURA MIRKINSON 219315 0 0 0 496 0 25266 0 270 0 245347 0 0 0 KATHY SILVERMAN 172168 0 3400 0 516 0 21351 0 7998 0 205433 0 0 0 MARY DIDIE 170893 0 3400 0 792 0 42072 0 21499 0 238656 0 0 0 PART I, LINES 4A-B JUDI PEACOCK $145,009. SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN - EFFECTIVE AS OF JANUARY 1, 2008, THE HOSPITAL IMPLEMENTED THE BLYTHEDALE CHILDREN'S HOSPITAL SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) TO PROVIDE PENSION BENEFITS FOR A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES. THIS PLAN IS UNFUNDED AND A TARGET DEFINED BENEFIT PLAN. AS OF DECEMBER 31, 2012 AND 2011, THE PROJECTED BENEFIT OBLIGATION WAS $1,245,926 AND $1,076,770, RESPECTIVELY AND IS INCLUDED IN ACCRUED PENSION LIABILITY IN THE STATEMENTS OF FINANCIAL POSITION. IN 2012 THE HOSPITAL CONTRIBUTED $89,074 TO A SERP ON BEHALF OF LARRY LEVINE. EFFECTIVE AS OF JANUARY 1, 2012 THE HOSPITAL IMPLEMENTED AN ADDITIONAL SERP. THIS PLAN IS UNFUNDED AND A DEFINED CONTRIBUTION PLAN. FOR EACH PLAN YEAR THE HOSPITAL WILL MAKE A CONTRIBUTION ON BEHALF OF THE PARTICIPANT IN AN AMOUNT EQUAL TO TEN PERCENT (10%) OF THE PARTICIPANT'S BASE COMPENSATION. BOTH PLANS ARE MAINTAINED TO PROVIDE DEFERRED COMPENSATION TO A MEMBER OF A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES. IN 2012 THE HOSPITAL CONTRIBUTED $30,425 TO A SERP ON BEHALF OF JOHN CANNING. PART I, LINE 7 BLYTHEDALE ENGAGED SULLIVAN COTTER IN 2011 TO DEVELOP AND PROVIDE RECOMMENDATIONS TO THE COMPENSATION COMMITTEE OF THE BOARD REGARDING PAYMENT OF AN ANNUAL PERFORMANCE INCENTIVE PLAN FOR EMPLOYEES WITH MANAGEMENT RESPONSIBILITIES. THIS INCENTIVE PLAN CONDITIONS PAYMENTS BASED UPON THE ACHIEVEMENT OF MULTIPLE INDIVIDUAL AND ORGANIZATIONAL MEASURES. FUNDING FOR THE PLAN IS DEPENDENT UPON ANNUAL BOARD OF TRUSTEES APPROVAL. BASED UPON THE FINANCIAL CONDITIONS TOWARD THE END OF EACH FISCAL YEAR, THE BOARD WILL EVALUATE THE APPROPRIATENESS OF ESTABLISHING A LUMP SUM POOLED AMOUNT. EVEN IF ALL RELEVANT PERFORMANCE MEASURES ARE ACHIEVED, THE BOARD OF TRUSTEES RETAINS FULL DISCRETION TO MAKE, NOT MAKE OR REDUCE THE AMOUNT OF ANY INCENTIVE AWARDS. A DORMITORY AUTHORITY OF THE STATE OF NEW YORK 146000293 649905DG8 2009-06-19 27000000 CONSTRUCTION 0 0 0 A 27227655 65392 540000 820868 25801395 479342 2011 0 0 0 1 A 0 0 1 0 0 0 0 1 A 0 0 0 0 1 0 0 0 0 A 0 SCHEDULE K SUPPLENTAL INFORMATION PART 1, COLUMN (E) & PART II, LINE 3 THE DIFFERENCES BETWEEN THE ISSUE PRICE (PART I, COLUMN (E)) AND TOTAL PROCEEDS (PART II, LINE 3) ARE DUE TO INVESTMENT EARNINGS PART II, LINE 4 THE AMOUNT ENTERED HERE IS A DEBT SERVICE FUND BALANCE AND PREPAYMENTS ON THE BOND PRINCIPAL. X 11 86263 COST OR SELLING PRICE 0 1 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: PART I, COLUMN (B): THE AMOUNT REPORTED IN COLUMN (B) REFERS TO THE NUMBER OF CONTRIBUTORS; THERE WERE 13 STOCK CONTRIBUTIONS IN 2012. FORM 990, PART VI, SECTION A, LINE 2 JOHN FURTH AND OWEN GUTFREUND (BOARD MEMBERS) HAVE A FAMILY RELATIONSHIP. DAVID PEDOWITZ HAS BUSINESS RELATIONSHIPS WITH PEGGY EPSTEIN TANNER, PATRICIA STANLEY AND LARRY COHEN (BOARD MEMBERS). ANDREW HERENSTEIN (SPOUSE OF BOARD MEMBER TERRI HERENSTEIN) HAS BUSINESS RELATIONSHIPS WITH DAVID TANNER (SPOUSE OF BOARD MEMBER PEGGY EPSTEIN TANNER) AND LARRY COHEN. FRANK STERN AND JOHN BARKER (BOARD MEMBERS) HAVE A BUSINESS RELATIONSHIP. JOHN BARKER, DAVID PEDOWITZ AND DARREN FOGEL ARE EMPLOYEES OF NEUBERGER BERMAN, WHICH MANAGES SOME ASSET AND PENSION PORTFOLIOS FOR THE HOSPITAL. THESE MEMBERS RECUSE THEMSELVES FROM ALL ISSUES RELATED TO THESE INVESTMENTS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 IS PROVIDED TO EACH MEMBER OF THE BLYTHEDALE CHILDREN'S HOSPITAL'S BOARD OF TRUSTEES PRIOR TO ITS FILING WITH THE INTERNAL REVENUE SERVICE. THE FORM 990 IS REVIEWED BY THE BLYTHEDALE FINANCE DEPARTMENT AS WELL AS BY DELOITTE TAX, LLP, BEFORE IT IS PRESENTED TO THE BOARD'S EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE THEN PROVIDES AN OVERVIEW OF THE FORM 990 TO THE FULL BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS, SENIOR MANAGEMENT AND KEY EMPLOYEES OF BLYTHEDALE CHILDREN'S HOSPITAL MUST COMPLETE A STATEMENT ANNUALLY AND WHENEVER NEW INFORMATION ARISES, WHICH DISCLOSES ANY POTENTIAL CONFLICT OF INTEREST, AS REQUIRED BY THE HOSPITAL'S CONFLICT OF INTEREST POLICY. THESE STATEMENTS ARE REVIEWED BY THE HOSPITAL'S COMPLIANCE OFFICER WHO PREPARES A REPORT ON DISCLOSURES FOR THE BOARD'S EXECUTIVE COMMITTEE. HOSPITAL BOARD MEMBERS AND STAFF ARE TRAINED AND EDUCATED ON THEIR OBLIGATIONS UNDER THIS POLICY, INCLUDING ITS GIFT AND GRATUITIES PROVISIONS. FORM 990, PART VI, SECTION B, LINE 15 IT IS THE PRACTICE OF BLYTHEDALE CHILDREN'S HOSPITAL TO ENGAGE AN INDEPENDENT COMPENSATION CONSULTANT APPROXIMATELY EVERY 2 YEARS TO PROVIDE THE COMPENSATION COMMITTEE WITH A THOROUGH REVIEW AND ASSESSMENT OF ALL ELEMENTS OF EXECUTIVE COMPENSATION TO ENSURE THE OVERALL REASONABLENESS OF THE TOTAL COMPENSATION PROVIDED TO ITS EXECUTIVES. IN SEPTEMBER 2011, SULLIVAN, COTTER AND ASSOCIATES, INC ASSISTED THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES IN REVIEWING BLYTHEDALE'S EXECUTIVE COMPENSATION PHILOSOPHY STATEMENT AND A COMPENSATION COMMITTEE CHARTER STATEMENT. ADDITIONALLY, SULLIVAN COTTER PROVIDED TO THE BOARD'S COMPENSATION COMMITTEE AN ASSESSMENT OF THE COMPETITIVENESS OF THE TOTAL COMPENSATION PROVIDED TO BLYTHEDALE'S EXECUTIVES RELATIVE TO PREVALENT AND COMPARABLE MARKETPLACE PRACTICES. IN DECEMBER OF 2011 THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES APPROVED ALL 2012 EXECUTIVE COMPENSATION. IN DECEMBER OF 2012 THE COMPENSATION COMMITTEE APPROVED INCENTIVE COMPENSATION AWARDS FOR THE EXECUTIVE MANAGEMENT TEAM. SINCE ITS FOUNDING IN 1992, SULLIVAN COTTER'S EFFORTS HAVE BEEN DEVOTED TO ASSISTING HEALTHCARE ORGANIZATIONS WITH THE DESIGN AND IMPLEMENTATION OF COMPENSATION SYSTEMS AND PROGRAMS. THE FIRM HAS WORKED WITH OVER 700 HEALTHCARE ORGANIZATIONS INCLUDING MANY PEDIATRIC HOSPITALS/HEALTH SYSTEMS. SULLIVAN COTTER MAINTAINS A LIBRARY CONTAINING NEARLY ALL OF THE MAJOR HEALTHCARE EXECUTIVE COMPENSATION SURVEYS AS WELL AS THE RESULTS OF ITS OWN CUSTOM SURVEYS. IN ORDER FOR BLYTHEDALE TO ESTABLISH A "REBUTTABLE PRESUMPTION OF REASONABLENESS" ACCORDING TO INTERMEDIATE SANCTIONS REGULATIONS, EXECUTIVE'S COMPENSATION WAS REVIEWED TO ENSURE THE OVERALL REASONABLENESS OF THE "TOTAL" PACKAGE PROVIDED. THUS, SULLIVAN COTTER PREPARED AN ANALYSIS OF COMPPLUS360 TOTAL COMPENSATION (DOLLAR VALUE OF CASH PLUS BENEFITS) RELATIVE TO MARKET PRACTICE, WHICH WILL SATISFY REQUIREMENTS TO ESTABLISH A "REBUTTABLE PRESUMPTION OF REASONABLENESS." THE ANALYSIS ENABLED THE COMPENSATION COMMITTEE TO REVIEW COMPENSATION DATA FROM INDEPENDENT SOURCES FOR FUNCTIONALLY COMPARABLE POSITIONS IN ORGANIZATIONS COMPARABLE TO BLYTHEDALE TO ENSURE THAT COMPENSATION PROVIDED TO BLYTHEDALE EXECUTIVES IS REASONABLE AND CONSISTENT WITH THESE MARKET PRACTICES. THE ANALYSIS WAS SUBMITTED IN ACCORDANCE WITH THE PROVISIONS OF TREASURY REGULATION SECTION 53.4958-6(C)(2) AND IS ALSO INTENDED TO SATISFY THE PROFESSIONAL ADVICE REQUIREMENTS OF TREASURY REGULATION SECTION 53.4958-1(0)(III). IN LIGHT OF THESE PROVISIONS, THE COMPENSATION COMMITTEE ENSURED FULL DISCLOSURE AND TRANSPARENCY OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 BLYTHEDALE CHILDREN'S HOSPITAL MAKES ITS FORM 990 AND FORM 1023 AVAILABLE TO THE PUBLIC BY RETAINING A COPY OF EACH AT THE ADDRESS LISTED ON PAGE 1 OF THIS RETURN. THE ORGANIZATION' S FORM 990 IS ALSO AVAILABLE FOR PUBLIC INSPECTION ON WWW.GUIDESTAR .ORG. THE ORGANIZATION'S GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST AND AT MANAGEMENT'S DISCRETION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN PENSION LIABILITY -2,620,873. ROUNDING -2. NET ASSETS RELEASED FROM RESTRICTIONS - OPERATIONS 0.