2012-08-06T15:10:39-05:00 2011-09-30 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2010-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON 5089417000 2012-07-25 1 ALAN GAROFALO 6177427788 2010 2016-02-24 21:20:13Z KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 5147490 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. 17 12 0 191 0 0 236421 194997 0 0 366743 395471 1764989 1523827 2368153 2114295 0 0 0 0 0 0 0 20000 402799 453255 557820 453255 577820 1914898 1536475 68135959 65184942 28786629 25866130 39349330 39318812 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 1291373 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. 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 7 0 1 0 1 0 0 0 0 0 1 1 0 0 0 0 X 17 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 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 A DRINKWATER MD 1.00 X 0 493975 30607 DAVID P FRENETTE 1.00 X 0 0 0 ROBERT S GREENBERG MD 1.00 X 0 274141 39297 ROBERT J MCMAHAN 1.00 X 0 0 0 PATRICIA TORTORELLA 1.00 X 0 0 0 JAMES E LEARY 1.00 X 0 0 0 TIMOTHY R LYNCH MD 1.00 X 0 251245 17235 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 DALE J ELLENBERG MD 1.00 X 0 216774 37206 MICHAEL L DERN MD 1.00 X 0 355782 44061 DAVID R WOLOHOJIAN 1.00 X 0 0 0 MARY WALDRON 1.00 X 0 0 0 KEVIN P LEONARD 40.00 X 0 247363 42055 KIM HOLLON 40.00 X 0 239607 21188 JULIE G WHITE MD 0.00 X 0 319847 29926 ROBERT COVETT MD 0.00 X 0 301043 17099 EUGENE C WALLACE 0.00 X 0 478126 32508 NORMAN B GOODMAN 0.00 X 0 155772 0 0 3333675 311182 0 1 1 0 CRESCENT CREDIT UNION PO BOX 4290 BROCKTON MA 02303 FACILITIES 137660 1 49129 145868 194997 343768 343768 3753000 2892227 860773 860773 860773 51703 51703 51703 51703 373422 49129 140968 232454 232454 BLUE CROSS REVENUE 900099 430600 430600 430600 2114295 1291373 0 627925 20000 20000 FUNDRAISING EXPENSES 382799 382799 ADMINISTRATION EXPENSES 175021 175021 577820 0 175021 402799 78254 116426 436000 494500 31828 45966986 7077484 40161102 38889502 13448523 8948378 13980252 16736136 68135959 65184942 97133 78909 28105920 25186137 583576 601084 28786629 25866130 X 36733870 36849618 1160379 1014113 1455081 1455081 39349330 39318812 68135959 65184942 X 1536475 -1566993 X 0 1 1 X 0 X X 0 0 0 BROCKTON HOSPITAL AMBASSADORS CLUB INC 043160078 9 1 1 1 0 SIGNATURE MEDICAL GROUP INC 043306782 9 1 1 1 0 BROCKTON HOSPITAL INC 222472297 3 1 1 1 0 3 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3335390 -168892 0 3166498 3187674 147716 3335390 3404596 250 -217172 3187674 0.00000 0.96000 0.04000 0 0 2857454 2857454 39193950 4341570 34852380 2989692 2335430 654262 423790 334302 89488 502100 66182 435918 38889502 LONG TERM INVESTMENTS 6479184 F TEMPORARILY RESTRICTED INVESTMENTS 1014113 F PERMANENTLY RESTRICTED INVESTMENTS 1455081 F 8948378 DUE FROM RELATED PARTY 13982055 SPLIT DOLLAR LIFE INSURANCE POLICY 2461500 DEBT ISSUE COSTS, NET 292581 16736136 DEFERRED ASSET RETIREMENT OBLIGATION 601084 601084 2114295 577820 1536475 -1566993 -1566993 -30518 4603723 2489428 2489428 2114295 0 2114295 3067248 2489428 2489428 577820 0 577820 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: EFFECTIVE OCTOBER 2008, NEW ACCOUNTING GUIDANCE WAS ISSUED FOR ACCOUNTING AND REPORTING FOR UNCERTAINTY IN INCOME TAXES. THE CORPORATION ADOPTED THIS STANDARD AND IT DID NOT HAVE A MATERIAL IMPACT ON ITS FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: UNREALIZED LOSS ON UNRESTRICTED INVESTMENTS -693,732. UNREALIZED LOSS ON TEMP RESTRICTED INVESTMENTS -201,884. TRANSFER FROM AFFILIATE 10,623. CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY -682,000. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,892,227. FUNDRAISING EXPENSES -402,799. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,892,227. FUNDRAISING EXPENSES -402,799. X X X X X 1 SALIENT HEALTH SOLUTIONS 99 SUMMER STREET BOSTON MA 02110 GRANT WRITER 0 0 0 20000 20000 RING OF CHAMPIONS 84101 2375 81726 50 1044 1449 15397 350 3379 CANCER WALK 213387 32955 180432 614 6196 6230 2364 105 85543 1 125063 13799 111264 60 3359 11228 0 3600 422551 49129 373422 724 10599 7679 28989 455 92522 140968 232454 X 1 1 X X X X X X 1 1 0 0 0 0 0 0 0 DAVID A DRINKWATER MD 0 493975 0 0 0 0 0 14419 0 16188 0 524582 0 0 ROBERT S GREENBERG MD 0 272426 0 0 0 1715 0 22000 0 17297 0 313438 0 0 TIMOTHY R LYNCH MD 0 251245 0 0 0 0 0 0 0 17235 0 268480 0 0 DALE J ELLENBERG MD 0 216774 0 0 0 0 0 20000 0 17206 0 253980 0 0 MICHAEL L DERN MD 0 355782 0 0 0 0 0 22000 0 22061 0 399843 0 0 KEVIN P LEONARD 0 247363 0 0 0 0 0 20800 0 21255 0 289418 0 0 KIM HOLLON 0 224276 0 0 0 15331 0 12321 0 8867 0 260795 0 0 JULIE G WHITE MD 0 319847 0 0 0 0 0 16120 0 13806 0 349773 0 0 ROBERT COVETT MD 0 276043 0 25000 0 0 0 8914 0 8185 0 318142 0 0 EUGENE C WALLACE 0 365624 0 0 0 112502 0 18615 0 13893 0 510634 0 0 NORMAN B GOODMAN 0 0 0 0 0 155772 0 0 0 0 0 155772 0 0 PART I, LINES 4A-B THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RESIGNED IN JUNE 2009. PURSUANT TO AN AGREEMENT BETWEEN THE PARTIES, THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RECEIVED CERTAIN SEPARATION PAYMENTS FROM BROCKTON HOSPITAL (A RELATED ORGANIZATION) IN CALENDAR YEAR 2010. CONSISTENT WITH REPORTING REQUIREMENTS FOR IRS FORM 990, COMPENSATION AND OTHER PAYMENTS TO EMPLOYEES AND FORMER EMPLOYEES ARE REPORTED ON A CALENDAR YEAR (FORM W-2) BASIS. CONSEQUENTLY, SEPARATION PAYMENTS TO THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER MADE IN CALENDAR YEAR 2010 AMOUNTING TO $155,772 ARE REPORTED FOR THE FISCAL YEAR ENDED 9/30/11. THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RESIGNED IN SEPTEMBER 2010, AND HAS A SEVERANCE ARRANGEMENT WHICH STATES THAT THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER WILL RECEIVE BASE SALARY PLUS CONTINUATION OF BENEFITS FOR THREE MONTHS. THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RECEIVED SEPARATION PAYMENTS TOTALING $112,502 DURING CALENDAR YEAR 2010. NORMAN B GOODMAN LOAN RECEIVABLE (SPLIT DOLLAR LIFE INSURANCE POLICY) X 2461500 2461500 0 1 1 2461500 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 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: UNREALIZED LOSS ON UNRESTRICTED INVESTMENTS -693,732. UNREALIZED LOSS ON TEMP RESTRICTED INVESTMENTS -201,884. TRANSFER FROM AFFILIATE 10,623. CHANGE IN FAIR VALUE OF SPLIT DOLLAR LIFE POLICY -682,000. TOTAL TO FORM 990, PART XI, LINE 5: -1,566,993. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE STREET BROCKTON MA 02302 320048951 REALTY COMPANY MA 3204000 33218237 SIGNATURE HEALTHCARE CORPORATION BROCKTON HOSPITAL AMBASSADORS CLUB INC 680 CENTRE STREET BROCKTON MA 02302 043160078 FUNDRAISING MA 501C(3) 501C(3) SIGNATURE HEALTHCARE CORPORATION 0 SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE STREET BROCKTON MA 02302 043306782 MEDICAL CARE MA 501C(3) 501C(3) SIGNATURE HEALTHCARE CORPORATION 0 BROCKTON HOSPITAL INC 680 CENTRE STREET BROCKTON MA 02302 222472297 MEDICAL CARE MA 501C(3) 501C(3) SIGNATURE HEALTHCARE CORPORATION 0 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN PRACTICE MA SIGNATURE HEALTHCARE CORPORATION C 42433980 14196195 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 549000 FMV SIGNATURE MEDICAL GROUP INC P 13567 FMV SIGNATURE MEDICAL GROUP INC R 19000 FMV BROCKTON HOSPITAL INC B 174945 FMV BROCKTON HOSPITAL INC N 289963 FMV BROCKTON HOSPITAL INC O 127400 FMV BROCKTON HOSPITAL INC P 150541 FMV BROCKTON HOSPITAL INC Q 815120 FMV BROCKTON HOSPITAL INC R 200030 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES O 2300000 FMV BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES Q 10000 FMV 110 LIBERTY STREET COMPANY LLC Q 1333334 FMV