2012-05-14T12:12:18-05:00 2011-06-30 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2010-07-01 020519436 ALLIANCE AMBULATORY SERVICES ALLI 6036683545 100 MCGREGOR ST MANCHESTER NH 03102 EDWARD L DUDLEY III 6036683545 2012-05-02 E DREW CHENEY 2078792100 2010 2016-02-24 21:20:13Z EDWARD L DUDLEY III 100 MCGREGOR ST MANCHESTER NH 03102 3130637 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 22 17 0 21 0 0 0 0 2962194 3130375 0 262 227 0 2962421 3130637 0 0 0 0 0 0 0 0 0 317432 317432 317432 317432 2644989 2813205 6162597 6535802 0 0 6162597 6535802 TO CREATE AND PROMOTE HEALTHCARE PROGRAMS IN THE MANCHESTER NEW HAMPSHIRE COMMUNITY. 0 0 317432 3130375 REVENUE FROM PARTNERSHIP INTEREST IN BEDFORD AMBULATORY SURGICAL CENTER, LLC 317432 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 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 22 17 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 ALYSON PITMAN GILES 1.00 X X 0 749399 371016 CONNOR J HAUGH 1.00 X 0 611034 16790 WILLIAM CLUTTERBUCK 1.00 X 0 353421 29595 GUY D CHAPDELAINE 1.00 X X 0 0 0 STEPHEN CAMANN 1.00 X X 0 0 0 JOSEPH GRAHAM 1.00 X X 0 0 0 MSGR JOHN P QUINN 1.00 X X 0 0 0 ADELE BOUFFORD BAKER 1.00 X 0 0 0 GARY BOUCHARD PHD 1.00 X 0 0 0 SUZANNA D MAJEWSKI 1.00 X 0 0 0 PAUL S BOYNTON 1.00 X 0 0 0 SUZANNE K MELLON PHD RN 1.00 X 0 0 0 DARYL J CADY 1.00 X 0 0 0 MARGARET-ANN MORAN ESQ 1.00 X 0 0 0 ANNE M O'CONNOR MD 1.00 X 0 0 0 ELEANOR WM DAHAR ESQ 1.00 X 0 0 0 RONALD J RIOUX 1.00 X 0 0 0 JEROME DUVAL 1.00 X 0 0 0 KEITH A STAHL MD 1.00 X 0 251327 27443 JEFF EISENBERG 1.00 X 0 0 0 REV GAYLE WHITTEMORE 1.00 X 0 0 0 RAEF FAHMY DPM 1.00 X 0 56612 0 BEJAMIN WESTBROOK MD 1.00 X 0 0 0 KATHLEEN ZAFFION MD 1.00 X 0 0 0 BISHOP FRANCIS J CHRISTIAN 1.00 X 0 0 0 RAYMOND BONITO 1.00 X 0 407078 132829 ALLEN ERICSON 1.00 X 0 342167 49551 KEVIN KILDAY 0.00 X 0 344398 44045 0 3115436 671269 0 1 1 0 0 INTEREST IN AMBULATORY 621990 3130375 3130375 3130375 262 262 3130637 3130375 0 262 317432 317432 317432 317432 0 0 113803 211065 6048794 6324737 6162597 6535802 0 0 X 6162597 6535802 6162597 6535802 6162597 6535802 X 2813205 -2440000 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 6324737 6324737 3130637 317432 2813205 -2440000 -2440000 373205 PART XI, LINE 8 - OTHER ADJUSTMENTS: TRANSFER TO AFFILIATES -2,440,000. X X X X X 1 1 0 0 0 0 0 1 0 ALYSON PITMAN GILES 0 611927 0 137472 0 0 0 274487 0 96529 0 1120415 0 0 CONNOR J HAUGH 0 491157 0 119877 0 0 0 14723 0 2067 0 627824 0 0 WILLIAM CLUTTERBUCK 0 353421 0 0 0 0 0 10979 0 18616 0 383016 0 0 KEITH A STAHL MD 0 219994 0 31333 0 0 0 8299 0 19144 0 278770 0 0 RAYMOND BONITO 0 346879 0 60199 0 0 0 91093 0 41736 0 539907 0 0 ALLEN ERICSON 0 306319 0 35848 0 0 0 16045 0 33506 0 391718 0 0 KEVIN KILDAY 0 344398 0 0 0 0 0 12707 0 31338 0 388443 0 0 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 $137,977 4B: THE FOLLOWING INDIVIDUALS TAKE PART IN A SECTION 457(F) FORFEITABLE NONQUALIFIED DEFERRED COMPENSATION PLAN. THIS REPRESENTS CONTRIBUTIONS FOR MANY YEARS OF SERVICE. ALYSON PITMAN GILES: $257,348 RAYMOND BONITO: $80,065 ALLEN ERICSON: $5,019 KEVIN KILDAY: $9,356 PART I, LINE 7 A PORTION OF COMPENSATION IS AT-RISK AND VARIABLE, AND PAYMENT DEPENDS ON THE QUALITY OF JOB PERFORMANCE. 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 A FORM 990 IS PRESENTED TO THE BOARD BEFORE IT IS FINALIZED. 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 GOVERNING DOCUMENTS, THE CONFLICT OF INTEREST POLICY, AND THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FROM 990, PART VII, LINE 1B: AVERAGE HOURS PER WEEK FOR A RELATED ORGANIZATION ALYSON GILES: 60 HRS WILLIAM CLUTTERBUCK, MD: 40 HRS CONNOR HAUGH, MD: 40 HRS KEITH STAHL, MD: 40 HRS RAYMOND BONITO: 50 HRS ALLEN ERICSON: 50 HRS RAEF FAHMY, DPM: 40 HRS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: TRANSFER TO AFFILIATES -2,440,000. TOTAL TO FORM 990, PART XI, LINE 5: -2,440,000. ALLIANCE HEALTH SERVICES 100 MCGREGOR ST MANCHESTER NH 03102 611508839 PRACTICES NH 501(C)(3) LINE 11B, II CMC SYSTEM 0 CATHOLIC MEDICAL CENTER 100 MCGREGOR ST MANCHESTER NH 03102 020315693 HOSPITAL NH 501(C)(3) LINE 3 CMC SYSTEM 0 CMC HEALTHCARE SYSTEM 100 MCGREGOR ST MANCHESTER NH 03102 010568516 PARENT NH 501(C)(3) LINE 11B, II N/A 0 CMC ASSOCIATES 100 MCGREGOR ST MANCHESTER NH 03102 020344786 GIFT SHOP NH 501(C)(3) LINE 11B, II CMC 0 CMC PHYSICIAN PRACTICE ASSOCIATES 100 MCGREGOR ST MANCHESTER NH 03102 020460245 PRACTICES NH 501(C)(3) LINE 11B, II CMC SYSTEM 0 NEHI FOUNDATION 100 MCGREGOR ST MANCHESTER NH 03102 223041916 SUPPORT NH 501(C)(3) LINE 7 CMC 0 ST PETERS HOME 100 MCGREGOR ST MANCHESTER NH 03102 020222228 HOME NH 501(C)(3) LINE 9 CMC SYSTEM 0 ALLIANCE RESOURCES 100 MCGREGOR ST MANCHESTER NH 03102 020398138 REAL ESTATE NH 501(C)(3) LINE 11B, II CMC SYSTEM 0 MCGREGOR STEET MOB 100 MCGREGOR ST MANCHESTER NH 03102 134347316 MEDICAL OFFICE BUILDING NH CMC SYSTEM 0 0 0.00000 DOCTORS MEDICAL ASSOCIATION 100 MCGREGOR ST MANCHESTER NH 03102 020340690 MEDICAL OFFICE BUILDING NH CMC SYSTEM C ALLIANCE ENTERPRISES 100 MCGREGOR ST MANCHESTER NH 03102 020386795 REAL ESTATE NH CMC 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 0 3726826 0 0 1