2012-08-09T14:54:01-05:00 2011-09-30 FEELEY & DRISCOLL PC 200 PORTLAND STREET BOSTON MA 02114 990 2010-10-01 222472997 BROCKTON HOSPITAL INC BROC 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON 5089417000 2012-08-08 1 ALAN GAROFALO 6177427788 2010 2016-02-24 21:20:13Z KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 206098310 0 X WWW.SIGNATURE-HEALTHCARE.ORG X 1890 MA THE HOSPITAL OPERATES A 253 BED ACUTE CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO 20 COMMUNITIES IN SOUTHEASTERN MASSACHUSETTS. IN FISCAL YEAR 2011 THE HOSPITAL PROVIDED $16,538,684 OF UNREIMBURSED CHARITY CARE. THIS EQUATES TO THOUSANDS OF VISITS TO PRIMARY CARE AND SPECIALTY CLINICS. THE HOSPITAL'S CHILDREN AND YOUTH PROGRAM, A HOSPITAL-BASED PRIMARY CARE PRACTICE THAT TREATS UNDER-PRIVILEGED CHILDREN, ACCOMMODATED APPROXIMATELY 11,000 PATIENT VISITS. THOUSANDS OF UNDERINSURED PEOPLE TOOK ADVANTAGE OF ONGOING COMMUNITY HEALTH LECTURES, SCREENINGS, CLASSES AND SUPPORT GROUPS BOTH AT THE HOSPITAL AND IN THE COMMUNITY. 17 12 1937 174 399257 -230894 60422 359394 208030249 195529352 1489191 2024830 8450222 8184734 218030084 206098310 0 0 0 0 108265722 107738311 0 0 0 90074266 82172442 198339988 189910753 19690096 16187557 113969058 121382625 106711042 115084661 7258016 6297964 BROCKTON HOSPITAL'S MISSION IS TO BE A PRIVATE NOT-FOR-PROFIT COMMUNITY BASED HOSPITAL THAT IS RECOGNIZED AS THE "HOSPITAL OF CHOICE" BY STAFF, PATIENTS, AND THE COMMUNITY IT SERVES. 0 0 167687104 201231716 THE HOSPITAL OPERATES A 253 BED ACUTE CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO 20 COMMUNITIES IN SOUTHEASTERN MASSACHUSETTS. IN FISCAL YEAR 2011 THE HOSPITAL PROVIDED $16,538,684 OF UNREIMBURSED CHARITY CARE. THIS EQUATES TO THOUSANDS OF VISITS TO PRIMARY CARE AND SPECIALTY CLINICS. THE HOSPITAL'S CHILDREN AND YOUTH PROGRAM, A HOSPITAL-BASED PRIMARY CARE PRACTICE THAT TREATS UNDER-PRIVILEDGED CHILDREN, ACCOMODATED APPROXIMATELY 11,000 PATIENT VISITS. THOUSANDS OF UNDERINSURED PEOPLE TOOK ADVANTAGE OF ONGOING COMMUNITY HEALTH LECTURES, SCREENINGS, CLASSES AND SUPPORT GROUPS BOTH AT THE HOSPITAL AND IN THE COMMUNITY. 167687104 1 1 0 1 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 274 0 1 1937 1 1 1 0 0 0 0 0 0 0 0 0 X 17 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 0 MA X X KIM HOLLON 5089417000 680 CENTRE STREET BROCKTON MA 023023395 ROBERT J MCMAHAN 1.00 X 0 0 0 TIMOTHY R LYNCH MD 1.00 X 0 251245 17235 JAMES E LEARY 1.00 X 0 0 0 MICHAEL J SULLIVAN 1.00 X 0 0 0 PATRICIA TORTORELLA 1.00 X 0 0 0 DALE J ELLENBERG MD 1.00 X 0 216774 37206 ROBERT D SULLIVAN 1.00 X 0 0 0 ROBERT S GREENBERG MD 1.00 X 0 274141 39297 MICHAEL L DERN MD 1.00 X 0 355782 44061 DAVID R WOLOHOJIAN 1.00 X 0 0 0 TIMOTHY J CRUZ 1.00 X 0 0 0 DAVID P FRENETTE 1.00 X 0 0 0 PATTI ROLAND 1.00 X 0 0 0 DAVID DRINKWATER MD 1.00 X 0 493975 30607 WALLACE H PECKHAM III 1.00 X 0 0 0 JOSEPH P DRIER III 1.00 X 0 0 0 MARY V WALDRON 1.00 X 0 0 0 KEVIN P LEONARD 40.00 X 247363 0 42055 KIM N HOLLON 40.00 X 239607 0 21188 KIMBERLY WALSH 40.00 X 213543 0 30067 DEBORAH WILSON 40.00 X 313278 0 46034 STEPHEN BORGES 40.00 X 158808 0 32946 DAVID J FISHER 40.00 X 177179 0 51191 STELLA A PARRY 40.00 X 200410 0 33937 KIM MCCARTHY-WALSH 40.00 X 162486 0 29102 BEVERLY A CAPECE 40.00 X 154789 0 38699 KENNETH LUCAS 40.00 X 149915 0 38243 ELAINE GILL 40.00 X 186779 0 0 JULIE WHITE MD 0.00 X 0 319847 29926 ROBERT COVETT MD 0.00 X 0 301043 17099 NORMAN B GOODMAN 0.00 X 155772 0 0 EUGENE C WALLACE 40.00 X 478126 0 32508 2838055 2212807 611401 110 1 1 0 MATRIX ANESTHESIA PD 1342 BELMONT STREET BROCKTON MA 02302 PHYSICIAN SERVICES 2528341 PRATT PEDIATRIC ASSOCIATES 750 WASHINGTON STREET BOSTON MA 02111 PHYSICIAN SERVICES 491420 ROPES & GRAY ONE INTERNATIONAL PLACE BOSTON MA 021102624 LEGAL 481456 FISHER COLLEGE 118 BEACON STREET BOSTON MA 02116 TEACHING SERVICES 416444 PRICEWATERHOUSECOOPERS PO BOX 7247-8001 PHILADELPHIA PA 19170 AUDIT SERVICES 365827 16 254625 104769 359394 PATIENT SERVICE REVENU 900099 191487843 191487843 MEANINGFUL USE EHR REV 900099 3642252 3642252 OUTREACH LAB SERVICES 541380 399257 399257 195529352 1835495 1835495 189335 189335 189335 189335 SCHOOL OF NURSING 900099 4749772 4749772 VANTAGE JOINT VENTURE 900099 1124867 1124867 CAFETERIA 900099 667458 667458 1642637 226982 1415655 8184734 206098310 201231716 399257 4107943 2702612 1972907 729705 83277432 76527361 6750071 4620725 3373129 1247596 10849511 7920143 2929368 6288031 4590263 1697768 4194147 4142051 52096 891574 650849 240725 201000 146730 54270 58000 42340 15660 460182 336420 123762 3089265 2623707 465558 1417363 1034675 382688 3196549 2333481 863068 55730 45821 9909 1726247 1260160 466087 6162535 4498651 1663884 2058948 1503032 555916 OTHER PROFESSIONAL SERV 18949046 17775579 1173467 PURCHASED SERVICES 9449361 7925218 1524143 MEDICAL AND SURGICAL SU 9073566 9051324 22242 DRUGS AND MEDICATIONS 5977406 5970396 7010 CLINICAL SUPPLIES 5845648 5828201 17447 9365875 8134666 1231209 189910753 167687104 22223649 0 2641451 2114147 18725912 21183086 25478617 26537952 933518 1456714 1813185 5555954 169995125 135081879 37849104 34913246 13448523 8948378 13078748 20673148 113969058 121382625 21057210 22789167 1698400 1390839 38110794 36915292 6901961 6431372 1414622 37528055 47557991 106711042 115084661 X 2963745 2136591 1160379 1108286 3133892 3053087 7258016 6297964 113969058 121382625 X 16187557 -17147609 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 0 0 1 214100 214100 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE HOSPITAL PAID THE FOLLOWING COMPANIES FOR LOBBYING ON BEHALF OF THE HOSPITAL REGARDING VARIOUS STATE AND FEDERAL LEGISLATION IMPACTING BOTH THE HOSPITAL AND THE HEALTHCARE INDUSTRY AS A WHOLE. THESE ACTIVITIES REPRESENT AN INSUBSTANTIAL PART OF THE HOSPITAL'S ACTIVITIES. $40,000 WENT TO DENNIS A. SMITH ASSOCIATES, $40,000 WAS PAID TO NELSON, MULLINS, RILEY AND SCARBOROUGH. $60,800 WAS PAID TO ELLEN MURPHY & ASSOCIATES. THE ALLOCATED PORTION OF DUES TO THE FOLLOWING ORGANIZATIONS: $25,259 MASSACHUSETTS HOSPITAL ASSOCIATION; $9,069 AMERICAN HOSPITAL ASSOCIATION. ADDITIONALLY, $38,972 OF STAFF WAGES HAS BEEN ALLOCATED TO LOBBYING IN RELATION TO STAFF EFFORTS TO SIMILARLY REPRESENT THE INTERESTS OF THE HOSPITAL AND THE HEALTHCARE INDUSTRY AS A WHOLE IN RELATION TO VARIOUS FEDERAL AND STATE LEGISLATION. 3335390 -168892 0 3166498 3187674 147716 3335390 3404596 250 -217172 3187674 0.96000 0.04000 0 0 30564 30564 56922706 35323012 21599694 112561495 99758867 12802628 480360 480360 34913246 INTEREST IN SIGNATURE HEALTHCARE, INC. INVESTMENTS 8948378 F 8948378 ASSETS WHOSE USE IS LIMITED 19102518 UNAMORTIZED BOND ISSUANCE COSTS 161618 INVESTMENT IN JOINT VENTURE 722767 LOAN RECEIVABLE - SPLIT DOLLAR LIFE INSURANCE 624000 SECURITY DEPOSIT 62245 20673148 AMOUNTS DUE 3RD PARTY PAYORS 4637951 PENSION LIABILITY 42920040 47557991 206098310 189910753 16187557 -1600492 -15547117 -17147609 -960052 206098310 0 206098310 0 206098310 189910753 0 189910753 0 189910753 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF INDIVIDUAL DONOR RESTRICTED ENDOWMENT FUNDS FOR A VARIETY OF PURPOSES AS WELL AS SPLIT INTEREST AGREEMENTS, WHICH HAVE BEEN DESIGNATED FOR ENDOWMENT. PART XI, LINE 8 - OTHER ADJUSTMENTS: ADJUSTMENT TO MINIMUM PENSION LIABILITY -10,783,625. CHANGE IN INTEREST IN INVESTMENTS OF SIGNATURE HEALTHCARE, INC. -4,847,035. TRANSFERS FROM SIGNATURE HEALTHCARE CORPORATION FOR CAPITAL 174,945. CHANGE IN FAIR VALUE OF SPLIT-INTEREST AGREEMENTS -91,402. 1 1 1 X 0 1 0 1 1 10056000 7346673 2709327 0.01430 41816235 38229376 3586859 0.01890 4925422 4152806 772616 0.00410 56797657 49728855 7068802 0.03730 10136 0 10136 0.00010 7295210 7203470 91740 0.00050 6446829 4814779 1632050 0.00860 14500 14500 0.00010 13766675 12018249 1748426 0.00930 70564332 61747104 8817228 0.04660 45 30 45 30 1 12153431 62618989 55955569 6663420 X 1 1 1 1 BROCKTON HOSPITAL INC

680 CENTRE STREET BROCKTON MA 02302

X X X TCU/PSYCH BROCKTON HOSPITAL 1 1 X X X X X X X 10 1 1 1 X X X X X X 0 1 1 200.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X X X 1 X 1 1 X 0 0 PART III, LINE 4: THE HOSPITAL PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS EQUAL TO ESTIMATED BAD DEBT LOSSES. THE ESTIMATED LOSSES ARE BASED ON HISTORICAL COLLECTION EXPERIENCE TOGETHER WITH A REVIEW OF THE CURRENT STATUS OF EXISTING RECEIVABLES.THE HOSPITAL USED A RATIO OF ITS TOTAL COSTS TO CHARGES TO CALCULATE THE AMOUNT OF BAD DEBT EXPENSE AT COST. PART III, LINE 8: THE HOSPITAL USED A RATIO OF ITS TOTAL COSTS TO CHARGES TO CALCULATE THE ALLOWABLE COSTS RELATED TO MEDICARE REVENUE RECEIVED. BROCKTON HOSPITAL PART V, SECTION B, LINE 3: THIS COMMUNITY HEALTH NEEDS ASSESSMENT WAS LEAD BY HEALTH IMPERATIVES WITH PARTICIPATION FROM COMMUNITY AGENCIES AND SIGNATURE HEALTHCARE WAS A PART OF THAT GROUP. THE NEEDS ASSESSMENT USED A FIVE PRONGED APPROACH TO ADDRESS THE AREAS OF FOCUS AND THEY INCLUDE THE FOLLOWING. FIRST AN EMPLOYEE OF HEALTH IMPERATIVES CONDUCTED COMMUNITY IMPRESSION SESSIONS MAINLY WITH BROCKTON RESIDENTS TO EXAMINE THEIR PERCEPTIONS OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH PROBLEMS IN THAT AREA. SECONDLY, EXISTING DATA WAS ANALYZED TO DETERMINE HOW HEALTH OUTCOMES IN THE CITY OF BROCKTON AND SURROUNDING TOWNS DIFFER FROM THE STATES OVERALL NUMBERS. THIRD, ANONYMOUS SURVEYS WERE GIVEN TO AREA RESIDENTS THROUGH BOXES LOCATED IN AREA TOWNS. FOURTH, A REVIEW OF EXISTING PROGRAMS AND SERVICES IN THE AREA WAS DONE TO DETERMINE GAPS IN SERVICES. LASTLY, KEY INFORMANT INTERVIEW WERE GIVEN TO CHNA TOWNS OTHER THAN BROCKTON TO DISCOVER HOW THE NEEDS OF RESIDENTS IN AREA TOWNS COMPARE TO THE NEEDS OF RESIDENTS INSIDE THE CITY. BROCKTON HOSPITAL PART V, SECTION B, LINE 4: CARITAS GOOD SAMARITAN HOSPITAL BROCKTON HOSPITAL PART V, SECTION B, LINE 5C: CHNA ORGANIZATION WEBSITE. BROCKTON HOSPITAL PART V, SECTION B, LINE 7: THE HEALTH NEEDS ASSESSMENT WAS VERY IN DEPTH. THE HOSPITAL DOES NOT BELIEVE THERE WOULD BE ANY WAY FOR IT TO ADDRESS ALL OF THE NEEDS FOUND IN THIS DOCUMENT. FOR INSTANCE, THERE WERE ISSUES FOUND REGARDING HOUSING AND HOMELESSNESS AND WE DON'T BELIEVE THAT WE PROVIDE A SPECIFIC PROGRAM TO ASSIST THESE TYPES OF PEOPLE, BUT WE ARE SURE IF SOMEONE CAME INTO OUR HOSPITAL AND WAS IN NEED OF SHELTER, THAT OUR SOCIAL WORKERS WOULD TRY TO MAKE ARRANGEMENTS FOR THEM. WE DO PROVIDE GREAT ACCESS TO HEALTH CARE IN THE BROCKTON AREA WITH VARIOUS SITES IN THE CITY THAT PROVIDE PRIMARY AND SPECIALTY CARE, LABORATORY AND RADIOLOGY SERVICES AS WELL AS INTERPRETER SERVICES AT OUR AMBULATORY SITES. AS FOR SAFETY, WE DON'T HAVE MUCH TO DO WITH SAFETY FOR THE CITY , BUT DO PROVIDE SECURITY AT AND AROUND OUR HOSPITAL FACILITY. NEXT WOULD BE SUBSTANCE USE AND BEHAVIORAL HEALTH. THIS IS NOT PART OF OUR COMMUNITY BENEFIT PROGRAM, BUT WE DO HAVE PSYCHIATRY SERVICES ALONG WITH PROGRAMS RELATED TO SUBSTANCE ABUSE WITHIN OUR EMERGENCY DEPARTMENT. NEXT IS MATERNAL AND CHILD HEALTH AND AGAIN IT'S NOT NECESSARILY PART OF OUR COMMUNITY BENEFIT, BUT WE DO HAVE OUR FAIRLY NEW CENTER FOR HEALTHY BEGINNINGS PROGRAM. INDIVIDUALS ARE ABLE TO STOP IN AND RECEIVE A FREE PREGNANCY TEST, IF THEY ARE PREGNANT, OUR HEALTHY BEGINNINGS STAFF WILL WORK WITH THEM TO REGISTER FOR INSURANCE IF NEEDED AND GET THEM SCHEDULED WITH AN OB/GYN PROVIDER. THESE PATIENTS ARE FOLLOWED ALL THROUGH THEIR CARE FROM PRE-NATAL CARE TO DELIVERY AND BEYOND. PRIOR TO DELIVERY, THE PATIENTS ARE ABLE TO MEET WITH SOME OF THE PEDIATRICIANS FROM SIGNATURE HEALTHCARE SO THE IMPORTANCE OF HAVING A PRIMARY CARE FOR THEIR CHILDREN BEFORE DELIVERY IS EXPLAINED AND A RELATIONSHIP IS ESTABLISHED. IN ADDITION, WE ALSO HAVE CHILDBIRTH EDUCATION THAT IS PROVIDED BY ONE OF OUR LABOR AND DELIVERY NURSES. NOT ONLY IS EDUCATION GIVEN PRIOR TO DELIVERY BUT BABY AND ME CLASSES ARE OFFERED AT NO COST AFTER DELIVERY AS WELL AS A BREASTFEEDING SUPPORT GROUP. THE NEXT ISSUE THAT CAME UP WAS WITH STD'S AND HIV, AND ALTHOUGH WE DON'T HAVE A PROGRAM THAT DEALS WITH THESE ISSUES WE DO HAVE OB/GYN'S WHO WOULD HANDLE ISSUES AS WELL AS INFECTIOUS DISEASE PROVIDERS IN BROCKTON AND RANDOLPH. IN SECTION 8 IT MENTIONS RISK BEHAVIORS AND HEALTH SCREENINGS AND THIS IS SOMETHING THAT WE DO ON A REGULAR BASIS. WE AS AN ORGANIZATION PARTICIPATE IN OVER 30 COMMUNITY OUTREACH EVENTS PER YEAR AND MANY OF THEM INCLUDE FREE GLUCOSE, CHOLESTEROL AND BLOOD PRESSURE SCREENINGS. WE HAVE IN THE PAST ALSO PROVIDED VASCULAR SCREENINGS AT NO COST WHICH INCLUDES PAD, AAA AND CAROTID ARTERY SCANS. NOT ONLY THAT, BUT OUR RADIATION THERAPY DEPARTMENT HAS WORKED WITH AN AREA ENT GROUP TO OFFER FREE HEAD & NECK CANCER SCREENINGS AS WELL AS PROSTATE CANCER SCREENINGS WHICH ARE FREE TO THE PUBLIC. THE SECTION ON CHRONIC DISEASE IS WHERE OUR COMMUNITY BENEFIT DOES FALL INTO AS WE'VE BEEN FOCUSING IN FY11 AND FY12 ON DIABETES AND OBESITY AND ISSUES AROUND THESE TWO AREAS WERE IDENTIFIED IN THE NEEDS ASSESSMENT. IT DOES ALSO MENTION ASTHMA AS BEING A CONCERN AND ALTHOUGH IT'S NOT THE COMMUNITY BENEFIT, OUR PEDIATRICS DEPARTMENT DOES PROVIDE FREE EDUCATION AND HOSTS A FREE ASTHMA CAMP EACH FALL. X 0 1 X X X X X X 1 1 0 0 0 0 0 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 ROBERT S GREENBERG MD 0 272426 0 0 0 1715 0 22000 0 17297 0 313438 0 0 MICHAEL L DERN MD 0 355782 0 0 0 0 0 22000 0 22061 0 399843 0 0 DAVID DRINKWATER MD 0 493975 0 0 0 0 0 14419 0 16188 0 524582 0 0 KEVIN P LEONARD 247363 0 0 0 0 0 20800 0 21255 0 289418 0 0 0 KIM N HOLLON 224276 0 0 0 15331 0 12321 0 8867 0 260795 0 0 0 KIMBERLY WALSH 213543 0 0 0 0 0 16500 0 13567 0 243610 0 0 0 DEBORAH WILSON 306598 0 0 0 6680 0 33000 0 13034 0 359312 0 0 0 STEPHEN BORGES 158808 0 0 0 0 0 10400 0 22546 0 191754 0 0 0 DAVID J FISHER 177179 0 0 0 0 0 31300 0 19891 0 228370 0 0 0 STELLA A PARRY 200410 0 0 0 0 0 17938 0 15999 0 234347 0 0 0 KIM MCCARTHY-WALSH 162486 0 0 0 0 0 22000 0 7102 0 191588 0 0 0 BEVERLY A CAPECE 154789 0 0 0 0 0 16500 0 22199 0 193488 0 0 0 KENNETH LUCAS 149915 0 0 0 0 0 21600 0 16643 0 188158 0 0 0 ELAINE GILL 0 0 0 0 186779 0 0 0 0 0 186779 0 0 0 JULIE 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 NORMAN B GOODMAN 0 0 0 0 155772 0 0 0 0 0 155772 0 0 0 EUGENE C WALLACE 365624 0 0 0 112502 0 18615 0 13893 0 510634 0 0 0 PART I, LINE 1B THE COMPENSATION ELEMENTS INDICATED ON SCHEDULE J, PART I (TAX INDEMNIFICATION/GROSS-UP PAYMENTS) WERE PROVIDED PURSUANT TO THE EMPLOYMENT CONTRACT MAINTAINED BETWEEN THE HOSPITAL AND THE INDIVIDUAL. PART I, LINES 4A-B THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RESIGNED FROM THE HOSPITAL IN JUNE 2009. PURSUANT TO AN AGREEMENT BETWEEN THE PARTIES, THE FORMER PRESIDENT AND CHIEF EXECUTIVE OFFICER RECEIVED CERTAIN SEPARATION PAYMENTS FROM THE HOSPITAL IN CALENDAR YEAR 2010 AND CONTINUED TO RECEIVE PAYMENTS THROUGH 2011. 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, 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 ENDING 9/30/2011. 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. THE SENIOR VICE PRESIDENT OF AMBULATORY SERVICES AND PHYSICIAN SERVICES RESIGNED IN JANUARY 2011, AND HAS A SEVERANCE AGREEMENT WHICH STATES THAT IN THE EVENT OF TERMINATION OF EMPLOYMENT WITHOUT CAUSE, THE SENIOR VICE PRESIDENT WOULD RECEIVE BASE SALARY PLUS CONTINUATION OF BENEFITS FOR NINE MONTHS. DURING THE YEAR ENDED 9/30/2011 THE HOSPITAL MADE SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CONTRIBUTIONS 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 9/30/2011: DEBORAH WILSON - $16,500 DAVID FISHER - $9,300 MICHAEL L CONNORS LOAN RECEIVABLE - SPLIT DOLLAR LIFE INSURANCE POLICY X 624000 624000 0 1 1 624000 ROBERT D SULLIVAN SISTER AND BROTHER-IN-LAW 168934 THE HOSPITAL PAID FOR MOVING SERVICES AND RECORD STORAGE FEES TO THIS INTERESTED PERSON. 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S FORM 990 IS PREPARED BY AN OUTSIDE INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT IN CONJUCTION WITH INPUT PROVIDED BY ORGANIZATION MANAGEMENT. THE COMPLETED FORM 990 WAS PROVIDED TO EACH BOARD MEMBER ELECTRONICALLY. IN ADDITION, A BOARD MEETING WAS CONVENED TO REVIEW THE FORM 990 IN ADVANCE OF THE FILING DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR THE ORGANIZATION CIRCULATES A CONFLICT OF INTEREST QUESTIONNAIRE. RESPONSES TO THE STATEMENT ARE REVIEWED 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 18 THE ORGANIZATION MAKES ITS 990 AND 990-T AVAILABLE UPON REQUEST. ADDITIONALLY, THE ORGANIZATION'S FORM 990 IS AVAILABLE ON THE WEBSITE OF THE MASSACHUSETTS ATTORNEY GENERAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS CONFLICT OF INTEREST, FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ADDITIONALLY, THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE WEBSITE OF THE MASSACHUSETTS ATTORNEY GENERAL AS WELL AS WITH THE MUNICIPAL SECURITIES RULEMAKING BOARD. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,600,492. TRANSFERS FROM SIGNATURE HEALTHCARE CORPORATION FOR CAPITAL 174,945. ADJUSTMENT TO MINIMUM PENSION LIABILITY -10,783,625. CHANGE IN INTEREST IN SIGNATURE HEALTHCARE CORPORATION INVESTMENTS -4,847,035. CHANGE IN FAIR VALUE OF SPLIT INTEREST AGREEMENTS -91,402. TOTAL TO FORM 990, PART XI, LINE 5: -17,147,609. SIGNATURE HEALTHCARE CORPORATION 680 CENTRE STREET BROCKTON MA 02302 042103554 FUNDRAISING MA 501(C)(3) PUBLIC CHARITY N/A 0 BROCKTON HOSPITAL AMBASSADORS CLUB 680 CENTRE STREET BROCKTON MA 02302 043160078 FUNDRAISING MA 501(C)(3) PUBLIC CHARITY SIGNATURE HEALTHCARE CORPORATION 0 SIGNATURE HEALTHCARE MEDICAL GROUP 680 CENTRE STREET BROCKTON MA 02302 043306782 MEDICAL CARE MA 501(C)(3) PUBLIC CHARITY SIGNATURE HEALTHCARE CORPORATION 0 BROCKTON RADIATION ONCOLOGY LLC 680 CENTRE STREET BROCKTON MA 02302 222472997 RADIATION ONCOLOGY SERVICES MA RELATED 1124867 1280400 0 0 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN GROUP MA C BROCKTON PHYSICIAN HOSPITAL ORGANIZATION 680 CENTRE STREET BROCKTON MA 02302 043189274 MEDICAL MANAGEMENT MA C 1842 145794 0.50000 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1