efile Public Visual Render
Submission Date - 2012-08-15
TIN: 03-0284813
Form
990
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)
The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
20
10
Open to Public Inspection
A
For the
2010
calendar year, or tax year beginning
10-01-2010
and ending
09-30-2011
B
Check if applicable:
Address change
Name change
Initial return
Terminated
Amended return
Application pending
C
Name of organization
Springfield Medical Care Systems Inc
Doing Business As
Number and street (or P.O. box if mail is not delivered to street address)
25 Ridgewood Road
Room/suite
City or town, state or country, and ZIP + 4
Springfield
,
VT
05156
D Employer identification number
03-0284813
E Telephone number
(802) 885-2151
G
Gross receipts $
20,667,340
F
Name and address of principal officer:
Andrew Majka
25 Ridgewood Road
Springfield
,
VT
05156
I
Tax-exempt status:
501(c)(3)
501(c)
(
)
(insert no.)
4947(a)(1)
or
527
J
Website:
www.springfieldmed.org
H(a)
Is this a group return for
affiliates?
Yes
No
H(b)
Are all affiliates included?
Yes
No
If "No," attach a list. (see instructions)
H(c)
Group exemption number
K
Form of organization:
Corporation
Trust
Association
Other
L
Year of formation:
1982
M
State of legal domicile:
VT
Part I
Summary
1
Briefly describe the organizations mission or most significant activities:
Our mission is to excel at providing personalized, quality care. (Continued on Schedule O) Where people come first. Our vision is to be the provider of choice by creating a professional environment where: * patients want to receive care; * clinicians want to practice medicine; and, * employees want to work. We will accomplish this by: * empowering our caregivers with education, technology, and opportunities for personal and professional development; * creating an environment which builds collaborative relationships among clinicians, staff, and patients; * providing our communities with the educational resources and support to make informed decisions and apply preventive care; and, * offering safe, personalized, high quality care.
2
Check this box
3
Number of voting members of the governing body (Part VI, line 1a)
....
3
11
4
Number of independent voting members of the governing body (Part VI, line 1b)
....
4
10
5
Total number of individuals employed in calendar year 2010 (Part V, line 2a)
...
5
224
6
Total number of volunteers (estimate if necessary)
....
6
7
7a
Total unrelated business revenue from Part VIII, column (C), line 12
..
7a
0
b
Net unrelated business taxable income from Form 990-T, line 34
..
7b
0
Prior Year
Current Year
8
Contributions and grants (Part VIII, line 1h)
.........
1,374,503
2,782,365
9
Program service revenue (Part VIII, line 2g)
.........
11,297,806
12,618,306
10
Investment income (Part VIII, column (A), lines 3, 4, and 7d )
....
219,554
359,747
11
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)
325,337
72,253
12
Total revenueadd lines 8 through 11 (must equal Part VIII, column (A), line 12)
...................
13,217,200
15,832,671
13
Grants and similar amounts paid (Part IX, column (A), lines 13 )
...
8,000
9,000
14
Benefits paid to or for members (Part IX, column (A), line 4)
....
0
0
15
Salaries, other compensation, employee benefits (Part IX, column (A), lines 510)
10,106,705
11,597,893
16a
Professional fundraising fees (Part IX, column (A), line 11e)
....
58,216
0
b
Total fundraising expenses (Part IX, column (D), line 25)
261,142
17
Other expenses (Part IX, column (A), lines 11a11d, 11f24f)
....
4,020,961
4,231,704
18
Total expenses. Add lines 1317 (must equal Part IX, column (A), line 25)
14,193,882
15,838,597
19
Revenue less expenses. Subtract line 18 from line 12
......
-976,682
-5,926
Beginning of Current Year
End of Year
20
Total assets (Part X, line 16)
............
12,892,723
18,296,700
21
Total liabilities (Part X, line 26)
............
4,805,888
10,523,127
22
Net assets or fund balances. Subtract line 21 from line 20
.....
8,086,835
7,773,573
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
2012-08-15
Signature of officer
Date
Andy Majka
CFO
Type or print name and title.
Paid Preparer's Use Only
Preparer's
signature
Rachel Williamson CPA
Date
2012-08-15
Check if
self-
employed
Preparers taxpayer identification number
(see instructions)
Firms name (or yours
if self-employed),
address, and ZIP + 4
Berry Dunn McNeil & Parker LLC
1000 Elm Street 15th Floor
Manchester
,
NH
03101
EIN
Phone no.
(603) 669-7337
May the IRS discuss this return with the preparer shown above? (see instructions)
.........
Yes
No
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form
990
(2010)
Form 990 (2010)
Page
2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III
.
.
.
.
.
.
.
.
.
.
1
Briefly describe the organizations mission:
Our mission is to excel at providing personalized, quality care; where people come first. Our vision is to be the provider of choice by creating a professional environment where patients want to receive care, clinicians want to practice medicine, (Continued on Schedule O) and employees want to work. Our plan is to accomplish this by: * Empowering our caregivers with education, technology, and opportunities for personal and professional development; * Creating an environment, which builds collaborative relationships among clinicians, staff, and patients; * Providing our communities with the educational resources and support to make informed decisions emphasizing prevention and wellness; and, * Offering safe, personalized, high-quality care.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ?
....................
Yes
No
If Yes, describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services?
..........................
Yes
No
If Yes, describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organizations three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a
(Code:
) (Expenses $
11,712,934
including grants of $
) (Revenue $
10,335,050
)
Primary Care Services * Springfield Medical Care Systems (SMCS) operates an eight-site, federally-qualified health center network. These offices provide access for primary and preventive health care to the general population, and make financial assistance and charity care available to all based on need. Services include primary and preventive health care for people of all ages, pediatrics, health screenings, mental health programs, dental care, and access to discounted pharmaceuticals. SMCS operates The Ludlow Dental Center in Ludlow, VT, which opened for operation in July of 2011. Through its integrated care model, SMCS also offers diagnostic lab, radiology, and a full array of acute hospital and specialty services to its patients through Springfield Hospital, a subsidiary, and other referral sources and partnership arrangements.Our primary care network provides ongoing care and outreach to our service area, utilizing a medical home model of care and focusing on prevention and efficient care management. We work closely with the Chronic Care Collaborative and the Vermont Blueprint for Health in developing and implementing strategies for improving overall community health outcomes. Primary care offices, specialty clinics, the local hospital, and appropriate referral sources for specialists and tertiary care when needed, are carefully utilized to provide the best possible outcomes. Our goal is to deliver the highest quality care, i.e. appropriate care provided in the appropriate setting, with the end result being improved health outcomes, high patient satisfaction, and improved cost efficiency. A Community Health Team is now fully operational, meeting monthly to collaborate and partner with area agencies to remove barriers and improve access to care. The team now exceeds 70 participants and is growing. New members are welcomed at each meeting as word of the team spreads throughout the community. The Team is developing a community resource guide, a newsletter, and an ongoing community calendar to facilitate communications about area services and improve networking.Through the employment of primary care physicians in Charlestown, New Hampshire; Ludlow, Vermont; Bellows Falls, Vermont; Chester, VT; and Springfield, Vermont, SMCS assures access to high quality medical care with emphasis on prevention and wellness in these communities. Due to the tenuous economics of rural primary care practices, this physician availability would not exist without SMCS support. The Ludlow area has been designated by the State of Vermont as a Health Professional Shortage Area. The state and federal governments have designated the Bellows Falls, VT and Charlestown, NH areas as serving a medically-underserved population. These health centers serve an inordinately high Medicare and Medicaid caseload. During FY 2011, SMCS served 23,747 patients and provided 86,889 visits.
4b
(Code:
) (Expenses $
703,256
including grants of $
) (Revenue $
1,674,214
)
Reduced Fee 340B Pharmacy Program * SMCS operates a federal 340B Drug Pricing Program that helps expand access to affordable medications. The 340B program allows SMCS to purchase drugs at steep discounts and pass along the savings to eligible participants, based on financial need. Patients with prescription coverage can save on medications not covered by their plan while helping families who are less fortunate. In 2011, this program operated in partnership with four local pharmacies in Bellows Falls, Springfield, and Ludlow. The 340B program was implemented in June 2010. There are 428 active members who receive financial assistance with revenues generated by the 340B program. Financial assistance for this program totaled $54,327.
4c
(Code:
) (Expenses $
696,286
including grants of $
) (Revenue $
617,176
)
SMCS has a comprehensive outpatient Mental Health/ Substance abuse program and also provides Psychiatric counseling and medical direction for the Windham Center- the inpatient psychiatric unit operated by its subsidiary, Springfield Hospital. With early adoption of Healthy People 2010 and NCQI Medical Home guidelines, SMCS has aggressively integrated Mental Health counseling with primary care medical care by virtue of the on-site stationing of Mental Health Counselors at its primary care (FQHC) sites. SMCS practitioners also coordinate care with the Hospital inpatient services and to an even greater extent, work with the Hospital emergency department to assist in managing patients that present with mental health related diagnosis. During the fiscal year, SMCS provided 8,521 Mental Health visits.
(Code:
) (Expenses $
495,186
including grants of $
) (Revenue $
423,866
)
Charity Care Policy * SMCS has a charity care policy under which patients who meet certain criteria will receive care without charge, or at amounts less than established rates. Patients qualify for 100% charity care at up to 200% of the federal poverty guideline and 50% assistance up to 300% of the federal poverty guideline. SMCS does not bill patients nor pursue collection of amounts determined to qualify as charity care. In the fiscal year, which ended on September 30, 2011, charges foregone for charity care, based on established rates, amounted to $305,138.Dental Care * SMCS opened its Ludlow Dental Center office in July 2011 to serve a growing need for dental services throughout the SMCS primary care service area. Patients from all offices can be referred to the Dental Center for care, and a financial assistance program is available for those needing assistance, based on a sliding fee scale. Operations were slowed in the early weeks after opening due to Hurricane Irene, however, the Center served 425 patients in FY 2011, and provided financial assistance in the amount of $12,218.Eligibility Assistance and Enrollment Counseling Services * Through a partnership arrangement with Valley Health Connections (a designated 501(c)3 non-profit organization), SMCS patients can receive eligibility assistance counseling to help remove barriers and facilitate access to health care for uninsured and under-insured people. Although many health care insurance options are available to Vermont residents, VHC reports many people need guidance to navigate enrollment processes and programs are often unaffordable for many Vermonters. This includes enrollment assistance for preventive health care, health education and screenings, referrals to providers for ongoing health care through a medical home, and assistance with enrollment in State and local programs that pay for health care. Subsidiary * SMCS is the parent corporation of Springfield Hospital. Springfield Hospital is a 25-bed critical access hospital located in Springfield, VT. Springfield Hospital also operates The Windham Center, a comprehensive inpatient mental health program in Bellows Falls, VT; off-site physical therapy services, five hospital-owned specialty clinics: urology, ENT, surgery, orthopaedics and skin care; and an adult day care center in Springfield, VT.
4d
Other program services. (Describe in Schedule O.)
(Expenses $
495,186
including grants of $
) (Revenue $
423,866
)
4e
Total program service expenses
$
13,607,662
Form
990
(2010)
Form 990 (2010)
Page
3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)?
If Yes, complete Schedule A
.....................
1
Yes
2
Is the organization required to complete Schedule B, Schedule of Contributors?
........
2
Yes
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office?
If Yes, complete Schedule C, Part I
..........
3
No
4
Section 501(c)(3) organizations.
Did the organization engage in lobbying activities?
If Yes, complete Schedule C,
Part II
.........................
4
Yes
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19?
If Yes, complete Schedule C, Part III
........................
5
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts?
If Yes, complete
Schedule D, Part I
.......................
6
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures?
If Yes, complete Schedule D, Part II
...
7
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets?
If Yes, complete Schedule D, Part III
....................
8
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services?
If Yes,
complete Schedule D, Part IV
...................
9
No
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments?
If Yes, complete Schedule D, Part V
10
No
11
If the organizations answer to any of the following questions is Yes, then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10?
If Yes, complete Schedule D, Part VI.
11a
Yes
b
Did the organization report an amount for investmentsother securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VII.
11b
No
c
Did the organization report an amount for investmentsprogram related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part VIII.
11c
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16?
If Yes, complete Schedule D, Part IX.
11d
Yes
e
Did the organization report an amount for other liabilities in Part X, line 25?
If Yes, complete Schedule D, Part X.
11e
Yes
f
Did the organizations separate or consolidated financial statements for the tax year include a footnote that addresses the organizations liability for uncertain tax positions under FIN 48 (ASC 740)?
If Yes, complete Schedule D, Part X.
11f
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If Yes, complete Schedule D, Parts XI, XII, and XIII
12a
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year?
If Yes, and if the organization answered No to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional
12b
Yes
13
Is the organization a school described in section 170(b)(1)(A)(ii)?
If Yes, complete Schedule E
13
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?
....
14a
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States?
If Yes, complete Schedule F, Part I
.........
14b
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.?
If Yes, complete Schedule F, Part II
..
15
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.?
If Yes, complete Schedule F, Part III
..
16
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e?
If Yes, complete Schedule G, Part I
17
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a?
If Yes, complete Schedule G, Part II
..........
18
Yes
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a?
If Yes, complete Schedule G, Part III
...................
19
No
Form
990
(2010)
Form 990 (2010)
Page
4
Part IV
Checklist of Required Schedules
(continued)
20a
Did the organization operate one or more hospitals?
If Yes, complete Schedule H
.....
20a
No
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements.
.....
20b
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1?
If Yes, complete Schedule I, Parts I and II
..
21
Yes
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2?
If Yes, complete Schedule I, Parts I and III
.....
22
No
23
Did the organization answer Yes to Part VII, Section A, questions 3, 4, or 5, about compensation of the organizations current and former officers, directors, trustees, key employees, and highest compensated employees?
If Yes, complete Schedule J
................
23
Yes
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002?
If Yes, answer questions 24b24d and complete Schedule K. If No, go to line 25
................
24a
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?
...
24b
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?
......................
24c
d
Did the organization act as an on behalf of issuer for bonds outstanding at any time during the year?
...
24d
25a
Section 501(c)(3) and 501(c)(4) organizations.
Did the organization engage in an excess benefit transaction with a disqualified person during the year?
If Yes, complete Schedule L, Part I
......
25a
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organizations prior Forms 990 or 990-EZ?
If Yes, complete Schedule L, Part I
................
25b
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organizations tax year?
If Yes, complete Schedule L,
Part II
...........................
26
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual?
If Yes, complete Schedule L, Part III
...............
27
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee?
If Yes, complete Schedule L, Part IV
.........................
28a
No
b
A family member of a current or former officer, director, trustee, or key employee?
If Yes,
complete Schedule L, Part IV
...................
28b
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner?
If Yes, complete Schedule L, Part IV
..
28c
No
29
Did the organization receive more than $25,000 in non-cash contributions?
If Yes, complete Schedule M
29
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions?
If Yes, complete Schedule M
............
30
No
31
Did the organization liquidate, terminate, or dissolve and cease operations?
If Yes, complete Schedule N,
Part I
...........................
31
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets?
If Yes, complete Schedule N, Part II
.......................
32
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3?
If Yes, complete Schedule R, Part I
........
33
No
34
Was the organization related to any tax-exempt or taxable entity?
If Yes, complete Schedule R, Parts II, III, IV, and V, line 1
.....................
34
Yes
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)?
.....
35
Yes
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)?
If Yes, complete Schedule R, Part V, line 2
...
Yes
No
36
Section 501(c)(3) organizations.
Did the organization make any transfers to an exempt non-charitable related organization?
If Yes, complete Schedule R, Part V, line 2
...........
36
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes?
If Yes, complete Schedule R, Part VI
37
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19?
Note.
All Form 990 filers are required to complete Schedule O.
............
38
Yes
Form
990
(2010)
Form 990 (2010)
Page
5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V
.
.
.
.
.
.
.
.
.
.
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable.
.......
1a
22
b
Enter the number of Forms W-2G included in line 1a.
Enter -0-
if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners?
..................
1c
Yes
2a
Enter the number of employees reported on Form W-3,
Transmittal of Wage and Tax Statements
filed for the calendar year ending with or within the year covered by this return
.....................
2a
224
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note.
If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?
.............................
3a
No
b
If Yes, has it filed a Form 990-T for this year?
If No, provide an explanation in Schedule O
.....
3b
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?
.......................
4a
No
b
If "Yes," enter the name of the foreign country:
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?
..
5a
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
No
c
If Yes to line 5a or 5b, did the organization file Form 8886-T?
........
5c
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?
..........
6a
No
b
If Yes, did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?
........................
6b
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?
....................
7a
Yes
b
If Yes, did the organization notify the donor of the value of the goods or services provided?
.....
7b
No
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?
...........................
7c
No
d
If Yes, indicate the number of Forms 8282 filed during the year
....
7d
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
..........................
7e
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?
..
7f
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?
...................
7g
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?
...............
7h
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations.
Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?
................
8
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?
.........
9a
b
Did the organization make a distribution to a donor, donor advisor, or related person?
......
9b
10
Section 501(c)(7) organizations.
Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12
...
10a
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
11
Section 501(c)(12) organizations.
Enter:
a
Gross income from members or shareholders
.........
11a
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.)
........
11b
12a
Section 4947(a)(1) non-exempt charitable trusts.
Is the organization filing Form 990 in lieu of Form 1041?
12a
b
If Yes, enter the amount of tax-exempt interest received or accrued during the year.
12b
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note.
All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
c
Enter the aggregate amount of reserves on hand.
13c
14a
Did the organization receive any payments for indoor tanning services during the tax year?
.....
14a
b
If "Yes," has it filed a Form 720 to report these payments?
If No, provide an explanation in Schedule O
..
14b
Form
990
(2010)
Form 990 (2010)
Page
6
Part VI
Governance, Management, and Disclosure
For each Yes response to lines 2 through 7b below, and for a No response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI
.
.
.
.
.
.
.
.
.
.
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
..............
1a
11
b
Enter the number of voting members included in line 1a, above, who are independent
.................
1b
10
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee?
.................
2
Yes
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person?
..
3
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
No
5
Did the organization become aware during the year of a significant diversion of the organizations assets?
.
5
No
6
Does the organization have members or stockholders?
................
6
No
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body?
.........................
7a
No
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons?
..
7b
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body?
.........................
8a
Yes
b
Each committee with authority to act on behalf of the governing body?
............
8b
Yes
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organizations mailing address? If Yes, provide the names and addresses in Schedule O
.....
9
No
Section B. Policies
(This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates?
............
10a
No
b
If Yes, does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization?
....
10b
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
No
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990.
.....
12a
Does the organization have a written conflict of interest policy?
If No, go to line 13
.......
12a
Yes
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts?
...........................
12b
Yes
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If Yes, describe in Schedule O how this is done
....................
12c
Yes
13
Does the organization have a written whistleblower policy?
...............
13
Yes
14
Does the organization have a written document retention and destruction policy?
.........
14
Yes
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organizations CEO, Executive Director, or top management official
...........
15a
Yes
b
Other officers or key employees of the organization
................
15b
Yes
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year?
......................
16a
No
b
If Yes, has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organizations exempt status with respect to such arrangements?
............
16b
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filed
VT
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
Own website
Another's website
Upon request
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
Andrew J Majka
25 Ridgewood Road
Springfield
,
VT
05156
(802) 885-2151
Form
990
(2010)
Form 990 (2010)
Page
7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII
.
.
.
.
.
.
.
.
.
.
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a
Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organizations tax year.
List all of the organizations
current
officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and
current
key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.
List all of the organizations
current
key employees, if any. See instructions for definition of "key employee."
List the organizations five
current
highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.
List all of the organizations
former
officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.
List all of the organizations
former directors or trustees
that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.
List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title
(B)
Average hours per week (describe hours for related organizations in Schedule O)
(C)
Position (check all that apply)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(1)
Eric R Bibens II
Chairperson
.50
X
X
0
0
0
(2)
Steve Birge
Vice-Chairperson
.50
X
X
0
0
0
(3)
Sharon Bixby
Director
.50
X
0
0
0
(4)
Stephen Geller
Director
.50
X
0
0
0
(5)
George Lamb
Director
.50
X
0
0
0
(6)
Lori Muse
Director
.50
X
0
0
0
(7)
George S Norfleet III
Treasurer
.50
X
X
0
0
0
(8)
Willie Pelton
Director
.50
X
0
0
0
(9)
Mary Perry
Secretary
.50
X
X
0
0
0
(10)
Albert St Pierre
Director
.50
X
0
0
0
(11)
Crystal Stokarski
Director
.50
X
0
0
0
(12)
Glenn Cordner
CEO
40.00
X
293,332
0
39,558
(13)
Andrew Majka
CFO
40.00
X
182,653
0
6,326
(14)
Cecil Beehler MD
Physician
40.00
X
298,653
0
20,028
(15)
Mark Hamilton MD
Physician
40.00
X
203,335
0
19,487
(16)
Barbara Dalton MD
Physician
40.00
X
202,354
0
20,873
(17)
Daniel Caloras MD
Physician
40.00
X
197,534
0
15,858
Form
990
(2010)
Form 990 (2010)
Page
8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
(continued)
(A)
Name and Title
(B)
Average hours per week (describe hours for related organizations in Schedule O)
(C)
Position (check all that apply)
(D)
Reportable compensation from the organization (W- 2/1099-MISC)
(E)
Reportable compensation from related organizations (W- 2/1099-MISC)
(F)
Estimated amount of other compensation from the organization and related organizations
(18)
Anne Stohrer MD
Physician
40.00
X
196,007
0
2,010
1b
Sub-Total
................
c
Total from continuation sheets to Part VII, Section A
....
d
Total (add lines 1b and 1c)
............
1,573,868
0
124,140
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organization
22
Yes
No
3
Did the organization list any
former
officer, director or trustee, key employee, or highest compensated employee on line 1a?
If Yes, complete Schedule J for such individual
.............
3
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000?
If Yes, complete Schedule J for such individual
...........................
4
Yes
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization?
If Yes, complete Schedule J for such person
.....
5
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address
(B)
Description of services
(C)
Compensation
Sleepmed Inc
200 Corporate Place Ste 5B
Peabody
,
MA
019603840
Sleep Studies
123,625
Comphealth Medical Staffing
PO Box 972651
Dallas
,
TX
753972651
Locum Tenens
113,717
D&Y
PO Box 635715
Cincinnati
,
OH
452635715
Locum Tenens
101,191
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization
3
Form
990
(2010)
Form 990 (2010)
Page
9
Part VIII
Statement of Revenue
(A)
Total revenue
(B)
Related or
exempt
function
revenue
(C)
Unrelated
business
revenue
(D)
Revenue
excluded from
tax under sections
512, 513, or 514
1a
Federated campaigns
..
1a
b
Membership dues
....
1b
c
Fundraising events
....
1c
16,950
d
Related organizations
...
1d
e
Government grants (contributions)
1e
2,575,371
f
All other contributions, gifts, grants, and
similar amounts not included above
1f
190,044
g
Noncash contributions included in lines 1a-1f:$
h
Total.
Add lines 1a-1f
.......
2,782,365
Business Code
2a
Patient Service Revenu
621,110
12,017,345
12,017,345
b
Child Daycare Revenue
624,410
339,451
339,451
c
Physician Billing
621,110
240,365
240,365
d
Other revenue
900,099
15,618
15,618
e
Gift Shop Revenue
453,220
5,527
5,527
f
All other program service revenue .
g
Total.
Add lines 2a2f
........
12,618,306
3
Investment income (including dividends, interest
and other similar amounts)
.....
140,105
140,105
4
Income from investment of tax-exempt bond proceeds
..
5
Royalties
............
(i) Real
(ii) Personal
6a
Gross Rents
78,888
b
Less: rental expenses
c
Rental income or (loss)
78,888
d
Net rental income or (loss)
.......
78,888
78,888
(i) Securities
(ii) Other
7a
Gross amount from sales of assets other than inventory
5,027,471
b
Less: cost or other basis and sales expenses
4,807,829
c
Gain or (loss)
219,642
d
Net gain or (loss)
..........
219,642
219,642
8a
Gross income from fundraising events (not including
$
16,950
of contributions reported on line 1c).
See Part IV, line 18
...
a
20,205
b
Less: direct expenses
...
b
26,840
c
Net income or (loss) from fundraising events
..
-6,635
-6,635
9a
Gross income from gaming activities.
See Part IV, line 19
...
a
b
Less: direct expenses
...
b
c
Net income or (loss) from gaming activities
...
10a
Gross sales of inventory, less
returns and allowances
.
a
b
Less: cost of goods sold
..
b
c
Net income or (loss) from sales of inventory
..
Miscellaneous Revenue
Business Code
11a
b
c
d
All other revenue
....
e
Total.
Add lines 11a11d
......
12
Total revenue.
See Instructions.
...
15,832,671
12,697,194
0
353,112
Form
990
(2010)
Form 990 (2010)
Page
10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns.
All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII.
(A)
Total expenses
(B)
Program service
expenses
(C)
Management and
general expenses
(D)
Fundraising
expenses
1
Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21
9,000
9,000
2
Grants and other assistance to individuals in the U.S. See Part IV, line 22
3
Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16
4
Benefits paid to or for members
5
Compensation of current officers, directors, trustees, and key employees
....
521,869
521,869
6
Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)
....
7
Other salaries and wages
9,046,906
8,251,893
673,582
121,431
8
Pension plan contributions (include section 401(k) and section 403(b) employer contributions)
....
107,539
104,182
3,357
9
Other employee benefits
.......
1,311,112
992,086
287,264
31,762
10
Payroll taxes
...........
610,467
457,244
138,584
14,639
11
Fees for services (non-employees):
a
Management
......
b
Legal
.........
5,499
5,499
c
Accounting
...........
35,250
35,250
d
Lobbying
...........
e
Professional fundraising.
See Part IV, line 17
..
f
Investment management fees
......
g
Other
..........
1,036,612
855,337
177,493
3,782
12
Advertising and promotion
....
49,617
45,180
4,437
13
Office expenses
.......
172,987
137,239
15,249
20,499
14
Information technology
......
15
Royalties
..
16
Occupancy
...........
589,296
522,371
58,041
8,884
17
Travel
............
30,502
25,802
2,867
1,833
18
Payments of travel or entertainment expenses for any federal, state, or local public officials
......
19
Conferences, conventions, and meetings
....
20
Interest
...........
60,786
57,252
3,534
21
Payments to affiliates
.......
22
Depreciation, depletion, and amortization
.....
308,128
292,071
15,372
685
23
Insurance
..............
198,075
198,075
24
Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a
Medical supplies
1,006,986
1,006,986
b
Miscellaneous expenses
239,812
203,415
10,706
25,691
c
Telephone
109,800
97,559
10,840
1,401
d
Dues & books
92,313
87,697
4,616
e
Maintenance & repairs
85,746
73,319
3,859
8,568
f
All other expenses
210,295
190,954
5,168
14,173
25
Total functional expenses.
Add lines 1 through 24f
15,838,597
13,607,662
1,969,793
261,142
26
Joint costs.
Check here
if following
SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation
Form
990
(2010)
Form 990 (2010)
Page
11
Part X
Balance Sheet
(A)
Beginning of year
(B)
End of year
1
Cashnon-interest-bearing
..........
97,348
1
200
2
Savings and temporary cash investments
.......
71,569
2
1,667,544
3
Pledges and grants receivable, net
.........
372,073
3
2,153,593
4
Accounts receivable, net
.........
1,230,685
4
981,455
5
Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L
..........
5
6
Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L
..........
6
7
Notes and loans receivable, net
.............
7
8
Inventories for sale or use
..............
6,421
8
9
Prepaid expenses and deferred charges
............
297,780
9
376,759
10a
Land, buildings, and equipment: cost or other basis.
Complete Part VI of Schedule D
10a
11,450,842
b
Less: accumulated depreciation.
.....
10b
1,944,615
4,691,287
10c
9,506,227
11
Investmentspublicly traded securities
..........
5,278,000
11
2,762,187
12
Investmentsother securities. See Part IV, line 11
......
12
13
Investmentsprogram-related. See Part IV, line 11
..
13
14
Intangible assets
.........
14
15
Other assets. See Part IV, line 11
...........
847,560
15
848,735
16
Total assets.
Add lines 1 through 15 (must equal line 34)
...
12,892,723
16
18,296,700
17
Accounts payable and accrued expenses
.
1,416,910
17
2,969,873
18
Grants payable
..........
18
19
Deferred revenue
..........
341,178
19
1,154,509
20
Tax-exempt bond liabilities
..........
20
21
Escrow or custodial account liability.
Complete Part IV of Schedule D
..
21
22
Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons.
Complete Part II of Schedule L
..........
22
23
Secured mortgages and notes payable to unrelated third parties
..
323,968
23
3,182,238
24
Unsecured notes and loans payable to unrelated third parties
....
400,000
24
951,447
25
Other liabilities.
Complete Part X of Schedule D
.....
2,323,832
25
2,265,060
26
Total liabilities.
Add lines 17 through 25
.....
4,805,888
26
10,523,127
Organizations that follow SFAS 117,
check here
and complete lines 27 through 29, and lines 33 and 34.
27
Unrestricted net assets
.....
8,086,835
27
7,773,573
28
Temporarily restricted net assets
.....
28
29
Permanently restricted net assets
.....
29
Organizations that do not follow SFAS 117,
check here
and complete lines 30 through 34.
30
Capital stock or trust principal, or current funds
.....
30
31
Paid-in or capital surplus, or land, building or equipment fund
.....
31
32
Retained earnings, endowment, accumulated income, or other funds
32
33
Total net assets or fund balances
.....
8,086,835
33
7,773,573
34
Total liabilities and net assets/fund balances
.....
12,892,723
34
18,296,700
Form
990
(2010)
Form 990 (2010)
Page
12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI
.
.
.
.
.
.
.
.
.
.
1
Total revenue (must equal Part VIII, column (A), line 12)
.
.
.
1
15,832,671
2
Total expenses (must equal Part IX, column (A), line 25)
.
.
.
.
.
2
15,838,597
3
Revenue less expenses. Subtract line 2 from line 1
.
.
.
.
3
-5,926
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A))
.
.
4
8,086,835
5
Other changes in net assets or fund balances (explain in Schedule O)
.
.
.
.
5
-307,336
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B))
.
.
.
.
.
.
6
7,773,573
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII
.
.
.
.
.
.
.
.
.
.
Yes
No
1
Accounting method used to prepare the Form 990:
Cash
Accrual
Other
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organizations financial statements compiled or reviewed by an independent accountant?
..
2a
No
b
Were the organizations financial statements audited by an independent accountant?
........
2b
Yes
c
If Yes, to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
...........................
2c
Yes
d
If Yes to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
Separate basis
Consolidated basis
Both consolidated and separated basis
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
................
3a
Yes
b
If Yes, did the organization undergo the required audit or audits?
If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
..
3b
Yes
Form
990
(2010)
Additional Data
Software ID:
Software Version:
Form 990, Special Condition Description:
Special Condition Description