Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
MOUNT AUBURN HOSPITAL
 
Employer identification number

04-2103606
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e)Original principal amount (f)Balance due (g) In default? (h) Approved by board or committee? (i)Written agreement?
To From Yes No Yes No Yes No
Total ......Small Bullet $  
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Schedule L (Form 990 or 990-EZ) 2012
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) MICHAEL SHORTSLEEVE TRUSTEE 302,139     No
(2) DR SUSAN ABOOKIRE FAMILY MEMBER 261,410     No
(3) JAMES RAFFERTY FAMILY MEMBER 101,347     No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
SCHEDULE L, PART IV - BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS   MOUNT AUBURN HOSPITAL AND MOUNT AUBURN PROFESSIONAL SERVICES MAY BE REFERRED TO IN THESE EXPLANATORY NOTES TO FORM 990 SCHEDULE L PART IV AS MAH AND MAPS RESPECTIVELY.MICHAEL SHORTSLEEVE, M.D., A MEMBER OF THE MAH BOARD OF TRUSTEES AND CHAIR OF THE MAH DEPARTMENT OF RADIOLOGY, IS THE PRESIDENT OF SCHATZKI ASSOCIATES. SCHATZKI ASSOCIATES PROVIDED RADIOLOGY AND TEACHING SERVICES TO MAH. CHARGES FOR THOSE SERVICES DURING THE FISCAL YEAR WERE $302,139. THE FEES PAID TO SCHATZKI ASSOCIATES REFLECTED FAIR MARKET VALUE RATES. CHRISTOPHER PECKINS, MD, HUSBAND OF DR. SUSAN ABOOKIRE, CHAIR OF QUALITY AND SAFETY FOR MOUNT AUBURN HOSPITAL, IS EMPLOYED AS A PRIMARY CARE PHYSICIAN BY MAPS, A SUPPORTING ORGANIZATION OF MAH AND AN ORGANIZATION FOR WHICH MAH SERVES AS SOLE MEMBER. HIS SALARY AND OTHER INCOME INCLUDE:BASE COMPENSATION: $220,002INCENTIVE COMPENSATION: $27,757OTHER REPORTABLE COMPENSATION: $1,063DEFERRED COMPENSATION: $12,388NON-TAXABLE BENEFITS: $200KATHERINE RAFFERTY, COMMUNITY RELATIONS DIRECTOR AT MOUNT AUBURN HOSPITAL, IS THE SISTER OF JAMES RAFFERTY WHO IS A MOUNT AUBURN HOSPITAL TRUSTEE. HER SALARY AND OTHER INCOME INCLUDE:BASE COMPENSATION: $87,954INCENTIVE COMPENSATION: $420OTHER REPORTABLE COMPENSATION: $72DEFERRED COMPENSATION: $4,511NON-TAXABLE BENEFITS: $8,390JANICE SAAL, M.D., PHD, CO-MEDICAL DIRECTOR OF HOFFMAN BREAST CANCER AT MOUNT AUBURN HOSPITAL, IS THE SPOUSE OF A. KIM SAAL, WHO IS A TRUSTEE AND CHIEF OF THE DIVISION OF CARDIOLOGY AT MOUNT AUBURN HOSPITAL. HER SALARY AND OTHER INCOME INCLUDE:BASE COMPENSATION: $9,807INCENTIVE COMPENSATION: $0OTHER REPORTABLE COMPENSATION: $0DEFERRED COMPENSATION: $0NON-TAXABLE BENEFITS: $0ALL DIRECTORS/TRUSTEES SERVE WITHOUT COMPENSATION OR BENEFITS. COMPENSATION PAID TO OFFICERS, DIRECTORS, TRUSTEES, OR KEY EMPLOYEES WAS EARNED FOR WORK PERFORMED IN A CAPACITY OTHER THAN THAT OF DIRECTOR/TRUSTEE. MOUNT AUBURN HOSPITAL (MAH) MAINTAINS AN ACCOUNTABLE BUSINESS EXPENSE REIMBURSEMENT PLAN. FROM TIME TO TIME, MAH MAY REIMBURSE ITS OFFICERS, DIRECTORS/TRUSTEES AND/OR KEY EMPLOYEES FOR EXPENSES THEY INCURRED AND WHICH ARE PROPERLY ORDINARY AND NECESSARY BUSINESS EXPENSES OF THE REPORTING ENTITY. THE POLICIES AND PROCEDURES REQUIRED BY THE ACCOUNTABLE BUSINESS PLAN MUST BE FOLLOWED IN ORDER TO RECEIVE REIMBURSEMENT FOR SUCH EXPENSES AND IT IS POSSIBLE THAT ONE OR MORE INDIVIDUALS RECEIVED NON-TAXABLE REIMBURSEMENTS WHICH TOTALED $10,000 OR MORE DURING THE FISCAL PERIOD COVERED BY THIS FILING.ALL OF THE ABOVE TRANSACTIONS WERE NEGOTIATED AT ARMS-LENGTH AND IN ACCORDANCE WITH THE MAH CONFLICT OF INTEREST POLICY AND REFLECT FAIR MARKET PAYMENTS AND RATES.
Schedule L (Form 990 or 990-EZ) 2012

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