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ObjectId: 201432269349301968 - Submission: 2014-08-14
TIN: 06-0646844
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
Attach to Form 990.
See separate instructions.
OMB No. 1545-0047
20
12
Open to Public Inspection
Name of the organization
ST MARY'S HOSPITAL INC
Employer identification number
06-0646844
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
....
1b
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
.......
2
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
................
4a
Yes
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
...........................
5a
No
b
Any related organization?
.........................
5b
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
...........................
6a
Yes
b
Any related organization?
.........................
6b
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
.............................
8
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012
Page 2
Schedule J (Form 990) 2012
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2 and/or 1099-MISC compensation
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation
reported as deferred
in prior Form 990
(i)
Base compensation
(ii)
Bonus & incentive compensation
(iii)
Other reportable compensation
(1)
CHAD WABLE
PRESIDENT AND CEO
(i)
(ii)
424,421
0
61,500
0
25,201
0
100,391
0
36,813
0
648,326
0
0
0
(2)
ROBERT HALKO
VP AND CFO (Former)
(i)
(ii)
119,090
0
0
0
0
0
0
0
3,731
0
122,821
0
0
0
(3)
JAMES UBERTI MD
DIRECTOR
(i)
(ii)
0
212,431
0
370
0
0
6,384
0
3,053
0
222,238
0
0
(4)
SANDRA ROOSA
VP PATIENT SERVICE CNO
(i)
(ii)
500,796
0
0
0
0
0
0
0
18,523
0
519,319
0
0
0
(5)
MICHAEL NOVAK
VP OPERATIONS
(i)
(ii)
225,232
0
20,000
0
414
0
14,700
0
28,060
0
288,406
0
0
0
(6)
CAROLYN ORRELL
CHIEF INFORMATION OFFICER
(i)
(ii)
175,871
0
10,000
0
358
0
0
0
5,022
0
191,251
0
0
0
(7)
M CLARK KEARNEY
VP HUMAN RESOURCES
(i)
(ii)
194,531
0
18,000
0
1,166
0
12,822
0
25,675
0
252,194
0
0
0
(8)
JOSEPH CONNOLLY
CHIEF MARKETING OFFICER
(i)
(ii)
155,944
0
10,000
0
208
0
9,970
0
25,366
0
201,488
0
0
0
(9)
STEPHEN HOLLAND MD
VP/CMO (ROTATED OFF 8/3/2012)
(i)
(ii)
279,816
0
30,000
0
452
0
14,700
0
4,848
0
329,816
0
0
0
(10)
ELIZABETH BOZZUTO
VP SURGICAL SERVICES
(i)
(ii)
231,588
0
20,000
0
1,506
0
14,700
0
26,799
0
294,593
0
0
0
(11)
STEVEN SCHNEIDER MD
CMO
(i)
(ii)
0
345,429
0
0
0
1,188
0
14,700
0
5,783
0
367,100
0
0
Schedule J (Form 990) 2012
Page 3
Schedule J (Form 990) 2012
Page
3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier
Return Reference
Explanation
PARTICIPATION IN OR PAYMENT FROM NONQUALIFIED RETIREMENT PLANS.
SCHEDULE J - PART I - LINE 4B
CHAD WABLE AND SANDRA ROOSA PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. CHAD WABLE PARTICIPATES IN A 457(F) DEFERRED COMPENSATION PLAN. NO PAYMENT WAS RECEIVED DURING FISCAL YEAR ENDING 2013. SANDRA ROOSA'S EMPLOYMENT CONTRACT INCLUDES A PROVISION FOR SUPPLEMENTAL RETIREMENT PAYMENTS. THERE WERE PAYMENTS MADE UNDER THIS PROVISION IN THE CALENDAR YEAR 2012.
COMPENSATION CONTINGENT ON NET EARNINGS
SCHEDULE J - PART I - QUESTION 6A
EACH SENIOR LEADER IS PROVIDED A BONUS BASED ON NET EARNINGS AND OTHER CORPORATE GOALS. THE BONUS IS CONTINGENT ON CORPORATE GOALS AND OBJECTIVES EACH YEAR. DURING FY2013, THERE WERE 5 OBJECTIVES: PEOPLE, SERVICE, QUALITY, FINANCE, AND GROWTH. THE BONUS IS COMPUTED ON A PERCENTAGE ALLOCATION FOR THE WEIGHT OF EACH OBJECTIVE WHICH IS DIFFERENT FOR EACH SENIOR LEADER BASED ON THEIR JOB FUNCTION.
SEVERANCE AGREEMENT
SCHEDULE J, LINE 4A
SAINT MARY'S HOSPITAL ENTERED INTO A SEVERANCE AGREEMENT WITH A FORMER EMPLOYEE, WHICH ENDED IN CALENDAR YEAR 2012.
Schedule J (Form 990) 2012
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