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ObjectId: 201521359349307597 - Submission: 2015-05-15
TIN: 84-0255530
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, line 23.
Attach to Form 990.
See separate instructions.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
13
Open to Public Inspection
Name of the organization
Lutheran Hosp Assoc of the San Luis Valley
Employer identification number
84-0255530
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
directors, trustees, officers, including 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
No
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
No
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
Yes
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) 2013
Page 2
Schedule J (Form 990) 2013
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
steven w kitchen
physician
(i)
(ii)
505,204
3,545
12,750
18,925
540,424
2
nuwan pilapitiya
physician
(i)
(ii)
203,058
250
168
10,463
17,186
231,125
3
henry garvin
cch administrator - former
(i)
(ii)
155,845
34,666
63,465
16,012
269,988
4
konnie martin
ceo
(i)
(ii)
221,731
481
11,495
20,292
253,999
5
robert marshall
physician
(i)
(ii)
327,581
16,473
1,458
12,664
19,039
377,215
6
patti thompson
cno
(i)
(ii)
155,842
295
2,584
17,491
176,212
7
greg mcauliffe md
cmo
(i)
(ii)
252,110
1,660
12,750
20,500
287,020
8
shane mortensen
cfo
(i)
(ii)
146,199
268
7,650
16,962
171,079
9
dennard ellison
physician
(i)
(ii)
390,004
18,499
12,311
19,039
439,853
10
david geiger
PHYSICIAN
(i)
(ii)
337,976
17,904
19,097
12,750
18,925
406,652
11
clifford robbins
PHYSICIAN
(i)
(ii)
336,106
0
6,708
0
665
0
12,750
0
8,610
0
364,839
0
0
0
12
carissa tripi
physician
(i)
(ii)
495,717
25,000
432
3,462
12,251
536,862
13
james grigsby
physician
(i)
(ii)
379,571
19,312
5,590
9,718
414,191
Schedule J (Form 990) 2013
Page 3
Schedule J (Form 990) 2013
Page
3
Part III
Supplemental Information
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.
Return Reference
Explanation
schedule j, PART I, LINE 4A
THE FOLLOWING AMOUNTS LISTED ARE SEVERANCE PAYMENTS: - HENRY GARVIN $90,131 $34,666 of this amount will be reported on henry garvin's 2013 w-2 and $55,465 will be reported on his 2014 w-2.
schedule j, part i, line 7
CLINICAL KEY EMPLOYEES MAY EARN A PRODUCTIVITY BONUS. SENIOR MANAGEMENT IS ELIGIBLE FOR ANNUAL VARIABLE PAY UP TO 35% FOR CEO AND 20% FOR ALL OTHER SENIOR MANAGEMENT BASED UPON CRITERIA INCLUDING HOSPITAL WIDE MEASURES AND POSITION SPECIFIC GOALS. VARIABLE PAY IS AWARED AT THE DISCRETION OF THE BOARD FOR THE CEO AND THE CEO FOR ALL OTHER SENIOR MANAGEMENT.
Schedule J (Form 990) 2013
Additional Data
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