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ObjectId: 201602239349300615 - Submission: 2016-08-10
TIN: 59-3322533
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.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
14
Open to Public Inspection
Name of the organization
SOUTH LAKE HOSPITAL INC
Employer identification number
59-3322533
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
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), 501(c)(4), and 501(c)(29) organizations 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
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) 2014
Page 2
Schedule J (Form 990) 2014
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 in column(B) reported as deferred in prior Form 990
(i)
Base compensation
(ii)
Bonus & incentive compensation
(iii)
Other reportable compensation
1
LUSHANTHA GUNASEKERA MD
BOARD MEMBER
(i)
(ii)
.................
396,596
.................
297,164
.................
1,692
.................
28,550
.................
23,063
.................
747,065
.................
2
MILDRED BEAM
VICE PRESIDENT
(i)
(ii)
.................
372,750
.................
140,104
.................
78,336
.................
58,311
.................
15,976
.................
665,477
.................
52,286
3
CARY D'ORTONA
TREASURER
(i)
(ii)
.................
182,600
.................
38,749
.................
8,724
.................
38,911
.................
22,063
.................
291,047
.................
4
JOHN MOORE
HOSPITAL PRESIDENT
(i)
(ii)
.................
217,330
.................
84,373
.................
11,789
.................
57,646
.................
22,332
.................
393,470
.................
8,641
5
LANCE SEWELL
CFO
(i)
(ii)
.................
145,300
.................
27,123
.................
12,074
.................
22,731
.................
23,052
.................
230,280
.................
8,956
6
PAUL JOHNS
COO
(i)
(ii)
.................
126,332
.................
23,040
.................
6,814
.................
9,745
.................
22,332
.................
188,263
.................
7
LINDA WALTON
CNO
(i)
(ii)
.................
125,704
.................
23,607
.................
3,860
.................
36,898
.................
16,906
.................
206,975
.................
8
BRAHMBHATT JAMIN MD
PHYSICIAN
(i)
(ii)
442,352
.................
.................
384
.................
16,442
.................
16,783
.................
475,961
.................
.................
9
PAREKATTIL SIJO MD
PHYSICIAN
(i)
(ii)
438,702
.................
.................
480
.................
16,442
.................
16,783
.................
472,407
.................
.................
10
ANDREW KAREN MD
PHYSICIAN
(i)
(ii)
315,892
.................
47,429
.................
330
.................
17,500
.................
14,672
.................
395,823
.................
.................
11
JEROME STURM MD
PHYSICIAN
(i)
(ii)
266,726
.................
49,733
.................
1,165
.................
17,500
.................
16,783
.................
351,907
.................
.................
12
JACOB SINDU MD
PHYSICIAN
(i)
(ii)
188,952
.................
.................
7,424
.................
.................
16,783
.................
213,159
.................
.................
13
SHERRIE SITARIK
FORMER PRESIDENT
(i)
(ii)
.................
.................
.................
978,146
.................
.................
14,406
.................
992,552
.................
Schedule J (Form 990) 2014
Page 3
Schedule J (Form 990) 2014
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, PAGE 1, PART I, LINE 3
NONE OF THE INDIVIDUAL BOARD MEMBERS OR OFFICERS ARE COMPENSATED BY THE FILING ORGANIZATION. THE FILING ORGANIZATION, INSTEAD, RELIES ON THE METHODS USED BY THE RELATED ORGANIZATION AND PROVIDER OF MANAGEMENT SERVICES, ORLANDO HEALTH INC. (OH), TO ESTABLISH COMPENSATION OF THE CEO AND EXECUTIVE OFFICERS. COMPENSATION DETERMINATION BY OH INCLUDES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, AND BOARD APPROVAL. THESE METHODS ARE WELL DOCUMENTED.
SCHEDULE J, PAGE 1, PART I, LINE 4
MILDRED BEAM 0 55,061 0 CARY D'ORTONA 0 12,600 0 JOHN MOORE 0 31,500 0 LANCE SEWELL 0 9,918 0 PAUL JOHNS 0 7,700 0 LINDA WALTON 0 8,750 0 SHERRIE SITARIK 787,985 0 0
SCHEDULE J, PART III
THE 457F DEFERRED COMPENSATION PLAN IS A RETENTION PLAN WHEREBY 7% OF THE EXECUTIVE'S BASE SALARY IS DEPOSITED INTO A LINCOLN ACCOUNT. EACH YEAR'S DEPOSIT IS SUBJECT TO A THREE YEAR VESTING SCHEDULE. UPON VESTING THE ACCOUNT IS TAXED AND PAID OUT LESS ANY 403B DEDUCTIONS. IF THE EXECUTIVE VOLUNTARILY SEPARATES FOR ANY REASON, ALL UNVESTED AMOUNTS ARE FORFEITED. BONUS PLAN DEPARTMENT DIRECTORS RECEIVE AN INCENTIVE FOR THE ACHIEVEMENT OF CERTAIN FINANCIAL, PERSONNEL, CUSTOMER SATISFACTION AND QUALITY GOALS. PHYSICIANS ARE ELIGIBLE FOR BONUS/INCENTIVE PAYMENTS. THESE PAYMENTS ARE BASED ON VARIOUS ORGANIZATIONAL GOALS OF WHICH RELATIVE VALUE UNIT (RVU) EXPECTATIONS MAKE UP ONE OF THE COMPONENTS.
Schedule J (Form 990) 2014
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