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ObjectId: 201640479349301114 - Submission: 2016-02-15
TIN: 37-0673506
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
GRAHAM HOSPITAL ASSOCIATION
Employer identification number
37-0673506
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
No
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
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) 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
ERIC FRANZ
VP FINANCE/CFO
(i)
(ii)
165,882
.................
0
0
.................
0
1,089
.................
0
20,548
.................
0
12,738
.................
0
200,257
.................
0
0
.................
0
2
CAROLYN JACOBUS
VP CLINIC SERVICES
(i)
(ii)
131,588
.................
0
17,574
.................
0
34,423
.................
0
19,022
.................
0
12,554
.................
0
215,161
.................
0
33,800
.................
0
3
TERESA MCCONKEY
VP PATIENT SERVICES
(i)
(ii)
147,068
.................
0
17,094
.................
0
381
.................
0
19,735
.................
0
14,638
.................
0
198,916
.................
0
0
.................
0
4
JIM SCHREINER
VP INFO SERVICES
(i)
(ii)
118,275
.................
0
17,942
.................
0
911
.................
0
15,429
.................
0
6,412
.................
0
158,969
.................
0
0
.................
0
5
ROBERT G SENNEFF
PRESIDENT AND CEO
(i)
(ii)
468,823
.................
0
63,886
.................
0
1,242
.................
0
67,889
.................
0
6,264
.................
0
608,104
.................
0
0
.................
0
6
DWAYNE BERNARD MD
MEDICAL DIRECTOR
(i)
(ii)
518,318
.................
0
400
.................
0
1,386
.................
0
7,800
.................
0
28,238
.................
0
556,142
.................
0
0
.................
0
7
JOHN QUINONES DO
FORMER MEDICAL DIRECTOR ED
(i)
(ii)
337,317
.................
0
400
.................
0
4,752
.................
0
7,769
.................
0
20,320
.................
0
370,558
.................
0
0
.................
0
8
JEFFREY HEMP MD
PHYSICIAN
(i)
(ii)
357,711
.................
0
400
.................
0
2,289
.................
0
7,800
.................
0
28,520
.................
0
396,720
.................
0
0
.................
0
9
DUSTIN KERN CRNA
CRNA
(i)
(ii)
258,915
.................
0
400
.................
0
252
.................
0
4,604
.................
0
19,504
.................
0
283,675
.................
0
0
.................
0
10
MATTHEW MCMILLIN MD
PHYSICIAN
(i)
(ii)
276,394
.................
0
200
.................
0
0
.................
0
3,901
.................
0
0
.................
0
280,495
.................
0
0
.................
0
11
JULIO ANTONIO RAMOS MD
PHYSICIAN
(i)
(ii)
378,056
.................
0
400
.................
0
3,096
.................
0
7,800
.................
0
13,994
.................
0
403,346
.................
0
0
.................
0
12
JOHN ZYGIEL MD
PHYSICIAN
(i)
(ii)
320,293
.................
0
400
.................
0
4,197
.................
0
7,706
.................
0
13,184
.................
0
345,780
.................
0
0
.................
0
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
PART I, LINE 4B
THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) PLAN IN 2014 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: CAROLYN JACOBUS - $13,417, TERESA MCCONKEY - $14,639, JIM SCHREINER - $11,215, ROBERT G. SENNEFF - $60,089 AND ERIC FRANZ - $16,837. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR CONTRIBUTION MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUALS TO THE PLAN IN 2014. THIS INFORMATION IS INCLUDED IN DEFERRED COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE J, PART II. THE FOLLOWING INDIVIDUAL PARTICIPATED IN A 457(F) PLAN IN 2014 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: CAROLYN JACOBUS - $32,950. THE DOLLAR AMOUNT REPRESENTS THE CURRENT YEAR DISTRIBUTION FROM THE PLAN IN 2014. THIS INFORMATION IS INCLUDED IN REPORTABLE COMPENSATION ON THE FORM 990, PART VII AND SCHEDULE K, PART II.
PART I, LINE 7
INCENTIVE AWARDS ARE BASED ON THE ATTAINMENT OF HOSPITAL AND INDIVIDUAL TARGETS AND ARE CALCULATED AS A PERCENTAGE OF WAGES. PAYMENT OF INCENTIVE AWARDS IS DEPENDENT ON THE ACHIEVEMENT OF ORGANIZATIONAL KEY INDICATORS.
FORM 990, SCHEDULE J, PART II, COLUMN F:
THE FOLLOWING INDIVIDUAL ALSO PARTICIPATED IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN IN 2009, 2010, 2011, 2012, 2013, AND 2014 SPONSORED BY GRAHAM HOSPITAL ASSOCIATION: CAROLYN JACOBUS - $33,800. THE DOLLAR AMOUNT REPRESENTS PRIOR YEAR CONTRIBUTIONS MADE BY GRAHAM HOSPITAL ASSOCIATION ON BEHALF OF THE INDIVIDUAL TO THE PLAN IN 2009, 2010, 2011, 2012, AND 2013. THIS INFORMATION WAS INCLUDED IN DEFERRED COMPENSATION ON THE PRIOR YEARS' FORM 990, PART VII AND SCHEDULE J, PART II. THESE INDIVIDUALS REACHED A SPECIFIED LEVEL OF VESTING IN 2014, SO THE DOLLAR AMOUNT IS NOW INCLUDED IN REPORTABLE COMPENSATION ON THE CURRENT YEAR FORM 990, PART VII AND SCHEDULE J, PART II. THE DOLLAR AMOUNT IS ALSO LISTED AS COMPENSATION REPORTED IN A PRIOR FORM 990 ON THE CURRENT YEAR FORM 990, SCHEDULE J, PART II.
Schedule J (Form 990) 2014
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