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ObjectId: 201711319349305051 - Submission: 2017-05-11
TIN: 36-2596381
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" on 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
15
Open to Public Inspection
Name of the organization
Alexian Brothers Medical Center
Employer identification number
36-2596381
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 on 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 on 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 on 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," on line 5a or 5b, describe in Part III.
6
For persons listed on 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," on line 6a or 6b, describe in Part III.
7
For persons listed on 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 on 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" on 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) 2015
Page 2
Schedule J (Form 990) 2015
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 on 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 on prior Form 990
(i)
Base compensation
(ii)
Bonus & incentive compensation
(iii)
Other reportable compensation
1
JOHN WERRBACH
EX-OFFICIO DIRECTOR & PRESIDENT CEO
(i)
(ii)
0
-------------
456,058
0
-------------
122,137
0
-------------
27,525
0
-------------
44,845
0
-------------
24,944
0
-------------
675,509
0
-------------
27,525
2
SHERRI VINCENT
TREASURER (THROUGH 1/4/16)
(i)
(ii)
0
-------------
379,176
0
-------------
71,178
0
-------------
20,720
0
-------------
33,239
0
-------------
7,120
0
-------------
511,434
0
-------------
20,720
3
DIANA WOYTKO
SECRETARY
(i)
(ii)
0
-------------
228,584
0
-------------
38,646
0
-------------
11,822
0
-------------
37,206
0
-------------
18,244
0
-------------
334,503
0
-------------
11,822
4
LINDA BAKER
FORMER KEY EMPLOYEE
(i)
(ii)
0
-------------
192,429
0
-------------
38,696
0
-------------
3,713
0
-------------
35,053
0
-------------
29,016
0
-------------
298,907
0
-------------
3,713
5
SCOTT PETERSON
FORMER KEY EMPLOYEE
(i)
(ii)
0
-------------
0
0
-------------
0
0
-------------
110,504
0
-------------
0
0
-------------
0
0
-------------
110,504
0
-------------
0
6
JON ROZENFELD
FORMER KEY EMPLOYEE
(i)
(ii)
0
-------------
159,094
0
-------------
0
0
-------------
17,194
0
-------------
18,187
0
-------------
13,632
0
-------------
208,106
0
-------------
17,194
7
LAURENCE R DRY III
CHIEF OPERATING OFFICER
(i)
(ii)
0
-------------
260,706
0
-------------
51,247
0
-------------
0
0
-------------
20,069
0
-------------
30,435
0
-------------
362,457
0
-------------
0
8
TIMOTHY MALISCH MD
INTERVENTIONAL NEURORADIOLOGIST
(i)
(ii)
0
-------------
853,273
0
-------------
25,000
0
-------------
18,000
0
-------------
10,798
0
-------------
15,236
0
-------------
922,307
0
-------------
0
9
FRANKLIN A MARDEN MD
INTERVENTIONAL NEURORADIOLOGIST
(i)
(ii)
0
-------------
661,819
0
-------------
25,150
0
-------------
18,000
0
-------------
10,615
0
-------------
23,622
0
-------------
739,206
0
-------------
0
10
LAVERNA MENSAH MD
GYNECOLOGIST & ONCOLOGIST
(i)
(ii)
0
-------------
386,329
0
-------------
0
0
-------------
0
0
-------------
5,300
0
-------------
22,170
0
-------------
413,799
0
-------------
0
11
SZYMON S ROSENBLATT MD
NEUROSURGEON
(i)
(ii)
0
-------------
951,783
0
-------------
32,752
0
-------------
0
0
-------------
11,278
0
-------------
23,873
0
-------------
1,019,686
0
-------------
0
12
SANJAY YADLA PHD
NEUROSURGEON
(i)
(ii)
0
-------------
576,076
0
-------------
0
0
-------------
18,000
0
-------------
5,300
0
-------------
23,538
0
-------------
622,914
0
-------------
0
Schedule J (Form 990) 2015
Page 3
Schedule J (Form 990) 2015
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 II FORM 990, PART VII, SECTION A, LINE 5
The following individual(s) was compensated by Adventist Health System Sunbelt Healthcare Corporation "AHSSHC" in 2015 for services provided to the filing organization. Please see our response to Form 990, Part III, Line 4A for a discussion concerning the filing organization's affiliation with AHSSHC. Individuals that are considered Officers have been reported in Part VII. Individuals that are considered Key Employees have not been reported in Part VII since they did not receive reportable compensation in excess of $150,000 from this organization and/or related organizations. Name of Employer: Adventist Health System Sunbelt Healthcare Corporation Name of Employee: Donald J. Russell, Key Employee Type and Amount of Compensation Paid/Accrued from AHSSHC for services rendered to the filing organization: Base Compensation: $312,868 Bonus & Incentive Compensation: $40,291 Other Reportable Compensation: $31,149 Retirement & Other Deferred Compensation: $20,149 Nontaxable benefits: $40,754
Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation
Alexian Brothers - AHS Midwest Region Health Co., a related organization of the filing organization, uses the following methods to establish the compensation of the organization's CEO: - Compensation committee - Independent compensation consultant - Form 990 of other organizations - Compensation survey or study - Approval by the Compensation Committee
Schedule J, Part I, Line 4a Severance or change-of-control payment
The following individual listed in Schedule J was paid the referenced amount of severance in calendar 2015: Scott Peterson - $110,504
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
Alexian Brothers Health System offers a Supplemental Employee Retirement Plan to CERTAIN employees who participate in the executive benefits program and whose compensation exceeds the IRS allowable limit for a qualified pension plan. The purpose of the plan is to restore retirement benefits that are restricted because of compensation limits for the executives. No distributions from the supplemental nonqualified retirement plan were made in the current year.
Schedule J (Form 990) 2015
Additional Data
Software ID:
15000238
Software Version:
2015v3.0