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ObjectId: 201713189349306426 - Submission: 2017-11-14
TIN: 15-0584188
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
16
Open to Public Inspection
Name of the organization
NEWARK-WAYNE COMMUNITY HOSPITAL
Employer identification number
15-0584188
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 nonfixed
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) 2016
Page 2
Schedule J (Form 990) 2016
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
ERIC BIEBER MD
CEO
(i)
(ii)
162,329
-------------
953,686
349,208
-------------
2,051,597
0
-------------
0
147,178
-------------
864,668
7,718
-------------
46,344
666,433
-------------
3,916,295
155,682
-------------
914,635
2
THOMAS R CRILLY
CFO
(i)
(ii)
63,317
-------------
371,990
83,972
-------------
493,337
0
-------------
0
54,623
-------------
320,912
7,522
-------------
44,192
209,434
-------------
1,230,431
54,221
-------------
318,546
3
ROBERT NESSELBUSH
COO
(i)
(ii)
135,992
-------------
611,966
156,485
-------------
704,184
0
-------------
0
113,506
-------------
510,778
9,450
-------------
42,527
415,433
-------------
1,869,455
101,184
-------------
455,329
4
HUGH THOMAS
CAO
(i)
(ii)
79,603
-------------
467,671
99,442
-------------
584,224
0
-------------
0
67,832
-------------
398,516
6,734
-------------
39,563
253,611
-------------
1,489,974
64,323
-------------
377,898
5
DUSTIN RICCIO
PRESIDENT, EASTERN REGION
(i)
(ii)
176,477
-------------
66,179
119,500
-------------
44,812
0
-------------
0
74,534
-------------
27,950
31,000
-------------
11,625
401,511
-------------
150,566
74,773
-------------
28,040
6
MICHAEL CUNNINGHAM
PHYSICIAN
(i)
(ii)
288,536
-------------
0
63,335
-------------
0
0
-------------
0
59,196
-------------
0
13,200
-------------
0
424,267
-------------
0
0
-------------
0
7
EVE WILLIAMS
PHYSICIAN
(i)
(ii)
281,324
-------------
0
65,372
-------------
0
0
-------------
0
52,597
-------------
0
10,824
-------------
0
410,117
-------------
0
0
-------------
0
8
JAMES SYRETT
PHYSICIAN
(i)
(ii)
34,830
-------------
0
337,167
-------------
0
0
-------------
0
40,710
-------------
0
5,596
-------------
0
418,303
-------------
0
0
-------------
0
9
CYNTHIA MARTINEZ-CAPOLINO
PHYSICIAN
(i)
(ii)
24,057
-------------
0
326,665
-------------
0
0
-------------
0
34,506
-------------
0
5,644
-------------
0
390,872
-------------
0
0
-------------
0
10
BRIAN LAUX
PHYSICIAN
(i)
(ii)
273,073
-------------
0
21,929
-------------
0
0
-------------
0
90,082
-------------
0
6,336
-------------
0
391,420
-------------
0
0
-------------
0
11
MARK CLEMENT
FORMER CEO
(i)
(ii)
0
-------------
0
0
-------------
0
0
-------------
1,373,284
0
-------------
26,618
0
-------------
4,097
0
-------------
1,403,999
0
-------------
1,373,284
Schedule J (Form 990) 2016
Page 3
Schedule J (Form 990) 2016
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 3
COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIALS INCLUDING: - ERIC BIEBER, M.D. (PRESIDENT & CEO) - THOMAS CRILLY (CFO) - MARK CLEMENT (CEO UNTIL 11/30/14) - HUGH THOMAS (CAO) - ROBERT NESSELBUSH (COO) USED THE FOLLOWING TO ESTABLISH THEIR COMPENSATION AND BENEFITS: - COMPENSATION COMMITTEE, - INDEPENDENT COMPENSATION CONSULTANT, - FORM 990 OF OTHER ORGANIZATIONS, - COMPENSATION SURVEYS AND STUDIES; - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ON AN ANNUAL BASIS, THE ORGANIZATION USES AN INDEPENDENT COMPENSATION CONSULTANT TO REVIEW THE SALARIES FOR ALL EXECUTIVES TO ENSURE SUCH SALARIES ARE CONSISTENT WITH MARKET SALARIES PAID TO SIMILARLY SITUATED EXECUTIVES. IN ADDITION, A COMPENSATION COMMITTEE REVIEWS THIS INFORMATION ANNUALLY AND IT IS THEN APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD. FINALLY, EXECUTIVES RECEIVE A WRITTEN LETTER OUTLINING THE SPECIFICS OF THE COMPENSATION AGREEMENT AND THEIR EXPECTED PERFORMANCE.
PART I, LINES 4A-B
SUPPLEMENTAL EXECUTIVE RETIREMENT PLANS PROVIDE BENEFITS TO CERTAIN KEY EXECUTIVE EMPLOYEES OF NEWARK-WAYNE COMMUNITY HOSPITAL. THE ORGANIZATION MAINTAINS A SECTION 457(F) PLAN WHICH WOULD BE CONSIDERED A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. THERE WERE NO DISTIBUTIONS PAID IN 2016. IN 2014 AND PRIOR YEARS, THE TOTAL COMPENSATION OF THE FORMER CEO'S WAS DISCLOSED AS A COMBINATION OF CASH PAID BY THE ORGANIZATION AND DEFERRED COMPENSATION. THE CASH PAYMENTS TO THE FORMER CEO'S SHOWN ON THE 2016 TAX RETURNS REPRESENTS PAYMENTS OF COMPENSATION WHICH WAS RECOGNIZED IN PREVIOUS TAX RETURNS. THERE WAS NO INCREMENTAL EXPENSE RECOGNIZED BY THE ORGANIZATION IN 2016 FOR PAYMENTS MADE TO THE FORMER CEO'S.
Schedule J (Form 990) 2016
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