ST LAWRENCE HEALTH SYSTEM INC: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- ST LAWRENCE HEALTH SYSTEM INC (EIN 46-4259168)
- Tax period
- 2015-01-01 to 2015-12-31
- Filed
- 2016-11-15
- IRS object ID
- 201613209349303911
- Schema version
- 2015v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-11-15T09:25:29-06:00 | ReturnTs |
| Tax Period End | 2015-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 201767403 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HOFFMAN EELLS & GRAY CPAS PC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1 MAIN STREET SUITE 101 | AddressLine1Txt |
| City | CANTON | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 136171277 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 464259168 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ST LAWRENCE HEALTH SYSTEM INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | STLA | BusinessNameControlTxt |
| Phone | 3152615100 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 50 LEROY STREET | AddressLine1Txt |
| City | POTSDAM | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13676 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | RICHARD JACOBS | PersonNm |
| Person Title | ASSISTANT TREASURER | PersonTitleTxt |
| Phone | 3152615100 | PhoneNum |
| Signature | 2016-11-15 | SignatureDt |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JOHN J GRAY JR CPA | PreparerPersonNm |
| PTIN | P00076464 | PTIN |
| Phone | 3153862925 | PhoneNum |
| Preparation | 2016-11-14 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DAVID ACKER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 50 LEROY STREET | AddressLine1Txt |
| City | POTSDAM | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13676 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $154,377 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.STLAWRENCEHEALTHSYSTEM.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2013 | FormationYr |
| Legal Domicile State | NY | LegalDomicileStateCd |
| Activity Or Mission | ST. LAWRENCE HEALTH SYSTEM'S MISSION IS TO IMPROVE HEALTH, DELIVER BETTER CARE AND CONSUMER EXPERIENCE, AND LOWER COSTS IN ST. LAWRENCE COUNTY THROUGH COORDINATION AND INTEGRATION OF SERVICES. | ActivityOrMissionDesc |
| Voting Members Governing Body | 12 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 1 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| CY Contributions Grants | $0 | CYContributionsGrantsAmt |
| CY Program Service Revenue | $0 | CYProgramServiceRevenueAmt |
| CY Investment Income | $0 | CYInvestmentIncomeAmt |
| PY Other Revenue | $314,100 | PYOtherRevenueAmt |
| CY Other Revenue | $154,377 | CYOtherRevenueAmt |
| PY Total Revenue | $314,100 | PYTotalRevenueAmt |
| CY Total Revenue | $154,377 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| CY Salaries Comp Emp Bnft Paid | $0 | CYSalariesCompEmpBnftPaidAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $353,167 | PYOtherExpensesAmt |
| CY Other Expenses | $370,386 | CYOtherExpensesAmt |
| PY Total Expenses | $353,167 | PYTotalExpensesAmt |
| CY Total Expenses | $370,386 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$39,067 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$216,009 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $7,008,461 | TotalAssetsBOYAmt |
| Total Assets EOY | $15,351,110 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $5,745,952 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $13,608,575 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,262,509 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $1,742,535 | NetAssetsOrFundBalancesEOYAmt |
| Mission | ST. LAWRENCE HEALTH SYSTEM'S MISSION IS TO IMPROVE HEALTH, DELIVER BETTER CARE AND CONSUMER EXPERIENCE, AND LOWER COSTS IN ST. LAWRENCE COUNTY THROUGH COORDINATION AND INTEGRATION OF SERVICES. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Desc | ST. LAWRENCE HEALTH SYSTEM'S MISSION IS TO IMPROVE HEALTH, DELIVER BETTER CARE AND CONSUMER EXPERIENCE, AND LOWER COSTS IN ST. LAWRENCE COUNTY THROUGH COORDINATION AND INTEGRATION OF SERVICES. | Desc |
| Described In Section501c3 | Yes (true) | DescribedInSection501c3Ind |
| Schedule B Required | false | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Lobbying Activities | false | LobbyingActivitiesInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Temp Or Permanent Endowments | false | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (true) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | false | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (true) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (true) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | false | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (true) | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | false | OperateHospitalInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | Yes (true) | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | false | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | false | PYExcessBenefitTransInd |
| Loan Outstanding | false | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | Yes (true) | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | false | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (true) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | Yes (true) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (true) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (true) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | false | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (true) | ScheduleORequiredInd |
| IRP Document | 15 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | false | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Form8899 Filedind | false | Form8899Filedind |
| Form1098 C Filed | false | Form1098CFiledInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 12 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 1 | IndependentVotingMemberCnt |
| Family Or Business Rln | false | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | false | MembersOrStockholdersInd |
| Election Of Board Members | false | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | false | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | false | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (true) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (true) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (true) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (true) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (true) | WhistleblowerPolicyInd |
| Document Retention Policy | false | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (true) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (true) | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | NY | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ST LAWRENCE HEALTH SYSTEM | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 3152615100 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 50 LEROY STREET | AddressLine1Txt |
| City | POTSDAM | CityNm |
| State Abbreviation | NY | StateAbbreviationCd |
| ZIP | 13676 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (15 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|---|---|
| MICHAEL J TULLOCH MD | |||||||
| DIRECTOR | 5.00 | 40.00 | Yes (X) | $0 | $120,809 | $0 | |
| JUDY C CHITTENDEN | |||||||
| DIRECTOR | 5.00 | 4.00 | Yes (X) | $0 | $0 | $0 | |
| MARK J CORNETT | |||||||
| VICE CHAIR | 5.00 | 4.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| KATHRYN L MULLANEY | |||||||
| TREASURER | 5.00 | 4.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| DONALD R DANGREMOND | |||||||
| DIRECTOR | 5.00 | 2.00 | Yes (X) | $0 | $0 | $0 | |
| BRIAN D GARDAM | |||||||
| DIRECTOR | 5.00 | 2.00 | Yes (X) | $0 | $0 | $0 | |
| EDWARD S MUCENSKI | |||||||
| CHAIR | 5.00 | 2.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| JAMES C THEODORE | |||||||
| DIRECTOR | 5.00 | 2.00 | Yes (X) | $0 | $0 | $0 | |
| MARK BRACKETT | |||||||
| DIRECTOR | 5.00 | 1.00 | Yes (X) | $0 | $0 | $0 | |
| MICHAEL BURGESS | |||||||
| SECRETARY | 5.00 | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| ANNE RICHEY | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| STEPHEN KNIGHT | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID ACKER | |||||||
| PRESIDENT/CE | 5.00 | 50.00 | $0 | $508,974 | $100,650 | Yes (X) | |
| RICHARD JACOBS | |||||||
| ASSISTANT TR | 5.00 | 50.00 | $0 | $278,876 | $28,264 | Yes (X) | |
| KIMBERLY A SMITH | |||||||
| ASSISTANT SE | 5.00 | 40.00 | $0 | $47,326 | $10,199 | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tot Reportable Comp Rltd Org | $955,985 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $139,113 | TotalOtherCompensationAmt |
| Former Ofcr Employees Listed | false | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (true) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (3 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt | Address Line2ContractorAddress/USAddress/AddressLine2Txt |
|---|---|---|---|---|---|---|
| THE PIKE COMPANY INC | ||||||
| 1 CIRCLE STEET | ROCHESTER | NY | 14607 | CONSTRUCTION | $766,995 | |
| LATRIC SYSTEMS | ||||||
| PO BOX 845087 | BOSTON | MA | 022845087 | HEALTH INFO SER | $170,042 | |
| MCDERMOTT WILL & EMERY LLP | ||||||
| THE MCDERMOTT BUILDING | WASHINGTON | DC | 200011531 | CONSULTING | $140,464 | 500 NORTH CAPITOL ST NW |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 3 | CntrctRcvdGreaterThan100KCnt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | OTHER REVENUE | Desc |
| Business | 621110 | BusinessCd |
| Total Revenue Column | $154,377 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $154,377 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $154,377 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $154,377 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $154,377 | RelatedOrExemptFuncIncomeAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $166,066 | TotalAmt |
| Management And General | $166,066 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,028 | TotalAmt |
| Management And General | $1,028 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,540 | TotalAmt |
| Management And General | $4,540 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $25,142 | TotalAmt |
| Management And General | $25,142 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $669 | TotalAmt |
| Management And General | $669 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $154,377 | TotalAmt |
| Management And General | $154,377 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,781 | TotalAmt |
| Management And General | $14,781 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|
| REAL ESTATE TAXES | $3,358 | $3,358 |
| OTHER DIRECT EXPENSES | $300 | $300 |
| LICENSES AND DUES | $125 | $125 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $370,386 | TotalAmt |
| Program Services | $0 | ProgramServicesAmt |
| Management And General | $370,386 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $816,993 | BOYAmt |
| EOY | $3,996,035 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,900,103 | BOYAmt |
| EOY | $4,762,234 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $8,084 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $5,935,617 | LandBldgEquipCostOrOtherBssAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $939,413 | BOYAmt |
| EOY | $5,935,617 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $351,952 | BOYAmt |
| EOY | $649,140 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,008,461 | BOYAmt |
| EOY | $15,351,110 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $2,256,344 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $6,000,000 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,745,952 | BOYAmt |
| EOY | $5,352,231 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,745,952 | BOYAmt |
| EOY | $13,608,575 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,262,509 | BOYAmt |
| EOY | $1,742,535 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,262,509 | BOYAmt |
| EOY | $1,742,535 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,008,461 | BOYAmt |
| EOY | $15,351,110 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | -$216,009 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $696,035 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | false | AccountantCompileOrReviewInd |
| FS Audited | Yes (true) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (true) | AuditCommitteeInd |
| Federal Grant Audit Required | false | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | Yes (X) | SupportingOrganization509a3Ind |
| Supporting Org Type2 | Yes (X) | SupportingOrgType2Ind |
| Supported Organizations | 2 | SupportedOrganizationsCnt |
Supported Org Information SupportedOrgInformationGrp (2 entries)
| Business Name Line2SupportedOrganizationName/BusinessNameLine2Txt | EINEIN | Organization TypeOrganizationTypeCd | Governing Document ListedGoverningDocumentListedInd | SupportSupportAmt | Other SupportOtherSupportAmt |
|---|---|---|---|---|---|
| GOUVERNEUR HOSPITAL | |||||
| GOUVERNEUR HOSPITAL | 464249555 | 3 | Yes (true) | $630,430 | $0 |
| CANTON-POTSDAM HOSPITAL | |||||
| CANTON-POTSDAM HOSPITAL | 161012691 | 3 | Yes (true) | $0 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supported Organizations Total | 2 | SupportedOrganizationsTotalCnt |
| Support Sum | $630,430 | SupportSumAmt |
| Other Support Sum | $0 | OtherSupportSumAmt |
Form990 Sch A Supporting Org Form990SchASupportingOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Listed By Name Governing Doc | Yes (true) | ListedByNameGoverningDocInd |
| Suprt Org No IRS Determination | false | SuprtOrgNoIRSDeterminationInd |
| Supported Org Section C456 | false | SupportedOrgSectionC456Ind |
| Supported Org Not Organized US | false | SupportedOrgNotOrganizedUSInd |
| Organization Change Suprt Org | false | OrganizationChangeSuprtOrgInd |
| Support Non Supported Org | false | SupportNonSupportedOrgInd |
| Payment Substantial Contribtr | false | PaymentSubstantialContribtrInd |
| Loan Disqualified Person | false | LoanDisqualifiedPersonInd |
| Controlled Disqualified Prsn | false | ControlledDisqualifiedPrsnInd |
| Disqualified Prsn Controll Int | false | DisqualifiedPrsnControllIntInd |
| Disqualified Prsn Ownr Int | false | DisqualifiedPrsnOwnrIntInd |
| Excess Business Holdings Rules | false | ExcessBusinessHoldingsRulesInd |
| Contribution Controller | false | ContributionControllerInd |
| Contribution Family | false | ContributionFamilyInd |
| Contribution35 Controlled | false | Contribution35ControlledInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Majority Dir Trst Supported Org | false | MajorityDirTrstSupportedOrgInd |
Form990 Schedule A Part VI Form990ScheduleAPartVIGrp (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART IV, SECTION C, LINE 1 | NO |
| SUPPLEMENTAL INFORMATION | CANTON-POTSDAM HOSPITAL'S (CPH) BOARD CONSISTS OF 18 DIRECTORS. EIGHT (8) OF THESE DIRECTORS ARE MEMBERS OF THE ST. LAWRENCE HEALTH SYSTEM (SLHS) BOARD. THE BYLAWS OF THE SLHS BOARD PROVIDE THAT SLHS, AS SOLE MEMBER OF CPH, HAS THE FOLLOWING POWERS REGARDING CPH: A)APPOINT THE MEMBERS OF THE BOARD OF DIRECTORS; B)APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER; C)APPROVE THE ADOPTION AND AMENDMENT OF BYLAWS; D)APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; E)APPROVE STRATEGIC PLANS; F)APPROVE AND MAY INITIATE THE FILING OF CERTIFICATE OF NEED APPLICATIONS; AND G)APPROVE THE DISSOLUTION OF CPH. GOUVERNEUR HOSPITAL'S (GH) BOARD CONSISTS OF 7 DIRECTORS. TWO (2) OF THESE DIRECTORS ARE MEMBERS OF THE SLHS BOARD. THE BYLAWS OF THE SLHS BOARD PROVIDE THAT SLHS, AS SOLE MEMBER OF GH, HAS THE FOLLOWING POWERS REGARDING GH: A)APPOINT THE MEMBERS OF THE BOARD OF DIRECTORS; B)APPOINT AND REMOVE THE CHIEF EXECUTIVE OFFICER; C)APPROVE THE ADOPTION AND AMENDMENT OF BYLAWS; D)APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS; E)APPROVE STRATEGIC PLANS; F)APPROVE AND MAY INITIATE THE FILING OF CERTIFICATE OF NEED APPLICATIONS; G)APPROVE THE DISSOLUTION OF GH; H)APPROVE THE SALE, LEASE, MORTGAGE OR ENCUMBRANCE OF ANY ASSET OTHER THAN ANY SALE, LEASE OR MORTGAGE WHICH IS PART OF AN APPROVED BUDGET; I)APPROVE ANY MERGER, BUSINESS CONSOLIDATION, ACQUISITION OR JOINT VENTURE; J)APPROVE THE PURCHASE OR SALE OF PHYSICIAN PRACTICES OTHER THAN ANY PURCHASE OR SALE WHICH IS PART OF AN APPROVED BUDGET; K)APPROVE AND MAY INITIATE THE COMMENCEMENT AND SETTLEMENT OF LITIGATION; L)APPROVE ANY FILING OF A BANKRUPTCY PETITION; M)APPROVE THE INCURRENCE OF ANY DEBT OTHER THAN DEBT WHICH IS INCURRED IN THE ORDINARY COURSE OF BUSINESS AND WHICH IS NOT INCONSISTENT WITH AN APPROVED BUDGET; N)APPROVE NEW CLINICAL PROGRAMS OR THE TERMINATIONS OF EXISTING CLINICAL PROGRAMS OTHER THAN ANY ACTION WHICH IS PART OF AN APPROVED BUDGET; O)APPROVE ANY OF THE FOLLOWING AGREEMENTS: (A) MANAGEMENT SERVICES AGREEMENT OTHER THAN ANY AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; (B) CONTRACTS WITH A PHYSICIAN OR PHYSICIAN GROUP; (C) AGREEMENTS FOR THE OUTSOURCING OF A HOSPITAL SERVICE OR FUNCTION; (D) COLLECTIVE BARGAINING AGREEMENTS; AND (E) ANY AGREEMENTS TO PARTICIPATE IN RISK BEARING ARRANGEMENT SUCH AS AN ACCOUNTABLE CARE ORGANIZATION OR A BUNDLED PAYMENT ARRANGEMENT. P)INITIATE, NEGOTIATE AND APPROVE MANAGED CARE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS AND OTHER PAYORS OTHER THAN AGREEMENT WHICH IS PART OF AN APPROVED BUDGET; Q)DEVELOP INTEGRATED SERVICES AND MANDATE PARTICIPATION IN SUCH SERVICES (E.G., FINANCIAL MANAGEMENT, STRATEGIC PLANNING, HUMAN RESOURCES, INFORMATION TECHNOLOGY, LEGAL, QUALITY ASSURANCE, RISK MANAGEMENT, CONTRACTING AND RECRUITMENT); AND R)REQUIRE THE GUARANTEE OF LOANS THROUGH AN OBLIGATED GROUP STRUCTURE THAT WILL SUPPORT ACCESS TO CAPITAL AND MAY INCLUDE DEBT SERVICES. |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $943,342 | OtherCostOrOtherBasisAmt |
| Book Value | $943,342 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,992,275 | OtherCostOrOtherBasisAmt |
| Book Value | $4,992,275 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $5,935,617 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| NOTE-LT | $4,456,760 |
| DUE TO AFFILIATES | $895,471 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $5,352,231 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $154,377 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Subtotal | $154,377 | RevenueSubtotalAmt |
| Total Revenue Per Form990 | $154,377 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $370,386 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Subtotal | $370,386 | ExpensesSubtotalAmt |
| Total Expenses Per Form990 | $370,386 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE D, PAGE 3, PART X | FormAndLineReferenceDesc |
| Explanation | FOOTNOTE 1U - INCOME TAXES OF THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS: THE SYSTEM AND ITS AFFILIATES ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM AND AFFILIATES RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. RECOGNIZED INCOME TAX POSITIONS ARE MEASURED AT THE LARGEST AMOUNT THAT IS GREATER THAN FIFTY PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT. CHANGES IN RECOGNITION IN MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. THE SYSTEM AND AFFILIATES DID NOT RECOGNIZE THE EFFECT OF ANY UNCERTAIN INCOME TAX POSITIONS IN EITHER 2015 OR 2014. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | false | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | false | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | false | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | false | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | false | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | false | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | false | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | false | AnyNonFixedPaymentsInd |
| Initial Contract Exception | false | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)
| TitleTitleTxt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt |
|---|---|---|---|---|---|
| DAVID ACKER | |||||
| PRESIDENT/CEO | $506,380 | $2,594 | $86,050 | $14,600 | $609,624 |
| RICHARD JACOBS | |||||
| ASSISTANT TREASURER | $278,876 | $18,442 | $9,822 | $307,140 | |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE J, PART III | FormAndLineReferenceDesc |
| Explanation | THE ST. LAWRENCE HEALTH SYSTEM (SLHS) DOES NOT HAVE ANY EMPLOYEES ON ITS PAYROLL. THE PRESIDENT/CEO OF SLHS IS AN EMPLOYEE OF RELATED (AND CONTROLLED) ORGANIZATION, CANTON-POTSDAM HOSPITAL. AS SUCH, THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS OF CANTON-POTSDAM HOSPITAL SEEKS INPUT OF A CONSULTING FIRM WITH NATIONAL EXPERIENCE TO REVIEW COMPENSATION PACKAGES OFFERED TO TOP MANAGEMENT AND THE REGULATORY COMPLIANCE ISSUES OF NON-FOR-PROFITS. UPON THE FINDINGS OF THE CONSULTANT AND DELIBERATIONS OF THE COMPENSATION COMMITTEE, THE COMMITTEE WILL THEN MAKE RECOMMENDATION TO THE FULL BOARD. THE FULL BOARD WILL THEN VOTE ON THE TOP OFFICIAL'S COMPENSATION PACKAGE. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | SEE PART V ADDITIONAL INFORMATION | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Sharing Of Revenues | false | SharingOfRevenuesInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE L, PART V | FormAndLineReferenceDesc |
| Explanation | DUE TO OUR BOARD MEMBERS' AFFILIATIONS WITH RELATED HOSPITALS CANTON- POTSDAM HOSPITAL (CPH) AND GOUVERNEUR HOSPITAL (GH) (AS DISCLOSED ON SCHEDULE R), WE ARE DISCLOSING THE FOLLOWING: 1.KATHRYN MULLANEY, THE SLHS AND CPH BOARD TREASURER, RETIRED AS THE VICE PRESIDENT FOR FINANCE AT ST. LAWRENCE UNIVERSITY (SLU) IN 2014. CPH PROVIDES HEALTHCARE SERVICES AND STAFFS A CLINIC ON THE SLU CAMPUS. THE OPERATION COSTS OF THAT CLINIC IN 2015 WERE APPROXIMATELY 614,361, WHICH WERE REIMBURSED BY SLU ON A PASS THROUGH BASIS. 2.DONALD DANGREMOND, SLHS AND CPH BOARD MEMBER, RETIRED AS AN EMPLOYEE OF CLARKSON UNIVERSITY (CU) AS OF JUNE 30, 2015. CPH PROVIDES HEALTHCARE SERVICES AND STAFFS A CLINIC ON THE CU CAMPUS. THE OPERATION COSTS OF THAT CLINIC IN 2015 WERE APPROXIMATELY 331,760, WHICH WERE REIMBURSED BY CU ON APASS THROUGH BASIS. 3.DR. MICHAEL TULLOCH, BOARD MEMBER OF SLHS AND CPH, IS CONTRACTED TO PERFORM INTERPRETATIONS OF CARDIOLOGY SERVICES PROVIDED AT CPH. HE WAS COMPENSATED 120,809 FOR THIS SERVICE IN 2015. HIS PAYMENT FOR PROFESSIONAL SERVICES IS BASED ON A PER PROCEDURE FEE STRUCTURE. 4.BRIAN GARDAM, SLHS AND CPH BOARD MEMBER, IS ALSO THE EXECUTIVE DIRECTOR OF HOSPICE OF PALLIATIVE CARE OF ST. LAWRENCE VALLEY (HOSPICE). HOSPICE CONTRACTS WITH CPH FOR INPATIENT HOSPICE SERVICES FOR SYMPTOM MANAGEMENT AND PAIN CONTROL. IN 2015, 5,690 WAS REMITTED TO HOSPICE FOR THESE SERVICES. CANTON-POTSDAM HOSPITAL ALSO REMITTED TO HOSPICE 2,000 TO SUPPORT THE TASTE OF SPRING AND TASTE OF AUTUMN ANNUAL HOSPICE FUNDRAISERS. 5.JAMES THEODORE, SLHS AND CPH BOARD MEMBER, IS ALSO THE MORGAN STANLEY SMITH BARNEY LLC FINANCIAL ADVISOR FOR AN ACCOUNT HELD IN THE NAME OF CANTON-POTSDAM HOSPITAL FOUNDATION, INC. (A RELATED TAX-EXEMPT ORGANIZATION TO CPH). THIS FOUNDATION ACCOUNT IS USED AS A PASS-THROUGH FOR DONATIONS OF STOCK. THE BALANCE IN THIS ACCOUNT AS OF DECEMBER 31, 2015 WAS 0. 6.DURING 2010, BOND ISSUES WERE OBTAINED FOR CPH FROM COMMUNITY BANK, NA AND KEY BANK, AS DISCLOSED IN SCHEDULE K OF CPH'S FORM 990. THE COMMUNITY BANK, NA PORTION OF THESE BOND ISSUES WERE IN THE AMOUNT OF 3,585,000. IN 2011, CPH WAS ISSUED A MORTGAGE BY COMMUNITY BANK, NA FOR CONSTRUCTION OF THE E.J. NOBEL ANNEX BUILDING, IN THE AMOUNT OF 2,200,000. EDWARD MUCENSKI, SLHS CHAIR AND CPH BOARD MEMBER, IS A BOARD MEMBER OF COMMUNITY BANK, NA. AS OF DECEMBER 31, 2015 CPH WAS CURRENT ON ANY OBLIGATIONS DUE TO THE BANK. 7.SLHS VICE CHAIR AND CPH BOARD MEMBER, MARK CORNETT, IS A CONSULTANT EMPLOYED BY SLIC NETWORK SOLUTIONS. SLIC RENTS OFFICE SPACE AT CPH'S MEDICAL OFFICE BUILDING IN CANTON, NEW YORK. CPH REMITTED APPROXIMATELY 161,577 TO SLIC IN 2015 FOR TELECOMMUNICATION SERVICES. 8.MARK BRACKETT, SLHS DIRECTOR AND GH BOARD SECRETARY/TREASURER, WAS PRESIDENT OF KINNEY DRUGS FOUNDATION FROM JANUARY 1, 2014 UNTIL JUNE 30, 2014. HE REMAINS ON THE KINNEY DRUGS FOUNDATION BOARD OF DIRECTORS. KINNEY DRUGS FOUNDATION IS UNDER THE PARENT ORGANIZATION, KPH HEALTHCARE SERVICES. CPH AND GH PARTICIPATED WITH ONE OR MORE OF THE KPH HEALTHCARE CORPORATE DIVISIONS IN THE HOSPITALS' 340B PROGRAMS. 9.MICHAEL BURGESS, SLHS BOARD SECRETARY AND GH BOARD CHAIR, IS VP OF FINANCIAL PLANNING AND TREASURY WITH KPH HEALTHCARE SERVICES, INC. CORPORATE DIVISIONS OF KPH HEALTHCARE SERVICES ARE KINNEY DRUGS, HEALTH DIRECT INSTITUTIONAL PHARMACY SERVICES, PROACT AND NOBLE SPECIALTY PHARMACY. CPH AND GH PARTICIPATED WITH ONE OR MORE OF THE CORPORATE DIVISIONS IN THE HOSPITALS' 340B PROGRAMS. 10.ANNE RICHEY, SLHS BOARD DIRECTOR, IS EXECUTIVE DIRECTOR OF UNITED CEREBRAL PALSY ASSOCIATION OF THE NORTH COUNTRY, INC., DBA COMMUNITY HEALTH CENTER OF THE NORTH COUNTRY. IN 2015, THE UNITED CEREBRAL PALSY ASSOCIATION RENTED OUTPATIENT CLINIC SPACE FROM GH, FOR APPROXIMATELY 9,844 PER MONTH FOR THE COMMUNITY HEALTH CENTER OF THE NORTH COUNTRY. IN 2015, CPH LEASED A NURSE PRACTITIONER TO THE SAME CLINIC AND INVOICED THE CLINIC FOR TELEPHONE/DATA SERVICE. AT YEAR END, CEREBRAL PALSY WAS CURRENT IN THEIR OBLIGATIONS TO CPH AND GH. 11.STEPHEN KNIGHT, SLHS BOARD MEMBER, IS ALSO ON THE BOARD OF NORTHERN LIGHTS HEALTH CARE PARTNERSHIP, INC. CANTON-POTSDAM HOSPITAL, RELATED ORGANIZATION, HAS AN INTEREST IN NORTHERN LIGHTS. IN 2015, THERE WERE NO FINANCIAL TRANSACTIONS BETWEEN CANTON-POTSDAM HOSPITAL AND NORTHERN LIGHTS. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PAGE 6, PART VI, LINE 11B | THE FORM 990 IS PREPARED BY FINANCE OFFICE STAFF MEMBERS. UPON COMPLETION, A COPY WITH SUPPORTING DOCUMENTATION IS REVIEWED BY THE VICE PRESIDENT FOR FINANCE AND THE CONTROLLER. AFTER REVIEW, ANY CHANGES ARE MADE AND A COPY IS PRESENTED TO THE FULL BOARD OF DIRECTORS FOR THEIR REVIEW, COMMENTS AND APPROVAL. |
| FORM 990, PAGE 6, PART VI, LINE 12C | BOARD MEMBER CONFLICT OF INTEREST DISCLOSURE FORMS ARE COMPLETED AND REVIEWED BY THE BOARD ANNUALLY. |
| FORM 990, PAGE 6, PART VI, LINE 15A | ST. LAWRENCE HEALTH SYSTEM DOES NOT HAVE ANY EMPLOYEES AND THERE IS NO COMPENSATION FOR DIRECTORS. THE ORGANIZATION'S CEO IS PAID BY THE RELATED ORGANIZATION, CANTON-POTSDAM HOSPITAL, AND CPH'S COMPENSATION PROCEDURES ARE FOLLOWED ACCORDINGLY. |
| FORM 990, PAGE 6, PART VI, LINE 15B | ST. LAWRENCE HEALTH SYSTEM DOES NOT HAVE ANY EMPLOYEES AND THERE IS NO COMPENSATION FOR DIRECTORS. THE ORGANIZATION'S OTHER OFFICERS ARE PAID BY THE RELATED ORGANIZATION, CANTON-POTSDAM HOSPITAL, AND CPH'S COMPENSATION PROCEDURES ARE FOLLOWED ACCORDINGLY. DR. TULLOCH RECEIVES COMPENSATION FOR PROVIDING CERTAIN CONTRACTED MEDICAL SERVICES TO CPH. THESE PAYMENTS ARE FOR SERVICES DR. TULLOCH PROVIDES AS A PHYSICIAN AND NOT AS A BOARD MEMBER. |
| FORM 990, PAGE 6, PART VI, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9 | TRANSFER TO GH -630,430 TRANSFER FROM CPH 1,326,465 TOTAL 696,035 |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (4 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| CANTON-POTSDAM HOSPITAL INC | |||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 161012691 | HOSPITAL | NY | 501C | 3 | SLHS | Yes (true) | |
| GOUVERNEUR HOSPITAL INC | |||||||||||
| 77 WEST BARNEY STREET | GOUVERNEUR | NY | 13642 | 464249555 | HOSPITAL | NY | 501C | 3 | SLHS | Yes (true) | |
| CANTON-POTSDAM HOSPITAL FOUNDATION | |||||||||||
| 29 GROVE STREET | POTSDAM | NY | 13676 | 161279472 | FUNDRAISG | NY | 501C | 3 | false | N/A | |
| CANTON-POTSDAM MEDICAL PRACTICEPLLC | |||||||||||
| 50 LEROY STREET | POTSDAM | NY | 13676 | 460714367 | OUT PATIEN | NY | 501C | 3 | SLHS | Yes (true) | |
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ACCOUNTABLE CARE ORGANIZATION | BusinessNameLine1Txt |
| Business Name Line2 | OF THE NORTH COUNTRY LLC | BusinessNameLine2Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 555 WEST GRANADA BLVD 555 | AddressLine1Txt |
| City | ORMOND BEACH | CityNm |
| State Abbreviation | FL | StateAbbreviationCd |
| ZIP | 32174 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 454106154 | EIN |
| Primary Activities | SERV COORD | PrimaryActivitiesTxt |
| Legal Domicile State | FL | LegalDomicileStateCd |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Predominant Income Type | RELATED | PredominantIncomeTypeTxt |
| Share Of Total Income | $370,597 | ShareOfTotalIncomeAmt |
| Share Of EOY Assets | $39,312 | ShareOfEOYAssetsAmt |
| Disproportionate Allocations | false | DisproportionateAllocationsInd |
| General Or Managing Partner | false | GeneralOrManagingPartnerInd |
| Ownership | 0.25500 | OwnershipPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | false | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (true) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (true) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | false | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | false | DivRelatedOrganizationInd |
| Asset Sale To Other Org | false | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | false | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | false | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (true) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | false | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | false | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | false | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | false | SharingOfFacilitiesInd |
| Paid Employees Sharing | false | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (true) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (true) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | false | TransferToOtherOrgInd |
| Transfer From Other Org | false | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (6 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt | Business Name Line2OtherOrganizationName/BusinessNameLine2Txt |
|---|---|---|---|
| CANTON-POTSDAM HOSPITAL | |||
| C | $3,172,616 | CASH EXCHANGED | |
| CANTON-POTSDAM HOSPITAL | |||
| P | $1,846,151 | CASH EXCHANGED | |
| GOUVERNEUR HOSPITAL INC | |||
| B | $630,430 | CASH EXCHANGED | |
| ACCOUNTABLE CARE ORG OF NC LLC | |||
| B | $348,771 | CASH EXCHANGED | THE NORTH COUNTRY LLC |
| GOUVERNER HOSPITAL INC | |||
| J | $154,743 | FMV | |
| GOUVERNEUR HOSPITAL INC | |||
| Q | $164,865 | FMV | |