2013-05-10T14:08:04-05:00 2012-06-30 520783935 SMITH ELLIOTT KEARNS & COMPANY LLC 804 WAYNE AVENUE CHAMBERSBURG PA 17201 990 2011-07-01 230465970 THE CHAMBERSBURG HOSPITAL CHAM 7172673000 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 PATRICK W O'DONNELL 7172677106 2013-05-01 1 GREGORY P HALL CPA P00156653 7172633910 2011 2016-02-25 16:41:14Z PATRICK W O'DONNELL 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 284028884 0 X WWW.SUMMITHEALTH.ORG X 1904 PA THE CHAMBERSBURG HOSPITAL IS A REGIONAL NONPROFIT HEALTH CARE ORGANIZATION COMMITTED TO THE IMPROVEMENT OF THE HEALTH AND WELL-BEING OF THE PEOPLE IN SOUTH CENTRAL PENNSYLVANIA. 18 17 1966 0 2500635 -24951 3617330 183791 260075061 277222023 5516347 2402832 6114025 3563416 275322763 283372062 2071004 1421143 0 0 132307566 139995575 0 0 0 105203373 109339410 239581943 250756128 35740820 32615934 433623570 444750411 231040706 291294782 202582864 153455629 THE CHAMBERSBURG HOSPITAL IS A REGIONAL NONPROFIT HEALTH CARE ORGANIZATION COMMITTED TO THE IMPROVEMENT OF THE HEALTH AND WELL-BEING OF THE PEOPLE IN SOUTH-CENTRAL PENNSYLVANIA. 0 0 187891235 278023180 THE CHAMBERSBURG HOSPITAL PROVIDES NEEDED MEDICAL CARE TO THE COMMUNITY REGARDLESS OF ANY PATIENT'S ABILITY TO PAY. HEALTH CARE SERVICES INCLUDE INPATIENT ROUTINE, INPATIENT ANCILLARY AND OUTPATIENT CARE. ALL MANAGEMENT AND GENERAL EXPENSES ARE CONSIDERED PROGRAM RELATED. 1421143 1421143 GRANTS TO VARIOUS NON-PROFIT ORGANIZATIONS IN THE COMMUNITY TO DEVELOP OR EXPAND HEALTH CARE PROGRAMS TO EDUCATE THE COMMUNITY ABOUT HEALTH CARE ISSUES. CHAMBERSBURG HOSPITAL PARTNERS WITH COMMUNITY ORGANIZATIONS LIKE THE FRANKLIN COUNTY THERAPEUTIC RIDING PROGRAM, MERCERSBURG AREA COUNCIL FOR WELLNESS AND CUMBERLAND VALLEY ASTHMA ALLIANCE TO ENHANCE, PROMOTE AND OFFER COMMUNITY PROGRAMS FOR THE HEALTH AND WELLBEING OF RESIDENTS IN SOUTH CENTRAL PENNSYLVANIA. 189312378 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 160 0 1 1966 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 18 17 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 PA X PATRICK W O'DONNELL 7172673000 112 N SEVENTH STREET CHAMBERSBURG PA 17201 NANCY H MEYERS ESQUIRE 0.20 X X 0 0 0 PHILIP E FAGUE 0.40 X X 0 0 0 DENNIS L WILSON 0.40 X X 0 0 0 NORMAN B EPSTEIN 0.20 X X 683398 292885 98560 DENISE B BARROWS CPA 0.50 X 0 0 0 JOHN BOOZER 0.30 X 0 0 0 MICHAEL J COLLI MD 0.20 X 0 0 0 SAM KING 0.10 X 0 0 0 PETER LAGIOVANE 0.50 X 0 0 0 JULIO LECUONA 0.30 X 0 0 0 CHRISTINE A MOLLY MD 0.40 X 0 0 0 ROGER J ROBERTSON MD 0.10 X 0 0 0 LYNN C ROTZ CPA 0.20 X 0 0 0 MICHAEL STARR 0.20 X 0 0 0 JOHN VANHORN 0.40 X 0 0 0 CHERYL PLUMMER 0.40 X 0 0 0 R WILLIAM HAPPEL 0.10 X 0 0 0 JEFF REEDER 0.10 X 0 0 0 JOHN MASSIMILLA 40.00 X 274693 0 57716 PATRICK W O'DONNELL 24.00 X 274987 183324 92359 LOUIS GREGORIO 40.00 X 238151 0 44375 THOMAS ANDERSON MD 32.00 X 317781 79445 41693 PATRICIA BARBAROWICZ 30.00 X 139935 46645 51378 KIMBERLY M RZOMP 38.00 X 171174 9009 47726 SHERRI STAHL 32.00 X 195478 48870 44860 MICHELLE ZEIGLER 28.00 X 181922 77966 55903 DAVID GRANT 40.00 X 196150 0 37213 EVANS T PRIESTON 40.00 X 154857 0 48310 AMANDA G SCHMEIDER 40.00 X 164238 0 27381 CHRISTA ZIMMERMAN 40.00 X 163073 0 28255 KELLAN COOK 40.00 X 158977 0 15056 3314814 738144 690785 36 0 1 0 HOSPITAL BUILDING AND EQUIPMENT 11330 OLIVE BOULEVARD ST LOUIS MO 63141 CONSTRUCTION CONTRACTOR 45158159 AMERISOURCE BERGEN PO BOX 5187 NEW YORK NY 10087 PARAMEDICALS 6862466 CUMERLAND VALLEY ER ASSOCIATION 720 ORCHARD COURT CHAMBERSBURG PA 17201 ER DOCTORS 6643756 OWENS & MINOR INC PO BOX 360878 PITTSBURGH PA 15251 MEDICAL SUPPLIES 6298073 ZIMMER US INC 14235 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 MEDICAL SUPPLIES 2900135 134 183791 183791 PATIENT SERVICE REVENU 621990 277222023 277222023 277222023 1454938 1454938 466733 656822 -190089 -190089 -190089 933267 14627 0 0 933267 14627 947894 947894 UNRELATED BUSINESS INC 621990 2500635 2500635 PURCHASE DISCOUNTS 621990 843469 843469 CAFETERIA 621990 409401 409401 3753505 283372062 278065492 2500635 2622144 1421143 1421143 2930019 2930019 99158769 74186287 24972482 10807030 8103390 2703640 19627357 14412484 5214873 7472400 5452610 2019790 1019795 900 1018895 62648 62648 10358792 10358792 965378 672289 293089 514201 358090 156111 3574617 2489363 1085254 155222 108097 47125 151856 105753 46103 1174959 855370 319589 9206844 6702582 2504262 1849519 1288005 561514 SUPPLIES 40334037 28088623 12245414 BAD DEBTS 22636423 22636423 CONTRACTED SERVICES 11728861 8167979 3560882 EQUIPMENT RENTAL & MAIN 4717859 3285517 1432342 888399 618681 269718 250756128 189312378 61443750 0 6695 6929 23510990 9802491 168070 117070 20090721 20950348 4276914 3125408 2136483 2164527 3022859 3356332 333788331 182327948 96475153 151460383 55378424 29923261 216751935 189202580 11805326 34641082 433623570 444750411 22881576 33378549 142604148 140683727 65554982 117232506 231040706 291294782 X 195369566 146627998 7213298 6827631 202582864 153455629 433623570 444750411 X 32615934 -81743169 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1254623 -627 -19044 1234952 1056054 217297 18728 1254623 962458 110820 17224 1056054 1196623 -204425 29740 962458 0.73000 0.27000 1 0 6257981 6257981 70087609 46437954 23649655 150347854 130805461 19542393 10565628 96529259 5084533 102010354 151460383 16297861 F CASH AND MONEY FUNDS 12012146 F FIXED INCOME SECURITIES 87728439 F OTHER INVESTMENTS 401 F HEDGE FUNDS 18452464 F REAL ASSETS 37716328 F GOVERNMENT AGENCY OBLIGATIONS 12139896 F CORPORATE AND FOREIGN BONDS 4120045 F MUNICIPAL OBLIGATIONS 735000 F 189202580 ACCRUED INTEREST RECEIVABLE 58484 OTHER RECEIVABLES 3100909 DEFERRED FINANCING COSTS 1092816 PERPETUAL TRUSTS HELD BY THIRD PARTIES 6488873 RESTRICTED CASH 23900000 34641082 ADVANCES FROM THIRD-PARTY PAYORS 9316424 OTHER LIABILITIES 4730055 ESTIMATED AMOUNTS PAYABLE UNDER THIRD PARTY AGREEMENTS 8969548 ACCRUED PENSION OBLIGATION 61907074 OBLIGATIONS UNDER INTEREST RATE SWAP AGREEMENTS 32309405 117232506 283372062 250756128 32615934 -5077440 -76665729 -81743169 -49127235 257677730 -23327342 -23327342 281005072 2366990 2366990 283372062 249334223 0 249334223 1421905 1421905 250756128 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE TO BE USED FOR DEVELOPMENT OR EXPANSION OF COMMUNITY HEALTHCARE INIATIVES AND PROGRAMS. FUNDS ARE ALSO USED TO EDUCATE THE COMMUNITY ABOUT HEALTHCARE ISSUES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED AS TAX-EXEMPT PURSUANT TO SEC. 501(C) (3) OF THE INTERNAL REVENUE CODE. IT IS CLASSIFIED AS A PUBLIC CHARITY. THE HOSPITAL EXPENSED $ 222,000 AND $ 253,000 FOR ESTIMATED UNRELATED BUSINESS INCOME TAXES FOR THE YEARS ENDED JUNE 30, 2012 AND 2011, RESPECTIVELY. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO FEDERAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2009. WHEN TAX RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD BE ULTIMATELY SUSTAINED. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS TAKEN ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50 PERCENT LIKELY OF BEING REALIZED UPON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE PORTION OF THE BENEFITS ASSOCIATED WITH TAX POSITIONS TAKEN THAT EXCEEDS THE AMOUNT MEASURED AS DESCRIBED ABOVE WOULD BE REFLECTED AS A LIABILITY FOR UNRECOGNIZED TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEET ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. INTEREST AND PENALTIES ASSOCIATED WITH UNRECOGNIZED TAX BENEFITS WOULD BE CLASSIFIED AS EXPENSES AGAINST OTHER OPERATING REVENUE IN THE STATEMENT OF OPERATIONS. AT JUNE 30, 2012 AND 2011, THERE WAS NO LIABILITY FOR UNRECOGNIZED TAX BENEFITS. PART XI, LINE 8 - OTHER ADJUSTMENTS: TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT HEALTH -2,750,166. TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT PHYSICIAN SERVICES -17,499,270. CHANGE IN VALUE OF DERIVATIVE -23,327,342. PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -33,088,951. TOTAL TO SCHEDULE D, PART XI, LINE 8: -76,665,729. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF DERIVATIVES -23,327,342. PART XII, LINE 4B - OTHER ADJUSTMENTS: NET REALIZED LOSSES SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 933,267. INVESTMENT INCOME SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 1,454,938. RENTAL INCOME (EXPENSE) SHOWN ELSEWHERE ON FINANCIAL STATEMENTS -190,089. GAIN(LOSS) ON DISPOSAL OF EQUIPMENT SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 14,627. CONTRIBUTION INCOME SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 154,247. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GRANT EXPENSE SHOWN ELSEWHERE ON FINANCIAL STATEMENTS 1,421,905. CENTRAL AMERICAN AND CARRIBBEAN 0 0 INVESTMENT IN ALTERNATIVE VEHICLE 18390207 0 0 0 0 0 0 18390207 0 18390207 0 0 1 0 0 0 1 1 X 1 X 125.000000000000 1 X 1 1 1 0 1 1 3553555 3553555 0.01420 14977765 14977765 0.05970 127573 127573 0.00050 18658893 18658893 0.07440 18 10590 71344 71344 0.00030 2 455 113163 113163 0.00050 2 19 1508520 1508520 0.00600 5 1626506 1626506 0.00650 27 11064 3319533 3319533 0.01330 27 11064 21978426 21978426 0.08770 1 5296 5296 0.00000 2 401 1058 1058 0.00000 3 401 6354 6354 0 22636423 8466022 60732636 85349093 -24616457 X 1 1 1 1 THE CHAMBERSBURG HOSPITAL

112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201

X NOT REQUIRED 1 1 1 125.000000000000 1 250.000000000000 1 X X X 1 1 X X X X X X 1 X 1 X X X 1 X 0 0 PART I, LINE 3C: THE ORGANIATION USES FEDERAL POVERTY GUIDELINES (FPG) TO DETERMINE CHARITY CARE. PART I, LINE 7: THE ORGANIZATION USES FEDERAL POVERTY GUIDLINES (FPG) TO DETERMINE CHARITY CARE. NOTE 1. TO THE FINANCIAL STATEMENTS: PATIENT RECEIVABLESTHE HOSPITAL PROVIDES CREDIT IN THE NORMAL COURSE OF ITS BUSINESS TO PATIENTS. PATIENT RECEIVABLES ARE GENERALLY DUE 60DAYS AFTER BILLED. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IS CARRIED FOR PATIENT ACCOUNTS THAT MAY BECOME UNCOLLECTIBLE IN FUTURE PERIODS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED ON MANAGEMENT'S JUDGMENT OF UNCOLLECTIBLE ACCOUNTS, HISTORICAL TRENDS AND OTHER INFORMATION. PATIENT RECEIVABLES ARE CHARGED AGAINST THE ALLOWANCE WHEN, IN THE JUDGMENT OF MANAGEMENT, IT IS UNLIKELY THEY WILL BE COLLECTED. THE SHORTFALL FOR MEDICARE IS NOT INCLUDED IN OUR COMMUNITY BENEFIT REPORTING. A COST TO CHARGE RATIO WAS USED TO CALCULATE THE MEDICARE ALLOWABLE COST. ALL PATIENTS ARE SUBJECT TO THE DEBT COLLECTION POLICY REGARDLESS OF THEIR ABILITY TO PAY. PART II: CHAMBERSBURG HOSPITAL WORKS TO STRENGTHEN OUR COMMUNITY THROUGH HEALTH EDUCATION EFFORTS FOR CHILDREN AND ADULTS, HEALTH FAIRS PROVIDING HEALTH SCREENINGS, EDUCATING COMMUNITY GROUPS ON SPECIFIC HEALTH TOPICS, FUNDING HEALTH PROGRAMS OF LOCAL NONPROFIT ORGANIZATIONS THROUGH THE SUMMIT ENDOWMENT PROGRAM, PROVIDING CAPACITY-BUILDING WORKSHOPS AND ASSISTANCE THROUGH SUMMIT ENDOWMENT, PARTICIPATING IN MANY LOCAL CIVIC ORGANIZATIONS, SPONSORING EVENTS HELD BY LOCAL CHARITABLE ORGANIZATIONS, AND SUPPORTING WORKFORCE DEVELOPMENT INITIATIVES THROUGH SUMMIT HEALTH'S SCHOOL LIAISON PROGRAMS. PART III, LINE 4: THE HOSPITAL PROVIDES CREDIT IN THE NORMAL COURSE OF ITS BUSINESS TO PATIENTS. PATIENT RECEIVABLES ARE GENERALLY DUE 60 DAYS AFTER BILLED. AN ALLOWANCE FOR DOUBTFUL ACCOUNTS IS CARRIED FOR PATIENT ACCOUNTS THAT MAY BECOME UNCOLLECTIBLE IN FUTURE PERIODS. THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IS BASED ON MANAGEMENT'S JUDGMENT OF UNCOLLECTIBLE ACCOUNTS, HISTORICAL TRENDS AND OTHER INFORMATION. PATIENT RECEIVABLES ARE CHARGED AGAINST THE ALLOWANCE WHEN, IN THE JUDGMENT OF MANAGEMENT, IT IS UNLIKELY THEY WILL BE COLLECTED. THE SHORTFALL FOR MEDICARE IS NOT INCLUDED IN OUR COMMUNITY BENEFIT REPORTING. A COST TO CHARGE RATIO WAS USED TO CALCULATE THE MEDICARE ALLOWABLE COST. ALL PATIENTS ARE SUBJECT TO THE DEBT COLLECTION POLICY REGARDLESS OF THEIR ABILITY TO PAY. PART III, LINE 8: THE INFORMATION WAS OBTAINED USING COST METHODS USED IN PREPARING THE MEDICARE COST REPORT. THE SHORTFALL ABOVE RELATES TO OUR MISSION OF PROVIDING SERVICES TO MEMBERS OF OUR COMMUNITY. NOT REQUIRED PART V, SECTION B, LINE 19D: A SLIDING SCALE IS USED TO DETERMINE THE DISCOUNTED RATE. ANYONE WHO QUALIFIES RECEIVES A MINIMUM OF 25% OFF CHARGES. PART VI, LINE 2: HEALTH NEEDS OF FRANKLIN COUNTY RESIDENTS AND SURROUNDING COMMUNITIES ARE ASSESSED THROUGH NUMEROUS RESEARCH METHODS INCLUDING CONDUCTING A COMMUNITY HEALTH NEEDS ASSESSMENT (SURVEY FORMAT) IN SPRING 2009, A REVIEW OF REGIONAL HEALTH DATA AND INTERVIEWS WITH KEY COMMUNITY ORGANIZATIONS INCLUDING SCHOOLS, AREA AGENCY ON AGING, PA DEPARTMENT OF HEALTH, FRANKLIN COUNTY HUMAN SERVICES, POST ACUTE CARE PROVIDERS, AND THE HEALTHY COMMUNITIES PARTNERSHIP. PART VI, LINE 3: PATIENTS ARE MADE AWARE OF THE CHARITY PROGRAM AND OTHER BILLING ASSISTANCE SERVICES AT REGISTRATION, DURING EMERGENCY ROOM VISITS, AND NOTICES PLACED IN SERVICE AREAS. BILLING STATEMENTS ALSO INFORM PATIENTS OF CHARITY CARE AND OTHER BILLING ASSISTANCE PROGRAMS. PART VI, LINE 4: CHAMBERSBURG HOSPITAL PRIMARILY SERVES COMMUNITY MEMBERS FROM FRANKLIN COUNTY, PA, AND NEARBY COMMUNITIES IN FULTON COUNTY, PA, CUMBERLAND COUNTY, PA, AND WASHINGTON COUNTY, MD. ACCORDING TO U.S. CENSUS DATA, FRANKLIN COUNTY RESIDENTS HAVE A SLIGHTLY LOWER INCOME AND ARE SLIGHTLY OLDER THAN THE STATE AVERAGE. FOR A HEALTH SYSTEM, THIS TYPICALLY RESULTS IN AN INCREASED NEED FOR HEALTHCARE SERVICES. PART VI, LINE 5: CHAMBERSBURG HOSPITAL PROVIDES FINANCIAL AND MANAGERIAL SUPPORT TO KEYSTONE HEALTH, A RURAL HEALTH CENTER THAT SERVES THE UNDERPRIVLEGED COMMUNITY. IN ADDITION, THE HOSPITAL SUPPORTS LOCAL NON-PROFIT ORGANIZATIONS WITH FINANCIAL GRANTS FROM THE SUMMIT ENDOWMENT. PART VI, LINE 6: THE HOSPITAL IS PART OF SUMMIT HEALTH, A REGIONAL NETWORK OF TWO HOSPITALS, OUTPATIENT DIAGNOSTIC AND ANCILLARY SERVICES OFFICES, AND HEALTHCARE PROVIDERS. CHAMBERSBURG HOSPITAL AND THESE SUMMIT ENTITIES ARE SERVED BY THE ORGANIZATION'S COMMUNITY HEALTH DEPARTMENT. THIS DEPARTMENT'S MISSION IS TO IMPROVE THE HEALTH OF THE COMMUNITY THROUGH EDUCATION, EARLY DETECTION AND PREVENTION PROGRAMS INCLUDING HEALTH FAIRS, SCREENINGS, AND SEMINARS. MANY OF THE DEPARTMENT'S PROGRAMS ARE PLANNED AND PROVIDED THROUGH COLLABORATION WITH OTHER COMMUNITY ORGANIZATIONS INCLUDING THE PA DEPARTMENT OF HEALTH. IN THE LAST FISCAL YEAR, OVER 6,690 PERSONS WERE DIRECTLY SERVED. 1 PSMA NURSING PROGRAM PSU MONT ALTO 1 CAMPUS DR MONT ALTO PA 17237 130000 PROVIDE SUPPORT FOR TWO NURSING FACULTY POSITIONS IN THE REGISTERED NURSE ASSOCIATE DEGREE PROGRAM. CHILDREN'S AID SOCIETY 343 LINCOLN WAY WEST NEW OXFORD PA 17350 6450 CHILD MENTAL HEALTH THERAPY PROGRAM FOR HEAD START PROGRAM OVER THE SUMMER. INTERFAITH HOUSING ALLIANCE 731 NORTH MARKET STREET FREDERICK MD 21701 5955 ON-SITE IMPLEMENTATON OF HEALTH AND WELLNESS PROGRAM FOR SENIORS. PENN STATE CO-OPERATIVE EXTENSION (ADAMS COUNTY) 670 OLD HARRISBURG ROAD SUITE 204 GETTYSBURG PA 17325 9997 PROVIDE DINING WITH DIABETES, A RESEARCH BASED EDUCATION PROGRAM THROUGH PENN STATE COOPERATIVE EXTENSION, 3 SERIES OF 5 CLASSES WILL BE OFFERED. UNITED CEREBRAL PALSY 550 CLEVELAND AVENUE SUITE 213 CHAMBERSBURG PA 17201 5000 ASSISTANCE WITH PEACH TREE PRE SCHOOL PROGRAM. KEYSTONE RURAL HEALTH CENTER 755 NORLAND AVENUE CHAMBERSBURG PA 17201 1125000 GRANT TO COVER OPERATING DEFICITS. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL FUNDING DECISIONS ARE MADE BY THE SUMMIT ENDOWMENT COMMITTEE, A COMMITTEE OF THE SUMMIT HEALTH BOARD. THE ENDOWMENT MANAGER PROCESSES GRANT APPLICATIONS, ASSISTS GRANTEES IN DEVELOPING SOUND PROGRAM EVALUATION METHODOLOGIES, RECEIVES AND SUMMARIZES PERIODIC REPORTS, AND VISITS PROGRAM SITES, REPORTING ALL ACTIVITIES TO THE SUMMIT ENDOWMENT COMMITTEE. AS WELL, ENDOWMENT COMMITTEE MEETING MINUTES ARE SHARED WITH WAYNESBORO HOSPITAL, CHAMBERSBURG HOSPITAL AND SUMMIT HEALTH BOARDS. X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 NORMAN B EPSTEIN 514822 220638 138600 59400 29976 12847 52635 22558 16357 7010 752390 322453 0 0 JOHN MASSIMILLA 212630 0 41020 0 21043 0 40615 0 17101 0 332409 0 0 0 PATRICK W O'DONNELL 199730 133153 57443 38295 17814 11876 45094 30063 10321 6881 330402 220268 0 0 LOUIS GREGORIO 186748 0 32159 0 19244 0 27173 0 17202 0 282526 0 0 0 THOMAS ANDERSON MD 252669 63167 45360 11340 19752 4938 21598 5400 11756 2939 351135 87784 0 0 PATRICIA BARBAROWICZ 105475 35158 24375 8125 10085 3362 33548 11183 4985 1662 178468 59490 0 0 KIMBERLY M RZOMP 142175 7483 27779 1462 1220 64 29117 1532 16223 854 216514 11395 0 0 SHERRI STAHL 154356 38589 29518 7380 11604 2901 24132 6033 11756 2939 231366 57842 0 0 MICHELLE ZEIGLER 141317 60564 27180 11649 13425 5753 24925 10682 14207 6089 221054 94737 0 0 DAVID GRANT 172466 0 20000 0 3684 0 25271 0 11942 0 233363 0 0 0 EVANS T PRIESTON 142916 0 10000 0 1941 0 31251 0 17059 0 203167 0 0 0 AMANDA G SCHMEIDER 144238 0 20000 0 0 0 19118 0 8263 0 191619 0 0 0 CHRISTA ZIMMERMAN 141843 0 21230 0 0 0 19992 0 8263 0 191328 0 0 0 KELLAN COOK 138977 0 20000 0 0 0 6793 0 8263 0 174033 0 0 0 PART I, LINE 1A THE OFFICERS RECEIVE AN ALLOWANCE THAT CAN BE CONSIDERED A DISCRETIONARY SPENDING ACCOUNT. THE MONIES ARE IN LIEU OF AN AUTOMOBILE ALLOWANCE, TO PURCHASE ADDITIONAL LIFE INSURANCE, ETC. THESE MONIES ARE INCLUDED IN COMPENSATION AS REPORTED IN THE COMPENSATION OF OFFICERS TABLE. RESULTS FITNESS CLUB MEMBERSHIP IS AVAILABLE FREE OF CHARGE FOR ANY OFFICER AND ACTIVE BOARD MEMBER. PART I, LINE 4B NORMAN EPSTEIN - NONE PATRICK W. O'DONNELL - NONE LOUIS GREGORIO - NONE JOHN MASSIMILLA - NONE PAT BARBAROWICZ - NONE TOM ANDERSON - NONE SHERRI STAHL - NONE PART I, LINE 7 INCENTIVE COMPENSATION IS BASED ON PRE-DETERMINED, MEASURABLE GOALS APPROVED BY THE BOARD OF DIRECTORS' EXECUTIVE COMPENSATION COMMITTEE. THE MEASURABLE GOALS ARE BASED ON QUALITY, COMMUNITY ACCESS TO CARE, PATIENT SAFETY AND LEADERSHIP. FCIDA HEALTH CARE REVENUE BONDS SERIES 2009-08-24 30000000 ISSUED OT REFINANCING SERIES OF 2000 0 0 0 FRANKLIN COUNTY INDUSTRIAL DEVELOPMENT 230458500 2010-08-28 127225000 NEW BUILDING AND REFINANCE 1998 BOND 0 0 0 30000000 117184 0 1 1 1 127225000 28179850 2834394 1721680 53562795 44247702 0 1 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 SUMMIT HEALTH, A 501(C)(3) ENTITY, IS A MEMBER OF THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A SUMMIT HEALTH, A 501(C)(3) ENTITY, ELECTS THE GOVERNING BODY OF THIS ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B SUMMIT HEALTH, A 501(C)(3) ENTITY, HAS CERTAIN RESERVE POWERS OVER THIS ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING THE 990 IS REVIEWED BY THE AUDIT COMMITTEE AND PRESENTED TO FULL BOARD OF DIRECTORS FOR APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS ARE ASKED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST THEY MAY HAVE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION IS DISCUSSED WITH A COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THIS IS PERFORMED IN CONCERT WITH A COMPENSATION CONSULTANT WHO ASSISTS THE COMMITTEE IN SETTING THE COMPENSATION FOR THESE INDIVIDUALS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THESE DOCUMENTS ARE HELD IN THE FINANCE DEPARTMENT OF THE CHAMBERSBURG HOSPITAL. HOSPITAL BYLAWS AND ALL POLICIES AND PROCEDURES ARE FOUND ON THE CHAMBERSBURG HOSPITAL INTRANET. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -5,077,440. TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT HEALTH -2,750,166. TRANSFER TO AFFILLIATED ORGANIZATION - SUMMIT PHYSICIAN SERVICES -17,499,270. CHANGE IN VALUE OF DERIVATIVE -23,327,342. PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -33,088,951. TOTAL TO FORM 990, PART XI, LINE 5: -81,743,169. THE PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR. SUMMIT HEALTH 112 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 251515371 MANAGE AND ADMINISTER THE LOCAL AND REGIONAL NETWORK OF HEALTHCARE PROVIDERS PA 501(C)(3) 7 SUMMIT HEALTH 0 WAYNESBORO HOSPITAL 501 EAST MAIN STREET WAYNESBORO PA 17268 231360854 SERVE THE HEALTH CARE NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING COMMUN PA 501(C)(3) 3 SUMMIT HEALTH 0 CHAMBERSBURG HEALTH SERVICES 260 NORTH SEVENTH STREET CHAMBERSBURG PA 17201 251515376 SERVE THE HEALTH CARE NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING COMMUN PA 501(C)(3) 11A - TYPE 1 SUMMIT HEALTH 0 SUMMIT PHYSICIAN SERVICES 785 FIFTH AVENUE SUITE 3 CHAMBERSBURG PA 17201 251716306 MANAGE AND ADMINISTER THE LOCAL AND REGIONAL NETWORK OF HEALTHCARE PROVIDERS PA 501(C)(3) 11A - TYPE 1 SUMMIT HEALTH 0 SUMMIT SURGERY CENTER LP 757 NORLAND AVENUE CHAMBERSBURG PA 17201 251845303 SERVE THE SURGICAL HEALTH NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING CO PA CHAMBERSBURG HEALTH SERVICES RELATED 0 0 SURGERY CENTER ASSOCIATES LLC 757 NORLAND AVENUE CHAMBERSBURG PA 17201 251845304 SERVE THE SURGICAL HEALTH NEEDS OF FRANKLIN COUNTY PA AND THE SURROUNDING CO PA CHAMBERSBURG HEALTH SERVICES RELATED 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 1 0