TA RETURN FILING INSTRUCTIONS PUBLIC INSPECTION COPY Prepared y Grant Thornton LLP 21 Market Street, Suite 7 Philadelphia, PA 1913 Returns should e signed and dated y the appropriate officer(s). Special Instructions Exempt organizations are required to provide copies of their most recent Forms 99, and their Application for Recognition of Exemption (Form 123 or 124) for pulic inspection upon request. Charities must also make availale Forms 99-T filed after August 17, 26. Schedules, attachments, and supporting documents filed with Form 99-T that do not relate to the imposition of unrelated usiness income tax are not required to e made availale for pulic inspection and copying (e.g. Form 5471, Information Return of U.S. Persons With Respect to Certain Foreign Corporations and Form 8886, Reportale Transaction Disclosure Statement ). Forms 99 and 99-T must e made availale for the three-year period eginning on the last day prescried for filing such return (determined with regard to any extension of time for filing). The names of any contriutors should not e disclosed, so we have deleted them. Application for Recognition of Exemption The copy of the Application for Recognition of Exemption must include any papers sumitted in support of such application and any letter or other document issued y the Internal Revenue Service with respect to such application. An organization that sumitted its Form 123 or 124 on or efore July 15, 1987 must make this form availale for pulic inspection only if they had a copy of the Application on July 15, 1987. Requests made in person Requests made in writing If the request is made in person, the organization must respond y the end of the usiness day. If the request is made in writing, the organization must respond within 3 days. Fees charged for copies The organization can make a reasonale charge for copying and posting. The regulations limit the copying charge to that charged y the IRS for providing copies, currently $.2 for each page. What if we post Form 99 on our wesite? The requirement to provide copies can e eliminated if the organization posts the relevant documents on its we site. The pulic must e ale to download the documents and print them in the exact form they were filed with the IRS (except for disclosing contriutors). The download must e free and use software that is availale without charge. Even if the documents are posted on the we, the organization must still have a copy availale for inspection at its offices. What if we fail to comply with requests? The IRS may impose significant monetary penalties on an organization that does not adhere to the disclosure requirements.
E-file Status Page 1 of 1 Cumulative E-File History 214 Federal Locator: 4228CV Taxpayer Name: SHORE HEALTH SYSTEM, INC. Return Type: 99, 99 Sumitted Date 5/12/216 4:12:11 AM Acknowledgement Date 5/12/216 4:27:54 AM Status Accepted Sumission ID 236953216133512 Print Close
5/16/216
Return of Organization Exempt From Income Tax OMB No. 1545-47 Form Under section 51(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) 99 À¾µ Do not enter Social Security numers on this form as it may e made pulic. Open to Pulic Department of the Treasury Internal Revenue Service I Information aout Form 99 and its instructions is at www.irs.gov/form99. Inspection A For the 214 calendar year, or tax year eginning, 214, and ending, 2 B I J Check if applicale: Address change Name change Initial return C Name of organization Doing Business As Numer and street (or P.O. ox if mail is not delivered to street address) Room/suite D E Employer identification numer Telephone numer Terminated City or town, state or province, country, and ZIP or foreign postal code Amended return EASTON, MD 2161 G Gross receipts $ 247,316,23. Application F Name and address of principal officer: H(a) Is this a group return for Yes No pending KENNETH KOZEL suordinates? 219 SOUTH WASHINGTON ST. EASTON, MD 2161 H() Are all suordinates included? Yes No Tax-exempt status: 51(c)(3) 51(c) ( ) (insert no.) 4947(a)(1) or 527 If "No," attach a list. (see instructions) J Wesite: H(c) Group exemption numer I K Form of organization: Corporation Trust Association Other L Year of formation: M State of legal domicile: Summary Activities & Governance Revenue Expenses Net Assets or Fund Balances I 2 Check this ox if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Numer of voting memers of the governing ody (Part VI, line 1a) 3 4 Numer of independent voting memers of the governing ody (Part VI, line 1) 4 5 Total numer of individuals employed in calendar year 214 (Part V, line 2a) 5 6 Total numer of volunteers (estimate if necessary) m m m m m m m m 6 7a Total unrelated usiness revenue from Part VIII, column (C), line 12 7a Net unrelated usiness taxale income from Form 99-T, line 34 m m m m m m m m m m m m m m m m m m m m m m m m 7 Prior Year 8 9 1 11 12 13 14 15 16 17 18 19 2 21 22 Part II SHORE HEALTH SYSTEM, INC. I m m m m m m m m m m m m m m m m m m m m m m m Contriutions and grants (Part VIII, line 1h) COPY FOR Program service revenue (Part VIII, line 2g) m m m m m m m m m PUBLIC INSPECTION Investment income (Part VIII, column (A), lines 3, 4, and 7d) m m m m m Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 1c, and 11e) Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), m m line m m 12) m Grants and similar amounts paid (Part I, column (A), lines 1-3) Benefits paid to or for memers (Part I, column (A), line 4) m m m m m m m m m m Salaries, other compensation, employee enefits (Part I, column (A), lines 5-1) a Professional fundraising fees (Part I, column (A), line 11e) m m m m m m m m m m m m m m m m m Total fundraising expenses (Part I, column (D), line 25) I Other expenses (Part I, column (A), lines 11a-11d, 11f-24e) m m m m m m Total expenses. Add lines 13-17 (must equal Part I, column (A), line 25) Revenue less expenses. Sutract line 18 from line 12 m m m m m m m m m m m m m m m m m m m m Total assets (Part, line 16) m Total liailities (Part, line 26) m m m m m m m m m m m m m Net assets or fund alances. Sutract line 21 from line 2 m m m m m m m m m m m m m m m m m m Signature Block 7/1 6/3 15 52-61538 219 SOUTH WASHINGTON STREET (41) 822-1 HTTP://UMSHOREREGIONAL.ORG/ 196 MD Part I 1 Briefly descrie the organization's mission or most significant activities: SHORE HEALTH SYSTEM IS A REGIONAL, NOT-FOR-PROFIT NETWORK OF INPATIENT AND OUTPATIENT SERVICES WITH FACILITIES IN TALBOT, DORCHESTER, CAROLINE, AND QUEEN ANNE'S COUNTIES. Beginning of Current Year I 26. 22. 2,264. 385. 7,231,695. -367,877. Current Year 1,73,363. 1,86,63. 231,762,966. 239,177,87. 9,315,124. 3,76,411. -521,968. 2,272,181. 241,629,485. 246,295,742. 13,22,6. 12,437,363. 116,43,38. 118,672,383. 219,425,98. 221,19,746. 22,23,55. 25,185,996. End of Year 37,246,91. 387,633,83. 149,49,498. 144,122,687. 221,196,593. 243,51,396. Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete. Declaration of preparer (other than officer) is ased on all information of which preparer has any knowledge. Sign Here Paid M Signature of officer Date M JOANNE HAHEY Type or print name and title Print/Type preparer's name Preparer's signature Date Check if PTIN self-employed FRANK GIARDINI I Firm's EIN I Phone no. m m m m m m m m m m m m m m m m m m m m m m m m m Preparer Firm's name GRANT THORNTON LLP 36-655558 Use Only Firm's address 21 MARKET STREET, SUITE 7 PHILADELPHIA, PA 1913 215-561-42 May the IRS discuss this return with the preparer shown aove? (see instructions) Yes No For Paperwork Reduction Act Notice, see the separate instructions. Form 99 (214) CFO 5/16/216 P532355 4E165 1. 4228CV 7P V 14-7.16 18223-38 PAGE 3
Form 8868 Application for Extension of Time To File an (Rev. January 214) Exempt Organization Return I OMB No. 1545-179 Department of the Treasury File a separate application for each return. Internal Revenue Service Information aout Form 8868 and its instructions is at www.irs.gov/form8868. % I m m m m m m m m m m m m m m m m m If you are filing for an Automatic 3-Month Extension, complete only Part I and check this ox If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II (on page 2 of this form). Do not complete Part II unless you have already een granted an automatic 3-month extension on a previously filed Form 8868. Electronic filing (e-file). You can electronically file Form 8868 if you need a 3-month automatic extension of time to file (6 months for a corporation required to file Form 99-T), or an additional (not automatic) 3-month extension of time. You can electronically file Form 8868 to request an extension of time to file any of the forms listed in Part I or Part II with the exception of Form 887, Information Return for Transfers Associated With Certain Personal Benefit Contracts, which must e sent to the IRS in paper format (see instructions). For more details on the electronic filing of this form, visit www.irs.gov/efile and click on e-file for Charities & Nonprofits. Part I Automatic 3-Month Extension of Time. Only sumit original (no copies needed). A corporation required to file Form 99-T and requesting an automatic 6-month extension - check this ox and complete Part I only m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m I All other corporations (including 112-C filers), partnerships, REMICs, and trusts must use Form 74 to request an extension of time to file income tax returns. Enter filer's identifying numer, see instructions Type or print File y the due date for filing your return. See instructions. Name of exempt organization or other filer, see instructions. Numer, street, and room or suite no. If a P.O. ox, see instructions. City, town or post office, state, and ZIP code. For a foreign address, see instructions. Enter the Return code for the return that this application is for (file a separate application for each return) Application Is For Form 99 or Form 99-EZ Form 99-BL Form 472 (individual) Form 99-PF Form 99-T (sec. 41(a) or 48(a) trust) Form 99-T (trust other than aove) % The ooks are in the care of I Telephone No. I % Return Code 1 2 3 4 5 6 Application Is For Form 99-T (corporation) Form 141-A Form 472 (other than individual) Form 5227 Form 669 Form 887 Employer identification numer (EIN) or Social security numer (SSN) m m m m m m m m m m m m I m m m m m m m m m m m m m m m m m m m m m I m m m m m m m I I Return Code 41 822-1 FA No. If the organization does not have an office or place of usiness in the United States, check this ox I If this is for a Group Return, enter the organization's four digit Group Exemption Numer (GEN). If this is for the whole group, check this ox. If it is for part of the group, check this ox and attach a list with the names and EINs of all memers the extension is for. 1 I request an automatic 3-month (6 months for a corporation required to file Form 99-T) extension of time until 2/15, 2 16, to file the exempt organization return for the organization named aove. The extension is I for the organization's return for: calendar year 2 or tax year eginning 7/1, 2 14, and ending 6/3, 2 15. 2 If the tax year entered in line 1 is for less than 12 months, check reason: Initial return Final return Change in accounting period 3a If this application is for Form 99-BL, 99-PF, 99-T, 472, or 669, enter the tentative tax, less any nonrefundale credits. See instructions. 3a $ If this application is for Form 99-PF, 99-T, 472, or 669, enter any refundale credits and estimated tax payments made. Include any prior year overpayment allowed as a credit. 3 $ c Balance due. Sutract line 3 from line 3a. Include your payment with this form, if required, y using EFTPS (Electronic Federal Tax Payment System). See instructions. 3c $ Caution. If you are going to make an electronic funds withdrawal (direct deit) with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instructions. For Privacy Act and Paperwork Reduction Act Notice, see instructions. Form 8868 (Rev. 1-214) SHORE HEALTH SYSTEM, INC. 52-61538 219 SOUTH WASHINGTON ST. EASTON, MD 2161 JOANNE HAHEY, CFO, 219 SOUTH WASHINGTON ST. EASTON, MD 2161 7 8 9 1 11 12 1 4F854 1. V 14-7.1F 18223-38 PAGE 2
Cumulative e-file History 214 Locator: Taxpayer Name: Return Type: FED 4228CV SHORE HEALTH SYSTEM, INC. 99, 99 & 99T (Corp) Sumitted Date: 1/12/215 9:39:7 Acknowledgement Date: 1/12/215 9:58:13 Status: Accepted Sumission ID: 236953215285523
% If you are filing for an Additional (Not Automatic) 3-Month Extension, complete only Part II and check this ox m m m m m m m m Note. Only complete Part II if you have already een granted an automatic 3-month extension on a previously filed Form 8868. % Form 8868 (Rev. 1-214) Page 2 If you are filing for an Automatic 3-Month Extension, complete only Part I (on page 1). Additional (Not Automatic) 3-Month Extension of Time. Only file the original (no copies needed). Part II Type or print File y the due date for filing your return. See instructions. Name of exempt organization or other filer, see instructions. Numer, street, and room or suite no. If a P.O. ox, see instructions. City, town or post office, state, and ZIP code. For a foreign address, see instructions. Enter filer's identifying numer, see instructions Employer identification numer (EIN) or Social security numer (SSN) EASTON, MD 2161 Enter the Return code for the return that this application is for (file a separate application for each return) m m m m m m m m m m m m Application Is For Return Code Application Is For Form 99 or Form 99-EZ Form 99-BL Form 472 (individual) Form 99-PF Form 99-T (sec. 41(a) or 48(a) trust) Form 99-T (trust other than aove) 1 2 3 4 5 6 Form 141-A Form 472 (other than individual) Form 5227 Form 669 Form 887 8 9 1 11 12 STOP! Do not complete Part II if you were not already granted an automatic 3-month extension on a previously filed Form 8868. % I Telephone No. I % I I 1 Return Code The ooks are in the care of JOANNE HAHEY, CFO, 219 SOUTH WASHINGTON ST. EASTON, MD 2161. 41 822-1. Fax No.. If the organization does not have an office or place of usiness in the United States, check this ox m m m m m m m m m m m m m m m I If this is for a Group Return, enter the organization's four digit Group Exemption Numer (GEN). If this is m m m m m m I m m m m m m m I for the whole group, check this ox. If it is for part of the group, check this ox and attach a list with the names and EINs of all memers the extension is for. 4 I request an additional 3-month extension of time until 5/15, 2 16. 5 For calendar year, or other tax year eginning 7/1, 2 14, and ending 6/3, 2 15. 6 If the tax year entered in line 5 is for less than 12 months, check reason: Initial return Final return 7 SHORE HEALTH SYSTEM, INC. 52-61538 219 SOUTH WASHINGTON ST. Change in accounting period State in detail why you need the extension ADDITIONAL TIME IS NEEDED TO GATHER INFORMATION NECESSARY TO FILE A COMPLETE AND ACCURATE RETURN. 8a c If this application is for Forms 99-BL, 99-PF, 99-T, 472, or 669, enter the tentative tax, less any nonrefundale credits. See instructions. 8a $ If this application is for Forms 99-PF, 99-T, 472, or 669, enter any refundale credits and estimated tax payments made. Include any prior year overpayment allowed as a credit and any amount paid previously with Form 8868. 8 $ Balance Due. Sutract line 8 from line 8a. Include your payment with this form, if required, y using EFTPS (Electronic Federal Tax Payment System). See instructions. Signature and Verification must e completed for Part II only. 8c $ Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the est of my knowledge and elief, it is true, correct, and complete, and that I am authorized to prepare this form. I I TA PRINCIPAL I Signature Title Date 2/2/216 Form 8868 (Rev. 1-214) 4F855 1. V 14-7.16 18223-38 PAGE 2
Electronic Filing Page 1 of 1 Cumulative e-file History 214 Locator: Taxpayer Name: Return Type: FED 4228CV SHORE HEALTH SYSTEM, INC. 99, 99 & 99T (Corp) Sumitted Date: 2/2/216 15:12:1 Acknowledgement Date: 2/2/216 15:27:46 Status: Accepted Sumission ID: 23695321633516
Form 99 (214) Page 2 Part III SHORE HEALTH SYSTEM, INC. 52-61538 Statement of Program Service Accomplishments Check if Schedule O contains a response or note to any line in this Part III m m m m m m m m m m m m m m m m m m m m m m m m 1 Briefly descrie the organization's mission: TO ECEL IN QUALITY CARE AND PATIENT SATISFACTION. m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If "Yes," descrie these new services on Schedule O. m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 99 or 99-EZ? Yes No 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? Yes No If "Yes," descrie these changes on Schedule O. 4 Descrie the organization's program service accomplishments for each of its three largest program services, as measured y expenses. Section 51(c)(3) and 51(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported. 4a (Code: ) (Expenses $ 196,674,383. including grants of $ ) (Revenue $ 234,343,627. ) SSEE SCHEDULE O 4 (Code: ) (Expenses $ including grants of $ ) (Revenue $ ) 4c (Code: ) (Expenses $ including grants of $ ) (Revenue $ ) 4d Other program services (Descrie in Schedule O.) (Expenses $ including grants of $ ) (Revenue $ ) 4e Total program service expenses 196,674,383. 4E12 1. I Form 99 (214) 4228CV 7P V 14-7.16 18223-38 PAGE 4
SHORE HEALTH SYSTEM, INC. 52-61538 Form 99 (214) Page 3 Part IV Checklist of Required Schedules 1 2 3 4 5 6 7 8 9 1 12a 13 14 15 16 17 18 19 2 m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Is the organization required to complete Schedule B, Schedule of Contriutors (see instructions)? m m m m m m m m m Did the organization engage in direct or indirect political campaign activities on ehalf of or in opposition to candidates for pulic office? If "Yes," complete Schedule C, Part I m m m m m m m m m m m m m m m m m m m m m m m m m m m Section 51(c)(3) organizations. Did the organization engage in loying activities, or have a section 51(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II m m m m m m m m m m m m m m m m m m m m m m Is the organization descried in section 51(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A 1 2 Is the organization a section 51(c)(4), 51(c)(5), or 51(c)(6) organization that receives memership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part III m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distriution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part Im m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II m m m m m m m m m m Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report an amount in Part, line 21, for escrow or custodial account liaility; serve as a custodian for amounts not listed in Part ; or provide credit counseling, det management, credit repair, or det negotiation services? If "Yes," complete Schedule D, Part IV m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part Vm m m m m m m m 11 If the organization s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, I, or as applicale. a Did the organization report an amount for land, uildings, and equipment in Part, line 1? If "Yes," c d e f a a 4E121 1. complete Schedule D, Part VI m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report an amount for investments-other securities in Part, line 12 that is 5% or more of its total assets reported in Part, line 16? If "Yes," complete Schedule D, Part VII m m m m m m m m m m m m m m m m m Did the organization report an amount for investments-program related in Part, line 13 that is 5% or more of its total assets reported in Part, line 16? If "Yes," complete Schedule D, Part VIII m m m m m m m m m m m m m m m m m Did the organization report an amount for other assets in Part, line 15 that is 5% or more of its total assets reported in Part, line 16? If "Yes," complete Schedule D, Part I m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report an amount for other liailities in Part, line 25? If "Yes," complete Schedule D, Part Did the organization s separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liaility for uncertain tax positions under FIN 48 (ASC 74)? If "Yes," complete Schedule D, Part m m m m m m Did the organization otain separate, independent audited financial statements for the tax year? If "Yes," complete Schedule D, Parts I and IIm m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts I and II is optional m m m Is the organization a school descried in section 17()(1)(A)(ii)? If "Yes," complete Schedule E Did the organization maintain an office, employees, or agents outside of the United States? m m m m m m m m m m m m Did the organization have aggregate revenues or expenses of more than $1, from grantmaking, fundraising, usiness, investment, and program service activities outside the United States, or aggregate foreign investments valued at $1, or more? If "Yes," complete Schedule F, Parts I and IV m m m m m m m m m m m Did the organization report on Part I, column (A), line 3, more than $5, of grants or other assistance to or for any foreign organization? If "Yes," complete Schedule F, Parts II and IV m m m m m m m m m m m m m m m m m m m m m m Did the organization report on Part I, column (A), line 3, more than $5, of aggregate grants or other assistance to or for foreign individuals? If "Yes," complete Schedule F, Parts III and IV m m m m m m m m m m m m m m m m Did the organization report a total of more than $15, of expenses for professional fundraising services on Part I, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) m m m m m m m m m m m m m Did the organization report more than $15, total of fundraising event gross income and contriutions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report more than $15, of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H m m m m m m m If "Yes" to line 2a, did the organization attach a copy of its audited financial statements to this return? m m m m m m 3 4 5 6 7 8 9 1 11a 11 11c 11d 11e 11f 12a 12 13 14a 14 15 16 17 18 19 2a 2 Yes No Form 99 (214) 4228CV 7P V 14-7.16 18223-38 PAGE 5
SHORE HEALTH SYSTEM, INC. 52-61538 Form 99 (214) Page 4 Part IV Checklist of Required Schedules (continued) 21 22 23 24 a d 25 a 26 27 28 29 3 31 32 33 34 35 a 36 37 38 c a c m m m m m m m m m m Part I, column (A), line 2? If Yes, complete Schedule I, Parts I and III m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report more than $5, of grants or other assistance to any domestic organization or domestic government on Part I, column (A), line 1? If "Yes," complete Schedule I, Parts I and II 21 Did the organization report more than $5, of grants or other assistance to or for domestic individuals on 22 Did the organization answer Yes to Part VII, Section A, line 3, 4, or 5 aout compensation of the organization s current and former officers, directors, trustees, key employees, and highest compensated employees? If Yes, complete Schedule J m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization have a tax-exempt ond issue with an outstanding principal amount of more than $1, as of the last day of the year, that was issued after Decemer 31, 22? If "Yes," answer lines 24 through 24d and complete Schedule K. If No, go to line 25a m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization invest any proceeds of tax-exempt onds eyond a temporary period exception?m m m m m m m Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt onds? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization act as an "on ehalf of" issuer for onds outstanding at any time during the year? m m m m m m Section 51(c)(3), 51(c)(4), and 51(c)(29) organizations. Did the organization engage in an excess enefit transaction with a disqualified person during the year? If Yes, complete Schedule L, Part I m m m m m m m m m m m m Is the organization aware that it engaged in an excess enefit transaction with a disqualified person in a prior year, and that the transaction has not een reported on any of the organization's prior Forms 99 or 99-EZ? If "Yes," complete Schedule L, Part I m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization report any amount on Part, line 5, 6, or 22 for receivales from or payales to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, sustantial contriutor or employee thereof, a grant selection committee memer, or to a 35% controlled entity or family memer of any of these persons? If "Yes," complete Schedule L, Part III m m m m m m m m m m m m m m m Was the organization a party to a usiness transaction with one of the following parties (see Schedule L, Part IV instructions for applicale filing thresholds, conditions, and exceptions): A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV m m m m m m m A family memer of a current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m An entity of which a current or former officer, director, trustee, or key employee (or a family memer thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IVm m m m m Did the organization receive more than $25, in non-cash contriutions? If "Yes," complete Schedule M m m m m Did the organization receive contriutions of art, historical treasures, or other similar assets, or qualified conservation contriutions? If "Yes," complete Schedule M m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization own 1% of an entity disregarded as separate from the organization under Regulations sections 31.771-2 and 31.771-3? If "Yes," complete Schedule R, Part I m m m m m m m m m m m m m m m m m m m m Was the organization related to any tax-exempt or taxale entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1 m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization have a controlled entity within the meaning of section 512()(13)? m m m m m m m m m m m m m m If "Yes" to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512()(13)? If "Yes," complete Schedule R, Part V, line 2 m m m m m Section 51(c)(3) organizations. Did the organization make any transfers to an exempt non-charitale related organization? If "Yes," complete Schedule R, Part V, line 2 m m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 19? Note. All Form 99 filers are required to complete Schedule O m m m m m m m m m m m m m m m m m m m m m m m m m Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 23 24a 24 24c 24d 25a 25 26 27 28a 28 28c 29 3 31 32 33 34 35a 35 36 37 38 Yes No Form 99 (214) 4E13 1. 4228CV 7P V 14-7.16 18223-38 PAGE 6
Form 99 (214) Page 5 Part V Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule O contains a response or note to any line in this Part V m m m m m m m m m m m m m m m m m m m m m Yes 1a 1a 1 912 c Did the organization comply with ackup withholding rules for reportale payments to vendors and reportale gaming (gamling) winnings to prize winners? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 1c 2a Enter the numer of employees reported on Form W-3, Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered y this return m 2a 2,264 If at least one is reported on line 2a, did the organization file all required federal employment tax returns? 2 3 4a See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). 5a Was the organization a party to a prohiited tax shelter transaction at any time during the tax year? m m m m m m m m Did any taxale party notify the organization that it was or is a party to a prohiited tax shelter transaction? c If "Yes" to line 5a or 5, did the organization file Form 8886-T? m m m m m m m m m m m m m m m m m m m m m m m m m m m m 6a Does the organization have annual gross receipts that are normally greater than $1,, and did the 7 a 8 9 1 11 12 a c d e f g h a a a a c 14 a Enter the numer reported in Box 3 of Form 196. Enter -- if not applicale m Enter the numer of Forms W-2G included in line 1a. Enter -- if not applicale m m m m m m m m m Note. If the sum of lines 1a and 2a is greater than 25, you may e required to e-file (see instructions) Did the organization have unrelated usiness gross income of $1, or more during the year? m m m If "Yes," has it filed a Form 99-T for this year? If "No" to line 3, provide an explanation in Schedule O m m m m m m m At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a ank account, securities account, or other financial account)? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If Yes, enter the name of the foreign country: I organization solicit any contriutions that were not tax deductile as charitale contriutions? m m m m m m m m m m m If "Yes," did the organization include with every solicitation an express statement that such contriutions or gifts were not tax deductile? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Organizations that may receive deductile contriutions under section 17(c). Did the organization receive a payment in excess of $75 made partly as a contriution and partly for goods and services provided to the payor? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If "Yes," did the organization notify the donor of the value of the goods or services provided? m m m m m m m m m m m m Did the organization sell, exchange, or otherwise dispose of tangile personal property for which it was required to file Form 8282? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If "Yes," indicate the numer of Forms 8282 filed during the year m m m m m m m m m m m m m m m m 7d Did the organization receive any funds, directly or indirectly, to pay premiums on a personal enefit contract? Did the organization, during the year, pay premiums, directly or indirectly, on a personal enefit contract? m m m m m If the organization received a contriution of qualified intellectual property, did the organization file Form 8899 as required? If the organization received a contriution of cars, oats, airplanes, or other vehicles, did the organization file a Form 198-C? Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained y the sponsoring organization have excess usiness holdings at any time during the year? m m m m m m m m m m m m m m m m m Sponsoring organizations maintaining donor advised funds. Did the sponsoring organization make any taxale distriutions under section 4966? m m m m m m Did the sponsoring organization make a distriution to a donor, donor advisor, or related person? m m m m m m m m m m Section 51(c)(7) organizations. Enter: Initiation fees and capital contriutions included on Part VIII, line 12 m m m m m m m m m m 1a Gross receipts, included on Form 99, Part VIII, line 12, for pulic use of clu facilities m m m m 1 Section 51(c)(12) organizations. Enter: Gross income from memers or shareholders m m m m m m m m m m m m m m m m m m m m m m m m m m 11a Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) m m m m m m m m m m m m m m m m m m m m m m m m m m m 11 Section 4947(a)(1) non-exempt charitale trusts. Is the organization filing Form 99 in lieu of Form 141? If "Yes," enter the amount of tax-exempt interest received or accrued during the year m m m m m 12 Section 51(c)(29) qualified nonprofit health insurance issuers. Is the organization licensed to issue qualified health plans in more than one state? m m m m m m m m m m m m m m m m m m 13 a Note. See the instructions for additional information the organization must report on Schedule O. Enter the amount of reserves the organization is required to maintain y the states in which 4E14 1. SHORE HEALTH SYSTEM, INC. 52-61538 the organization is licensed to issue qualified health plans 13 Enter the amount of reserves on hand m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 13c Did the organization receive any payments for indoor tanning services during the tax year? m m m m m m m If "Yes," has it filed a Form 72 to report these payments? If "No," provide an explanation in Schedule O m m m m m m 3a 3 4a 5a 5 5c 6a 6 7a 7 7c 7e 7f 7g 7h 8 9a 9 12a 13a 14a 14 No Form 99 (214) 4228CV 7P V 14-7.16 18223-38 PAGE 7
Form 99 (214) Page 6 Part VI Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7 elow, and for a "No" response to line 8a, 8, or 1 elow, descrie the circumstances, processes, or changes in Schedule O. See instructions. Check if Schedule O contains a response or note to any line in this Part VI Section A. Governing Body and Management 1a 2 3 4 5 6 7a Enter the numer of voting memers of the governing ody at the end of the tax year m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If there are material differences in voting rights among memers of the governing ody, or if the governing ody delegated road authority to an executive committee or similar committee, explain in Schedule O. Enter the numer of voting memers included in line 1a, aove, who are independent m m m m m 1 any other officer, director, trustee, or key employee? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m supervision of officers, directors, or trustees, or key employees to a management company or other person? Did the organization make any significant changes to its governing documents since the prior Form 99 was filed? m m Did the organization ecome aware during the year of a significant diversion of the organization's assets? Did the organization have memers or stockholders? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m one or more memers of the governing ody? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m stockholders, or persons other than the governing ody? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Did any officer, director, trustee, or key employee have a family relationship or a usiness relationship with Did the organization delegate control over management duties customarily performed y or under the direct Did the organization have memers, stockholders, or other persons who had the power to elect or appoint Are any governance decisions of the organization reserved to (or suject to approval y) memers, 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year y the following: a The governing ody? m m m m m m m m m m m m m m m m m m m m m m m m m m m m 8a Each committee with authority to act on ehalf of the governing ody? m m m m m m m m m m m m m m m m m m m m m m 8 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot e reached at the organization's mailing address? If "Yes," provide the names and addresses in Schedule O m m m m m m m m m m m 9 Section B. Policies (This Section B requests information aout policies not required y the Internal Revenue Code.) 1a 11a 12a 13 14 15 c a 16a Did the organization have local chapters, ranches, or affiliates? m m m m m m m m m m m m m m m m m m m m m m m m m m If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and ranches to ensure their operations are consistent with the organization's exempt purposes? m m m Has the organization provided a complete copy of this Form 99 to all memers of its governing ody efore filing the form? m Descrie in Schedule O the process, if any, used y the organization to review this Form 99. Did the organization have a written conflict of interest policy? If "No," go to line 13 m m m m m m m m m m m m m m m m rise to conflicts? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m descrie in Schedule O how this was done m m m m m m m m Did the organization have a written whistlelower policy? m m m m m m m m m m m m Did the organization have a written document retention and destruction policy? m m m m m m m m m m m m m m m m m m Were officers, directors, or trustees, and key employees required to disclose annually interests that could give Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," Did the process for determining compensation of the following persons include a review and approval y independent persons, comparaility data, and contemporaneous sustantiation of the delieration and decision? The organization's CEO, Executive Director, or top management official m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m Other officers or key employees of the organization If "Yes" to line 15a or 15, descrie the process in Schedule O (see instructions). Did the organization invest in, contriute assets to, or participate in a joint venture or similar arrangement with a taxale entity during the year? m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicale federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? m m m m m m m m m m m m m m m m m m m m m m m m m List the states with which a copy of this Form 99 is required to e filed MD, I Section C. Disclosure 17 18 19 2 Section 614 requires an organization to make its Forms 123 (or 124 if applicale), 99, and 99-T (Section 51(c)(3)s only) availale for pulic inspection. Indicate how you made these availale. Check all that apply. Own wesite Another's wesite Upon request Other (explain in Schedule O) Descrie in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements availale to the pulic during the tax year. State the name, address, and telephone numer of the person who possesses the organization's ooks and records: I JOANNE HAHEY, CFO 219 SOUTH WASHINGTON ST. EASTON, MD 2161 41-822-1 Form 99 (214) 4E142 1. SHORE HEALTH SYSTEM, INC. 52-61538 4228CV 7P V 14-7.16 18223-38 PAGE 8 1a 26 22 2 3 4 5 6 7a 7 1a 1 11a 12a 12 12c 13 14 15a 15 16a 16 Yes Yes No No
SHORE HEALTH SYSTEM, INC. 52-61538 Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Form 99 (214) Page 7 Part VII Section A. Check if Schedule O contains a response or note to any line in this Part VII m m m m m m m m m m m m m m m m m m m m m m Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this tale for all persons required to e listed. Report compensation for the calendar year ending with or within the organization's % tax year. List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -- in columns (D), (E), and (F) if no compensation was paid. % List all of the organization's current key employees, if any. See instructions for definition of "key employee." List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportale compensation (Box 5 of Form W-2 and/or Box 7 of Form 199-MISC) of more than $1, from the organization and any related organizations. % List all of the organization's former officers, key employees, and highest compensated employees who received more than $1, of reportale compensation from the organization and any related organizations. % List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $1, of reportale compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this ox if neither the organization nor any related organization compensated any current officer, director, or trustee. (C) (A) (B) Position (D) (E) (F) Name and Title Average hours per week (list any (do not check more than one ox, unless person is oth an officer and a director/trustee) hours for related organizations elow dotted line) Individual trustee or director Institutional trustee Officer Key employee Highest compensated employee Former Reportale compensation from the organization (W-2/199-MISC) Reportale compensation from related organizations (W-2/199-MISC) Estimated amount of other compensation from the organization and related organizations (1) JOHN DILLON CHAIRMAN 1. 5. (2) RICHARD LOEFFLER VICE CHAIRMAN 1. 4. (3) STUART BOUNDS SECRETARY 1. 4. (4) WAYNE L. GARDNER, SR. TREASURER 1. 4. (5) MYRA BUTLER DIRECTOR 1. 4. (6) CHARLES CAPUTE DIRECTOR 1. 5. (7) ART CECIL DIRECTOR 1. 4. (8) JOSEPH CIOTOLA DIRECTOR 1. 4. (9) DEBORAH DAVIS DIRECTOR 1. 4. (1) KATHY DEOUDES DIRECTOR 1. 4. (11) MARLENE FELDMAN DIRECTOR 1. 4. (12) WAYNE HOWARD DIRECTOR 1. 4. (13) MICHAEL JOYCE DIRECTOR 1. 4. (14) KEITH MCMAHAN 1. DIRECTOR 5. Form 99 (214) 4E141 1. 4228CV 7P V 14-7.16 18223-38 PAGE 9
SHORE HEALTH SYSTEM, INC. 52-61538 Form 99 (214) Page 8 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) (F) Name and title Average hours per week (list any hours for related organizations elow dotted line) Position (do not check more than one ox, unless person is oth an officer and a director/trustee) Individual trustee or director Institutional trustee Officer Key employee Highest compensated employee 1 Su-total m m m m m m m m m m m m m m m m m m m m m m m m m c Total from continuation sheets to Part VII, Section A m m m m m m m m m m m m m m m m m m m m m m m m m m m m d Total (add lines 1 and 1c) I Former Reportale compensation from the organization (W-2/199-MISC) Reportale compensation from related organizations (W-2/199-MISC) 2 Total numer of individuals (including ut not limited to those listed aove) who received more than $1, of reportale compensation from the organization I 61 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual m m m m m m m m m m m m m m m m m m m m m m m m m m 3 4 For any individual listed on line 1a, is the sum of reportale compensation and other compensation from the organization and related organizations greater than $15,? If Yes, complete Schedule J for such individual m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 4 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If Yes, complete Schedule J for such person m m m m m m m m m m m m m m m m 5 Section B. Independent Contractors 1 Complete this tale for your five highest compensated independent contractors that received more than $1, of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. Estimated amount of other compensation from the organization and related organizations ( 15) DAVID MILLIGAN 1. DIRECTOR 4. ( 16) WILLIAM NOLL 1. DIRECTOR 4. ( 17) GEOFF ONAM 1. DIRECTOR 4. ( 18) MARTHA RUSSELL 1. DIRECTOR 4. ( 19) C. DANIEL SAUNDERS, ESQ. 1. DIRECTOR 4. ( 2) THOMAS STAUCH 1. DIRECTOR 4. ( 21) ROBERT SWAM 1. DIRECTOR 4. ( 22) MYRON SZCZUKOWSKI 1. DIRECTOR 4. ( 23) ROBERT A. CHRENCIK 1. E-OFFICIO/DIRECTOR 49. 6,881,71. 21,95. ( 24) JOHN W. ASHWORTH, III 1. E-OFFICIO/DIRECTOR 49. 597,21. 21,95. ( 25) KENNETH KOZEL 32. PRESIDENT/CEO 18. 547,964. 87,862. 3,272,569. 7,478,281. 388,479. 3,272,569. 7,478,281. 388,479. Yes No ATTACHMENT 1 (A) Name and usiness address (B) Description of services (C) Compensation 2 Total numer of independent contractors (including ut not limited to those listed aove) who received more than $1, in compensation from the organization I 31 4E155 1. Form 99 (214) 4228CV 7P V 14-7.16 18223-38 PAGE 1
SHORE HEALTH SYSTEM, INC. 52-61538 Form 99 (214) Page 8 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) (F) Name and title Average hours per week (list any hours for related organizations elow dotted line) Position (do not check more than one ox, unless person is oth an officer and a director/trustee) Individual trustee or director Institutional trustee Officer Key employee Highest compensated employee Former Reportale compensation from the organization (W-2/199-MISC) Reportale compensation from related organizations (W-2/199-MISC) Estimated amount of other compensation from the organization and related organizations ( 26) JOANNE R. HAHEY 32. CFO/SVP FINANCE 18. 197,76. 35,22. ( 27) WILLIAM HUFFNER 5. CMO 484,197. 66,621. ( 28) CHRISTOPHER J. PARKER 48. SVP - PT CARE/CNO 2. 33,65. 22,856. ( 29) JONATHAN COOK 4. VP/PHYSICIAN SERVICES 35,967. 2,247. ( 3) PATTI K. WILLIS 4. VP ETERNAL RELATIONS & COMM 244,49. 2,532. ( 31) MICHELE WILSON 4. VP/PHYSICIAN SERVICES 182,178. 25,61. ( 32) FRANCIS G. LEE 1. VP - PHILANTHROPY 39. 19,194. 35,93. ( 33) JOHN SAWYER 4. SR. MEDICAL PHARMACIST 181,56. 21,68. ( 34) WALTER J. ZAJAC 35. VP FINANCE 5. 261,7. 23,352. ( 35) GERARD M. WALSH 45. COO 5. 348,249. 4,676. 1 Su-total m m m m m m m m m m m m m m m m m m m m m m m m m c Total from continuation sheets to Part VII, Section A m m m m m m m m m m m m m m m m m m m m m m m m m m m m d Total (add lines 1 and 1c) I 2 Total numer of individuals (including ut not limited to those listed aove) who received more than $1, of reportale compensation from the organization I 61 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual m m m m m m m m m m m m m m m m m m m m m m m m m m 3 4 For any individual listed on line 1a, is the sum of reportale compensation and other compensation from the organization and related organizations greater than $15,? If Yes, complete Schedule J for such individual m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m 4 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If Yes, complete Schedule J for such person m m m m m m m m m m m m m m m m 5 Section B. Independent Contractors 1 Complete this tale for your five highest compensated independent contractors that received more than $1, of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year. Yes No (A) Name and usiness address (B) Description of services (C) Compensation 2 Total numer of independent contractors (including ut not limited to those listed aove) who received more than $1, in compensation from the organization I 4E155 1. Form 99 (214) 4228CV 7P V 14-7.16 18223-38 PAGE 11