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Nonprofiteer
← GOOD SAMARITAN HOSPITAL FREE CLINIC

Form 990 for tax year 2022

Filed by GOOD SAMARITAN HOSPITAL FREE CLINIC.

Totals

Total revenue
$1,663,514
Total expenses
$1,007,874
Contributions and grants received
$1,663,514
Grants paid
$4,584
Program service revenue
$0
Investment income
$0
Other revenue
$0
Total assets, end of year
$5,077,428
Total liabilities, end of year
$0
Net assets or fund balances, end of year
$5,077,428
Program services expenses (Part IX)
$1,007,874
Management and general expenses
$0
Fundraising expenses
$0
Program service expenses (Part III)
$1,007,874

Program services were 100.0% of total expenses calculated — Part IX's program-services column over total expenses, both as filed.

Listed in Part VII

  • MARK CLEMENT

    CHAIRPERSON

    Total calculated
    $2,317,728
    From this org
    $0
    From related orgs
    $2,238,265
    Other
    $79,463
    Hours/week
    1 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $1,519,500 related
    Bonus
    $0 + $527,124 related
    Other
    $0 + $191,641 related
    Deferred
    $0 + $55,675 related
    Nontaxable benefits
    $0 + $23,788 related
    Filer's total
    $0 + $2,317,728 related

  • ANDREW DEVOE

    TREASURER

    Total calculated
    $1,379,857
    From this org
    $0
    From related orgs
    $1,284,173
    Other
    $95,684
    Hours/week
    1 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $738,138 related
    Bonus
    $0 + $488,508 related
    Other
    $0 + $57,527 related
    Deferred
    $0 + $58,175 related
    Nontaxable benefits
    $0 + $37,509 related
    Filer's total
    $0 + $1,379,857 related

  • MARLA SILLIMAN

    PRESIDENT

    Total calculated
    $898,401
    From this org
    $0
    From related orgs
    $828,602
    Other
    $69,799
    Hours/week
    1 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $598,682 related
    Bonus
    $0 + $152,579 related
    Other
    $0 + $77,341 related
    Deferred
    $0 + $58,175 related
    Nontaxable benefits
    $0 + $11,624 related
    Filer's total
    $0 + $898,401 related

  • JOHN WARD

    TRUSTEE

    Total calculated
    $864,564
    From this org
    $0
    From related orgs
    $775,177
    Other
    $89,387
    Hours/week
    1 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $586,982 related
    Bonus
    $0 + $152,196 related
    Other
    $0 + $35,999 related
    Deferred
    $0 + $58,486 related
    Nontaxable benefits
    $0 + $30,901 related
    Filer's total
    $0 + $864,564 related

  • STEVE GRACEY

    SECRETARY

    Total calculated
    $760,046
    From this org
    $0
    From related orgs
    $675,796
    Other
    $84,250
    Hours/week
    1 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $500,083 related
    Bonus
    $0 + $140,225 related
    Other
    $0 + $35,488 related
    Deferred
    $0 + $47,484 related
    Nontaxable benefits
    $0 + $36,766 related
    Filer's total
    $0 + $760,046 related

  • LINDA SMITH-BERRY

    EXECUTIVE DIRECTOR

    Total calculated
    $155,222
    From this org
    $0
    From related orgs
    $128,626
    Other
    $26,596
    Hours/week
    30 + 30 related

    Schedule J breakdown matched by us

    Base
    $0 + $107,831 related
    Bonus
    $0 + $15,248 related
    Other
    $0 + $5,547 related
    Deferred
    $0 + $16,148 related
    Nontaxable benefits
    $0 + $10,448 related
    Filer's total
    $0 + $155,222 related

  • GAIL DONOVAN

    FORMER OFFICER

    Total calculated
    $582,038
    From this org
    $0
    From related orgs
    $582,038
    Other
    $0
    Hours/week
    0

    Schedule J breakdown matched by us

    Base
    $0
    Bonus
    $0
    Other
    $0 + $582,038 related
    Deferred
    $0
    Nontaxable benefits
    $0
    Filer's total
    $0 + $582,038 related

  • MIKE CROFTON

    FORMER OFFICER

    Total calculated
    $529,853
    From this org
    $0
    From related orgs
    $440,848
    Other
    $89,005
    Hours/week
    0 + 60 related

    Schedule J breakdown matched by us

    Base
    $0 + $310,077 related
    Bonus
    $0 + $124,932 related
    Other
    $0 + $5,839 related
    Deferred
    $0 + $64,878 related
    Nontaxable benefits
    $0 + $24,127 related
    Filer's total
    $0 + $529,853 related

Compensation is as filed in Part VII: reportable pay from this organization and from related organizations, other compensation, and hours per week. The total, marked calculated, is our sum of the three dollar columns, with a blank column counted as $0; the form itself has no total. On a Form 990-EZ the columns are Part IV's instead, and on a Form 990-PF Part VIII's — compensation, contributions to benefit plans, and expense account — and the total sums those. A Schedule J breakdown is as filed: base pay, bonus, other, deferred compensation and nontaxable benefits from this organization, with any from related organizations beside each, and the filer's own total. It is shown with the Part VII listing of the same name on the same return. The form gives no key between the two, so that pairing is ours, and is marked matched by us.

Schedule J

Answered yes

  • 4b · Supplemental nonqualified retirement plan

Answered no

  • 4a · Severance or change-of-control payment
  • 4c · Equity-based compensation arrangement
  • 5a · Pay contingent on this organization's revenues
  • 5b · Pay contingent on a related organization's revenues
  • 6a · Pay contingent on this organization's net earnings
  • 6b · Pay contingent on a related organization's net earnings
  • 7 · Other non-fixed payments
  • 8 · Paid under the initial-contract exception

The filer's explanations (Part III)

PART I, LINE 4B
ELIGIBLE EXECUTIVES (GENERALLY VICE PRESIDENTS AND ABOVE) PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. THE FOLLOWING INDIVIDUAL(S) LISTED IN SCHEDULE J, PART II, RECEIVED A PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN WHICH WAS TREATED AS TAXABLE COMPENSATION BY TRIHEALTH, INC. GAIL DONOVAN - $582,038
PART I, LINE 3:
TRIHEALTH, INC., A RELATED ORGANIZATION OF THE GOOD SAMARITAN HOSPITAL FREE CLINIC, USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: * COMPENSATION COMMITTEE, * INDEPENDENT COMPENSATION CONSULTANT, * COMPENSATION SURVEY OR STUDY, AND * APPROVAL BY THE BOARD/COMPENSATION COMMITTEE.
PART I, LINE 4A:
THE REPORTABLE INDIVIDUALS OF THE GOOD SAMARITAN HOSPITAL FREE CLINIC ARE PAID BY TRIHEALTH, INC., A RELATED ORGANIZATION, RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). TRIHEALTH, INC. HAS A STANDARD EMPLOYEE SEVERANCE PACKAGE. GENERAL SEVERANCE PAY IS BASED ON LENGTH OF SERVICE. IN ADDITION, NOTICE PAY, IF APPLICABLE UNDER TRIHEALTH, INC. POLICY, MAY BE ADDED TO THE SEVERANCE PACKAGE AND THE AMOUNT OF NOTICE PAY WILL BE DETERMINED BY HUMAN RESOURCES IN ACCORDANCE WITH TRIHEALTH, INC. POLICY. PAYMENTS OF SEVERANCE ARE CONDITIONED UPON SIGNING A SEPARATION AND RELEASE AGREEMENT. DURING THE 2022 CALENDAR YEAR, NO REPORTABLE INDIVIDUAL(S) RECEIVED SEVERANCE PAYMENTS FROM TRIHEALTH, INC.

Part I's answers as filed. A line not listed was left unanswered; on lines 1a and 3 that means the box was not checked.

Grants on this return

No itemized grants to organizations on this return.

Related organizations on this return

Schedule R Part II: tax-exempt organizations related to the filer by control. It does not record shared board members or money.

Taxable family on this return

Schedule R Parts I, III and IV, as filed. These record ownership and control, not shared board members or money moved.

Related partnerships

Part III: related organizations taxable as a partnership, with the filer's share.

Related corporations and trusts

Part IV: related organizations taxable as a corporation or trust.

Provenance

Return type
form_990
Tax year
2022
Filed
13 May 2024
IRS schema version
2022v5.0
Source object
202431349349303338

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