MILE BLUFF MEDICAL CENTER FOUNDATION INC: Form 990EZ, tax year 2015

View the entire original 990 at ProPublica ↗

Organization: MILE BLUFF MEDICAL CENTER FOUNDATION INC (EIN 27-1865510)
Tax period: 2015-10-01 to 2016-09-30
Filed: 2017-06-09
IRS object ID: 201701609349200225
Schema version: 2015v3.0
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
Form 990-EZ
Schedule A
Schedule B
Schedule G
Schedule O
Transfer Prsnl Bnft Contracts Decl

Return header ReturnHeader

Field	Value	IRS element (for citing)
Return	2017-06-09T15:08:41-05:00	ReturnTs
Tax Period End	2016-09-30	TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

Field	Value	IRS element (for citing)
Preparer Firm EIN	450250958	PreparerFirmEIN

Preparer Firm Name PreparerFirmName

Field	Value	IRS element (for citing)
Business Name Line1	EIDE BAILLY LLP	BusinessNameLine1Txt

Preparer US Address PreparerUSAddress

Field	Value	IRS element (for citing)
Address Line1	1545 ASSOCIATES DR STE 101	AddressLine1Txt
City	DUBUQUE	CityNm
State Abbreviation	IA	StateAbbreviationCd
ZIP	52002	ZIPCd

Field	Value	IRS element (for citing)
Return Type	990EZ	ReturnTypeCd
Tax Period Begin	2015-10-01	TaxPeriodBeginDt

Filer Filer

Field	Value	IRS element (for citing)
EIN	271865510	EIN

Business Name BusinessName

Field	Value	IRS element (for citing)
Business Name Line1	Mile Bluff Medical Center Foundation	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
Business Name Control	MILE	BusinessNameControlTxt
Phone	6088476161	PhoneNum

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1050 Division Street	AddressLine1Txt
City	Mauston	CityNm
State Abbreviation	WI	StateAbbreviationCd
ZIP	53948	ZIPCd

Business Officer BusinessOfficerGrp

Field	Value	IRS element (for citing)
Person	James O'Keefe	PersonNm
Person Title	President/CEO	PersonTitleTxt
Phone	6088476161	PhoneNum
Signature	2017-05-31	SignatureDt
Discuss With Paid Preparer	Yes (1)	DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

Field	Value	IRS element (for citing)
Preparer Person	Carmen Krantz	PreparerPersonNm
PTIN	P00031958	PTIN
Phone	5635561790	PhoneNum
Preparation	2017-05-31	PreparationDt

Field	Value	IRS element (for citing)
Tax	2015	TaxYr
Build TS	2021-01-29 14:40:06Z	BuildTS

Form 990-EZ IRS990EZ

Field	Value	IRS element (for citing)
Method Of Accounting Accrual	Yes (X)	MethodOfAccountingAccrualInd
Website Address	n/a	WebsiteAddressTxt
Organization501c3	Yes (X)	Organization501c3Ind
Type Of Organization Corp	Yes (X)	TypeOfOrganizationCorpInd
Gross Receipts	$137,119	GrossReceiptsAmt
Info In Schedule O Part I	Yes (X)	InfoInScheduleOPartIInd
Contributions Gifts Grants Etc	$114,732	ContributionsGiftsGrantsEtcAmt
Program Service Revenue	$16,937	ProgramServiceRevenueAmt
Investment Income	$857	InvestmentIncomeAmt
Fundraising Gross Income	$4,593	FundraisingGrossIncomeAmt
Special Events Direct Expenses	$8,613	SpecialEventsDirectExpensesAmt
Special Events Net Income Loss	-$4,020	SpecialEventsNetIncomeLossAmt
Total Revenue	$128,506	TotalRevenueAmt
Grants And Similar Amounts Paid	$46,058	GrantsAndSimilarAmountsPaidAmt
Occupancy Rent Utlts And Maint	$712	OccupancyRentUtltsAndMaintAmt
Other Expenses Total	$41,153	OtherExpensesTotalAmt
Total Expenses	$87,923	TotalExpensesAmt
Excess Or Deficit For Year	$40,583	ExcessOrDeficitForYearAmt
Net Assets Or Fund Balances BOY	$160,681	NetAssetsOrFundBalancesBOYAmt
Other Changes In Net Assets	$0	OtherChangesInNetAssetsAmt
Net Assets Or Fund Balances EOY	$201,264	NetAssetsOrFundBalancesEOYAmt
Info In Schedule O Part II	Yes (X)	InfoInScheduleOPartIIInd

Cash Savings And Investments CashSavingsAndInvestmentsGrp

Field	Value	IRS element (for citing)
BOY	$154,623	BOYAmt
EOY	$186,030	EOYAmt

Other Assets Total Detail OtherAssetsTotalDetail

Field	Value	IRS element (for citing)
BOY	$13,148	BOYAmt
EOY	$23,736	EOYAmt

Form990 Total Assets Form990TotalAssetsGrp

Field	Value	IRS element (for citing)
BOY	$167,771	BOYAmt
EOY	$209,766	EOYAmt

Sum Of Total Liabilities SumOfTotalLiabilitiesGrp

Field	Value	IRS element (for citing)
BOY	$7,090	BOYAmt
EOY	$8,502	EOYAmt

Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp

Field	Value	IRS element (for citing)
BOY	$160,681	BOYAmt
EOY	$201,264	EOYAmt

Field	Value	IRS element (for citing)
Info In Schedule O Part III	Yes (X)	InfoInScheduleOPartIIIInd
Primary Exempt Purpose	Mile Bluff Medical Center Foundation provides philanthropic opportunities and support to Mile Bluff Medical Center, assisting in fulfilling its mission, adhering to its core values and pursuing its vision to provide the community with exceptional, personalized healthcare services.	PrimaryExemptPurposeTxt

Program Srvc Accomplishment ProgramSrvcAccomplishmentGrp

Field	Value	IRS element (for citing)
Description Program Srvc Accom	Mile Bluff Medical Center Foundation strives to build and cultivate community partnerships that ensure lifelong commitments to healthcare advancement, personal well-being and improvement throughout Mile Bluff's six-county service area.	DescriptionProgramSrvcAccomTxt
Grants And Allocations	$46,058	GrantsAndAllocationsAmt
Program Service Expenses	$87,923	ProgramServiceExpensesAmt

Field	Value	IRS element (for citing)
Total Program Service Expenses	$87,923	TotalProgramServiceExpensesAmt

Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (5 entries)

TitleTitleTxt	Average Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRt	CompensationCompensationAmt	Employee Benefit ProgramEmployeeBenefitProgramAmt	Expense Account Other AllwncExpenseAccountOtherAllwncAmt
James O'Keefe
President/CEO	0.25	$0	$0	$0
Molly Scully
Secretary	0.25	$0	$0	$0
Sandy Linsmeyer
Treasurer	0.25	$0	$0	$0
Christine Carter
Director	0.25	$0	$0	$0
Nora Scully
Director	0.25	$0	$0	$0

Field	Value	IRS element (for citing)
Info In Schedule O Part V	Yes (X)	InfoInScheduleOPartVInd
Activities Not Previously Rpt	0	ActivitiesNotPreviouslyRptInd
Chg Made To Orgnzng Doc Not Rpt	0	ChgMadeToOrgnzngDocNotRptInd
Organization Had UBI	0	OrganizationHadUBIInd
Subject To Proxy Tax	0	SubjectToProxyTaxInd
Organization Dissolved Etc	0	OrganizationDissolvedEtcInd
Direct Indirect Pltcl Expend	$0	DirectIndirectPltclExpendAmt
Made Loans To From Officers	0	MadeLoansToFromOfficersInd
Tax Imposed Under IRC4911	$0	TaxImposedUnderIRC4911Amt
Tax Imposed Under IRC4912	$0	TaxImposedUnderIRC4912Amt
Tax Imposed Under IRC4955	$0	TaxImposedUnderIRC4955Amt
Engaged In Excess Benefit Trans	0	EngagedInExcessBenefitTransInd
Tax Imposed On Organization Mgr	$0	TaxImposedOnOrganizationMgrAmt
Tax Reimbursed By Organization	$0	TaxReimbursedByOrganizationAmt
Prohibited Tax Shelter Trans	0	ProhibitedTaxShelterTransInd
States Where Copy Of Return Is Fld	WI	StatesWhereCopyOfReturnIsFldCd

Books In Care Of Detail BooksInCareOfDetail

Business Name BusinessName

Field	Value	IRS element (for citing)
Business Name Line1	James O'Keefe	BusinessNameLine1Txt

US Address USAddress

Field	Value	IRS element (for citing)
Address Line1	1050 Division Street	AddressLine1Txt
City	Mauston	CityNm
State Abbreviation	WI	StateAbbreviationCd
ZIP	53948	ZIPCd

Field	Value	IRS element (for citing)
Phone	6088476161	PhoneNum

Field	Value	IRS element (for citing)
Foreign Financial Account	0	ForeignFinancialAccountInd
Foreign Office	0	ForeignOfficeInd
Donor Advised Fnds	0	DonorAdvisedFndsInd
Operate Hospital	0	OperateHospitalInd
Tanning Services Provided	0	TanningServicesProvidedInd
Related Organization Ctrl Ent	0	RelatedOrganizationCtrlEntInd
Political Campaign Acty	0	PoliticalCampaignActyInd
Lobbying Activities	0	LobbyingActivitiesInd
School Operating	0	SchoolOperatingInd
Trnsfr Exmpt Non Chrtbl Rltd Org	0	TrnsfrExmptNonChrtblRltdOrgInd
Part VI Of Comp Of Hghst Pd Empl	NONE	PartVIOfCompOfHghstPdEmplTxt
Part VI Hghst Pd Cntrct Prof Srvc	NONE	PartVIHghstPdCntrctProfSrvcTxt
Filed Schedule A	Yes (1)	FiledScheduleAInd

Schedule A IRS990ScheduleA

Field	Value	IRS element (for citing)
Supporting Organization509a3	Yes (X)	SupportingOrganization509a3Ind
Supporting Org Type1	Yes (X)	SupportingOrgType1Ind
IRS Written Determination	Yes (X)	IRSWrittenDeterminationInd
Supported Organizations	1	SupportedOrganizationsCnt

Supported Org Information SupportedOrgInformationGrp

Supported Organization Name SupportedOrganizationName

Field	Value	IRS element (for citing)
Business Name Line1	Mile Bluff Medical Center Inc	BusinessNameLine1Txt

Field	Value	IRS element (for citing)
EIN	390992883	EIN
Organization Type	3	OrganizationTypeCd
Governing Document Listed	Yes (1)	GoverningDocumentListedInd
Support	$48,346	SupportAmt
Other Support	$0	OtherSupportAmt

Field	Value	IRS element (for citing)
Supported Organizations Total	1	SupportedOrganizationsTotalCnt
Support Sum	$48,346	SupportSumAmt
Other Support Sum	$0	OtherSupportSumAmt

Form990 Sch A Supporting Org Form990SchASupportingOrgGrp

Field	Value	IRS element (for citing)
Listed By Name Governing Doc	Yes (1)	ListedByNameGoverningDocInd
Suprt Org No IRS Determination	0	SuprtOrgNoIRSDeterminationInd
Supported Org Section C456	0	SupportedOrgSectionC456Ind
Supported Org Not Organized US	0	SupportedOrgNotOrganizedUSInd
Organization Change Suprt Org	0	OrganizationChangeSuprtOrgInd
Support Non Supported Org	0	SupportNonSupportedOrgInd
Payment Substantial Contribtr	0	PaymentSubstantialContribtrInd
Loan Disqualified Person	0	LoanDisqualifiedPersonInd
Controlled Disqualified Prsn	0	ControlledDisqualifiedPrsnInd
Disqualified Prsn Controll Int	0	DisqualifiedPrsnControllIntInd
Disqualified Prsn Ownr Int	0	DisqualifiedPrsnOwnrIntInd
Excess Business Holdings Rules	0	ExcessBusinessHoldingsRulesInd
Contribution Controller	0	ContributionControllerInd
Contribution Family	0	ContributionFamilyInd
Contribution35 Controlled	0	Contribution35ControlledInd

Form990 Sch A Type1 Suprt Org Form990SchAType1SuprtOrgGrp

Field	Value	IRS element (for citing)
Power Appoint Majority Dir Trst	Yes (1)	PowerAppointMajorityDirTrstInd
Operate Benefit Non Suprt Org	0	OperateBenefitNonSuprtOrgInd

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp (2 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
Schedule A, Part IV, Section A, Line 1:	The Foundation was organized and will be operated exclusively to benefit and carry out the purposes of the Medical Center and certain of the Medical Center's related organizations (collectively, the "Supported Organizations"). The Medical Center is a Wisconsin nonstock corporation that is a Code Section 501(c)(3) organization and a public charity described in Code Sections 170(b)(1)(A)(iii) and 509(a)(1). As set forth in the Foundation's Articles of Incorporation, in order for one of the Medical Center's related organizations to qualify as a Supported Organization of the Foundation, the related organization must (1) be described in Code Section 501(c)(3); (2) be a public charity described in Code Section 509(a)(1) or 509(a)(2); and (3) be directly or indirectly controlled by, under common control with, or in control of the Medical Center.
Schedule A, Part IV, Section B, Line 1:	The Foundation's Supported Organizations serve as its members, will elect all of the Foundation's directors, and have the authority to amend the Foundation's governing documents. At this time, only the Medical Center is acting as a member, and therefore Supported Organization, of the Foundation.

Form And Line ReferenceFormAndLineReferenceDesc

ExplanationExplanationTxt

Schedule A, Part IV, Section A, Line 1:

The Foundation was organized and will be operated exclusively to benefit and carry out the purposes of the Medical Center and certain of the Medical Center's related organizations (collectively, the "Supported Organizations"). The Medical Center is a Wisconsin nonstock corporation that is a Code Section 501(c)(3) organization and a public charity described in Code Sections 170(b)(1)(A)(iii) and 509(a)(1). As set forth in the Foundation's Articles of Incorporation, in order for one of the Medical Center's related organizations to qualify as a Supported Organization of the Foundation, the related organization must (1) be described in Code Section 501(c)(3); (2) be a public charity described in Code Section 509(a)(1) or 509(a)(2); and (3) be directly or indirectly controlled by, under common control with, or in control of the Medical Center.

Schedule A, Part IV, Section B, Line 1:

The Foundation's Supported Organizations serve as its members, will elect all of the Foundation's directors, and have the authority to amend the Foundation's governing documents. At this time, only the Medical Center is acting as a member, and therefore Supported Organization, of the Foundation.

Schedule B IRS990ScheduleB

Contributor Information ContributorInformationGrp

Field	Value	IRS element (for citing)
Contributor	RESTRICTED	ContributorNum

Contributor Business Name ContributorBusinessName

Field	Value	IRS element (for citing)
Business Name Line1	RESTRICTED	BusinessNameLine1

Contributor US Address ContributorUSAddress

Field	Value	IRS element (for citing)
Address Line1	RESTRICTED	AddressLine1
Address Line2	RESTRICTED	AddressLine2
City	RESTRICTED	City
State	RESTRICTED	State
ZIP Code	RESTRICTED	ZIPCode

Field	Value	IRS element (for citing)
Total Contributions	RESTRICTED	TotalContributionsAmt

Schedule G IRS990ScheduleG

Fundraising Event Information FundraisingEventInformationGrp

Field	Value	IRS element (for citing)
Event1	Annual Golf Outing	Event1Nm
Gross Receipts Event1	$30,242	GrossReceiptsEvent1Amt
Charitable Contri Event1	$25,649	CharitableContriEvent1Amt
Gross Revenue Event1	$4,593	GrossRevenueEvent1Amt
Cash Prizes Event1	$700	CashPrizesEvent1Amt
Non Cash Prizes Event1	$2,077	NonCashPrizesEvent1Amt
Food And Beverage Event1	$4,593	FoodAndBeverageEvent1Amt
Other Direct Expenses Event1	$1,243	OtherDirectExpensesEvent1Amt
Gross Receipts Total	$30,242	GrossReceiptsTotalAmt
Charitable Contributions Tot	$25,649	CharitableContributionsTotAmt
Gross Revenue Total Events	$4,593	GrossRevenueTotalEventsAmt
Cash Prizes Total Events	$700	CashPrizesTotalEventsAmt
Non Cash Prizes Total Events	$2,077	NonCashPrizesTotalEventsAmt
Food And Beverage Total Events	$4,593	FoodAndBeverageTotalEventsAmt
Oth Direct Expnss Total Events	$1,243	OthDirectExpnssTotalEventsAmt
Direct Expense Summary Events	$8,613	DirectExpenseSummaryEventsAmt
Net Income Summary	-$4,020	NetIncomeSummaryAmt

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (5 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
Form 990-EZ, Part I, Line 4 - Other Investment Income	Description: Interest Income. Amount: 857.
Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid	Activity Classification: Operational support. Grantee Name: Mile Bluff Medical Center, Inc.. Grantee Address: 1050 Division Street Mauston, WI 53948-1997. Grantee Relationship: Supported organization. Amount Given: 44,308.
Form 990-EZ, Part I, Line 16 - Other Expenses	Description: Supplies. Amount: 3,813. Description: Continuing education. Amount: 206. Description: Travel. Amount: 118. Description: Women's Night Out expenses. Amount: 14,432. Description: Dues and subscriptions. Amount: 369. Description: Entertainment/meals. Amount: 5,355. Description: Marketing. Amount: 7,285. Description: Nurses Helping Nurses. Amount: 9,575. Total to Form 990-EZ, line 16: 41,153.
Form 990-EZ, Part II, Line 24 - Other Assets	Description: Pledges receivable. Beg. of Year Amount: 7,589. End of Year Amount: 18,177. Description: Investment - other security. Beg. of Year Amount: 5,559. End of Year Amount: 5,559.
Form 990-EZ, Part II, Line 26 - Other Liabilities	Description: Accounts payable. Beg. of Year Amount: 553. End of Year Amount: 1,960. Description: Due to Mile Bluff Medical Center. Beg. of Year Amount: 6,537. End of Year Amount: 6,542.

Transfer Prsnl Bnft Contracts Decl TransferPrsnlBnftContractsDecl

Field	Value	IRS element (for citing)
Declaration	The organization did not, during the year, receive any funds, directly,or indirectly, to pay premiums on a personal benefit contract.The organization, did not, during the year, pay any premiums, directly,or indirectly, on a personal benefit contract.	DeclarationDesc