2017-05-15T10:40:15-05:00 2016-06-30 381357951 PLANTE & MORAN PLLC 250 S HIGH ST SUITE 100 COLUMBUS OH 43215 990 2015-07-01 200934451 AVITA HEALTH FOUNDATION AVIT 4194684841 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME CFO 4194684841 2017-05-12 1 BERNIE OSTROWSKI P00366367 6148493000 2017-05-12 2015 2021-01-29 14:40:06Z JERRY MORASKO 269 PORTLAND WAY SOUTH GALION OH 44833 665981 0 X N/A X 2004 OH INSPIRE PHILANTHROPY AND PROVIDE FINANCIAL SUPPORT TO GALION COMMUNITY HOSPITAL AND AVITA HEALTH SYSTEM IN WAYS THAT HAVE A POSITIVE IMPACT ON PATIENTS, EMPLOYEES, AND THE COMMUNITY. 10 10 0 10 0 0 300915 512569 0 0 19715 20017 0 95515 320630 628101 225645 311858 0 0 0 0 0 0 209183 200125 216502 425770 528360 -105140 99741 929813 988073 5302 1554 924511 986519 TO INSPIRE PHILANTHROPY AND TO PROVIDE FINANCIAL SUPPORT TO GALION AND BUCYRUS COMMUNITY HOSPITALS IN ORDER TO ENHANCE HEALTHCARE SERVICES AND TO IMPROVE THE WELL BEING OF THE RESIDENTS OF OUR COMMUNITIES. 0 0 311858 311858 0 SUPPORT AVITA HEALTH SYSTEM, GALION COMMUNITY HOSPITAL AND SUBSIDIARY ORGANIZATIONS THAT PROMOTE HEALTH CARE IN CRAWFORD COUNTY, OHIO AND SURROUNDING COUNTIES. 311858 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X D ERIC DRAIME 4194685501 269 PORTLAND WAY SOUTH GALION OH 44833 CHANEL HIPP VICE CHAIR 0.20 0.00 X X 0 0 0 DAWN RATLIFF CHAIR 0.20 0.00 X X 0 0 0 KENNETH DAVIS SECRETARY/TREASURER 0.20 0.00 X X 0 0 0 NICHOLAS GESOURAS DIRECTOR 0.20 0.00 X 0 0 0 RANDY MCDONALD DIRECTOR 0.20 0.00 X 0 0 0 MARYLYN STRANG DIRECTOR 0.20 0.00 X 0 0 0 JAMES W PRY DIRECTOR 0.20 0.00 X 0 0 0 RICHARD HARER DIRECTOR 0.20 0.00 X 0 0 0 BOYD EPPERSON DIRECTOR 0.20 0.20 X 0 0 0 ERIC GEYER DIRECTOR 0.20 0.20 X 0 0 0 D ERIC DRAIME CFO 0.20 40.50 X 0 238303 1042 JERRY MORASKO PRESIDENT/CEO 0.20 40.50 X 0 430008 80366 0 668311 81408 0 0 1 0 0 5076 216184 291309 512569 20017 20017 133395 5076 37880 95515 95515 628101 0 0 115532 X 311858 311858 118606 118606 72383 72383 5724 5724 18020 7319 10701 1649 1649 SPECIAL PROJECT COSTS 120 120 528360 311858 7319 209183 165528 246860 764285 741213 929813 988073 5302 1554 5302 1554 X 572925 629132 351586 357387 924511 986519 929813 988073 99741 -37733 0 X X 0 1 X 1 0 X 289690 467541 128018 300915 608084 1794248 289690 467541 128018 300915 608084 1794248 61498 1732750 28697 5775 21731 19715 20017 95935 1890183 0.91670 0.87940 X 0 HELD FOR FUTURE CAPITAL IMPROVEMENTS 741213 741213 1 HILLARY LYONS & ASSOCIATES 139 BRIDGE ST DIMONDALE MI 48821 CONSULTING 0 0 0 60000 60000 OH WOMENS HEALTH 70072 4851 65221 1372 454 1159 1975 12483 CARDIAC GOLF OUTING 57130 57130 882 7150 3753 1718 1 11269 225 11044 452 186 6296 138471 5076 133395 2706 7604 5098 1975 20497 37880 95515 SCHEDULE G, PART I, LINE 2B, COLUMN (V) CONSULTING SERVICES AND TRAINING. 1 GALION COMMUNITY HOSPITAL 269 PORTLAND WAY SOUTH GALION OH 448332399 344451872 501(C)(3) 311858 SUPPORT THE HOSPITAL'S TAX EXEMPT PURPOSE 1 0 PART I, LINE 2: GRANTS ARE USED TO SUPPORT THE TAX-EXEMPT PURPOSE OF RELATED ENTITIES. THESE ARE MONITORED INTERNALLY. 0 1 0 0 0 0 0 0 0 D ERIC DRAIME CFO 0 207701 0 30602 0 0 0 0 0 1042 0 239345 0 0 JERRY MORASKO PRESIDENT/CEO 0 398708 0 30000 0 1300 0 80000 0 366 0 510374 0 0 PART I, LINE 4B 457(F)- SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE JERRY MORASKO- $80,000 PART I, LINE 3: AVITA HEALTH FOUNDATION RELIED ON A RELATED ORGANIZATION THAT USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD -COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION SHALL, AT ALL TIMES, BE GALION COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OR DIRECTORS SHALL HAVE THE APPROVAL OF THE BOARD OF DIRECTORS OF GALION COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER HAS THE RIGHT TO APPROVE OR RATIFY DECISIONS OF THE ORGANIZATION'S GOVERNING BODY, SUCH AS APPROVAL OF THE GOVERNING BODY'S ELECTION OR REMOVAL OF MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE SUB-COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND SENT TO THE EXECUTIVE COMMITTEE OF GALION COMMUNITY HOSPITAL'S BOARD FOR THEIR REVIEW PRIOR TO FILING. THE BOARD EXECUTIVE COMMITTEE APPROVES THE FORM 990 FOLLOWING REVIEW, AS AUTHORIZED BY THE FULL GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 12C GALION COMMUNITY HOSPITAL HAS A CONFLICT OF INTEREST POLICY THAT COVERS ALL BOARD OF DIRECTORS AND OFFICERS OF THE CORPORATION. CONFLICT OF INTEREST SURVEYS ARE REVIEWED BY BOARD CHAIRMAN AND THE CEO TO ENSURE COMPLIANCE. VARIOUS RESTRICTIONS ARE IMPOSED ON INDIVIDUALS WITH POTENTIAL CONFLICTS OF INTEREST (I.E. INABILITY TO VOTE) UNTIL DECISION HAS BEEN MADE ON POTENTIAL CONFLICT. AVITA HEALTH FOUNDATION HAS ADOPTED THIS POLICY. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC, OTHER THAN THE FINANCIAL STATEMENTS WHICH ARE ATTACHED TO GALION COMMUNITY HOSPITAL'S FORM 990. FORM 990, PART IX, LINE 11G CONSULTING FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 55,000. TOTAL EXPENSES 55,000. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 17,383. TOTAL EXPENSES 17,383. FORM 990, PART XI, LINE 2C THE ORGANIZATION HAS A FINANCE COMMITTEE WHICH OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. GALION COMMUNITY HOSPITAL 269 PORTLAND WAY SOUTH GALION OH 44833 344451872 HOSPITAL SERVICES OH 501(C)(3) LINE 3 AVITA HEALTH SYSTEM 1 COMMUNITY HEALTH ASSOCIATES INC 955 BUCYRUS ROAD GALION OH 44833 341784017 PHYSICIAN OFFICE OH 501(C)(3) LINE 11A, I GALION COMMUNITY HOSPITAL 1 NORTH CENTRAL OHIO FAMILY CARE CENTER INC 269 PORTLAND WAY SOUTH GALION OH 44833 341807906 PHYSICIAN OFFICE OH 501(C)(3) LINE 11A, I GALION COMMUNITY HOSPITAL 1 AVITA HEALTH SYSTEM 269 PORTLAND WAY SOUTH GALION OH 44833 274385692 HEALTHCARE OH 501(C)(3) LINE 11A, I N/A 0 CRAWFORD COUNTY SHARED HEALTH SERVICES INC 1220 NORTH MARKET STREET GALION OH 44833 341484014 HOME HEALTH & HOSPICE OH 501(C)(3) LINE 9 GALION COMMUNITY HOSPITAL 1 GALION COMMUNITY PAIN MANAGEMENT LLC 269 PORTLAND WAY SOUTH GALION OH 44833 300602607 HOSPITAL SUPPORT OH N/A GALION COMMUNITY VASCULAR SERVICES LLC 269 PORTLAND WAY SOUTH GALION OH 44833 611613817 HOSPITAL SUPPORT OH N/A AMERICAN SURGICAL SPINE SERVICES 629 N SANDUSKY AVE BUCYRUS OH 44820 371786727 HOSPITAL SUPPORT OH N/A 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 GALION COMMUNITY HOSPITAL S 216184 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL B 311858 NET ASSETS RELEASED