2016-08-12T09:26:37-05:00 2015-09-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2014-10-01 200936376 WEST GEORGIA HEALTH FOUNDATION INC WEST 7068821411 1514 VERNON ROAD LAGRANGE GA 30240 PAUL PERROTTI CFO 7068821411 2016-08-11 1 AMY BIBBY P00445891 8282542254 2014 2016-09-27 15:27:22Z PAUL PERROTTI 1514 VERNON ROAD LAGRANGE GA 30240 1553772 0 X WWW.WGHEALTH.ORG X 2004 GA THE FOUNDATION OPERATES EXCLUSIVELY FOR THE BENEFIT OF THE WEST GEORGIA MEDICAL CENTER, INC. AND ITS AFFILIATED ENTITIES. 14 10 3 72 0 0 2326527 1293169 0 0 437337 180189 0 0 2763864 1473358 517809 246666 0 0 0 0 0 0 0 139191 48182 657000 294848 2106864 1178510 11224768 11796819 300035 22680 10924733 11774139 THE FOUNDATION OPERATES EXCLUSIVELY FOR THE BENEFIT OF THE WEST GEORGIA MEDICAL CENTER, INC. AND ITS AFFILIATED ENTITIES. 0 0 34867 10355 TO PROVIDE FUNDS FOR SPECIFIC MEDICAL AND CANCER TREATING EQUIPMENT AND SUPPORT OF WEST GEORGIA MEDICAL CENTER. 225141 225141 TO PROVIDE FINANCIAL SUPPORT TO WEST GEORGIA MEDICAL CENTER, INC. FOR OPERATING THE HOSPICE CENTER. 11170 11170 HELPING HANDS FAMILY ASSISTANCE PROGRAM - TO ASSIST PRESENT AND RETIRED WGHS EMPLOYEES AND HOSPITAL AUXILIARY VOLUNTEERS WITH FINANCIAL SUPPORT IN TIMES OF CRISIS. QUALIFYING HARDSHIPS INCLUDE CATASTROPHIC ILLNESS OR ACCIDENT SUFFERED BY A RECIPIENT OR AN UNINSURED LOSS TO A PRIMARY RESIDENCE CAUSED BY FIRE OR OTHER MAJOR ACCIDENT OR DISASTER. FROM OCTOBER 1, 2014 - SEPTEMBER 30, 2015, THE HELPING HANDS PROGRAMS ASSISTED 23 WEST GEORGIA HEALTH SYSTEM EMPLOYEES BY PROVIDING $11,170 IN MONETARY ASSISTANCE. 271178 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 3 1 0 0 0 0 0 0 0 0 0 0 X 14 10 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 GA X PAUL PERROTTI 7068453934 1514 VERNON ROAD LAGRANGE GA 30240 X WESLEY SMITH CHAIRMAN 1.00 X X 0 0 0 DR RICHARD SANDY SIMMONS VICE CHAIRMAN 1.00 40.00 X X 0 426139 31681 WAYNE ABBOTT TREASURER 1.00 X X 0 0 0 GERALD FULKS SECRETARY 1.00 41.00 X X 0 472740 92545 DR ROBERT COGGINS MEMBER 1.00 X 0 42750 0 NANCY DURAND MEMBER 1.00 3.00 X 0 0 0 DR JULIAN DUTTERA MEMBER 1.00 X 0 1500 0 DR JOHN JACKSON MEMBER 1.00 X 0 0 0 ELLEN HARRIS MEMBER 1.00 X 0 0 0 BEVERLY LUNDBERG MEMBER 1.00 X 0 0 0 ROBBY BURCH MEMBER 1.00 X 0 0 0 RICK MALLORY MEMBER 1.00 X 0 0 0 MICHAEL LAMB MEMBER 1.00 40.00 X 0 55972 23740 CHARLES SMITH MEMBER 1.00 X 0 0 0 PAUL PERROTTI CFO 1.00 42.00 X 0 318015 52549 0 1317116 200515 0 0 1 0 0 77120 85000 1131049 1293169 206467 206467 26278 -26278 -26278 -26278 54136 77120 54136 0 1473358 0 0 180189 235123 235123 11543 11543 21015 21015 23564 20909 2655 CAMP DOGWOOD GRIEF CAMP 3603 3603 294848 271178 23670 0 3987030 1169565 767427 578324 6470311 10048930 11224768 11796819 22317 300035 363 300035 22680 X 10012733 10862139 912000 912000 10924733 11774139 11224768 11796819 1178510 -329104 0 X X 0 1 X 1 0 X 1007236 452183 1999511 2330235 1293169 7082334 1007236 452183 1999511 2330235 1293169 7082334 2903407 4178927 136866 399495 439876 437337 206467 1620041 8702375 0.48020 0.50910 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10924729 1314581 -148912 316259 11774139 8583037 2385121 672169 715598 10924729 6274836 1933958 551364 177121 8583037 5489839 451895 665832 332730 6274836 4800666 945878 155841 412546 5489839 0.00000 0.11370 0.88630 0 0 0 INTERCOMPANY PAYABLES 363 363 X 1177375 -329104 54136 -274968 1452343 21015 21015 1473358 327969 54136 54136 273833 21015 21015 294848 PART V, LINE 4: NET ASSETS ARE RELEASED FROM RESTRICTIONS WHEN EXPENSES ARE INCURRED TO SATISFY THE RESTRICTED PURPOSES, BY PASSAGE OF TIME OR BY OCCURENCE OF SPECIFIC EVENTS. NET ASSETS RELEASED DURING THE YEAR WERE PRIMARILY FOR THE CONTRIBUTIONS AND SUPPORT OF CONSTRUCTION OF ADDITIONAL FACILITIES, SPECIFIC MEDICAL AND CANCER TREATMENT EQUIPMENT, AND THE HOSPICE PROGRAM OF LAGRANGE-TROUP COUNTY HOSPITAL AUTHORITY. PART X, LINE 2: THE FOUNDATION HAS BEEN CLASSIFIED AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN DETERMINED NOT TO BE A PRIVATE FOUNDATION UNDER SECTION 509(A). ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN MADE. THE FOUNDATION HAS EVALUATED ITS TAX POSITIONS AND HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2015, AND 2014. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE 54,136. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE 54,136. GOLF TOURNAMENT 86690 49367 37323 10700 15277 7040 4305 POINSETTIA SALE 25140 13984 11156 11156 2 19426 13769 5657 53 5605 131256 77120 54136 10700 15330 7040 21066 54136 0 1 WEST GEORGIA MEDICAL CENTER INC 1514 VERNON ROAD LAGRANGE GA 30240 205497506 501(C)(3) 225141 SUPPORT FOR VARIUS BENEVOLENT PROGRAMS INCLUDING THE LIFELINE PROGRAM FOR HOSPICE PATIENTS 1 HELPING HANDS EMPLOYEE PROGRAM 23 11170 GEORGE KISH SCHOLARSHIP 1 373 PART I, LINE 2: FUNDS WERE USED TO SUPPORT WEST GEORGIA MEDICAL CENTER, INC., A RELATED 501(C)(3) ORGANIZATION AND OTHER AFFILIATED HEALTHCARE PROVIDERS. THE HELPING HANDS FAMILY ASSISTANCE PROGRAM IS AN EMPLOYEE EMERGENCY ASSISTANCE PROGRAM. 1 0 1 0 0 0 0 0 0 0 DR RICHARD SANDY SIMMONS VICE CHAIRMAN 0 373683 0 46440 0 6016 0 10400 0 21281 0 457820 0 0 GERALD FULKS SECRETARY 0 398304 0 64000 0 10436 0 76565 0 15980 0 565285 0 0 PAUL PERROTTI CFO 0 275838 0 32907 0 9270 0 30660 0 21889 0 370564 0 0 PART I, LINE 4B EMPLOYER CONTRIBUTIONS TO THE 457(F) SUPPLEMENTAL EXECUTIVE RETIREMENT BENEFIT PLAN (SERP) INCLUDE $20,260 FOR PAUL PERROTTI, CFO AND $55,700 FOR GERALD FULKS, CEO. IN ACCORDANCE WITH 457(F) REGULATIONS THESE AMOUNTS WERE VESTED DURING THE YEAR, HOWEVER, THEY WERE NOT RECEIVED BY THE EMPLOYEE. FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS WESLEY SMITH AND CHARLES SMITH HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS WEST GEORGIA HEALTH SERVICES, INC. A RELATED 501(C)(3) ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A UPON A VACANCY, THE MEMBERS OF THE BOARD OF DIRECTORS SHALL BE APPOINTED BY THE BOARD OF DIRECTORS OF W. GA HEALTH SERVICES, INC. TO SERVE A TERM OF 4 YEARS AND UNTIL A SUCCESSOR HAS BEEN APPOINTED, OR UNTIL THE MEMBER'S EARLIER DEATH, RESIGNATION, OR REMOVAL. A DIRECTOR MAY SERVE UP TO TWO 4 YEAR SUCCESSIVE TERMS. ANY DIRECTOR MAY BE REMOVED, EITHER FOR OR WITHOUT CAUSE, BY THE BOARD OF DIRECTORS OF W. GA HEALTH SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO THE APPROVAL OF THE ORGANIZATION'S SOLE MEMBER THROUGH THE SELECTION AND OVERSIGHT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. UPON COMPLETION AND REVIEW BY MANAGEMENT, A COPY OF THE 990 WAS PROVIDED TO EACH BOARD MEMBER VIA E-MAIL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR OF THE CORPORATION HAVING ANY POTENTIAL FINANCIAL INTEREST IN THE OUTCOME OF ANY DECISION THAT IS BEFORE THE BOARD OF DIRECTORS SHALL MAKE SUCH INTEREST APPARENT PRIOR TO THE DELIBERATIONS OR VOTE OF THE BOARD OF DIRECTORS ON THIS ISSUE, AND SAID DIRECTOR SHALL ABSTAIN FROM VOTING ON THIS ISSUE, AND ABSENT HIMSELF/HERSELF FROM THIS MEETING DURING DELIBERATIONS ON THIS ISSUE. THE NATURE OF ANY DIRECTOR'S POTENTIAL FINANCIAL INTEREST IN THE OUTCOME OF ANY BOARD DECISION SHALL BE DISCLOSED IN THE MINUTE BOOK OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 15 HUMAN RESOURCES MAKES COMPENSATION RECOMMENDATIONS BASED ON COMPARATIVE MARKET ANALYSIS WHICH IS THEN REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PART VII BOARD MEMBER COMPENSATION: BOARD MEMBERS DR. ROBERT COGGINS AND DR. JULIAN DUTTERA RECEIVED COMPENSATION FROM RELATED ORGANIZATION WEST GEORGIA MEDICA CENTER FOR MEDICAL SERVICES RENDERED TO THAT ORGANIZATION. BOARD MEMBER DR. SANDY SIMMONS SERVES AS THE CHIEF MEDICAL DIRECTOR AND AS A PULMONOLOGIST FOR RELATED ORGANIZATION WEST GEORGIA HEALTH PHYSICIAN. HE ALSO SERVES AS THE MEDICAL DIRECTOR FOR SLEEP CLINIC FOR WEST GEORGIA MEDICA CENTER. DR. SANDY SIMMONS RECEIVES COMPENSATION FROM THESE RELATED ORGANIZATONS FOR MEDICAL SERVICES RENDERED. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. LAGRANGE-TROUP COUNTY HOSPITAL AUTHORITY 1514 VERNON ROAD LAGRANGE GA 30240 562609278 HOSPITAL AUTHORITY GA 501(C)(3) LINE 3 N/A 0 VERNON WOODS RETIREMENT COMMUNITY INC 1514 VERNON ROAD LAGRANGE GA 30240 582575049 ASSISTED LIVING GA 501(C)(3) LINE 9 WEST GEORIGA HEALTH SERVICES INC 0 WEST GEORGIA HEALTH SERVICES INC 1514 VERNON ROAD LAGRANGE GA 30240 205497622 PARENT OF HEALTH SYSTEM GA 501(C)(3) LINE 11C, III-FI N/A 0 WEST GEORGIA MEDICAL CENTER INC 1514 VERNON ROAD LAGRANGE GA 30240 205497506 HOSPITAL GA 501(C)(3) LINE 3 WEST GEORIGA HEALTH SERVICES INC 0 MEDICAL PARK FOUNDATION INC 209 BROOME STREET LAGRANGE GA 30240 581303478 SUPPORTING ORGANIZATION GA 501(C)(3) LINE 11A, I WEST GEORIGA HEALTH SERVICES INC 0 WEST GEORGIA HEALTH PHYSICIANS INC 1514 VERNON ROAD LAGRANGE GA 30240 275125341 PHYSICIAN PRACTICE GA N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0