2016-05-16T15:39:31-05:00 2015-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2014-07-01 200934451 AVITA HEALTH FOUNDATION AVIT 4194684841 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME CFO 4194684841 2016-05-13 1 BERNIE OSTROWSKI P00366367 6148493000 2014 2016-08-17 19:52:53Z JERRY MORASKO 269 PORTLAND WAY SOUTH GALION OH 44833 320630 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. 9 9 0 9 0 0 239922 300915 0 0 89711 19715 0 0 329633 320630 156265 225645 0 0 0 0 0 0 192325 225078 200125 381343 425770 -51710 -105140 874450 929813 0 5302 874450 924511 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 225645 225645 0 SUPPORT AVITA HEALTH SYSTEM, GALION COMMUNITY HOSPITAL AND SUBSIDIARY ORGANIZATIONS THAT PROMOTE HEALTH CARE IN CRAWFORD COUNTY, OHIO AND SURROUNDING COUNTIES. 225645 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 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 9 9 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 OH X D ERIC DRAIME 4194685501 269 PORTLAND WAY SOUTH GALION OH 44833 ERIC GEYER CHAIR 0.20 0.20 X X 0 0 0 KENNETH DAVIS VICE CHAIR 0.20 0.20 X X 0 0 0 DICK LEUTHOLD SECRETARY/TREASURER 0.20 0.00 X X 0 0 0 BOYD EPPERSON DIRECTOR 0.20 0.00 X 0 0 0 RICHARD HARER DIRECTOR 0.20 0.20 X 0 0 0 JAMES W PRY DIRECTOR 0.20 0.00 X 0 0 0 MARYLYN STRANG DIRECTOR 0.20 0.00 X 0 0 0 DAWN RATLIFF DIRECTOR 0.20 0.00 X 0 0 0 CHANEL HIPP DIRECTOR 0.20 0.20 X 0 0 0 JERRY MORASKO PRESIDENT/CEO 0.20 40.50 X 0 425801 52344 D ERIC DRAIME CFO 0.20 40.50 X 0 214744 0 0 640545 52344 0 0 1 0 0 130545 170370 300915 19715 19715 320630 0 0 19715 X 225645 225645 108023 108023 69921 69921 5936 5936 13684 7800 5884 2545 2545 SPECIAL PROJECT COSTS 16 16 425770 225645 7800 192325 139741 165528 734709 764285 874450 929813 5302 0 5302 X 662721 572925 211729 351586 874450 924511 874450 929813 X -105140 15344 139857 X X 0 1 X 1 0 X 51374 289690 467541 128018 300915 1237538 51374 289690 467541 128018 300915 1237538 74195 1163343 9468 28697 5775 21731 19715 85386 1322924 0.87940 0.85970 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 HELD FOR FUTURE CAPITAL IMPROVEMENTS 764285 764285 X PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF JUNE 30, 2015, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2012. 1 GALION COMMUNITY HOSPITAL 269 PORTLAND WAY SOUTH GALION OH 448332399 344451872 501(C)(3) 225645 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 JERRY MORASKO PRESIDENT/CEO 0 425801 0 0 0 0 0 50000 0 2344 0 478145 0 0 D ERIC DRAIME CFO 0 187990 0 26754 0 0 0 0 0 0 0 214744 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 60,000. TOTAL EXPENSES 60,000. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 9,921. TOTAL EXPENSES 9,921. FORM 990, PART XI, LINE 9: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS 139,857. 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 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 GALION COMMUNITY HOSPITAL S 130545 FORGIVENESS OF PAYABLE GALION COMMUNITY HOSPITAL B 225645 NET ASSETS RELEASED