2014-11-10T15:30:01-06:00 2013-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-01-01 391459276 APPLETON MEDICAL CENTER FOUNDATION INC APPL 9207386506 1818 N MEADE STREET APPLETON WI 54911 DEAN HIGH PRESIDENT 9207386506 2014-10-20 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-10-20 2013 2015-11-30 17:44:51Z JEFF REISTER 1818 N MEADE STREET APPLETON WI 54911 7503728 0 X WWW.AMCFOUNDATION.ORG X 1983 WI ENHANCE THE HEALTH OF OUR COMMUNITIES. X 14 10 0 46 0 0 790656 382612 0 0 317747 880591 55150 -10025 1163553 1253178 143984 739950 0 0 279378 322208 0 0 277943 88134 82074 511496 1144232 652057 108946 12041669 814463 37905 814463 12003764 0 X TO RAISE FUNDS AND CARRY OUT THE PURPOSES OF THE APPLETON MEDICAL CENTER, APPLETON, WI. THESE PURPOSES INCLUDE THE ENCOURAGEMENT OF EFFECTIVE SERVICES WITHIN AND AROUND APPLETON AND THE GREATER FOX VALLEY AREA BY PROVIDING SCHOLARSHIPS AND GRANTS TO ORGANIZATIONS THAT SUPPORT AMC'S PURPOSE. TO CREATE AND SUPPORT HOSPITAL HEALTH CARE INITIATIVES THROUGH FUNDING FOR THE APPLETON MEDICAL CENTER AND RELATED OTHER COMMUNITY HEALTH CARE PROVIDERS. 0 0 719450 719450 TO RAISE FUNDS AND CARRY OUT THE PURPOSES OF THE APPLETON MEDICAL CENTER, APPLETON, WI. THESE PURPOSES INCLUDE THE ENCOURAGEMENT OF EFFECTIVE SERVICES WITHIN AND AROUND APPLETON AND THE GREATER FOX VALLEY AREA BY PROVIDING SCHOLARSHIPS AND GRANTS TO ORGANIZATIONS THAT SUPPORT AMC'S PURPOSE. TO CREATE AND SUPPORT HOSPITAL HEALTH CARE INITIATIVES THROUGH FUNDING FOR THE APPLETON MEDICAL CENTER AND RELATED OTHER COMMUNITY HEALTH CARE PROVIDERS. 20500 20500 10 SCHOLARSHIPS WERE GRANTED TO INDIVIDUALS WHO ARE GOING INTO THE MEDICAL FIELD OF STUDY. 739950 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 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 1 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 14 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 ANDERLADAVID MD DIRECTOR 1.00 41.00 X 0 317507 28818 BORENCLARK JR MD SECRETARY (CURRENT) 1.00 41.00 X X 0 294287 7968 BYTOFJOYCE DIRECTOR 1.00 0.00 X 0 0 0 DUNGAR STEVE C MD DIRECTOR 1.00 0.00 X 0 0 0 FULKERSONJAY DIRECTOR 1.00 0.00 X 0 0 0 HIGH DEAN V PRESIDENT 1.00 2.00 X X 0 0 0 OLSONTIM DIRECTOR 1.00 40.00 X 0 486483 104929 RAYMICHAEL MDPHD DIRECTOR 1.00 0.00 X 0 0 0 RIESTERJEFF TREASURER 1.00 1.00 X X 0 0 0 RUGLANDWALTER VICE PRESIDENT 1.00 1.00 X X 0 0 0 SCHAFFMEYER PASTOR ALAN DIRECTOR 1.00 0.00 X 0 0 0 SCHUBBE PETER J DC DIRECTOR 1.00 0.00 X 0 0 0 UEHLINGBARBARA SECRETARY (FORMER) 1.00 0.00 X X 0 0 0 WALSH CYRIL P PRESIDENT 1.00 3.00 X 0 0 0 HUNTER WILLIAM DIRECTOR 1.00 41.00 X 0 419674 76222 FROHNAMICHAEL EXECUTIVE DIRECTOR 15.00 28.00 X 69878 129772 22012 69878 1647723 239949 0 0 1 0 0 68906 313706 382612 260797 260797 6836672 6216878 619794 619794 619794 23647 68906 33672 -10025 -10025 1253178 0 0 870566 719450 719450 20500 20500 322208 80552 241656 18036 18036 7898 7898 26656 13328 13328 8593 8593 3429 1714 1715 2766 692 2074 2019 2019 SUPPLIES 10730 3541 7189 MEALS AND CATERING 3811 1906 1905 MEMBERSHIPS/SUBSCRIPTIO 2633 1316 1317 DONOR CULTIVATION 166 166 -4663 -4663 1144232 739950 126339 277943 1173565 814463 546981 0 10321123 0 12041669 814463 37905 814463 37905 814463 X 6249218 0 4091410 0 1663136 0 12003764 0 12041669 814463 X 108946 1125447 -13238157 X X 0 1 X 1 0 X 243392 1306897 507834 790656 382612 3231391 243392 1306897 507834 790656 382612 3231391 1232905 1998486 235618 112227 98740 140877 260797 848259 4079650 370742 0.48990 0.37310 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5257892 47322 129975 5395434 39755 5185470 31906 71610 31094 5257892 5188828 54597 -14882 43073 5185470 5148663 3305 64028 27168 5188828 4876903 1370 287444 17054 5148663 0 0 0 X 2412297 1125447 1125447 1286850 -33672 -33672 1253178 1177904 33672 33672 1144232 0 1144232 PART V, LINE 4: THE FOUNDATION HAS ADOPTED INVESTMENT AND SPENDING POLICIES FOR ENDOWMENT ASSETS THAT ATTEMPT TO PROVIDE A PREDICTABLE STREAM OF FUNDING TO PROGRAMS SUPPORTED BY ITS ENDOWMENT WHILE SEEKING TO MAINTAIN THE PURCHASING POWER OF THE ENDOWMENT ASSETS. ENDOWMENT ASSESTS INCLUDE THOSE ASSETS OF DONOR-RESTRICTED FUNDS THAT THE FOUNDATION MUST HOLD IN PERPETUITY OR FOR A DONOR-SPECIFIED PERIOD(S). UNDER THIS POLICY, AS APPROVED BY THE BOARD OF DIRECTORS, THE ENDOWMENT ASSETS ARE INVESTED IN A MANNER THAT IS INTENDED TO PRODUCE RESULTS THAT EXCEED THE PRICE AND YIELD RESULTS OF THE S & P 500 INDEX WHILE ASSUMING A MODERATE LEVEL OF INVESTMENT RISK. PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE FOUNDATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE FOUNDATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2013 OR 2012. FEDERAL TAX RETURNS FOR THE YEARS ENDED 2010 AND BEYOND, REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES -33,672. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 33,672. HIGH FLYIN' GOLF OUTING 53568 39790 13778 17162 4690 LAUGHTER IS THE BEST MEDICINE 38985 29116 9869 2026 1430 8364 92553 68906 23647 19188 1430 13054 33672 -10025 1 COTS INC 819 S WEST STREET APPLETON WI 54915 391913179 501(C)(3) 17000 SUPPORT OF AN AFTERCARE COORDINATOR APPLETON MEDICAL CENTER INC 1818 NORTH MEADE STREET APPLETON WI 54911 390824015 501(C)(3) 450926 CANCER CARE SUPPORT, NURSING EDUCATION, LEARNING CENTER FOR COLLABORATIVE CARE, NICONE EEG MACHINES APPLETON AREA SCHOOL DISTRICT 122 E COLLEGE AVE APPLETON WI 54911 396000710 APPLETON SCHOOL DIST 25000 LAWRENCE UNIVERSITY RESEARCH PROJECT INVOLVING THE BUILDING FOR KIDS CHILDREN'S MUSEUM LIVING HEALTHY COMMUNITY CLINIC 510 DOCTORS COURT OSHKOSH WI 54901 391805963 501(C)(3) 90000 GENERAL OPERATIONS FOX CITIES CHAMBER OF COMMERCE & INDUSTRY 125 N SUPERIOR STREET APPLETON WI 54911 391248133 501(C)(3) 25000 ANNUAL ECONOMIC DEVELOPMENT GRANT AMC VOLUNTEERS 1818 NORTH MEADE STREET APPLETON WI 54911 396062608 501(C)(3) 17500 AVS SCHOLARSHIP AWARDS CHAPS ACADEMY N5367 MAYFLOWER ROAD SHIOCTON WI 54170 450530019 501(C)(3) 8000 SUPPORT STAFFING OF A RN RIVERVIEW GARDENS PO BOX 1645 APPLETON WI 54911 391913179 501(C)(3) 50000 HOOPHOUSES AND MAINTENANCE FOR 5 YEARS REBUILDING TOGETHER FOR THE FOX VALLEY 605 E HANCOCK STREET APPLETON WI 54911 392013200 501(C)(3) 10000 GENERAL OPERATING EXPENSES BOYS & GIRLS CLUB PO BOX 411 OSHKOSH WI 549030411 396120658 501(C)(3) 23500 DEVELOPMENT OF AN AT-RISK YOUTH CAREER MENTORING/LIFE SKILLS INITIATIVE 10 0 SCHOLARSHIPS 10 20500 PART I, LINE 2: THE ORGANIZATION ONLY WRITES CHECKS OUT FOR GRANTS TO ORGANIZATIONS ONCE THE ITEM OR SERVICE HAS ALREADY BEEN RECEIVED BY THE ORGANIZATION. SCHOLARSHIP CHECKS ARE WRITTEN OUT TO THE COLLEGE AND THE RECIPIENT. X 0 1 X 0 1 0 0 0 0 0 0 0 ANDERLADAVID MD DIRECTOR 0 273015 0 43387 0 1105 0 9064 0 19754 0 346325 0 0 BORENCLARK JR MD SECRETARY (CURRENT) 0 276294 0 10373 0 7620 0 0 0 7968 0 302255 0 0 OLSONTIM DIRECTOR 0 387286 0 75178 0 24019 0 87550 0 17379 0 591412 0 0 HUNTER WILLIAM DIRECTOR 0 330851 0 77288 0 11535 0 58415 0 17807 0 495896 0 0 FROHNAMICHAEL EXECUTIVE DIRECTOR 59508 110514 5738 10655 4632 8603 1924 3573 5780 10735 77582 144080 0 0 PART I, LINE 1B CLUB DUES ARE A TAXABLE BENEFIT OFFERED INFREQUENTLY ON A CASE BY CASE BASIS. THEY NEED TO BE APPROVED UNANIMOUSLY BY THE HIRING VICE PRESIDENT, THE HUMAN RESOURCES VICE PRESIDENT, AND THE CEO. PART I, LINE 3 THE ORGANIZATION RELIES ON THEDACARE, INC., A RELATED 501(C)(3) ORGANIZATION, TO ESTABLISH THE COMPENSATION FOR ITS EXECUTIVE DIRECTOR. THEDACARE, INC. USES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AS ITS METHODS FOR ESTABLISHING THE COMPENSATION FOR APPLETON MEDICAL CENTER FOUNDATION'S EXECUTIVE DIRECTOR. PART I, LINE 4B TIM OLSON IS ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF HIS BASE COMPENSATION. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTIONS 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVESTED IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. NOTHING WAS PAID OUT IN 2013. CASH 2013-12-31 814463 ACTUAL COST 464112255 THEDACARE FAMILY OF FOUNDATIONS INC 1818 N MEADE ST PO BOX 1222 APPLETON WI 549129974 501(C)(3) OTHER ACCOUNTS RECEIVABLE 2013-12-31 -74297 BOOK VALUE 464112255 THEDACARE FAMILY OF FOUNDATIONS INC 1818 N MEADE ST PO BOX 1222 APPLETON WI 549129974 501(C)(3) PLEDGES RECEIVABLE 2013-12-31 103673 BOOK VALUE 464112255 THEDACARE FAMILY OF FOUNDATIONS INC 1818 N MEADE ST PO BOX 1222 APPLETON WI 549129974 501(C)(3) INVESTMENTS 2013-12-31 12394318 FAIR MARKET VALUE 464112255 THEDACARE FAMILY OF FOUNDATIONS INC 1818 N MEADE ST PO BOX 1222 APPLETON WI 549129974 501(C)(3) 1 1 0 0 PART II, LINE 2E: EXPLANATION OF INVOLVEMENT: DEAN HIGH, PRESIDENT OF APPLETON MEDICAL CENTER FOUNDATION BECAME A DIRECTOR OF THE TRANSFEREE ORGANIZATION, THEDACARE FAMILY OF FOUNDATIONS, INC.WALTER RUGLAND, VICE PRESIDENT OF APPLETON MEDICAL CENTER FOUNDATION BECAME A DIRECTOR OF THE TRANSFEREE ORGANIZATION, THEDACARE FAMILY OF FOUNDATIONS, INC.MICHAEL FROHNA, EXECUTIVE DIRECTOR OF APPLETON MEDICAL CENTER FOUNDATION BECAME A DIRECTOR OF THE TRANSFEREE ORGANIZATION, THEDACARE FAMILY OF FOUNDATIONS, INC. FORM 990, SCHEDULE N DURING 2013, THEDACARE, INC. FORMED A NEW FOUNDATION, THEDACARE FAMILY OF FOUNDATIONS, INC., IN ORDER TO CONSOLIDATE THE ACTIVITIES OF THEIR MULTIPLE FOUNDATIONS INTO ONE ORGANIZATION. ACCORDINGLY, AMC FOUNDATION'S BOARD OF DIRECTORS APPROVED A PLAN OF DISSOLUTION WHEREBY DURING 2013 THE FOUNDATION TRANSFERRED $13,238,157 OF NET ASSETS TO THEDACARE FAMILY OF FOUNDATIONS, INC. FORM 990, PART VI, SECTION A, LINE 6 APPLETON MEDICAL CENTER FOUNDATION, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THE ELECTION AND REMOVAL OF DIRECTORS REQUIRES THE APPROVAL OF THEDACARE,INC. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS SHALL NOT BE TAKEN WITHOUT THE APPROVAL OF THEDACARE, INC.: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. AMENDMENT OF THE BYLAWS 3. MERGER, CONSOLIDATION OR DISSOLUTION OF THIS CORPORATION 4. THE CREATION OF ANY SUBSIDIARIES OR AFFILIATES OF THIS CORPORATION FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS E-MAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY THROUGH SURVEYS, WHICH ARE REVIEWED BY THE COMPLIANCE OFFICER AND COMMITTEE. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTICIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION PROCESS FOR TOP OFFICIALS OF THE ORGANIZATION IS MANAGED BY THEIR EMPLOYER FOR PAYROLL PURPOSES, THEDACARE, INC., A RELATED ORGANIZATION. MANAGEMENT OF THEDACARE, INC. DETERMINES A FAIR AND REASONABLE COMPENSATION FOR THESE INDIVIDUALS BASED ON MARKET AND COMPARABILITY DATA PROVIDED BY HUMAN RESOURCES. NO OTHER OFFICERS OF THE ORGANIZATION RECEIVE ANY COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: NET ASSETS TRANSFERRED TO THEDACARE FAMILY OF FOUNDATIONS, INC. -13,238,157. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 HEALTHCARE WI 501(C)(3) LINE 11C, III-FI N/A 0 THEDA CLARK MEDICAL CENTER INC PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDACARE MEDICAL CENTER - NEW LONDON INC 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 APPLETON MEDICAL CENTER INC PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 SHAWANO MEDICAL CENTER INC 309 N BARTLETTE STREET SHAWANO WI 54166 390807068 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 1 THEDA CLARK MEDICAL CENTER FOUNDATION INC 1818 N MEADE STREET APPLETON WI 54911 311550056 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 1 WOLF RIVER AREA HEALTHCARE FOUNDATION INC 1405 MILL STREET NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 11A, I NEW LONDON FAMILY MEDICAL CENTER INC 1 GEORGE F PEABODY FOUNDATION INC 2600 S HERITAGE WOODS DRIVE APPLETON WI 54915 391702534 FOUNDATION WI 501(C)(3) LINE 11A, I APPLETON MEDICAL CENTER INC 1 COMMUNITY HOSPICE FOUNDATION INC 1818 N MEADE STREET APPLETON WI 54911 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 1 SHAWANO MEDICAL CENTER FOUNDATION INC 309 N BARTLETTE STREET SHAWANO WI 54166 391539117 FOUNDATION WI 501(C)(3) LINE 11A, I SHAWANO MEDICAL CENTER INC 1 THEDACARE FAMILY OF FOUNDATIONS INC 1818 N MEADE STREET APPLETON WI 54915 464112255 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 1 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 TRANSFER OF NET ASSETS TO THEDACARE FAMILY FOUNDATIONS INC R 13238157 FMV APPLETON MEDICAL CENTER INC B 739950 FMV