2014-05-14T15:34:21-05:00 2013-06-30 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2012-07-01 560611546 CHATHAM HOSPITAL INC CHAT 9197994000 PO BOX 649 SILER CITY NC 27344 ROBERT ENDERS 9197994000 2014-05-13 1 JOHN NORMAN P01506766 7049985200 2012 2015-11-30 17:44:51Z ROBERT ENDERS PO BOX 649 SILER CITY NC 27344 28196614 0 X WWW.CHATHAMHOSPITAL.ORG X 1939 NC PROVIDES SHORT-TERM MEDICAL CARE ON AN INPATIENT AND OUTPATIENT BASIS. 15 9 0 9 1164827 -112205 5000 0 28228156 27795038 82127 184396 192993 217180 28508276 28196614 0 0 0 0 10577873 10817512 0 0 0 21202461 20028006 31780334 30845518 -3272058 -2648904 47781140 42721602 36436831 33296840 11344309 9424762 X TO PARTICIPATE IN AND PROMOTE THE PROVISION OF PATIENT CARE, FACILITATE THE EDUCATION OF PHYSICIANS AND OTHER HEALTH CARE PROVIDERS, PROMOTE RESEARCH IN COLLABORATION WITH THE HEALTH SCIENCES SCHOOLS OF THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, AND FACILITATE AND PROMOTE THE DELIVERY OF OTHER SERVICES DESIGNED TO PROMOTE THE HEALTH AND WELL-BEING OF THE CITIZENS OF NORTH CAROLINA. 0 0 23108150 26630211 CHATHAM HOSPITAL, INC. (THE "HOSPITAL") IS A PRIVATE, NOT-FOR-PROFIT HEALTH CARE ORGANIZATION LOCATED IN SILER CITY, NORTH CAROLINA. THE FACILITY IS A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL HAS A 70-YEAR HISTORY OF PROVIDING QUALITY HEALTH SERVICES. THE HOSPITAL PROVIDES COMPREHENSIVE CARE, INCLUDING EMERGENCY, GENERAL SURGERY, INTENSIVE CARE, LAB, CT, MRI, NUCLEUR MEDICINE, PHARMACY, CARDIOPULMANARY, CARIAC REHABILITATION, PHYSICAL THERAPY, AND DIABETES EDUCATION ON ITS CAMPUS. THE HOSPITAL REACHES BEYOND THE HOSPITAL SETTING TO PROVIDE DIABETES EDUCATION, PHYSICAL THERAPY, AND CARDIAC REHABILITATION IN TEMPORARY LEASED SPACE LOCATED IN SILER CITY NEAR THE MAIN HOSPITAL CAMPUS FOR A PORTION OF THE FISCAL YEAR. THE HOSPITAL CONTINUED ITS FOCUS ON QUALITY MEASURES FROM THE YEAR BEFORE WHICH RESULTED IN SIGNIFICANT IMPROVEMENTS. DURING 2012, CHATHAM HAD 1,695 ACUTE PATIENT DAYS AND AN AVERAGE LENGTH OF STAY OF 3.1 DAYS. THERE WERE 548 DISCHARGES AND 228 INPATIENT AND OUTPATIENT SURGERIES AS WELL AS 380 ENDOSCOPIC PROCEDURES. THERE WERE 14,565 EMERGENCY ROOM VISITS. 23108150 1 0 0 1 0 0 0 0 0 0 1 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 34 0 0 1 1 0 0 0 0 0 0 0 0 0 X 15 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X X DAVID PAUGH 9197994000 PO BOX 649 SILER CITY NC 27344 LAURA CLAPP 1.00 X 0 0 0 BARRY WILKIE 1.00 X 0 0 0 MARY BECK 1.00 59.00 X 0 301484 52226 BARRY HAYES 1.00 X 0 0 0 MEL HURSTON 1.00 59.00 X 0 303991 79587 CHARLES JOHNSON 1.00 X 0 0 0 JOHN LEWIS 1.00 59.00 X 0 528291 66303 TODD PETERSON 1.00 59.00 X 0 114164 40026 GABRIEL SOLTREN 1.00 X 0 0 0 TIM WEINER MD 1.00 X 0 0 0 MARK ZERINGUE MD 1.00 X 0 0 0 JAMES DAVIS MD 1.00 X 0 0 0 DONALD SPENCER MD 1.00 59.00 X 0 151752 9757 ROBERT ENDERS 1.00 59.00 X X 0 188086 28328 ETTA FOUSHEE 1.00 X 0 0 0 WALTER PETTY 1.00 X 0 0 0 PAUL POWELL DDS 1.00 X 0 0 0 DAVID W STRONG 1.00 59.00 X X 0 1312317 267356 TAMMY NEEDHAM 1.00 59.00 X 0 47241 9591 LINDA ELLINGTON 60.00 X 100616 0 0 SHERLYNN POWELL 60.00 X 0 124864 0 DONNA SESSOMS 60.00 X 138553 0 0 CHARLES PULLIAM 60.00 X 103370 0 0 342539 3072190 553174 3 1 1 0 LABCORP 458 S MAIN BURLINGTON NC 27215 LABORATORY 769186 ALLIANCE HEALTH CARE SERVICES 100 BAY VIEW CIRCLE NEWPORT BEACH CA 92660 MEDICAL EQUIPMENT 380407 ARAMARK CTS 10510 TWIN LAKES PARKWAY CHARLOTTE NC 28265 MEDICAL EQUIPMENT 190653 FIRST HEALTH OF THE CAROLINAS 155 MEMORIAL DRIVE PINEHURST NC 28374 148269 4 PATIENT REVENUE 621110 27665819 26500992 1164827 129219 129219 27795038 184396 184396 214202 0 214202 214202 214202 2978 2978 2978 28196614 26630211 1164827 401576 3153127 496784 2656343 5547422 5068020 479402 63112 40366 22746 1480310 866043 614267 573541 366832 206709 2722000 2722000 48685 48685 5709 5709 5703350 5469300 234050 7261 7261 2178584 1475582 703002 1866990 1866990 35714 2041 33673 11282 7761 3521 2371149 2371149 275970 275970 BAD DEBT EXPENSE 4712831 4712831 FOOD 88481 88481 30845518 23108150 7737368 0 2325 2502 3904871 5415437 22815 3519280 2472670 262019 266330 58176 141099 41386189 14342484 28175829 27043705 5259998 5761357 6575827 1618502 47781140 42721602 6562086 2924584 29175611 28353933 699134 2018323 36436831 33296840 X 11321494 9424762 22815 0 11344309 9424762 47781140 42721602 X -2648904 -965598 1694955 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 5709 5709 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: TOTAL NCHA AND AHA DUES. 402081 402081 32943251 8547497 24395754 8040857 5794987 2245870 27043705 INVESTMENTS 508374 F RESTRICTED ASSETS 5252983 F 5761357 X 25178738 -3017876 -3017876 28196614 0 28196614 26132687 0 26132687 4712831 4712831 30845518 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS INCORPORATED AS A NONPROFIT ORGANIZATION UNDER THE LAWS OF THE STATE OF NORTH CAROLINA AND IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PART XI, LINE 2D - OTHER ADJUSTMENTS: CAPITAL CONTRIBUTED FROM SOLE MEMBER 1,694,955. BAD DEBT EXPENSE -4,712,831. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 4,712,831. 1 1 1 X 250.000000000000 0 1 1 1 0 1 1 1092687 1092687 0.04180 3755976 2441915 1314061 0.05030 4848663 2441915 2406748 0.09210 8954 8954 0.00030 8954 8954 0.00030 4857617 2441915 2415702 0.09240 19843 19843 0.00080 19843 19843 0.00080 1 2839661 6471869 7023405 -551536 X 1 1 1 1 CHATHAM HOSPITAL

475 PROGRESS BLVD SILER CITY NC 27344

X X X X CHATHAM HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X 1 0 1 1 250.000000000000 0 1 X X X X X X X 1 1 X X X 1 X 1 X X X X 1 X 0 0 1 CHATHAM HOSPITAL MEDICAL OFFICE BUILDING

163 MEDICAL PARK DRIVE SILER CITY NC 27344

CARDIAC REHABILITATION, DIABETES EDUCATION, PT/OT, AND OTHER ADMIN FUNCTIONS PART I, LINE 3C: CHARITY CARE IS AVAILABLE FOR NORTH CAROLINA RESIDENTS WHO HAVE A HOUSEHOLD INCOME AT OR LESS THAN 250% OF THE FEDERAL POVERTY GUIDELINES FOR THEIR FAMILY SIZE. A COMPLETE APPLICATION WITH SUPPORTING DOCUMENTATION OF INCOME IS PROVIDED FOR A FINAL DETERMINATION TO BE MADE. CHARITY CARE IS A BENEFIT WHERE 100% OF THE PATIENTS BALANCE WILL BE WRITTEN OFF EXCEPT FOR CERTAIN LIMITATIONS SUCH AS ELECTIVE, NON-MEDICALLY NECESSARY SERVICES AND THOSE BALANCES COVERED BY OTHER EXTERNAL FUNDING SOURCES.FPG IS USED FOR CHARITY CARE/FREE CARE. FOR SELF PAY, CHATHAM HOSPITAL PROVIDES A STRAIGHT 35% DISCOUNT ON CHARGES. PART I, LINE 6A: PART OF UNC HEALTH CARE SYSTEM REPORTING PART I, LINE 7: AMOUNTS SHOWN IN PART I, LINE 7, COLUMN C WERE COMPUTED USING THE COST-TO-CHARGE RATIO WORKSHEET (WORKSHEET 2) FROM THE IRS INSTRUCTIONS FOR SCHEDULE H. PART I, L7 COL(F): SPECIFIC PATIENT BALANCES ARE WRITTEN OFF AT THE TIME THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART II: CHATHAM HOSPITAL STRIVES TO IMPROVE EMERGENCY CARE FOR KIDS BY INCREASING MEDICATION SAFETY. ALSO, THE HOSPITAL HAS A DIABETES SELF-MANAGEMENT PROGRAM FOR INDIVIDUALS WITH DIABETES WITHIN THE COMMUNITY. CHATHAM HOSPITAL PARTICIPATES IN NUMEROUS COMMUNITY HEALTH FAIRS, PARTNERS WITH OTHER COMMUNITY LEADERS IN ADDRESSING HEALTH RELATED MATERS, AND PARTICIPATES IN COMMUNITY FUND RAISING EVENTS. PART III, LINE 4: NET PATIENT SERVICE REVENUE IS RECORDED AT ESTABLISHED RATES WHEN SERVICES ARE PROVIDED WITH CONTRACTUAL ADJUSTMENTS, ESTIMATED BAD DEBT EXPENSES, AND SERVICES QUALIFYING AS CHARITY CARE DEDUCTED TO ARRIVE AT NET PATIENT SERVCIE REVENUE. CONTRACTUAL ADJUSTMENTS ARISE UNDER REIMBURSEMENT AGREEMENTS WITH CERTAIN INSURANCE CARRIERS, HEALTH MAINTENANCE ORGANIZATIONS AND PREFERRED PROVIDER ORGANIZATIONS, WHICH PROVIDE FOR PAYMENTS THAT ARE GENERALLY LESS THAN ESTABLISHED BILLING RATES. SPECIFIC PATIENT BALANCES ARE WRITTEN OFF AT THE TIME THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: AS A CRITICAL ACCESS HOSPITAL, THE DIFFERENCE BETWEEN REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COST IS THE AMOUNT DUE FROM THE PATIENTS IN THE FORM OF CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES. THE PATIENT AMOUNTS THAT ARE NOT COLLECTED END UP AS BAD DEBTS WHICH ARE PARTIALLY RECOVERABLE ON FUTURE COST REPORTS. PART III, LINE 9B: .POLICY DOES CONTAIN PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE. CHATHAM HOSPITAL PART V, SECTION B, LINE 20D: SELF PAY GETS A STRAIGHT 35% DISCOUNT. CHARITY CARE IS AVAILABLE AS OUTLINED IN THE FINANCIAL ASSISTANCE POLICY. PART VI, LINE 2: LESS THAN 20% OF OUR COUNTY'S RESIDENTS LIVE IN INCORPORATED TOWNS. THE COUNTY HAS ABOUT 85 RESIDENTS PER SQUARE MILE, WHICH REFLECTS ITS GENERALLY RURAL NATURE. A CRITICAL ACCESS HOSPITAL IS ESSENTIAL FOR A RURAL COMMUNITY SUCH AS THIS.CHATHAM HOSPITAL ADDRESSES THE COMMUNITY'S EMERGENCY HEALTH NEEDS BY PROVIDING AROUND-THE-CLOCK EMERGENCY SERVICES TO MORE THAN 1,000 PATIENTS EACH MONTH. OUR 5,500-SQUARE FOOT EMERGENCY ROOM IS NEWLY RENOVATED AND EQUIPPED WITH THE ADVANCED DIAGNOSTIC AND MONITORING EQUIPMENT REQUIRED TO DELIVER EXCELLENT CARE.CHATHAM HOSPITAL STRIVES TO IMPROVE EMERGENCY CARE FOR KIDS BY INCREASING MEDICATION SAFETY. ALSO, THE HOSPITAL HAS A DIABETES SELF-MANAGEMENT PROGRAM FOR INDIVIDUALS WITH DIABETES WITHIN THE COMMUNITY. PART VI, LINE 3: NOTICES OF PATIENT FINANCIAL PROGRAMS ARE POSTED IN SERVICE AREAS, AND BROCHURES ARE AVAILABLE DESCRIBING THE PROGRAMS AND PHONE NUMBERS FOR QUESTIONS OR TO REQUEST APPLICATIONS. FINANCIAL COUNSELORS ARE LOCATED IN SERVICE AREAS FOR DISCUSSIONS REGARDING FUNDING SOURCES, INCLUDING CHARITY CARE. SELF PAY PATIENT ACCOUNTS ARE AUTOMATICALLY ROUTED TO MEDICAID ASSISTANCE COUNSELORS FOR REVIEW OF POTENTIAL ELIGIBILITY FOR MEDICAID. REGISTRATION COVERS THE CHARITY PROGRAM WITH PATIENTS DURING REGISTRATION AND GIVES CHARITY APPLICATIONS TO THOSE WHO DON'T HAVE INSURANCE OR WHO MEET CERTAIN CRITERIA. REGISTRATION ALSO INFORMS PATIENTS THAT PATIENT FINANCIAL SERVICES IS AVAILABLE TO PATIENTS WHO WISH TO DISCUSS PAYMENT OPTIONS. PART VI, LINE 4: POPULATION INFORMATION: THE OFFICIAL 2010 CENSUS PLACES OUR 2010 POPULATION AT 63,505, AN INCREASE OF 28.74% SINCE 2000. THE STATE AVERAGE GROWTH FOR THIS DECADE WAS 18.5%. LESS THAN 20% OF OUR COUNTY'S RESIDENTS LIVE IN INCORPORATED TOWNS. THE COUNTY HAS ABOUT 85 RESIDENTS PER SQUARE MILE, WHICH REFLECTS ITS GENERALLY RURAL NATURE. ETHNIC/RACIAL DIVERSITY: THE OVERALL, RACIAL/ETHNIC COMPOSITION OF CHATHAM COUNTY IS: 71% WHITE, 13% AFRICAN AMERICAN, 12% HISPANIC, 2% ASIAN AND 2% OTHER.AGE: THE 2009 ESTIMATED MEDIAN AGE FOR CHATHAM COUNTY RESIDENTS IS 42, UP FROM 38.7 IN 2007 AND ABOVE THE STATE AVERAGE. THE GREATEST PERCENTAGE OF OUR POPULATION (54%) IS IN THE RANGE OF 20 TO 60 YEARS OLD, AND 21.9% ARE AGE 60 OR OLDER. INCOME AND POVERTY: THE ESTIMATED MEDIAN HOUSEHOLD INCOME FOR CHATHAM COUNTY IN 2008 WAS $46,574, A SIGNIFICANT DROP FROM $51,794 IN 2007, BUT STILL RANKS US 8TH IN THE STATE PER CAPITA INCOME FOR 2008 WAS $43,894, WHICH RANKS THIRD OUT OF THE 100 COUNTIES. THE PERCENTAGE OF INDIVIDUALS LIVING IN POVERTY IN 2008 WAS ESTIMATED AT 10.3%, LOWER THAN THE STATE AVERAGE OF 14.6%, BUT STILL SIGNIFICANT. THIS POINTS OUT THE CHALLENGES OF A COUNTY WITH RESIDENTS AT EXTREME ENDS OF THE INCOME SPECTRUM. PART VI, LINE 5: CHATHAM HOSPITAL STRIVES TO FURTHER ITS EXEMPT PURPOSES BY PARTNERING IN THE COMMUNITY TO ASSESS HEALTH NEEDS AND TO HELP DEVELOP STRATEGIES TO FULLFUL THOSE NEEDS. CHATHAM HOSPITAL IS WELL ENGAGED IN THE COMMUNITY THROUGH JOINT EFFORTS WITH OTHER ORGANIZATIONS, COMMUNITY OUTREACH THROUGH EDUCATION AND HEALTH FAIRS, DIRECTLY CONTRIBUTING TO FUNDRAISING EFFORTS, WORKING TO QUALIFY PATIENTS FOR EITHER INSURANCE OR CHARITY CARE AND IF NOT, PROVIDING DISCOUNTS TO HEALTH SERVICES. PART VI, LINE 6: CHATHAM HOSPITAL AND UNC HEALTH CARE ARE PARTNERING TO BRING NATIONALLY-RECOGNIZED HEALTH CARE TO CHATHAM COUNTY. OUR PARTNERSHIP MEANS YOU'LL CONTINUE TO HAVE ACCESS TO ADVANCED HEALTH CARE CLOSE TO HOME, WITH THE PERSONAL TOUCH YOU'VE COME TO EXPECT FROM US. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 X X X X X 0 1 0 0 0 1 1 0 0 MARY BECK 0 253690 0 22012 0 25782 0 49233 0 2993 0 353710 0 0 MEL HURSTON 0 238072 0 19449 0 46470 0 71883 0 7704 0 383578 0 0 JOHN LEWIS 0 462833 0 20297 0 45161 0 65129 0 1174 0 594594 0 0 TODD PETERSON 0 47053 0 0 0 67111 0 40026 0 0 0 154190 0 0 DONALD SPENCER MD 0 98187 0 22444 0 31121 0 9366 0 391 0 161509 0 0 ROBERT ENDERS 0 145636 0 0 0 42450 0 28328 0 0 0 216414 0 0 DAVID W STRONG 0 524539 0 226405 0 561373 0 252208 0 15148 0 1579673 0 529812 PART I, LINE 4B DURING THE CALENDAR YEAR 2012, DAVID STRONG PARTICIPATED IN A NON-QUALIFIED SUPPLEMENTAL RETIREMENT PLAN AND RECEIVED DISTRIBUTIONS TOTALING $529,812. HE ALSO EARNED COMPENSATION UNDER THIS PLAN TOTALING $226,442. THE CURRENT YEAR EARNINGS ARE PAYABLE IN THE FUTURE. PART I, LINE 6 EMPLOYEES IN MANAGERIAL ROLES PARTICIPATE IN AN ANNUAL INCENTIVE COMPENSATION PLAN. THE COMPENSATION EARNED UNDER THIS PLAN IS BASED PARTLY ON THE EARNINGS OF THE ORGANIZATION. ADDITIONALLY, THE INCENTIVE COMPENSATION OF THE PRESIDENT AND CFO IS BASED PARTLY ON THE EARNINGS OF THE UNC HEALTH CARE SYSTEM. OTHER PERFORMANCE MEASURES USED TO DETERMINE INCENTIVE COMPENSATION ARE PHYSICIAN SATISFACTION, PATIENT CARE QUALITY OUTCOMES, EFFECTIVE USE OF TECHNOLOGY AND INDIVIDUAL GOALS. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 657905ES0 2007-02-08 30540000 FHA INSURED MORTGAGE REVENUE BONDS 0 0 0 A 30540000 639326 1370283 29976186 2008 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 SEE RESPONSE TO QUESTION 7A. FORM 990, PART VI, SECTION A, LINE 7A IN ADDITION TO SUCH POWERS AND RIGHTS AS ARE VESTED IN IT BY LAW, THE AMENDED AND RESTATED ARTICLES OF INCORPORATION OF THE CORPORATION OR THE AMENDED AND RESTATED BYLAWS, THE MEMBER ("UNCHCS") SHALL HAVE THE FOLLOWING POWERS: (A) THE POWER TO APPOINT THE CHAIRMAN OF THE BOARD, VICE CHAIRMAN, PRESIDENT, EXECUTIVE VICE PRESIDENTS, SECRETARY/TREASURER AND OTHER CORPORATE OFFICERS OF THE CORPORATION; (B) THE POWER TO APPOINT INDIVIDUAL MEMBERS OF THE CORPORATION'S BOARD OF TRUSTEES; (C) THE POWER TO ESTABLISH AND MAINTAIN QUALITY, SERVICE DELIVERY, AND FINANCIAL STANDARDS TO BE OBSERVED BY ALL MEMBERS OF UNCHCS, INCLUDING THE CORPORATION; (D) THE POWER TO ESTABLISH A SCHEDULE OF COST-BASED ASSESSMENTS PAYABLE BY PROVIDER COMPONENTS OF UNCHCS FOR THE SUPPORT OF THAT PORTION OF ITS OPERATING BUDGET ATTRIBUTABLE TO UNCHCS-WIDE ADMINISTRATION AND INITIATIVES AND REFLECTING OPERATING ENTITY PERFORMANCE; (E) THE POWER TO NEGOTIATE, DEVELOP, AND APPROVE ALL MANAGED CARE PRODUCTS AND CONTRACTS FOR THE CORPORATION; (F) THE POWER TO APPROVE (I) THE CORPORATION'S NAME, (II) CAPITAL AND OPERATING BUDGETS OF THE CORPORATION, AND (III) NON-BUDGETED MATERIAL EXPENDITURES OF THE CORPORATION (AS "MATERIAL" IS ESTABLISHED BY THE MEMBER FROM TIME TO TIME), PROVIDED THAT ONLY THE BOARD OF TRUSTEES SHALL HAVE THE AUTHORITY TO INITIATE A CHANGE IN THE NAME OF THE CORPORATION OF THE HOSPITAL, WHICH SHALL BE SUBJECT TO FINAL APPROVAL BY UNCHCS; AND (G) OTHER POWERS MUTUALLY AGREED TO BY UNCHCS AND THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B SEE RESPONSE TO QUESTION 7A. FORM 990, PART VI, SECTION B, LINE 11 FORM 990, PART VI, SECTION A,LINE 10: THE FORM 990 WAS REVIEWED PRIOR TO FILING BY THE PRESIDENT AND CFO OF THE HOSPITAL. IN ADDITION, IT WAS MADE AVAILABLE TO EVERY MEMBER OF THE GOVERNING BODY BEFORE IT WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST STATEMENTS ARE COMPLETED BY THE BOARD MEMBERS ANNUALLY TO BE REVIEWED BY THE HOSPITAL PRESIDENT. THE CHATHAM HOSPITAL CONFLICT OF INTEREST POLICY OUTLINES THE PROCESS TO BE FOLLOWED IN DETERMINING THE EXISTENCE OF A POTENTIAL CONFLICT, AND HOW TO ADDRESS THE SITUATION WHEN DECISIONS FACE A FHA INSURED MORTGAGE REVENUE BONDS. FORM 990, PART VI, SECTION B, LINE 15 EFFECTIVE AUGUST 1, 2006, THE HOSPITAL ENETERED INTO A FIVE-YEAR CONTRACT WITH UNCH TO PROVIDE A CEO AND A CFO TO MANAGE THE DAY-TO-DAY OPERATIONS OF THE HOSPITAL. THE PRESIDENT OF CHATHAM HOSPITAL REPORTS MONTHLY TO THE PRESIDENT OF UNC HOSPITALS, DISCUSSING SURVEYS OF COMPENSATION DATA AND PLANNED RANGES OF SALARY OFFERS FOR EMPLOYEES OF CHATHAM. TARGET LEVELS ARE BASED ON LEVEL OF EDUCATION AND EXPERIENCE. WITH INPUT FROM THE MANAGEMENT OF UNC HOSPITALS, THE PRESIDENT OF CHATHAM HOSPITAL MAKES THE FINAL DECISION ON SALARIES, WITH THE EXCEPTION OF HIS/HER OWN, WHICH IS SET BY THE PRESIDENT OF UNCH WITH INPUT FROM THE UNC HOSPITALS MANAGEMENT TEAM. FORM 990, PART VI, SECTION C, LINE 19 PHOTOCOPIES OF THE FORM 1023 AND RECENT COPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT COPIES OF FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTED FROM SOLE MEMBER 1,694,955. FORM 990, PART XII, LINE 2C: NO CHANGE IN METHOD FROM PRIOR YEAR. UNIVERSITY OF NORTH CAROLINA HEALTHCARE SYSTEM 211 FRIDAY CENTER DRIVE CHAPEL HILL NC 27517 562206970 HEALTHCARE NC 501(C)(3) 0 REX HOSPITAL INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509260 HEALTHCARE NC 501(C)(3) 0 UNIVERSITY OF NORTH CAROLINA HOSPITALS 101 MANNING DRIVE CHAPEL HILL NC 27514 561118388 HEALTHCARE NC 501(C)(3) 0 REX HEALTHCARE INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561509129 HEALTHCARE NC 501(C)(3) 0 REX HEALTHCARE FOUNDATION INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 566052117 HEALTHCARE NC 501(C)(3) 0 REX HOME SERVICES INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 561636242 HEALTHCARE NC 501(C)(3) 0 TRIANGLE PHYSICIAN NETWORK 211 FRIDAY CENTER DRIVE CHAPEL HILL NC 27517 271081647 HEALTHCARE NC 501(C)(3) 0 UNC DEPARTMENT OF FAMILY MEDICINE 590 MANNING DRIVE CHAPEL HILL NC 27599 566001393 HEALTHCARE NC 501(C)(3) 0 REX ENTERPRISES COMPANY INC 4420 LAKE BOONE TRAIL RALEIGH NC 27607 HOLDING COMPANY NC C 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 UNIVERSITY OF NORTH CAROLINA HOSPITALS M 1473046 FMV CALCULATION UNIVERSITY OF NORTH CAROLINA HOSPITALS M 2721954 FMV CALCULATION UNIVERSITY OF NORTH CAROLINA HOSPITALS Q 677735 CASH UNIVERSITY OF NORTH CAROLINA HEALTH CARE SERVICES C 2000000 CASH UNIVERSITY OF NORTH CAROLINA HEALTH CARE SERVICES P 338788 CASH