AMERY REGIONAL MEDICAL CENTER FOUNDATION INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- AMERY REGIONAL MEDICAL CENTER FOUNDATION INC (EIN 39-1726539)
- Tax period
- 2012-05-01 to 2013-04-30
- Filed
- 2014-03-17
- IRS object ID
- 201420769349300217
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule G
- Schedule I
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2014-03-17T11:51:29-05:00 | Timestamp |
| Tax Period End Date | 2013-04-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 7601 FRANCE AVENUE SOUTH SUITE 400 | AddressLine1 |
| City | MINNEAPOLIS | City |
| State | MN | State |
| ZIP Code | 55435 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-05-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391726539 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER FOUNDATION INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | AMER | NameControl |
| Phone | 7152688000 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET EAST | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | DANIEL LIEN | Name |
| Title | CHAIRMAN | Title |
| Phone | 7152688000 | Phone |
| Date Signed | 2014-03-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TIM A RITTER CPA | Name |
| PTIN | P00732856 | PTIN |
| Phone | 9525483400 | Phone |
| Date Prepared | 2014-03-14 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | DANIEL LIEN | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET EAST | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 51462 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.AMERYMEDICALCENTER.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1991 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | THE FOUNDATION EXISTS TO PROMOTE THE HEALTH AND WELLNESS OF THE PEOPLE IN THE COMMUNITIES SERVED BY AMERY REGIONAL MEDICAL CENTER (ARMC) AND BY PARTICIPATING IN VARIOUS FUNDRAISING ACTIVITIES. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 12 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 10 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 40 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 37814 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 41172 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 0 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 361 | InvestmentIncomePriorYear |
| Investment Income Current Year | 272 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 1779 | OtherRevenuePriorYear |
| Other Revenue Current Year | 2534 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 39954 | TotalRevenuePriorYear |
| Total Revenue Current Year | 43978 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 30677 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 10902 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 0 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 0 | OtherExpensePriorYear |
| Other Expenses Current Year | 0 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 30677 | TotalExpensesPriorYear |
| Total Expenses Current Year | 10902 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 9277 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 33076 | RevenuesLessExpensesCY |
| Total Assets BOY | 139941 | TotalAssetsBOY |
| Total Assets EOY | 173017 | TotalAssetsEOY |
| Total Liabilities BOY | 0 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 0 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 139941 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 173017 | NetAssetsOrFundBalancesEOY |
| Mission Description | NONE | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 10902 | Expense |
| Grants | 10902 | Grants |
| Description | THE FOUNDATION PROVIDED FUNDS TO AMERY REGIONAL MEDICAL CENTER FOR CONTINUING EDUCATION FOR THE BEHAVIORAL HEALTH STAFF AT AMERY REGIONAL MEDICAL CENTER, SCHOLARSHIPS FOR AREA HIGH SCHOOL STUDENTS, AND FOR A CONTRIBUTION TO THE WESTERN WISCONSIN CANCER CENTER FUND RAISING CAMPAIGN. FUNDS WERE ALSO PROVIDED TO COVER SOME EXPENSES ASSOCIATED WITH DIABETES AWARENESS AND EDUCATION. | Description |
| Total Program Service Expense | 10902 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 0 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 1 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 12 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 10 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 0 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SCOTT EDIN | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7152688000 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET EAST | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (17 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer |
|---|---|---|---|---|---|---|---|
| CYLAN COE MD | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 1200 | 0 | |
| DAN DRAXLER | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| HEIDI ERSPAMER | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 1200 | 0 | |
| BETH HEINZ | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| KATHRYN ISAKSON | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 26832 | 597 | |
| NANCY MAGNINE PAC | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| RANAE NYGAARD | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 105904 | 9461 | |
| MARYANN SCOGLIO | |||||||
| DIRECTOR (THRU DECEMBER) | 1.00 | 1.00 | X | 0 | 1200 | 0 | |
| ANN SEAGREN MD | |||||||
| DIRECTOR | 1.00 | 1.00 | X | 0 | 0 | 0 | |
| JOHN C WHITE | |||||||
| DIRECTOR (THRU DECEMBER) | 1.00 | 1.00 | X | 0 | 1200 | 0 | |
| DANIEL LIEN | |||||||
| CHAIR | 1.00 | 1.00 | X | 0 | 1200 | 0 | |
| JAMES LEADHOLM | |||||||
| VICE CHAIR | 1.00 | 1.00 | X | 0 | 1200 | 0 | X |
| MICHAEL JENSON | |||||||
| TREASURER (THRU OCTOBER) | 1.00 | 1.00 | X | 0 | 1200 | 0 | X |
| ROSS BULLARD | |||||||
| TREASURER | 1.00 | 1.00 | X | 0 | 0 | 0 | X |
| JOAN BYRNES | |||||||
| SECRETARY | 1.00 | 1.00 | X | 0 | 1200 | 0 | X |
| MIKE KARUSCHAK | |||||||
| CHIEF EXECUTIVE OFFICER | 1.00 | 40.00 | 0 | 255492 | 74460 | X | |
| SCOTT EDIN | |||||||
| CHIEF FINANCIAL OFFICER | 1.00 | 40.00 | 0 | 170235 | 43540 | X | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 568063 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 128058 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Fundraising Events | 17709 | FundraisingEvents |
| All Other Contributions | 23463 | AllOtherContributions |
| Total Contributions | 41172 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 272 | TotalRevenueColumn |
| Exclusion | $272 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 10018 | GrossIncomeFundraisingEvents |
| Cntrbtns Rprtd Fundraising Events | 17709 | CntrbtnsRprtdFundraisingEvents |
| Fundraising Direct Expenses | 7484 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 2534 | TotalRevenueColumn |
| Exclusion | $2,534 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 43978 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $2,806 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 10902 | Total |
| Program Services | 10902 | ProgramServices |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 10902 | Total |
| Program Services | 10902 | ProgramServices |
| Management And General | 0 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 139941 | BOY |
| EOY | 173017 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 139941 | BOY |
| EOY | 173017 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 139941 | BOY |
| EOY | 173017 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 139941 | BOY |
| EOY | 173017 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 139941 | BOY |
| EOY | 173017 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | 33076 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org170b1 Avi | X | PubliclySupportedOrg170b1Avi |
Gifts Grants Contrib Received170 GiftsGrantsContribReceived170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 12201 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 23675 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 10151 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 37814 | CurrentTaxYearMinus1Year |
| Current Tax Year | 41172 | CurrentTaxYear |
| Total | 125013 | Total |
Total170 Total170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 12201 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 23675 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 10151 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 37814 | CurrentTaxYearMinus1Year |
| Current Tax Year | 41172 | CurrentTaxYear |
| Total | 125013 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Amounts Subst Contributors Total | 22193 | AmountsSubstContributorsTotal |
| Public Support Total170 | 102820 | PublicSupportTotal170 |
Gross Investment Income170 GrossInvestmentIncome170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 379 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 948 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 776 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 361 | CurrentTaxYearMinus1Year |
| Current Tax Year | 272 | CurrentTaxYear |
| Total | 2736 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Support | 127749 | TotalSupport |
| Gross Receipts From Admissions Etc | 76048 | GrossReceiptsFromAdmissionsEtc |
| Public Support Pertcentage170 | 0.80490 | PublicSupportPertcentage170 |
| Public Support Pertcent Prior Year | 0.89710 | PublicSupportPertcentPriorYear |
| Thirty Three Percnt Tests CY170 | X | ThirtyThreePercntTestsCY170 |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 33076 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 33076 | RevenueSubtotal |
| Other Revenues Not Included | 10902 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 10902 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 43978 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 0 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 0 | ExpensesSubtotal |
| Other Expenses Not Included | 10902 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 10902 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 10902 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X, LINE 2: | IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS 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 TAX AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE HOSPITAL HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2013 AND 2012. FEDERAL RETURNS FOR TAX YEARS 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | REVENUE INCLUDED NET OF EXPENSES ON FINANCIAL STATEMENTS 18,386. FUNDRAISING EVENT EXPENSE -7,484. | |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | AMERY REGIONAL MEDICAL CENTER GRANT AND ASSISTANCE 10,902. | |
| THE ORGANIZATION'S CONSOLIDATED FINANCIAL STATEMENTS ONLY PROVIDE THE NET INCOME OF THE FOUNDATION'S ACTIVITY. THE 990 REPRESENTS THE REVENUES AND EXPENSES IN THEIR GROSS AMOUNTS. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | GOLF TOURNAMENT | NameOfEvent1 |
| Gross Receipts Event1 | 27727 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 17709 | CharitableContributionsEvent1 |
| Gross Revenue Event1 | 10018 | GrossRevenueEvent1 |
| Non Cash Prizes Event1 | 1669 | NonCashPrizesEvent1 |
| Rent Facility Costs Event1 | 3954 | RentFacilityCostsEvent1 |
| Food And Beverage Event1 | 1074 | FoodAndBeverageEvent1 |
| Other Direct Expenses Event1 | 787 | OtherDirectExpensesEvent1 |
| Gross Receipts Total | 27727 | GrossReceiptsTotal |
| Charitable Contributions Total | 17709 | CharitableContributionsTotal |
| Gross Revenue Total Events | 10018 | GrossRevenueTotalEvents |
| Non Cash Prizes Total Events | 1669 | NonCashPrizesTotalEvents |
| Rent Facility Costs Total Events | 3954 | RentFacilityCostsTotalEvents |
| Food And Beverage Total Events | 1074 | FoodAndBeverageTotalEvents |
| Other Direct Expenses Total Events | 787 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 7484 | DirectExpenseSummaryEvents |
| Net Income Summary | 2534 | NetIncomeSummary |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 1 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET EAST | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 390908320 | EINOfRecipient |
| IRC Section | 501(C)(3) | IRCSection |
| Amount Of Cash Grant | 10902 | AmountOfCashGrant |
| Purpose Of Grant | PROVIDE SUPPORT THE AMERY REGIONAL MEDICAL CENTER OPERATIONS. | PurposeOfGrant |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Nbr Of501 C3 And Govt Grants | 1 | TotalNbrOf501C3AndGovtGrants |
| Total Nbr Of Other Organizations | 0 | TotalNbrOfOtherOrganizations |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | PROCEDURE FOR MONITORING GRANTS IN THE U.S.: | Identifier |
| Return Reference | PART I, LINE 2: | ReturnReference |
| Explanation | SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MONITORS THE USE OF GRANT FUNDS THROUGH ITS ONGOING RELATIONSHIP WITH AMERY REGIONAL MEDICAL CENTER, INC. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 1 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (2 entries)
| TitleTitle | Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MIKE KARUSCHAK | ||||||||||||||
| CHIEF EXECUTIVE OFFICER | 0 | 255492 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 74460 | 0 | 329952 | 0 | 0 |
| SCOTT EDIN | ||||||||||||||
| CHIEF FINANCIAL OFFICER | 0 | 170235 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 43540 | 0 | 213775 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| PART I, LINE 4A | RANAE NYGAARD RECEIVED RETIREMENT PAY OF $40,698 IN FISCAL YEAR 2013 FOR HER EMPLOYEMENT WITH AMERY REGIONAL MEDICAL CENTER. | |
| PART III | MICHAEL KARUSCHAK AND SCOTT EDIN ARE EMPLOYEES OF THE MANAGEMENT COMPANY QUORUM HEALTH RESOURCE. THEIR COMPENSATION INCLUDES SALARY AND BENEFITS PAID BY QUORUM HEALTH RESOURCE AND REIMBURSED BY AMERY REGIONAL MEDICAL CENTER. | SUPPLEMENTAL INFORMATION |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (5 entries)
| Return ReferenceReturnReference | ExplanationExplanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION HAS 5 CLASSES OF MEMBERSHIP; CHARTER MEMBERS, LIFETIME MEMBERS, REGULAR MEMBERS, HONORARY MEMBERS, AND NON-VOTING MEMBERS. |
| FORM 990, PART VI, SECTION A, LINE 7A | CHARTER MEMBERS, LIFETIME MEMBERS, REGULAR MEMBERS, AND HONORARY MEMBERS HAVE RIGHTS TO ELECT THE DIRECTORS OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 11 | FORM 990 IS REVIEWED BY THE ORGANIZATION'S SENIOR ACCOUNTANT, THEN THE CEO AND CFO. |
| FORM 990, PART VI, SECTION B, LINE 12C | AS PART OF THE PERFORMANCE REVIEW PROCESS, PERSONS ARE ASKED TO REVIEW THE CONFLICT OF INTEREST POLICY AND THEN COMPLETE A FORM AND SIGN. THE HUMAN RESOURCE DEPARTMENT OF ARMC ENSURES THE FORM IS RETURNED BY ALL STAFF AND REVIEWS THE FORMS. IF A POTENTIAL CONFLICT IS IDENTIFIED, THE COMPLIANCE OFFICER FOLLOWS UP. THE GOVERNING BOARD COMPLETE AND SIGN THE CONFLICT OF INTEREST FORM YEARLY. THE FORMS ARE REVIEWED BY THE BOARD SECRETARY AND IF A POTENTIAL CONFLICT IS IDENTIFIED, THE COMPLIANCE OFFICER FOLLOWS UP. BOARD MEMBERS WITH CONFLICTS ARE RESTRICTED FROM VOTING ON SUCH MATTERS. |
| 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. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET EAST | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390908320 | EIN |
| Primary Activities | HEALTHCARE SERVICES | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | LINE 3 | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Org | 1 | ControlledOrg |
Form990 Schedule R Part III Form990ScheduleRPartIII
Name Of Related Org NameOfRelatedOrg
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER PHARMACY LLC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 265 GRIFFIN STREET E | AddressLine1 |
| City | AMERY | City |
| State | WI | State |
| ZIP Code | 54001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390908320 | EIN |
| Primary Activity | PHARMACEUTICAL | PrimaryActivity |
| Legal Domicile State | MN | LegalDomicileState |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AMERY REGIONAL MEDICAL CENTER | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Share Of Total Income | -25795 | ShareOfTotalIncome |
| Share Of EOY Assets | 94983 | ShareOfEOYAssets |
| Disproportionate Allocations | 0 | DisproportionateAllocations |
| General Or Managing Partner | 1 | GeneralOrManagingPartner |
| Percentage Ownership | 0.50000 | PercentageOwnership |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 1 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
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