2014-03-17T11:51:29-05:00 2013-04-30 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2012-05-01 391726539 AMERY REGIONAL MEDICAL CENTER FOUNDATION INC AMER 7152688000 265 GRIFFIN STREET EAST AMERY WI 54001 DANIEL LIEN 7152688000 2014-03-14 1 TIM A RITTER CPA P00732856 9525483400 2014-03-14 2012 2016-02-25 16:41:14Z DANIEL LIEN 265 GRIFFIN STREET EAST AMERY WI 54001 51462 0 X WWW.AMERYMEDICALCENTER.ORG X 1991 WI 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. 12 10 0 40 0 0 37814 41172 0 0 361 272 1779 2534 39954 43978 30677 10902 0 0 0 0 0 0 0 0 0 30677 10902 9277 33076 139941 173017 0 0 139941 173017 NONE 0 0 10902 10902 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. 10902 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 10 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 X SCOTT EDIN 7152688000 265 GRIFFIN STREET EAST AMERY WI 54001 CYLAN COE MD 1.00 1.00 X 0 1200 0 DAN DRAXLER 1.00 1.00 X 0 0 0 HEIDI ERSPAMER 1.00 1.00 X 0 1200 0 BETH HEINZ 1.00 1.00 X 0 0 0 KATHRYN ISAKSON 1.00 1.00 X 0 26832 597 NANCY MAGNINE PAC 1.00 1.00 X 0 0 0 RANAE NYGAARD 1.00 1.00 X 0 105904 9461 MARYANN SCOGLIO 1.00 1.00 X 0 1200 0 ANN SEAGREN MD 1.00 1.00 X 0 0 0 JOHN C WHITE 1.00 1.00 X 0 1200 0 DANIEL LIEN 1.00 1.00 X 0 1200 0 JAMES LEADHOLM 1.00 1.00 X X 0 1200 0 MICHAEL JENSON 1.00 1.00 X X 0 1200 0 ROSS BULLARD 1.00 1.00 X X 0 0 0 JOAN BYRNES 1.00 1.00 X X 0 1200 0 MIKE KARUSCHAK 1.00 40.00 X 0 255492 74460 SCOTT EDIN 1.00 40.00 X 0 170235 43540 0 568063 128058 0 0 1 0 0 17709 23463 41172 272 272 10018 17709 7484 2534 2534 43978 0 0 2806 10902 10902 10902 10902 0 0 139941 173017 139941 173017 0 0 X 139941 173017 139941 173017 139941 173017 33076 0 X 0 1 X 1 0 X 12201 23675 10151 37814 41172 125013 12201 23675 10151 37814 41172 125013 22193 102820 379 948 776 361 272 2736 127749 76048 0.80490 0.89710 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 33076 0 33076 10902 10902 43978 0 0 0 10902 10902 10902 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. GOLF TOURNAMENT 27727 17709 10018 1669 3954 1074 787 27727 17709 10018 1669 3954 1074 787 7484 2534 1 AMERY REGIONAL MEDICAL CENTER INC 265 GRIFFIN STREET EAST AMERY WI 54001 390908320 501(C)(3) 10902 PROVIDE SUPPORT THE AMERY REGIONAL MEDICAL CENTER OPERATIONS. 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MONITORS THE USE OF GRANT FUNDS THROUGH ITS ONGOING RELATIONSHIP WITH AMERY REGIONAL MEDICAL CENTER, INC. 1 0 0 0 0 0 0 0 0 MIKE KARUSCHAK 0 255492 0 0 0 0 0 0 0 74460 0 329952 0 0 SCOTT EDIN 0 170235 0 0 0 0 0 0 0 43540 0 213775 0 0 PART I, LINE 4A RANAE NYGAARD RECEIVED RETIREMENT PAY OF $40,698 IN FISCAL YEAR 2013 FOR HER EMPLOYEMENT WITH AMERY REGIONAL MEDICAL CENTER. SUPPLEMENTAL INFORMATION 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. 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. AMERY REGIONAL MEDICAL CENTER INC 265 GRIFFIN STREET EAST AMERY WI 54001 390908320 HEALTHCARE SERVICES WI 501(C)(3) LINE 3 AMERY REGIONAL MEDICAL CENTER FOUNDATION 1 AMERY REGIONAL MEDICAL CENTER PHARMACY LLC 265 GRIFFIN STREET E AMERY WI 54001 390908320 PHARMACEUTICAL MN AMERY REGIONAL MEDICAL CENTER -25795 94983 0 1 0.50000 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0