2014-03-17T13:54:45-05:00 2013-09-30 411765929 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2012-10-01 391823757 Tomah Memorial Hospital Foundation TOMA 6083722181 321 Butts Avenue Tomah WI 54660 Ray Habelman Jr 6083722181 2014-03-18 1 Kim Hunwardsen CPA P00484560 9529446166 2014-03-18 2012 2015-11-30 17:44:51Z Ray Habelman Jr 321 Butts Avenue Tomah WI 54660 42337 0 X www.tomahhospital.org X 1996 WI Support of Tomah Memorial Hospital and surrounding community. 9 9 0 9 0 0 0 29719 0 0 0 4679 0 1527 0 35925 0 15400 0 0 0 0 0 0 0 0 254 0 15654 0 20271 460545 510286 0 5082 460545 505204 The mission of Tomah Memorial Hospital Foundation is to support the community of Tomah and the healthcare providers that serve its residents. 0 0 15400 15400 Tomah Memorial Hospital Foundation's focus of support continues to center on community-based wellness, facility upgrades, and the development of programs that benefit the local hospital and surrounding communities. During its 2013 fiscal year, the Foundation provided support to various community and healthcare organizations, including youth leadership programs, a local food pantry, and a free healthcare clinic. Additionally, the Foundation granted scholarships to several area students that are pursuing careers in the healthcare field. 15400 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 WI X Joseph Zeps 6083740286 321 Butts Avenue Tomah WI 54660 X Ray Habelman Jr 1.00 X X 0 0 0 Peter Reichardt 1.00 X X 0 0 0 Sandra Humphrey 1.00 X X 0 0 0 Mike Mayhew 1.00 X X 0 0 0 Laura Damrow 1.00 X 0 0 0 Brian Eirschele 1.00 X 0 0 0 Jennifer Parker 1.00 X 0 0 0 Therese Conway 1.00 X 0 0 0 Lorinda Lane 1.00 X 0 0 0 Jane Donaldson 1.00 X 0 0 0 Kate Schanhofer 1.00 X 0 0 0 Eric Prise 5.00 X 0 0 0 0 0 0 0 0 0 0 0 18091 11628 29719 4679 4679 6954 18091 6412 542 542 985 0 985 985 35925 0 0 6206 10900 10900 4500 4500 254 254 15654 15400 254 0 460545 510286 460545 510286 0 5082 0 5082 X 460545 505204 460545 505204 460545 510286 20271 24388 0 X 0 0 0 X 29496 24807 23717 27819 29719 135558 29496 24807 23717 27819 29719 135558 135558 10690 7854 6517 8089 4679 37829 173387 26023 0.78180 0.74300 X 0 Due to scholarships 4500 Due to Tomah Memorial Hospital 582 5082 Golf outing 25045 18091 6954 2524 3870 18 25045 18091 6954 2524 3870 18 6412 542 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Foundation Board reviews all potential grants to ensure funds are given only to reputable local community, civic, or healthcare organizations whose missions are consistent with that of the Foundation. The activities of these organizations are informally monitored on an ongoing basis to ensure the funds were used in a manner consistent with the Foundation's intent. Regarding scholarships, students are required to provide proof of enrollment and grade point average to be eligible for a scholarship. Form 990, Part VI, Section A, line 8b The Organization does not have committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The 990 is provided to the board members before it is filed. The CFO of Tomah Memorial Hospital reviews the Form 990. Form 990, Part VI, Section B, line 12 The Foundation does not have a separate conflict of interest policy from the Hospital. The Hospital's policy would be deferred to should any potential conflicts arise. The members of the Foundation board have not signed an annual conflict of interest statement in the past, as given the nature of the Foundation's activities, it has not been deemed necessary. If the Board determined a conflict existed, the person involved would abstain from voting on any matter related to the conflict. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy and financial statements are available to the public upon request.