NORTH COUNTRY HEALTH SYSTEMS INC: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- NORTH COUNTRY HEALTH SYSTEMS INC (EIN 22-2566964)
- Tax period
- 2012-10-01 to 2013-09-30
- Filed
- 2014-08-14
- IRS object ID
- 201422269349300047
- Schema version
- 2012v2.3
- 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 | 2014-08-14T10:11:55-05:00 | Timestamp |
| Tax Period End Date | 2013-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BKD LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 910 E ST LOUIS 200/PO BOX 1190 | AddressLine1 |
| City | SPRINGFIELD | City |
| State | MO | State |
| ZIP Code | 658062523 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 222566964 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NORTH COUNTRY HEALTH SYSTEMS INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| In Care Of Name | % ANDRE BISSONNETTE | InCareOfName |
| Name Control | NORT | NameControl |
| Phone | 8023343210 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| Address Line2 | Suite | AddressLine2 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | ANDRE BISSONNETTE | Name |
| Title | VP OF FINANCE | Title |
| Phone | 8023343210 | Phone |
| Date Signed | 2014-07-11 | DateSigned |
| Authorize Third Party | true | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Brian D Todd | Name |
| Phone | 4178658701 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | ANDRE BISSONNETTE | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 215877 | GrossReceipts |
| Group Return For Affiliates | false | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.NCHSI.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1984 | YearFormation |
| State Legal Domicile | VT | StateLegalDomicile |
| Activity Or Mission Description | TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 15 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 11 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 15 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 196325 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 196214 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 0 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 381 | InvestmentIncomePriorYear |
| Investment Income Current Year | 369 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -15682 | OtherRevenuePriorYear |
| Other Revenue Current Year | -11007 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 181024 | TotalRevenuePriorYear |
| Total Revenue Current Year | 185576 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 55563 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 37457 | 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 | 10539 | OtherExpensePriorYear |
| Other Expenses Current Year | 25468 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 66102 | TotalExpensesPriorYear |
| Total Expenses Current Year | 62925 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 114922 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 122651 | RevenuesLessExpensesCY |
| Total Assets BOY | 496486 | TotalAssetsBOY |
| Total Assets EOY | 619137 | TotalAssetsEOY |
| Total Liabilities BOY | 0 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 0 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 496486 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 619137 | NetAssetsOrFundBalancesEOY |
| Mission Description | TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. | MissionDescription |
| Significant New Program Services | false | SignificantNewProgramServices |
| Significant Change | false | SignificantChange |
| Expense | 47923 | Expense |
| Grants | 37457 | Grants |
| Revenue | 0 | Revenue |
| Description | TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. | Description |
| Total Program Service Expense | 47923 | TotalProgramServiceExpense |
| Described In501 C3 | true | DescribedIn501C3 |
| Schedule B Required | true | ScheduleBRequired |
| Political Activities | false | PoliticalActivities |
| Lobbying Activities | false | LobbyingActivities |
| Subject To Proxy Tax | false | SubjectToProxyTax |
| Donor Advised Funds | false | DonorAdvisedFunds |
| Conservation Easements | false | ConservationEasements |
| Collections Of Art | false | CollectionsOfArt |
| Credit Counseling | false | CreditCounseling |
| Term Or Permanent Endowments | false | TermOrPermanentEndowments |
| Report Land Bldg Equip | false | ReportLandBldgEquip |
| Report Invest Oth Securities | false | ReportInvestOthSecurities |
| Report Prog Rel Invest | false | ReportProgRelInvest |
| Report Other Assets | false | ReportOtherAssets |
| Report Other Liabilities | false | ReportOtherLiabilities |
| Report Fin48 Footnote | false | ReportFin48Footnote |
| Independent Audit Financial Stmt | false | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | true | ConsolidatedAuditFinancialStmt |
| School | false | School |
| Foreign Office | false | ForeignOffice |
| Foreign Activities | false | ForeignActivities |
| More Than5000 K To Organizations | false | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividuals |
| Professional Fundraising | false | ProfessionalFundraising |
| Fundraising Activities | true | FundraisingActivities |
| Gaming | false | Gaming |
| Hospital | false | Hospital |
| Grants To Organizations | false | GrantsToOrganizations |
| Grants To Individuals | true | GrantsToIndividuals |
| Schedule J Required | true | ScheduleJRequired |
| Tax Exempt Bonds | false | TaxExemptBonds |
| Excess Benefit Transaction | false | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | false | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | false | LoanToOfficerOrDQP |
| Grant To Related Person | false | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | false | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | false | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | false | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | false | DeductibleNonCashContributions |
| Deductible Contributions Of Art | false | DeductibleContributionsOfArt |
| Terminated | false | Terminated |
| Partial Liquidation | false | PartialLiquidation |
| Disregarded Entity | false | DisregardedEntity |
| Related Entity | true | RelatedEntity |
| Related Org Controlled Entity | true | RelatedOrgControlledEntity |
| Transaction Related Entity | true | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | false | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | false | ActivitiesConductedPartnership |
| Schedule O Required | true | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | true | ComplianceWithBackupWitholding |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | false | UnrelatedBusinessIncome |
| Foreign Financial Account | false | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTrans |
| Taxable Party Notification | false | TaxablePartyNotification |
| Non Deductible Contributions | false | NonDeductibleContributions |
| Quid Pro Quo Contributions | true | QuidProQuoContributions |
| Quid Pro Quo Disclosure | true | QuidProQuoDisclosure |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | false | FundsToPayPremiums |
| Premiums Paid | false | PremiumsPaid |
| Indoor Tanning Services | false | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 15 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 11 | NumberIndependentVotingMembers |
| Family Or Business Relationship | false | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | false | DelegationOfManagementDuties |
| Changes To Organizing Docs | false | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuse |
| Members Or Stockholders | true | MembersOrStockholders |
| Election Of Board Members | true | ElectionOfBoardMembers |
| Decisions Subject To Approval | true | DecisionsSubjectToApproval |
| Minutes Of Governing Body | true | MinutesOfGoverningBody |
| Minutes Of Committees | true | MinutesOfCommittees |
| Officer Mailing Address | false | OfficerMailingAddress |
| Local Chapters | false | LocalChapters |
| Form990 Provided To Governing Body | true | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | true | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | true | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | true | RegularMonitoringEnforcement |
| Whistleblower Policy | true | WhistleblowerPolicy |
| Document Retention Policy | true | DocumentRetentionPolicy |
| Compensation Process CEO | false | CompensationProcessCEO |
| Compensation Process Other | false | CompensationProcessOther |
| Investment In Joint Venture | false | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | ANDRE BISSONNETTE | NamePerson |
| Telephone Number | 8023347331 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (18 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|---|
| CLAUDIO D FORT | |||||||
| CEO | 1.0 | 41.0 | X | X | 0 | 267789 | 56865 |
| BOB WILSON | |||||||
| TRUSTEE | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| SCOTT PERRY | |||||||
| TRUSTEE | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| CHRISTOPHER RICKMAN MD | |||||||
| PHYSICIAN/TRUSTEE | 1.0 | 41.0 | X | 0 | 236042 | 38418 | |
| KATHRYN AUSTIN | |||||||
| CHAIR | 1.0 | 11.0 | X | X | 0 | 0 | 0 |
| MELISSA PETTERSSON | |||||||
| SECRETARY/CLERK | 1.0 | 6.0 | X | X | 0 | 0 | 0 |
| RICHARD BARAW | |||||||
| TRUSTEE | 1.0 | 10.0 | X | 0 | 0 | 0 | |
| ALAN WING | |||||||
| VICE CHAIR - BOARD | 1.0 | 6.0 | X | X | 0 | 0 | 0 |
| BILL STENGER | |||||||
| TRUSTEE | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| JEANE KADMIRI | |||||||
| TRUSTEE | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| DAVE LAFORCE | |||||||
| VICE CHAIR FINANCE END 01/13 | 1.0 | 6.0 | X | X | 0 | 0 | 0 |
| MARC BOUCHARD MD | |||||||
| MEDICAL STAFF VP ENDING 01/13 | 1.0 | 41.0 | X | 0 | 294512 | 55146 | |
| ROBERT PRIMEAU | |||||||
| MEDICAL STAFF PRESIDENT | 1.0 | 6.0 | X | 0 | 46500 | 0 | |
| JENNIFER LADD MD | |||||||
| VP MEDICAL STAFF BEG 01/13 | 1.0 | 41.0 | X | 0 | 389788 | 32767 | |
| FRANK KNOLL | |||||||
| TRUSTEE BEG 01/13 | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| GARY GILLESPIE | |||||||
| VICE CHAIR FINANCE | 1.0 | 6.0 | X | X | 0 | 0 | 0 |
| MARK BEAMS | |||||||
| TRUSTEE | 1.0 | 6.0 | X | 0 | 0 | 0 | |
| ANDRE BISSONNETTE | |||||||
| VP OF FINANCE | 1.0 | 41.0 | X | 0 | 142851 | 37682 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1377482 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 220878 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | false | FormersListed |
| Total Comp GT150 K | true | TotalCompGT150K |
| Compensation From Other Sources | false | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Fundraising Events | 73067 | FundraisingEvents |
| All Other Contributions | 123147 | AllOtherContributions |
| Noncash Contributions | 15000 | NoncashContributions |
| Total Contributions | 196214 | TotalContributions |
| Total Program Service Revenue | 0 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 369 | TotalRevenueColumn |
| Exclusion | $369 | ExclusionAmount |
Income From Invest Bond Proceeds IncomeFromInvestBondProceeds
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Royalties Revenue RoyaltiesRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
| Personal | 0 | Personal |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 19294 | GrossIncomeFundraisingEvents |
| Cntrbtns Rprtd Fundraising Events | 73067 | CntrbtnsRprtdFundraisingEvents |
| Fundraising Direct Expenses | 30301 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -11007 | TotalRevenueColumn |
| Exclusion | -$11,007 | ExclusionAmount |
Net Income From Gaming NetIncomeFromGaming
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Net Income Or Loss NetIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 0 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 185576 | TotalRevenueColumn |
| Exclusion | -$10,638 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1999 | Total |
| Program Services | 1999 | ProgramServices |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 35458 | Total |
| Program Services | 35458 | ProgramServices |
Foreign Grants ForeignGrants
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Benefits To Members BenefitsToMembers
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9451 | Total |
| Management And General | 9451 | ManagementAndGeneral |
Fees For Services Lobbying FeesForServicesLobbying
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Prof Fundraising FeesForServicesProfFundraising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 16017 | Total |
| Program Services | 10466 | ProgramServices |
| Management And General | 5551 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Royalties Royalties
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Travel Entrtnmnt Public Officials TravelEntrtnmntPublicOfficials
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Payments To Affiliates PaymentsToAffiliates
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 62925 | Total |
| Program Services | 47923 | ProgramServices |
| Management And General | 15002 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 97470 | BOY |
| EOY | 451990 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 383366 | BOY |
| EOY | 156075 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11650 | BOY |
| EOY | 10000 | EOY |
Receivables From Officers Etc ReceivablesFromOfficersEtc
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Receivables From Disqual Persons ReceivablesFromDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 600 | EOY |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Intangible Assets IntangibleAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4000 | BOY |
| EOY | 472 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 496486 | BOY |
| EOY | 619137 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Grants Payable GrantsPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Escrow Account Liability EscrowAccountLiability
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Loans From Officers Directors LoansFromOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | 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 | 113120 | BOY |
| EOY | 177600 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 383366 | BOY |
| EOY | 441537 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 496486 | BOY |
| EOY | 619137 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 496486 | BOY |
| EOY | 619137 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | 122651 | ReconcilationRevenueExpenses |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | false | AccountantCompileOrReview |
| FS Audited | true | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | true | AuditCommittee |
| Federal Grant Audit Required | false | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | X | SupportingOrganization509a3 |
| Supporting Org509a3 Type2 | X | SupportingOrg509a3Type2 |
| Certification Checkbox | X | CertificationCheckbox |
| Contrib By Controlling Individual | false | ContribByControllingIndividual |
| Contribution By Related Party | false | ContributionByRelatedParty |
| Contrib By35 Controlled Entity | false | ContribBy35ControlledEntity |
Supported Org Information SupportedOrgInformation (2 entries)
| EINEIN | Type Of OrganizationTypeOfOrganization | Listed In Governing DocListedInGoverningDoc | AmountAmount |
|---|---|---|---|
| NORTH CO HOSP | |||
| 030185556 | 03 | true | $1,999 |
| NORTH CO HLTH | |||
| 222570334 | 03 | true | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Number Of Supported Orgs | 2 | TotalNumberOfSupportedOrgs |
| Sum Of Amounts | 1999 | SumOfAmounts |
| General Explanation | THE FULL NAMES OF THE SUPPORTED ORGANIZATIONS ARE: NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. NORTH COUNTRY HEALTH SERVICES, INC. | GeneralExplanation |
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) |
|---|---|---|
| Art Public Exhibition Amts | ArtPublicExhibitionAmts | |
| Held Works Of Art Amts | HeldWorksOfArtAmts | |
| Current Year Minus3 Years | CurrentYearMinus3Years | |
| Current Year Minus4 Years | CurrentYearMinus4Years | |
| Land | Land | |
| Buildings | Buildings | |
| Leasehold Improvements | LeaseholdImprovements | |
| Equipment | Equipment | |
| Other Land Buildings | OtherLandBuildings | |
| Tot Revenue Etc Audited Fincl Stmt | 174591 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | -41286 | OtherRevenues |
| Revenue Not Rptd F990 | -41286 | RevenueNotRptdF990 |
| Revenue Subtotal | 215877 | RevenueSubtotal |
| Other Revenues Not Included | -30301 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | -30301 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 185576 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 51940 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 30301 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 30301 | ExpensesNotRptdF990 |
| Expenses Subtotal | 21639 | ExpensesSubtotal |
| Other Expenses Not Included | 41286 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 41286 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 62925 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| UNCERTAIN TAX POSITIONS | SCHEDULE D, PART X, LINE 2 | MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. |
| OTHER REVENUE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12 | SCHEDULE D, PART XI, LINE 2D | $ (41,286) CONTRIBUTIONS PAID |
| OTHER REVENUE INCLUDED ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1 | SCHEDULE D, PART XI, LINE 4B | $ (30,301) SPECIAL EVENT EXPENSES |
| OTHER EXPENSE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25 | SCHEDULE D, PART XII, LINE 2D | $ 30,301 SPECIAL EVENT EXPENSES |
| OTHER EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1 | SCHEDULE D, PART XII, LINE 4B | $ 41,286 CONTRIBUTIONS PAID |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | MIDNIGHT BALL | NameOfEvent1 |
| Gross Receipts Event1 | 71838 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 59388 | CharitableContributionsEvent1 |
| Gross Revenue Event1 | 12450 | GrossRevenueEvent1 |
| Rent Facility Costs Event1 | 1000 | RentFacilityCostsEvent1 |
| Food And Beverage Event1 | 12443 | FoodAndBeverageEvent1 |
| Entertainment Event1 | 6800 | EntertainmentEvent1 |
| Other Direct Expenses Event1 | 3413 | OtherDirectExpensesEvent1 |
| Name Of Event2 | GOLF TOURNEY | NameOfEvent2 |
| Gross Receipts Event2 | 20523 | GrossReceiptsEvent2 |
| Charitable Contributions Event2 | 13679 | CharitableContributionsEvent2 |
| Gross Revenue Event2 | 6844 | GrossRevenueEvent2 |
| Non Cash Prizes Event2 | 4349 | NonCashPrizesEvent2 |
| Rent Facility Costs Event2 | 815 | RentFacilityCostsEvent2 |
| Food And Beverage Event2 | 1350 | FoodAndBeverageEvent2 |
| Other Direct Expenses Event2 | 131 | OtherDirectExpensesEvent2 |
| Total Number Of Other Events | 0 | TotalNumberOfOtherEvents |
| Gross Receipts Total | 92361 | GrossReceiptsTotal |
| Charitable Contributions Total | 73067 | CharitableContributionsTotal |
| Gross Revenue Total Events | 19294 | GrossRevenueTotalEvents |
| Non Cash Prizes Total Events | 4349 | NonCashPrizesTotalEvents |
| Rent Facility Costs Total Events | 1815 | RentFacilityCostsTotalEvents |
| Food And Beverage Total Events | 13793 | FoodAndBeverageTotalEvents |
| Entertainment Total Events | 6800 | EntertainmentTotalEvents |
| Other Direct Expenses Total Events | 3544 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 30301 | DirectExpenseSummaryEvents |
| Net Income Summary | -11007 | NetIncomeSummary |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | true | RecordsMaintained |
Form990 Schedule I Part III Form990ScheduleIPartIII (2 entries)
| Type Of GrantTypeOfGrant | Number Of RecipientsNumberOfRecipients | Amount Of Cash GrantAmountOfCashGrant |
|---|---|---|
| SCHOLARSHIPS | 44 | 26000 |
| PATIENT ASSISTANCE | 124 | 9458 |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | MONITORING USE OF FUNDS | Identifier |
| Return Reference | PART I, LINE 2 | ReturnReference |
| Explanation | NORTH COUNTRY HEALTH SYSTEMS IS THE PARENT ORGANIZATION OF NORTH COUNTRY HOSPITAL & HEALTH CENTER AND SHARES CONSOLIDATED FINANCIALS WITH THE HOSPITAL; THEREFORE, THE ORGANIZATION HAS ACCESS TO THE HOSPITAL FINANCIALS AND IS ABLE TO MONITOR THE USE OF THE FUNDS. SCHOLARSHIP RECIPIENTS MUST COMPLETE AN APPLICATION SHOWING THAT THEY ARE A RESIDENT OF THE NORTH COUNTRY HOSPITAL SERVICE AREA INTENDING TO PURSUE A CAREER INVOLVING PATIENT CARE, PRESENTLY TRAINING FOR A HEALTH CARE CAREER INVOLVING PATIENT CARE, OR ALREADY PROVIDING PATIENT CARE IN THE HEALTH CARE FIELD AND INTERESTED IN CONTINUING THEIR EDUCATION IN THAT FIELD. THE SCHOLARSHIP AWARDS ARE BASED ON ACHIEVEMENT, APTITUDE, SCHOLASTICS, MOTIVATION, AND NEED. THE SCHOLARSHIP CHECKS ARE MADE PAYABLE DIRECTLY TO THE SCHOOL CHOSEN BY THE STUDENT. SUBSEQUENT AWARDS ARE AVAILABLE AFTER THE FIRST YEAR, AND RECIPIENT ARE EVALUATED EACH YEAR THROUGH A TRANSCRIPT REVIEW. PATIENT ASSISTANCE IS GIVEN TO SPECIFIC PATIENTS BASED ON IDENTIFIED NEEDS THROUGHOUT THE YEAR. THIS YEAR, AWARDS WERE GIVEN FOR THE PURCHASE OF PRESCRIPTIONS, MEDICAL BILLS, GAS CARDS, WRAPS THERAPY, MEDICAL SUPPLIES, PROTEIN BARS, AND OTHER BILLS THROUGH MANY DEPARTMENTS, INCLUDING ONCOLOGY, DIALYSIS, AND RESPIRATORY. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | false | SeverancePayment |
| Supplemental Nonqual Retire Plan | true | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | false | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | false | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | false | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | false | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | false | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | false | AnyNonFixedPayments |
| Initial Contract Exception | false | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (5 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CLAUDIO D FORT | ||||||||||||||
| CEO | 0 | 265220 | 0 | 0 | 0 | 2569 | 0 | 25746 | 0 | 31119 | 0 | 324654 | 0 | 0 |
| ANDRE BISSONNETTE | ||||||||||||||
| VP OF FINANCE | 0 | 141474 | 0 | 0 | 0 | 1377 | 0 | 7975 | 0 | 29707 | 0 | 180533 | 0 | 0 |
| CHRISTOPHER RICKMAN MD | ||||||||||||||
| PHYSICIAN/TRUSTEE | 0 | 224181 | 0 | 11861 | 0 | 0 | 0 | 14838 | 0 | 23580 | 0 | 274460 | 0 | 0 |
| MARC BOUCHARD MD | ||||||||||||||
| MEDICAL STAFF VP ENDING 01/13 | 0 | 294512 | 0 | 0 | 0 | 0 | 0 | 27378 | 0 | 27768 | 0 | 349658 | 0 | 0 |
| JENNIFER LADD MD | ||||||||||||||
| VP MEDICAL STAFF BEG 01/13 | 0 | 370466 | 0 | 19322 | 0 | 0 | 0 | 13625 | 0 | 19142 | 0 | 422555 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| COMPENSATION DETERMINATION | SCHEDULE J, PART I, LINE 3 | NORTH COUNTRY HOSPITAL, A RELATED ORGANIZATION, USES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD IN DETERMINING THE COMPENSATION OF THE CEO. |
| SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN | SCHEDULE J, PART I, LINE 4B | THE FOLLOWING INDIVIDUALS LISTED ON FORM 990, PART VII, RECEIVED 457(F) EMPLOYER CONTRIBUTIONS IN THE FOLLOWING AMOUNTS: $ 15,871 CLAUDIO FORT 10,000 MARC BOUCHARD |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (6 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| MEMBERS/STOCKHOLDERS/OTHER PERSONS | FORM 990, PART VI, SECTION A, LINES 6, 7A & 7B | THE MEMBERSHIP OF THE CORPORATION SHALL CONSIST OF ALL PERSONS REFERRED TO IN THE ARTICLES OF ASSOCIATION AS THE INITIAL MEMBERS OF THE CORPORATION, ALL PERSONS WHO SHALL THEREAFTER BE ELECTED MEMBERS IN CONFORMITY WITH THE BYLAWS, DEPARTMENT DIRECTORS AND ALL APPOINTEES OF THE ACTIVE MEDICAL STAFF OF NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. THE MEMBERS SHALL BE REFERRED TO AS "NORTH COUNTRY MEMBERS". AS LISTED IN THE ARTICLES OF ASSOCIATION, THE SOLE MEMBER OF THE CORPORATION IS NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. NORTH COUNTRY MEMBERS SHALL BE ELECTED AT THE ANNUAL MEETING BY A MAJORITY VOTE OF THE EXISTING NORTH COUNTRY MEMBERS PRESENT AND VOTING AT SAID MEETING. THE CORPORATION SHALL CONDUCT AN ANNUAL ENROLLMENT OF MEMBERS BUT PERSONS MAY BE ADMITTED TO MEMBERSHIP AT ANY TIME. THE OFFICER OR AGENT HAVING CHARGE OF THE BOOKS OF THE CORPORATION SHALL MAKE A COMPLETE RECORD OF THE MEMBERS ENTITLED TO VOTE AT EACH MEETING OF MEMBERS THEREOF, ARRANGED IN ALPHABETICAL ORDER. THE MEMBER LIST MUST BE AVAILABLE FOR INSPECTION BY ANY MEMBER, BEGINNING TWO (2) BUSINESS DAYS AFTER NOTICE OF THE MEETING IS GIVEN FOR WHICH THE LIST WAS PREPARED AND CONTINUING THROUGH THE MEETING DATE. THE LIST SHALL BE AVAILABLE AT THE PRINCIPLE OFFICE OF NORTH COUNTRY HOSPITAL. A MEMBER, HIS AGENT OR ATTORNEY IS ENTITLED, ON WRITTEN DEMAND, TO INSPECT AND TO COPY THE LIST DURING REGULAR BUSINESS HOURS AT HIS OR HER EXPENSE, DURING THE PERIOD IT IS AVAILABLE FOR INSPECTION. THE MEMBER LIST SHALL BE MAINTAINED IN WRITTEN FORM OR IN ANOTHER FORM CAPABLE OF CONVERSION TO WRITTEN FORM WITHIN A REASONABLE TIME. AT EACH ANNUAL MEETING, THE NORTH COUNTRY MEMBERS SHALL FIX, WITHIN THE LIMITS SPECIFIED ABOVE, THE SIZE OF THE BOARD OF TRUSTEES FOR THE ENSUING YEAR AND SHALL ELECT THE NUMBER OF TRUSTEES NECESSARY TO COMPLETE THE SIZE SO FIXED; PROVIDED, HOWEVER, THAT THE SIZE OF THE BOARD OF TRUSTEES MAY BE DECREASED ONLY TO ELIMINATE VACANCIES EXISTING BY REASONS OF THE DEATH, RESIGNATION, REMOVAL OR NATURAL EXPIRATION OF THE TERM OF ONE OR MORE TRUSTEES. THE BYLAWS MAY BE ALTERED, AMENDED OR REPEALED BY NORTH COUNTRY MEMBERS AT ANY REGULAR OR SPECIAL MEETING, PROVIDED THE NOTICE OF SUCH MEETING SHALL HAVE CONTAINED A COPY OF THE PROPOSED ALTERATION, AMENDMENT OR REPEAL AND PROVIDED A QUORUM IS PRESENT, SUBJECT TO RATIFICATION BY THE NORTH COUNTRY BOARD. |
| REVIEW OF THE FORM 990 | FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S MANAGEMENT AND FINANCE TEAM IN DETAIL. AFTER IT HAS BEEN REVIEWED, IT IS THEN PROVIDED TO THE FULL BOARD. |
| MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY | FORM 990, PART VI, SECTION B, LINE 12C | IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE BOARD, COMMITTEE, OR OTHER INDIVIDUALS WHO, ON BEHALF OF THE CORPORATION, ARE CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. IN THE EVENT THAT A TRUSTEE, OFFICER, COMMITTEE MEMBER OR MEMBER OF THE CORPORATION'S LEADERSHIP GROUP BECOMES CONCERNED THAT ANOTHER INTERESTED PERSON HAS AN UNDISCLOSED FINANCIAL INTEREST OR IS EXERTING INAPPROPRIATE INFLUENCE RELATED TO A FINANCIAL INTEREST, THIS CONCERN SHOULD BE RAISED WITH THE CHAIR OF THE APPROPRIATE BOARD OR COMMITTEE OR, IF INVOLVING THE LEADERSHIP GROUP, AN APPROPRIATE CORPORATE OFFICER. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD OR COMMITTEE MEMBERS. IT SHALL BE THE RESPONSIBILITY OF THE CHAIR OF THE BOARD OR COMMITTEE TO INSTRUCT AN INTERESTED PERSON ON THE RESTRICTIONS ON HIS OR HER PARTICIPATION PURSUANT TO THIS POLICY IN ANY FURTHER CONSIDERATION OF THE SUBJECT MATTER OF THE CONFLICT OF INTEREST AND TO ENFORCE THESE RESTRICTIONS. AWARENESS/COMPLIANCE WITH POLICY EACH INTERESTED PERSON SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT, IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. EACH INTERESTED PERSON SHALL DISCLOSE ON AN ANNUAL SURVEY FORM POTENTIAL CONFLICTS OF INTEREST AND FINANCIAL INTERESTS RELEVANT TO THIS POLICY. EACH INTERESTED PERSON SHALL ALSO PROVIDE ON AN ANNUAL SURVEY FORM A LIST OF IMMEDIATE FAMILY MEMBERS, INCLUDING SPOUSE, CHILDREN, GRANDCHILDREN, PARENTS, SIBLINGS AND ANY OTHER PERSON WHO LIVES IN HIS/HER HOUSEHOLD, IN ORDER THAT THE CORPORATION MAY HAVE A RECORD OF ALL INDIVIDUALS WHO MAY BE CONSIDERED DISQUALIFIED PERSONS UNDER INTERNAL REVENUE SERVICE REGULATIONS FOR THE PURPOSE OF ENSURING COMPLIANCE WITH TAX EXEMPT STATUS REQUIREMENTS FOR CHARITABLE ORGANIZATIONS. PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT INVOLVES THE CONFLICT OF INTEREST. THE CHAIR OF THE BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, INCLUDING A CONSIDERATION OF INDEPENDENT COMPARABILITY DATA, VALUATIONS OR APPRAISALS, THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE (OR QUORUM) OF ALL OF THE DISINTERESTED TRUSTEES OR COMMITTEE MEMBERS (REGARDLESS OF THE NUMBER PRESENT AT A MEETING): (I) WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST AND FOR ITS OWN BENEFIT, (II) WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, AND (III) WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATIONS. |
| COMPENSATION REVIEW | FORM 990, PART VI, SECTION B, LINES 15A & 15B | THE BOARD OF NORTH COUNTRY HOSPITAL & HEALTH CENTER, A RELATED ORGANIZATION, ANNUALLY REVIEWS THE CEO AND SENIOR TEAM SALARIES USING COMPARABILITY DATA. THE REVIEW PROCESS IS DOCUMENTED IN THE BOARD MINUTES. |
| DOCUMENT DISCLOSURE | FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO VIEW ON-SITE OR BY WRITTEN REQUEST. |
| BOARD OF DIRECTORS | FORM 990, PART VII, SECTION A | NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS SHARE A BOARD OF DIRECTORS. NO BOARD MEMBERS RECEIVE COMPENSATION FOR THEIR DUTIES AS DIRECTORS. CLAUDIO FORT, CEO, AND ANDRE BISSONNETTE, VP OF FINANCE, EACH WORK APPROXIMATELY 40 HOURS PER WEEK BETWEEN NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS. THEY ARE COMPENSATED FOR THEIR DUTIES IN THAT CAPACITY. CHRISTOPHER RICKMAN, MARC BOUCHARD AND JENNIFER LADD ARE COMPENSATED AS EMPLOYEES OF NORTH COUNTRY HOSPITAL. THEY DO NOT RECEIVE ANY COMPENSATION FOR THEIR DUTIES AS BOARD OF DIRECTORS MEMBERS. ROBERT PRIMEAU IS COMPENSATED AS AN INDEPENDENT CONTRACTOR FOR HIS SERVICES AS A PEDIATRIC HOSPITALIST. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrgControlledOrg |
|---|---|---|---|---|---|---|---|---|---|---|
| NORTH COUNTRY HOSPITAL & HEALTH CENTER | ||||||||||
| 189 PROUTY DRIVE | NEWPORT | VT | 05855 | 030185556 | HOSPITAL | VT | 501(C)(3) | 3 | NCHS | true |
| NORTH COUNTRY HLTH SRVCS DBA DERBY GREEN | ||||||||||
| 189 PROUTY DRIVE | NEWPORT | VT | 05855 | 222570334 | SKILLED NRSG | VT | 501(C)(3) | 9 | NCHS | true |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | false | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | true | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | false | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | false | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | false | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | false | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | false | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | false | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | false | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | false | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | true | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | false | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | true | SharingOfFacilities |
| Sharing Of Paid Employees | true | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | false | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | false | OtherTransferToOtherOrg |
| Other Transfer From Other Org | false | OtherTransferFromOtherOrg |
Comments