GASTON MEMORIAL HOSPITAL FOUNDATION INC: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
GASTON MEMORIAL HOSPITAL FOUNDATION INC (EIN 56-1479699)
Tax period
2011-07-01 to 2012-06-30
Filed
2013-04-04
IRS object ID
201300949349300750
Schema version
2011v1.5
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 ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-04-04T11:32:40-05:00Timestamp
Tax Period End Date2012-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN560747981EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1DIXON HUGHES GOODMAN LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1500 RIDGEFIELD COURTAddressLine1
CityASHEVILLECity
StateNCState
ZIP Code28806ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN561479699EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1GASTON MEMORIAL HOSPITAL FOUNDATION INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlGASTNameControl
Phone7048342000Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line12525 COURT DRIVE PO BOX 1747AddressLine1
CityGASTONIACity
StateNCState
ZIP Code28054ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameDAVID O'CONNORName
TitleCFOTitle
Phone7048342000Phone
Date Signed2013-04-01DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameAMY BIBBYName
PTINP00445891PTIN
Phone8282542254Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-03-07 17:11:31ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonDAVID O'CONNORNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line12525 COURT DRIVE PO BOX 1747AddressLine1
CityGASTONIACity
StateNCState
ZIP Code28054ZIPCode
FieldValueIRS element (for citing)
Gross Receipts4238426GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.CAROMONT.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1985YearFormation
State Legal DomicileNCStateLegalDomicile
Activity Or Mission DescriptionTO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE.ActivityOrMissionDescription
Nbr Voting Members Governing Body5NbrVotingMembersGoverningBody
Nbr Independent Voting Members4NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Nbr Volunteers0TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year3788620ContributionsGrantsPriorYear
Contributions Grants Current Year2606923ContributionsGrantsCurrentYear
Program Service Revenue Prior Year0ProgramServiceRevenuePriorYear
Program Service Revenue CY0ProgramServiceRevenueCY
Investment Income Prior Year476176InvestmentIncomePriorYear
Investment Income Current Year-65559InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year4264796TotalRevenuePriorYear
Total Revenue Current Year2541364TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year667258GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY3045308GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year0SalariesEtcPriorYear
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year3195OtherExpensePriorYear
Other Expenses Current Year8346OtherExpensesCurrentYear
Total Expenses Prior Year670453TotalExpensesPriorYear
Total Expenses Current Year3053654TotalExpensesCurrentYear
Revenues Less Expenses Prior Year3594343RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-512290RevenuesLessExpensesCY
Total Assets BOY15964319TotalAssetsBOY
Total Assets EOY15940285TotalAssetsEOY
Total Liabilities BOY0TotalLiabilitiesBOY
Total Liabilities EOY0TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY15964319NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY15940285NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense3053593Expense
Grants3045308Grants
DescriptionSEE SCHEDULE O.THE GASTON MEMORIAL HOSPITAL FOUNDATION (A SUBSIDIARY OF CAROMONT HEALTH) WAS ESTABLISHED IN 1985. IN ADDITION TO THE FOUNDATION UTILIZING ITS INVESTMENT EARNINGS FOR DONATIONS, CAROMONT HEALTH DONATES UP TO 10% OF ITS OPERATING INCOME TO THE GMH FOUNDATION EACH YEAR. THE FOUNDATION PARTNERS WITH DONORS, CORPORATIONS AND COMMUNITY ORGANIZATIONS TO SUPPORT CAROMONT HEALTH'S MISSION TO PROMOTE INDIVIDUAL HEALTH AND VIBRANT COMMUNITIES. THE FOUNDATION PROVIDES GRANTS TO COMMUNITY ORGANIZATIONS THAT SPONSOR PROGRAMS THAT DIRECTLY SUPPORT CAROMONT HEALTH'S MISSION.DURING FISCAL YEAR 2012, THE FOUNDATION DISTRIBUTED $3,045,308 TO CHARITABLE CAUSES THROUGHOUT GASTON COUNTY, INCLUDING GASTON FAMILY HEALTH SERVICES, GASTON TOGETHER, UNITED WAY, GASTON COUNTY SCHOOLS, HEALTHNET GASTON AND INDIGENT MEDICATION AND SERVICES.THE WAYNE F. SHOVELIN SCHOLARSHIP FUND, A $2.21 MILLION ENDOWMENT PLEDGED BY DUKE KIMBRELL, PROMOTES HIGHER EDUCATION AND ENGAGES LEARNING FOR CAROMONT HEALTH EMPLOYEES, VOLUNTEERS AND FAMILIES. RECIPIENTS ARE SELECTED BASED ON INDIVIDUAL FINANCIAL NEEDS, FUTURE CAREER ASPIRATIONS IN HEALTH CARE, AND CURRENT SCHOLASTIC STANDING.Description
Total Program Service Expense3053593TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets1ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations1GrantsToOrganizations
Grants To Individuals1GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members5NbrVotingGoverningBodyMembers
Number Independent Voting Members4NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs1ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1DAVID O'CONNORBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7048342000TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line12525 COURT DRIVEAddressLine1
CityGASTONIACity
StateNCState
ZIP Code28054ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (9 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationFormerFormer
JAMES R BEAM
CHAIRMAN1.00XX000
MARY FRANCES FORRESTER
DIRECTOR1.00X000
DAVID ALLEN SMITH
DIRECTOR1.00X000
SUSIE BROWN
DIRECTOR1.00X000
W BARRY SMITH
DIRECTOR1.00X000
DAVID O'CONNOR
CFO/ASST. TREASURER1.00X056949138816
MARIA LONG
EVP GEN. COUNSEL/ASST. SEC1.00X043234738015
RANDALL L KELLEY
CEO (AS OF DECEMBER 2011)1.00X000
VALINDA L RUTLEDGE
FORMER CEO0.00076697218607X
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs1768810TotalReportableCompFrmRltdOrgs
Total Other Compensation95438TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed1FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources
Number Of Contractors GT100 K0NumberOfContractorsGT100K
Related Organizations2601214RelatedOrganizations
All Other Contributions5709AllOtherContributions
Total Contributions2606923TotalContributions

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column287217TotalRevenueColumn
Exclusion$287,217ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities1344286Securities

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities1697062Securities

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities-352776Securities

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column-352776TotalRevenueColumn
Exclusion-$352,776ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column2541364TotalRevenueColumn
Related Or Exempt Function Income0RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion-$65,559ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total2950093Total
Program Services2950093ProgramServices

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total95215Total
Program Services95215ProgramServices

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total61Total
Management And General61ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total7500Total
Program Services7500ProgramServices

Other Expenses OtherExpenses

FieldValueIRS element (for citing)
DescriptionBANK SERVICE CHARGEDescription
Total785Total
Program Services785ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total3053654Total
Program Services3053593ProgramServices
Management And General61ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY382BOY
EOY469425EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY13621227BOY
EOY12849220EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY2342710BOY
EOY2621640EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY15964319BOY
EOY15940285EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY13621608BOY
EOY13318645EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY2342711BOY
EOY2621640EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY15964319BOY
EOY15940285EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY15964319BOY
EOY15940285EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses-512290ReconcilationRevenueExpenses
Reconcilation Other Changes488256ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org170b1 AviXPubliclySupportedOrg170b1Avi

Gifts Grants Contrib Received170 GiftsGrantsContribReceived170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years7205CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years1553180CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years774819CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year3788620CurrentTaxYearMinus1Year
Current Tax Year2606923CurrentTaxYear
Total8730747Total

Total170 Total170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years7205CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years1553180CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years774819CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year3788620CurrentTaxYearMinus1Year
Current Tax Year2606923CurrentTaxYear
Total8730747Total
FieldValueIRS element (for citing)
Amounts Subst Contributors Total2038611AmountsSubstContributorsTotal
Public Support Total1706692136PublicSupportTotal170

Gross Investment Income170 GrossInvestmentIncome170

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years377967CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years463406CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years262328CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year372927CurrentTaxYearMinus1Year
Current Tax Year287217CurrentTaxYear
Total1763845Total

Other Income170 OtherIncome170

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years74835CurrentTaxYearMinus3Years
Total74835Total
FieldValueIRS element (for citing)
Total Support10569427TotalSupport
Public Support Pertcentage1700.63320PublicSupportPertcentage170
Public Support Pertcent Prior Year0.54910PublicSupportPertcentPriorYear
Thirty Three Percnt Tests CY170XThirtyThreePercntTestsCY170

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance2342709BeginningOfYearBalance
Contributions364160Contributions
Investment Earnings Or Losses9986InvestmentEarningsOrLosses
Grants Or Scholarships95215GrantsOrScholarships
End Of Year Balance2621640EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance750985BeginningOfYearBalance
Contributions1505133Contributions
Investment Earnings Or Losses100784InvestmentEarningsOrLosses
Grants Or Scholarships7680GrantsOrScholarships
Other Expenditures6513OtherExpenditures
End Of Year Balance2342709EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance40686BeginningOfYearBalance
Contributions750000Contributions
Investment Earnings Or Losses-39463InvestmentEarningsOrLosses
Grants Or Scholarships238GrantsOrScholarships
End Of Year Balance750985EndOfYearBalance

Current Year Minus3 Years CurrentYearMinus3Years

FieldValueIRS element (for citing)
Beginning Of Year Balance30235BeginningOfYearBalance
Contributions15043Contributions
Investment Earnings Or Losses-1785InvestmentEarningsOrLosses
Grants Or Scholarships2807GrantsOrScholarships
End Of Year Balance40686EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance1.00000BoardDesignatedEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs0EndowmentsHeldByRelatedOrgs
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings

Other Assets OtherAssets (4 entries)

DescriptionDescriptionBook ValueBookValue
MACKIE SCHOLARSHIP FUND38266
SHOVELIN SCHOLARSHIP FUND2211232
HUDSON NURSING SCHOLARSHIP FUND366652
BUCCI SCHOLARSHIP FUND5490
FieldValueIRS element (for citing)
Total Book Value Other Assets2621640TotalBookValueOtherAssets
Total Revenue2541364TotalRevenue
Total Expenses3053654TotalExpenses
Excess Or Deficit For Year-512290ExcessOrDeficitForYear
Net Unrealized GL On Investments129586NetUnrealizedGLOnInvestments
Other$358,670OtherAmount
Total Adjustments488256TotalAdjustments
Excess Or Deficit Per FS-24034ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt-374419TotRevenueEtcAuditedFinclStmt
Net Unrealized Gains Investments129586NetUnrealizedGainsInvestments
Revenue Not Rptd F990129586RevenueNotRptdF990
Revenue Subtotal-504005RevenueSubtotal
Other Revenues Not Included3045369OtherRevenuesNotIncluded
Revenue Not Rptd On Fin Stmt3045369RevenueNotRptdOnFinStmt
Total Revenue Per Form9902541364TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt8285TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal8285ExpensesSubtotal
Other Expenses Not Included3045369OtherExpensesNotIncluded
Expenses Not Rptd On Fin Stmt3045369ExpensesNotRptdOnFinStmt
Total Expenses Per Form9903053654TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:PART V, LINE 4:THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X:THE SYSTEM IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM HAS DETERMINED THAT IT DOES NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2012 AND 2011, RESPECTIVELY.
PART XI, LINE 8 - OTHER ADJUSTMENTS:EQUITY TRANSFER 358,670.
PART XII, LINE 4B - OTHER ADJUSTMENTS:EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 3,045,369.
PART XIII, LINE 4B - OTHER ADJUSTMENTS:EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 3,045,369.

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable (7 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEIN Of RecipientEINOfRecipientIRC SectionIRCSectionAmount Of Cash GrantAmountOfCashGrantPurpose Of GrantPurposeOfGrant
GASTON FAMILY HEALTH SERVICES
991 WEST HUDSON BOULEVARDGASTONIANC28054581958398501(C)(3)480778FEDERALLY QUALIFIED HEALTH DEPARTMENT OFFERING MEDICAL CARE TO LOW INCOME RESIDENTS OF GASTON COUNTY
HEALTHNET GASTON
700 SOUTH MARIETTA STREETGASTONIANC28052561913112501(C)(3)75000CASE MANAGER, CARE NAVIGATOR AND PROGRAM COORDINATOR
GASTON COUNTY HEALTH DEPARTMENT
PO BOX 1578GASTONIANC28053566000300501(C)(3)800000ONGOING VITAL COMMUNITY HEALTH INITIATIVES
UNITED WAY OF GASTON COUNTY
200 EAST FRANKLIN BLVDGASTONIANC28052560653356501(C)(3)10000GENERAL ASSISTANCE
NORTH CAROLINA MISSIONS OF MERCY DENTAL HEALTH FUND
1600 EVANS ROADCARYNC27513581788699502(C)(3)25000PROVIDE DENTAL CARE TO THE UNINSURED, UNEMPLOYED, ELDERLY, AND DISABLED
HOSPICE OF GASTON COUNTY
2525 COURT DRIVEGASTONIANC28054581341530501(C)(3)150000HOSPICE HOUSE EXPANSION ASSISTANCE
GASTON MEMORIAL HOSPITAL INC
2525 COURT DRIVEGASTONIANC28054560619359501(C)(3)1131072VARIOUS COMMUNITY HEALTH INITIATIVES
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants6TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations1TotalNbrOfOtherOrganizations

Form990 Schedule I Part III Form990ScheduleIPartIII

FieldValueIRS element (for citing)
Type Of GrantNURSING EDUCATION SCHOLARSHIPTypeOfGrant
Number Of Recipients13NumberOfRecipients
Amount Of Cash Grant95215AmountOfCashGrant
Method Of ValuationFMVMethodOfValuation
Description Of Non Cash AssistanceSHOVELIN AND MACKIE NURSING SCHOLARSHIPSDescriptionOfNonCashAssistance

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierPROCEDURE FOR MONITORING GRANTS IN THE U.S.:Identifier
Return ReferencePART I, LINE 2:ReturnReference
ExplanationSCHEDULE I, PART I, LINE 2: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation CommitteeXCompensationCommittee
Independent ConsultantXIndependentConsultant
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org1CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs1CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (3 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
DAVID O'CONNOR
0332181018256505474509800029016060830700
MARIA LONG
0274556015030007491012740025275047036200
VALINDA L RUTLEDGE
03381370260451016838406750011857078557900

Form990 Schedule J Part III Form990ScheduleJPartIII

FieldValueIRS element (for citing)
Return ReferencePART I, LINE 6ReturnReference
ExplanationEXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES AND FINANCIAL PERFORMANCE OF THE CONSOLIDATED SYSTEM. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS.Explanation

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (11 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 4THE BYLAWS WERE AMENDED TO ENHANCE THE GOVERNANCE OF CONFLICTS OF INTEREST WITHIN THE HOSPITAL SYSTEM AND PROHIBIT LOANS WITH OFFICERS AND DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 6THE SOLE MEMBER OF THE CORPORATION SHALL BE CAROMONT HEALTH, INC., A NORTH CAROLINA NOT-FOR-PROFIT CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7ATHE MEMBERS OF THE BOARD OF DIRECTOR SHALL BE ELECTED AND MAY BE REMOVED AT WILL BY ITS SOLE MEMBER OF THE CORPORATION ACTING THOUGHT ITS BOARD OF DIRECTORS AT ITS ANNUAL MEETING FROM A SLATE OF NOMINEES PROVIDED TO THE CAROMONT HEALTH, INC. BOARD BY THE FOUNDATION.
FORM 990, PART VI, SECTION A, LINE 7BDECISIONS OF THE GOVERNING BODY INCLUDING THE ELECTION AND REMOVAL OF MEMBERS OF THE BOARD OR DIRECTORS MUST BE APPROVED BY THE CORPORATION'S SOLE MEMBER, CAROMONT HEALTH, INC.
FORM 990, PART VI, SECTION B, LINE 11THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS PRIOR TO PRESENTATION TO THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12CEACH APPLICABLE EMPLOYEE AND DIRECTOR SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE EMPLOYEE'S OBLIGATION TO IMMEDIATELY MAKE THE PRESIDENT AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID EMPLOYEE'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES SHALL BE REVIEWED ANNUALLY BY THE EXECUTIVE VICE PRESIDENT/GENERAL COUNSEL AND THE CORPORATE RESPONSIBILITY OFFICER.
FORM 990, PART VI, SECTION B, LINE 15THE CEO, CFO/ASSISTANT TREASURER AND EVP GENERAL COUNSEL/ASSISTANT SECRETARY ARE COMPENSATED FOR THEIR SERVICES BY GASTON MEMORIAL HOSPITAL, A SUBSIDIARY OF CAROMONT HEALTH, INC. THE COMPENSATION OF ALL CAROMONT EXECUTIVES FOR EACH YEAR IS ESTABLISHED BY THE COMPENSATION COMMITTEE OF THE CAROMONT HEALTH BOARD OF DIRECTORS, BASED ON GUIDANCE AND OPINIONS PROVIDED BY AN INDEPENDENT, THIRD-PARTY COMPENSATION CONSULTANT. BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND FREE OF ANY CONFLICT OF INTEREST. ANY COMPENSATION COMMITTEE MEMBER WHO DEVELOPS A CONFLICT OF INTEREST DURING HIS/HER TERM WITH RESPECT TO THE DISCUSSION OF ANY EXECUTIVE'S COMPENSATION LEAVES THE MEETING AND DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING INDEPENDENT MEMBERS OF THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE RETAINS JURISDICTION OVER THE TOTAL COMPENSATION PACKAGE FOR EXECUTIVES AND REVIEWS EXECUTIVE BENEFITS AND PERQUISITES AS WELL AS TOTAL CASH COMPENSATION. COMPENSATION FOR THE CEO IS ESTABLISHED THROUGH A PROCESS OF PERFORMANCE EVALUATION, COMPARISON WITH COMPARABLE MARKET DATA AND DETERMINATION BY THE COMPENSATION COMMITTEE OF ACCEPTABLE SALARY RANGE AND PERCENTILE RANKING. ALL COMPENSATION DECISIONS FOR THE CEO ARE RECOMMENDED BY THE COMPENSATION COMMITTEE AND APPROVED BY THE BOARD OF DIRECTORS. THE PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVE DIRECTORS AND MANAGEMENT, UTILIZES COMPENSATION SURVEYS AND STUDIES. FULL COLLECTED COMPENSATION INFORMATION AND ANY COMPENSATION OPINIONS PROVIDED DURING THESE PROCESSES WILL BE KEPT WITH THE COMPENSATION COMMITTEE OR BOARD MINUTES, AS APPLICABLE.
FORM 990, PART VI, SECTION C, LINE 18THE ORGANIZATION'S FORM 990 IS MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART VI, SECTION C, LINE 19AT THIS TIME, THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE ENTIRE ORGANIZATION'S COMBINED FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST.
FORM 990, PART XI, LINE 5:NET UNREALIZED GAINS ON INVESTMENTS: 129,586. EQUITY TRANSFER 358,670. TOTAL TO FORM 990, PART XI, LINE 5: 488,256.CHANGES IN NET ASSETS OR FUND BALANCES:
PART XII, LINE 2CTHE PROCESS FOR THIS HAS NOT CHANGED FROM THE PRIOR YEAR.RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT.

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (6 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusDirect Controlling Entity NADirectControllingEntityNAControlled OrgControlledOrgBusiness Name Line1DirectControllingEntityName/BusinessNameLine1
CAROMONT HEALTH INC
2525 COURT DRIVEGASTONIANC28054581636959MEDICAL SERVICESNC501(C)(3)LINE 11B, IIN/A0
CAROMONT HEALTH SERVICES INC
2526 COURT DRIVEGASTONIANC28054561455630OUTPATIENT SERVICESNC501(C)(3)LINE 30CAROMONT HEALTH INC
CAROMONT MEDICAL GROUP INC
2528 COURT DRIVEGASTONIANC28054561479712MEDICAL GROUPNC501(C)(3)LINE 90CAROMONT HEALTH INC
HOSPICE OF GASTON COUNTY INC
2529 COURT DRIVEGASTONIANC28054581341530HOSPICE CARENC501(C)(3)LINE 70CAROMONT HEALTH INC
GASTON MEMORIAL HOSPITAL INC
2530 COURT DRIVEGASTONIANC28054560619359HOSPITALNC501(C)(3)LINE 30CAROMONT HEALTH INC
GASTON EMERGENCY PHYSICIANS INC
2531 COURT DRIVEGASTONIANC28054562209423SUPPORTING ORGANIZATIONNC501(C)(3)LINE 11A, I0CAROMONT HEALTH INC
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org1GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org1GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org1OtherTransferToOtherOrg
Other Transfer From Other Org1OtherTransferFromOtherOrg

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