ANMED HEALTH CANNON: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
ANMED HEALTH CANNON (EIN 57-0342027)
Tax period
2011-10-01 to 2012-09-30
Filed
2013-08-14
IRS object ID
201302269349303200
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)
Timestamp2013-08-14T14:25:47-05:00Timestamp
Tax Period End Date2012-09-30TaxPeriodEndDate

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 Date2011-10-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN570342027EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITALBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlCANNNameControl
Phone8648784791Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1123 WG ACKER DRIVEAddressLine1
CityPICKENSCity
StateSCState
ZIP Code29671ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameNORMAN RENTZName
TitleCEOTitle
Phone8648784791Phone
Date Signed2013-08-13DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameAMY BIBBYName
PTINP00445891PTIN
Phone8282542254Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonNORMAN RENTZNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1123 WG ACKER DRIVEAddressLine1
CityPICKENSCity
StateSCState
ZIP Code29671ZIPCode
FieldValueIRS element (for citing)
Gross Receipts39340767GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.CANNONHOSPITAL.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1950YearFormation
State Legal DomicileSCStateLegalDomicile
Activity Or Mission DescriptionPROVIDING QUALITY HEALTHCARE IN A SAFE, COMPETENT, AND COMPASSIONATE MANNERActivityOrMissionDescription
Nbr Voting Members Governing Body12NbrVotingMembersGoverningBody
Nbr Independent Voting Members12NbrIndependentVotingMembers
Total Nbr Employees343TotalNbrEmployees
Total Nbr Volunteers102TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year89506ContributionsGrantsPriorYear
Contributions Grants Current Year1749417ContributionsGrantsCurrentYear
Program Service Revenue Prior Year35165469ProgramServiceRevenuePriorYear
Program Service Revenue CY37392079ProgramServiceRevenueCY
Investment Income Prior Year29932InvestmentIncomePriorYear
Investment Income Current Year16017InvestmentIncomeCurrentYear
Other Revenue Prior Year230713OtherRevenuePriorYear
Other Revenue Current Year183254OtherRevenueCurrentYear
Total Revenue Prior Year35515620TotalRevenuePriorYear
Total Revenue Current Year39340767TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year11696413SalariesEtcPriorYear
Salaries Etc Current Year12495038SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year50723TotalFundrsngExpCurrentYear
Other Expense Prior Year24034116OtherExpensePriorYear
Other Expenses Current Year26835729OtherExpensesCurrentYear
Total Expenses Prior Year35730529TotalExpensesPriorYear
Total Expenses Current Year39330767TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-214909RevenuesLessExpensesPriorYear
Revenues Less Expenses CY10000RevenuesLessExpensesCY
Total Assets BOY15708412TotalAssetsBOY
Total Assets EOY18545591TotalAssetsEOY
Total Liabilities BOY8070816TotalLiabilitiesBOY
Total Liabilities EOY10764226TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY7637596NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY7781365NetAssetsOrFundBalancesEOY
Mission DescriptionTHE MISSION OF CANNON MEMORIAL HOSPITAL IS TO PROVIDE QUALITY HEALTHCARE IN A SAFE, COMPETENT, AND COMPASSIONATE MANNER.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense35193084Expense
Grants0Grants
Revenue37392079Revenue
DescriptionCANNON MEMORIAL HOSPITAL OFFERS A FULL RANGE OF STATE-OF-THE-ART MEDICAL TECHNOLOGY, EQUIPMENT, AND SERVICES TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. THE EXPANDED SERVICES OF THE HOSPITAL INCLUDE A 24-HOUR EMERGENCY DEPARTMENT, A FULL SERVICE LABORATORY, PHYSICAL AND OCCUPATIONAL THERAPY, CRITICAL CARE UNIT, SLEEP CLINIC, WELLNESS PROGRAMS FOR BOTH CHILDREN AND ADULTS, AND DIAGNOSTIC IMAGING FOR BOTH INPATIENT AND OUTPATIENT TEST INCLUDING CT SCANS. FOR FISCAL YEAR 2012, THE HOSPITAL PROVIDED 3,601 PATIENT DAYS OF SERVICE.WE ALSO SPONSOR HEALTH FAIRS, FLU CLINICS, CPR TRAINING, FITNESS CLASSES, SUPPORT GROUPS, AND MANY OTHER COMMUNITY WELLNESS SERVICES THROUGH OUR WELLNESS CENTER LOCATED AT THE HOSPITAL.Description
Total Program Service Expense35193084TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets1ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds1TaxExemptBonds
Invest Tax Exempt Bonds0InvestTaxExemptBonds
Escrow Account0EscrowAccount
On Behalf Of Issuer0OnBehalfOfIssuer
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 Entity1RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109628NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees343NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
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 Members12NbrVotingGoverningBodyMembers
Number Independent Voting Members12NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties1DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
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
States Where Copy Of Return Is FiledSCStatesWhereCopyOfReturnIsFiled
Other WebsiteXOtherWebsite
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1GREG SCARBROUGHBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number8648784791TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1123 WG ACKER DRIVEAddressLine1
CityPICKENSCity
StateSCState
ZIP Code29671ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (20 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationHighest Compensated EmployeeHighestCompensatedEmployee
FRANCES C STOKES
CHAIRMAN (SEE SCH. O)1.00XX000
DR WILLIAM W SPEARMAN
VICE CHAIR1.00XX000
J FLETCHER PERRY
SECRETARY1.00XX000
KENNETH D ACKER
TREASURER1.00XX000
GEORGE D ACKER
BOARD MEMBER1.00X000
LINDA S CASSELL
BOARD MEMBER1.00X000
R JANINE PETERSEN
BOARD MEMBER1.00X000
RANDALL P GRIFFIN
BOARD MEMBER1.00X000
TIMOTHY E MORGAN
BOARD MEMBER1.00X000
DR DONALD L MARLER
BOARD MEMBER1.00X000
DR JAMES R MAHANES
BOARD MEMBER1.00X000
JOHN E SPARKS
BOARD MEMBER1.00X000
NORMAN RENTZ
CEO40.00X168475024004
MARY ARNETTE
CFO40.00X86258014016
DONNA ANDERSON
CNO40.00X91752017316
DR PETER SCHRIVER
PHYSICIAN40.00231518018697X
DR BYRON MARSH
PHYSICIAN40.0022425605244X
DR DANIEL DAHLAUSEN
PHYSICIAN40.00148036017028X
DR MARION CLINCH
PHYSICIAN40.00142030014525X
PETE WOODS
CHIEF ANESTHETIST40.00144920022397X
FieldValueIRS element (for citing)
Total Reportable Comp From Org1237245TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation133227TotalOtherCompensation
Number Individuals GT100 K10NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
ANMED HEALTH
800 NORTH FANT STREETANDERSONSC29621MANAGMENT SERVICES628114
MATRIX REHABILITATION
PO BOX 11407BIRMINGHAMAL35246REHABILITATION SERVICES349876
MICHAEL DILLARD MD
PO BOX 186PICKENSSC29671PHYSICIAN283965
JAMES CALDWELL MD
220 GLEN LAUREL DRIVEEASLEYSC29642PHYSICIAN281449
MICHAEL DONALD MD
350 NORTH SUMMIT DRIVESENECASC29672PHYSICIAN272815
FieldValueIRS element (for citing)
Number Of Contractors GT100 K8NumberOfContractorsGT100K
Related Organizations40000RelatedOrganizations
All Other Contributions1709417AllOtherContributions
Total Contributions1749417TotalContributions

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionNET PATIENT SERVICEDescription
Business Code621400BusinessCode
Total Revenue Column37392079TotalRevenueColumn
Related Or Exempt Function Income37392079RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue37392079TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column16017TotalRevenueColumn
Exclusion$16,017ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real27097Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real0Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real27097Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column27097TotalRevenueColumn
Exclusion$27,097ExclusionAmount

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnExclusionExclusionAmount
CAFETERIA & FOODSERVIC72221078503$78,503
SALES TO EMPLOYEES44611052066$52,066
MEDICAL TRANSCRIPTION90009922231$22,231

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column3357TotalRevenueColumn
Exclusion$3,357ExclusionAmount
FieldValueIRS element (for citing)
Total Other Revenue156157TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column39340767TotalRevenueColumn
Related Or Exempt Function Income37392079RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$199,271ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total401821Total
Management And General401821ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total9515531Total
Program Services8519547ProgramServices
Management And General962030ManagementAndGeneral
Fundraising33954Fundraising

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total54078Total
Program Services46456ProgramServices
Management And General7437ManagementAndGeneral
Fundraising185Fundraising

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total1800710Total
Program Services1546908ProgramServices
Management And General247637ManagementAndGeneral
Fundraising6165Fundraising

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total722898Total
Program Services621009ProgramServices
Management And General99414ManagementAndGeneral
Fundraising2475Fundraising

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total428324Total
Management And General428324ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total89420Total
Management And General89420ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total3032316Total
Program Services2311575ProgramServices
Management And General720314ManagementAndGeneral
Fundraising427Fundraising

Advertising Advertising

FieldValueIRS element (for citing)
Total51229Total
Management And General51229ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1761592Total
Program Services940007ProgramServices
Management And General814478ManagementAndGeneral
Fundraising7107Fundraising

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total20105Total
Management And General20105ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total326820Total
Program Services326820ProgramServices

Travel Travel

FieldValueIRS element (for citing)
Total73919Total
Program Services24065ProgramServices
Management And General49444ManagementAndGeneral
Fundraising410Fundraising

Interest Interest

FieldValueIRS element (for citing)
Total320581Total
Program Services320581ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total1217475Total
Program Services1217475ProgramServices

Insurance Insurance

FieldValueIRS element (for citing)
Total283177Total
Program Services87870ProgramServices
Management And General195307ManagementAndGeneral

Other Expenses OtherExpenses (2 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServices
BAD DEBT EXPENSE1719704917197049
MEDICAL SUPPLIES20337222033722

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total39330767Total
Program Services35193084ProgramServices
Management And General4086960ManagementAndGeneral
Fundraising50723Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY446120BOY
EOY140753EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY2404368BOY
EOY993029EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY3561593BOY
EOY4492347EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY15926BOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY645507BOY
EOY658851EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY237625BOY
EOY272626EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis26128282LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec17124096LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY7482976BOY
EOY9004186EOY

Investments Program Related InvestmentsProgramRelated

FieldValueIRS element (for citing)
BOY419204BOY
EOY653436EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY495093BOY
EOY2330363EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY15708412BOY
EOY18545591EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY1414395BOY
EOY2611387EOY

Tax Exempt Bond Liabilities TaxExemptBondLiabilities

FieldValueIRS element (for citing)
BOY5140000BOY
EOY4800000EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY1203151BOY
EOY880824EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY313270BOY
EOY2472015EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY8070816BOY
EOY10764226EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY7236492BOY
EOY7293292EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY401104BOY
EOY488073EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY7637596BOY
EOY7781365EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY15708412BOY
EOY18545591EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses10000ReconcilationRevenueExpenses
Reconcilation Other Changes133769ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

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 C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators0DirectContactLegislators
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$728OtherActivitiesAmount
Total Lobbying Expenditures IIB728TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierEXPLANATION OF LOBBYING ACTIVITIES:Identifier
Return ReferencePART II-B, LINE 1:ReturnReference
ExplanationTHE ORGANIZATION IS A MEMBER OF THE SOUTH CAROLINA HOSPITAL ASSOCIATION (SCHA). THIS ORGANIZATION ROUTINELY ENGAGES IN LOBBYING EFFORTS ON BEHALF OF ITS MEMBERSHIP BODIES, AND A PORTION OF THE DUES PAID TO THIS ORGANIZATIONS IS ALLOCATED TO THOSE EFFORTS EACH YEAR. FOR 2011, DUES PAID TO THIS ORGANIZATION ALLOCATED TO LOBBYING EFFORTS WERE APPROXIMATELY $728.Explanation

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis758191OtherCostOrOtherBasis
Book Value758191BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis11015607OtherCostOrOtherBasis
Depreciation7769704Depreciation
Book Value3245903BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis384370OtherCostOrOtherBasis
Depreciation216574Depreciation
Book Value167796BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis13968693OtherCostOrOtherBasis
Depreciation9137818Depreciation
Book Value4830875BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis1421OtherCostOrOtherBasis
Book Value1421BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings9004186TotalOfBookValueLandBuildings

Other Assets OtherAssets (5 entries)

DescriptionDescriptionBook ValueBookValue
ESTIMATED THIRD PARTY PAYOR SETTLEMENTS302419
DEFERRED FINANCE COSTS95926
NON-PATIENT RECEIVABLES215494
MEANINGFUL USE RECEIVABLE1698424
OTHER ASSET18100
FieldValueIRS element (for citing)
Total Book Value Other Assets2330363TotalBookValueOtherAssets

Other Liabilities OtherLiabilities (3 entries)

DescriptionDescriptionAmountAmount
INTEREST RATE SWAP AGREEMENT$244,200
ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS$40,000
LINE OF CREDIT$2,187,815
FieldValueIRS element (for citing)
Total Of Amounts2472015TotalOfAmounts
Total Revenue39340767TotalRevenue
Total Expenses39330767TotalExpenses
Excess Or Deficit For Year10000ExcessOrDeficitForYear
Other$133,769OtherAmount
Total Adjustments133769TotalAdjustments
Excess Or Deficit Per FS143769ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt39474075TotRevenueEtcAuditedFinclStmt
Other Revenues86969OtherRevenues
Revenue Not Rptd F99086969RevenueNotRptdF990
Revenue Subtotal39387106RevenueSubtotal
Other Revenues Not Included-46339OtherRevenuesNotIncluded
Revenue Not Rptd On Fin Stmt-46339RevenueNotRptdOnFinStmt
Total Revenue Per Form99039340767TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt39330306TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal39330306ExpensesSubtotal
Other Expenses Not Included461OtherExpensesNotIncluded
Expenses Not Rptd On Fin Stmt461ExpensesNotRptdOnFinStmt
Total Expenses Per Form99039330767TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X:THE HOSPITAL IS A TAX-EXEMPT ORGANIZATION UNDER INTERNAL REVENUE CODE SECTION 501 (C)(3) AND, ACCORDINGLY, NO PROVISION FOR INCOME TAX IS RECORDED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2012. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES.
PART XI, LINE 8 - OTHER ADJUSTMENTS:CHANGE IN VALUE OF INTEREST RATE SWAP AGREEMENT 86,969. CHANGE IN VALUE OF EQUITY IN FOUNDATION NET ASSETS 46,800. TOTAL TO SCHEDULE D, PART XI, LINE 8: 133,769.
PART XII, LINE 2D - OTHER ADJUSTMENTS:CHANGE IN VALUE OF EQUITY IN FOUNDATION NET ASSETS 86,969.
PART XII, LINE 4B - OTHER ADJUSTMENTS:CHANGE IN VALUE OF INTEREST RATE SWAP AGREEMENT -46,800. EMPLOYEE SALES EXPENSE 461.
PART XIII, LINE 4B - OTHER ADJUSTMENTS:EMPLOYEE SALES EXPENSE 461.

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
FPG Reference Free Care1FPGReferenceFreeCare
Pcent100XPcent100
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent200 DXPcent200D
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget1ExpensesExceededBudget
Unable To Provide Care0UnableToProvideCare
Annual Community Benefit Report1AnnualCommunityBenefitReport
Report Publically Available0ReportPublicallyAvailable

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense634516TotalCommunityBenefitExpense
Net Community Benefit Expense634516NetCommunityBenefitExpense
Percent Of Total Expense0.02870PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense2916714TotalCommunityBenefitExpense
Direct Offsetting Revenue2234651DirectOffsettingRevenue
Net Community Benefit Expense682063NetCommunityBenefitExpense
Percent Of Total Expense0.03080PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense3551230TotalCommunityBenefitExpense
Direct Offsetting Revenue2234651DirectOffsettingRevenue
Net Community Benefit Expense1316579NetCommunityBenefitExpense
Percent Of Total Expense0.05950PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense62959TotalCommunityBenefitExpense
Net Community Benefit Expense62959NetCommunityBenefitExpense
Percent Of Total Expense0.00280PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense62959TotalCommunityBenefitExpense
Net Community Benefit Expense62959NetCommunityBenefitExpense
Percent Of Total Expense0.00280PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense3614189TotalCommunityBenefitExpense
Direct Offsetting Revenue2234651DirectOffsettingRevenue
Net Community Benefit Expense1379538NetCommunityBenefitExpense
Percent Of Total Expense0.06230PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported1BadDebtExpenseReported
Bad Debt Expense$3,844,626BadDebtExpenseAmount
Amount Attributable To1537850AmountAttributableTo
Amount Reimbursed By Medicare3010086AmountReimbursedByMedicare
Cost Of Care Reimbursed By Medicare16077783CostOfCareReimbursedByMedicare
Medicare Surplus Or Shortfall-13067697MedicareSurplusOrShortfall

Costing Methodology Used CostingMethodologyUsed

FieldValueIRS element (for citing)
Cost Accounting SystemXCostAccountingSystem
FieldValueIRS element (for citing)
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITALBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line1123 WG ACKER DRIVEAddressLine1
CityPICKENSCity
StateSCState
ZIP Code29671ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITALBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent100.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent200.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
Asset LevelXAssetLevel
Medical IndigencyXMedicalIndigency
Insurance StatusXInsuranceStatus
Medicaid MedicareXMedicaidMedicare
Explains Application Method1ExplainsApplicationMethod
Includes Publicity Measures1IncludesPublicityMeasures
Posted On WebsiteXPostedOnWebsite
Available On RequestXAvailableOnRequest
Actions On Nonpayment1ActionsOnNonpayment
Collection Activities1CollectionActivities
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Medicare RateXMedicareRate
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges0GrossCharges

Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC

FieldValueIRS element (for citing)
Number Of Other Facilities5NumberOfOtherFacilities

Other Facilities OtherFacilities (5 entries)

Address Line1Address/AddressLine1CityAddress/CityStateAddress/StateZIP CodeAddress/ZIPCodeFacility TypeFacilityType
CANNON ORTHOPEDIC
123 WG ACKER DRIVEPICKENSSC29671ORTHOPEDIC PRACTICE
CANNON SURGICAL
123 WG ACKER DRIVEPICKENSSC29671GENERAL SURGERY PRACTICE
CANNON FAMILY PRACTICE - EASTSIDE
111 WEST ROPER ROADPICKENSSC29640RURAL HEALTH CLINIC
CANNON FAMILY PRACTICE - PICKENS
123 WG ACKER DRIVEPICKENSSC29671FAMILY PRACTICE
CANNON FAMILY PRACTICE - LIBERTY
105 LIBERTY BOULEVARDPICKENSSC29657FAMILY PRACTICE

Form990 Schedule H Part VI Form990ScheduleHPartVI (7 entries)

ExplanationExplanation
PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 17197049.
PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE ON BAD DEBT.WORKSHEET TWO OF THE 2011 SCHEDULE H INSTRUCTIONS WAS USED TO CALCULATE A COST-TO-CHARGES RATIO USED TO COMPUTE BAD DEBT AT COST.
PART III, LINE 9B: CANNON UTILIZES AN EXTENDED BUSINESS OFFICE SERVICE THROUGH A THIRD PARTY VENDOR TO MANAGE ALL OF ITS ACTIVE SELF-PAY ACCOUNTS. CANNON RECOGNIZES THREE ASSISTANCE/CHARITY PROGRAMS FOR ITS PATIENTS. THOSE PROGRAMS ARE: 1) MEDICALLY INDIGENT ASSISTANCE PROGRAM (MIAP), 2) CANNON MEMORIAL'S UNCOMPENSATED ASSISTANCE PROGRAM AND 3) PATIENTS REFERRED BY THE SAMARITAN HEALTH CLINIC OF PICKENS COUNTY. AT THE TIME OF DETERMINATION OF ELIGIBILITY, BILLING & COLLECTION EFFORTS ARE DISCONTINUED FOR THE ELIGIBLE ACCOUNTS. CANNON PROVIDES HELP TO ALL PATIENTS WHO NEED ASSISTANCE COMPLETING THE FINANCIAL AIDE APPLICATION.
PART VI, LINE 2: WE CURRENTLY USE DATA PROVIDED BY THE STATE TO ASSESS OUR COMMUNITY. THAT DATA INCLUDES INFORMATION ABOUT PATIENTS WHO USE OUR HOSPITAL, AS WELL AS PATIENTS FROM OUR SERVICE AREA WHO ACCESS HEALTHCARE AT OTHER HOSPITALS AND WHAT CHARGE CODE THAT CARE IS UNDER. THIS GIVES US AN IDEA OF THE HEALTH PROBLEMS IN OUR SERVICE AREA.
PART VI, LINE 3: THE ASSISTANCE/CHARITY PROGRAM POLICIES ARE POSTED ON CANNON'S WEBSITE AND THE PATIENT IS VERBALLY INFORMED DURING THE REGISTRATION PROCESS.
PART VI, LINE 4: CANNON MEMORIAL HOSPITAL SERVES GREATER PICKENS COUNTY, WITH THE PRIMARY COMMUNITY SERVED BY THE HOSPITAL CLASSIFIED AS RURAL. POPULATION ESTIMATES AS OF 2009 ARE APPROXIMATELY 118,000. THE PER CAPITA INCOME IS $27,487. A SIGNIFICANT PERCENTAGE OF THE POPULATION LIVES BELOW THE FEDERAL POVERTY LEVEL. PICKENS HAS A 10% UNEMPLOYMENT RATE AND APRROXIMATELY 24,000 RESIDENTS (OR 20.1%) ARE UNINSURED.
PART VI, LINE 5: CMH FURTHERS ITS EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY IN SEVERAL WAYS. THE MAJORITY OF OUR BOARD IS COMPRISED OF INDIVIDUALS WHO RESIDE IN PICKENS WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF CMH. CMH EXTENDS MEDICIAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA FOR ALL OF OUR DEPARTMENTS. ANY SURPLUS IS USED TO FUND IMPROVEMENTS IN PATIENT CARE. A DIGITAL MAMMOGRPAHY MACHINE BECAME AVAILABLE TO THE PUBLIC STARTING IN 2011. THE HOSPITAL ALSO PROMOTES HEALTH WITHIN PICKENS COUNTY BY PROVIDING EMERGENCY ROOM CARE TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY. CMH ALSO PARTICIPATES IN TRAINING OF STUDENTS FROM MULTIPLE CAREER CENTERS, TECHNICAL SCHOOLS AND UNIVERISTIES IN THE AREA. IN ADDITION, THE HOSPITAL PROVIDES VOLUNTEER OPPPORTUNITIES THROUGH THE AUXILIARY.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Club Dues Or FeesXClubDuesOrFees
Written Policy Re T And E Expenses1WrittenPolicyReTAndEExpenses
Substantiation Required1SubstantiationRequired
Compensation CommitteeXCompensationCommittee
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org1CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org1CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (6 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
NORMAN RENTZ
13991401973308828069290170750192479000
DR PETER SCHRIVER
2315180000047410139560250215000
DR BYRON MARSH
22425600000450007440229500000
DR DANIEL DAHLAUSEN
12741102062500030720139560165064000
DR MARION CLINCH
12698801504200029110116140156555000
PETE WOODS
1387000622000084410139560167317000

Form990 Schedule J Part III Form990ScheduleJPartIII (4 entries)

Return ReferenceReturnReferenceExplanationExplanation
PART I, LINE 1ATHE FILING ORGANIZATION PROVIDES THESE BENEFITS THE CEO. NO PART OF THE BENEFIT WAS TREATED AS TAXABLE COMPENSATION DURING FY2012. ALL PERSONAL USE AMOUNTS ARE REQUIRED TO BE PAID BACK TO THE ORGANIZATION.
PART I, LINE 4BTHE FOLLOWING INDIVIDUALS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN (457(F)) AND/OR DEFINED BENEFIT PLAN FOR 2011, AS FOLLOWS. THE AMOUNTS ARE REPRESENTED IN PART II, COLUMN (C): DONNA ANDERSON $1,920 DR. BYRON MARSH 4,500 DR. PETER SCHRIVER 4,741 DR. DANIEL DALHAUSEN 3,072 DR. MARION CLINCH 2,911 PETE WOODS 3,008
PART I, LINE 5FULL TIME FAMILY PRACTICE PHYSICIANS ARE INCENTIVIZED THROUGH A BONUS DERVIED FROM A FORMULA THAT INCLUDES REVENUES.
PART I, LINE 6FULL TIME FAMILY PRACTICE PHYSICIANS ARE INCENTIVIZED THROUGH A BONUS DERVIED FROM A FORMULA THAT INCLUDES NET EARNINGS.

Schedule K IRS990ScheduleK

Form990 Schedule K Part I Form990ScheduleKPartI

Issuer Name IssuerName

FieldValueIRS element (for citing)
Business Name Line1SC JOBS-ECONOMIC DEVELOPMENT AUTHORITYBusinessNameLine1
FieldValueIRS element (for citing)
Issuer EIN570960018IssuerEIN
CUSIP Number83703EHX6CUSIPNumber
Date Issued2004-06-15DateIssued
Issue Price6250000IssuePrice
Description Of PurposeSEE PART VIDescriptionOfPurpose
Defeased0Defeased
On Behalf Of Issuer0OnBehalfOfIssuer
Pool Financing0PoolFinancing

Form990 Schedule K Part II Form990ScheduleKPartII

FieldValueIRS element (for citing)
Amount Retired1450000AmountRetired
Total Proceeds6251328TotalProceeds
Issuance Costs From Proceeds125000IssuanceCostsFromProceeds
Credit Enhancement76836CreditEnhancement
Capital Expenditures1386152CapitalExpenditures
Other Spent Proceeds4663340OtherSpentProceeds
Year Of Subst Completion2002YearOfSubstCompletion
Current Refunding1CurrentRefunding
Advance Refunding0AdvanceRefunding
Final Allocation Made1FinalAllocationMade
Adequate Books And Recds Maintaind1AdequateBooksAndRecdsMaintaind

Form990 Schedule K Part III Form990ScheduleKPartIII

FieldValueIRS element (for citing)
Owning Bond Financed Property0OwningBondFinancedProperty
Any Lease Arrangements0AnyLeaseArrangements
Mngment Cntrct Bond Financd Prprty0MngmentCntrctBondFinancdPrprty
Any Research Agreements0AnyResearchAgreements
Prcntge Prvt Business Use By Others0.00000PrcntgePrvtBusinessUseByOthers
Percentage Of Prvt Business Re UBI0.00000PercentageOfPrvtBusinessReUBI
Total Private Business Use0.00000TotalPrivateBusinessUse
Post Issuance Compliance Procdrs1PostIssuanceComplianceProcdrs

Form990 Schedule K Part IV Form990ScheduleKPartIV

FieldValueIRS element (for citing)
Form8038 T Filed0Form8038TFiled
Variable Rate Issue1VariableRateIssue
Hedge Identified In Books And Recds1HedgeIdentifiedInBooksAndRecds

Name Of Hedge Provider NameOfHedgeProvider

FieldValueIRS element (for citing)
Business Name Line1NAT'L BANK OF SCBusinessNameLine1
FieldValueIRS element (for citing)
Term Of Hedge10.000000000000TermOfHedge
Superintegrated Hedge1SuperintegratedHedge
Hedge Terminated0HedgeTerminated
Gross Proceeds Invested In GIC0GrossProceedsInvestedInGIC
Gross Proceeds Invested0GrossProceedsInvested
Exception To Rebate1ExceptionToRebate

Form990 Schedule K Part VI Form990ScheduleKPartVI (3 entries)

IdentifierIdentifierExplanationExplanation
SCHEDULE,K, PART I, COLUMN (F), PURPOSE OF ISSUE:(I) TO DEFRAY THE COST OF REFINANCING THE EMERGENCY ROOM EXPANSION AND ACQUIRING EQUIPMENT, INCLUDING IMAGING EQUIPMENT AND INFORMATION TECHNOLOGY EQUIPMENT IN ADDITION TO ROUTINE CAPITAL EQUIPMENT TO BE USED AT THE FACILITIES OF THE HOSPITAL. (II) TO REFUND THE OUTSTANDING PRINCIPAL AMOUNT OF THE $5,805,000 PICKENS COUNTY, SOUTH CAROLINA, FIRST MORTGAGE HOSPITAL FACILITIES REFUNDING REVENUE BONDS (CANNON MEMORIAL HOSPITAL) SERIES 1996A, THE PROCEEDS OF WHICH WERE USED TO REFUND THE PICKENS COUNTY, SOUTH CAROLINA, HOSPITAL FACILITIES REFUNDING REVENUE BONDS, SERIES 1987 (CANNON MEMORIAL HOSPITAL PROJECT), WHICH WERE ISSUED TO REFINANCE THE COSTS OF THE ACQUISITION, CONSTRUCTION, FURNISHING, AND EQUIPPING OF A 55-BED ACUTE CARE HOSPITAL LOCATED AT 123 W.G. ACKER DRIVE, PICKENS, SOUTH CAROLINA, AND OWNED BY THE HOSPITAL; AND (III) TO PREPAY THE $650,000 NOTE OF THE PEOPLES NATIONAL BANK DATED JUNE 17, 2002, AND THE $200,000 NOTE OF THE PEOPLES NATIONAL BANK DATED SEPTEMBER 4, 2003; AND (IV) TO PAY COSTS OF ISSUANCE OF THE BONDS
SCHEDULE K, PART II, LINE 3, TOTAL PROCEEDS:THE AMOUNT PRESENTED ON LINE 3 INCLUDES TOTAL INVESTMENT EARNINGS OF $ 1,328.
SCHEDULE K, PART II, LINE 11, OTHER SPENT PROCEEDS:THE AMOUNT PRESENTED ON PART II, LINE 11 REPRESENTS AMOUNTS USED TO REFUND PRIOR BONDS ISSUED DECEMBER 19, 1996.

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (8 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 3ON OCTOBER 1, 2009, THE ORGANIZATION ENTERED INTO A MANAGEMENT SERVICES AGREEMENT WITH ANMED HEALTH, A SOUTH CAROLINA NON-PROFIT HEALTHCARE ORGANIZATION. ANMED HEALTH HAS BEEN APPOINTED AS THE MANAGER FOR THE HOSPITAL DURING THE TERM OF THE AGREEMENT. IN ADDITION TO GERERAL MANAGMENT RESPONSIBILITIES OUTLINED IN THE AGREEMENT, ANMED HEALTH IS REQUIRED TO HIRE AND EMPLOY ON A FULL-TIME BASIS A PRESIDENT AND CEO, CFO, AND OTHER EXECUTIVES AS ARE DESIGNATED AND AGREED UPON BY CANNON AND ANMED HEALTH. ANMED HEALTH IS GRANTED THE AUTHORITY AND RESPONSIBILITY FOR MANAGEMENT OF THE HOSPITAL, SUBJECT TO GENERAL APPROVAL OF THE BOARD OF DIRECTORS OF CANNON MEMORIAL HOSPITAL. THE BOARD SHALL REVIEW AND ACT PROMPTLY ON REQUESTS FOR APPROVAL SUBMITTED TO THE BOARD BY ANMED HEALTH FOR CERTAIN MATTERS OUTLINED IN THE MANAGEMENT AGREEMENT, INCLUDING LARGE CAPITAL EXPENDITURES, SALE OR OTHER DISPOSAL OF HOSPITAL ASSETS, AND BORROWING OTHER THAN IN THE ORDINARY COURSE OF CONDUCT OF HOSPITAL AFFAIRS.
FORM 990, PART VI, SECTION B, LINE 11THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTANT WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. UPON COMPLETION, THE RETURN WAS REVIEWED BY MANAGEMENT AND PROVIDED TO ALL VOTING MEMBERS OF THE BOARD OF DIRECTORS VIA E-MAIL. A PERIOD OF TIME WAS ALLOWED FOR QUESTIONS AND COMMENTS.
FORM 990, PART VI, SECTION B, LINE 12CTHE ADMINISTRATION REQUIRES ALL MANAGEMENT, KEY OFFICIALS, AND BOARD MEMBERS TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ON AN ANNUAL BASIS. ANY DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON THE PART OF ANY GOVERNING BOARD MEMBER SHALL BE DISCLOSED TO THE OTHER MEMBERS OF THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL PROCEDURE AND ALSO WHEN THE INTEREST BECOMES A MATTER OF BOARD ACTION. ANY GOVERNING BOARD MEMBER HAVING A DUALITY OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHALL NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER, EVEN WHERE PERMITTED BY LAW. THE MINUTES OF THE MEETING SHALL REFLECT THAT A DISCLOSURE WAS MADE, THE ABSTENTION FROM VOTING, AND THE QUORUM SITUATION. THE FOREGOING REQUIREMENTS SHALL NOT BE CONSTRUED AS PREVENTING THE GOVERNING BOARD MEMBER FROM BRIEFLY STATING A POSITION IN THE MATTER, NOR FROM ANSWERING PERTINENT QUESTIONS OF OTHER BOARD MEMBERS SINCE THE BOARD MEMBER'S KNOWLEDGE MAY BE OF GREAT ASSISTANCE. ANY NEW MEMBER OF THE BOARD WILL BE ADVISED OF THIS POLICY UPON ENTERING INTO THE DUTIES OF BOARD MEMBERSHIP.
FORM 990, PART VI, SECTION B, LINE 15A COMMITTEE OF FOUR CANNON BOARD MEMBERS KNOWN AS THE "CEO REVIEW COMMITTEE" MEETS ANNUALLY TO REVIEW THE PROGRESS OF THE CEO AGAINST GOALS DETERMINED THE PREVIOUS YEAR. THE COMMITTEE MAKES A RECOMMENDATION TO THE BOARD FOR A SALARY INCREASE AND/OR BONUS FOR THE CEO BASED UPON THAT PROGRESS. THE RECOMMENDATION IS VOTED ON BY THE FULL BOARD. THE BOARD APPROVES THE GOALS FOR THE CEO FOR THE UPCOMING YEAR IN ACCORDANCE WITH THE ORGANIZATION'S STRATEGIC GOALS. SALARY AND BONUS ARE REVIEWED AND COMPARED PERIODICALLY TO APPLICABLE COMPENSATION SURVEYS. THE CEO REVIEWS THE PROGRESS OF THE OTHER OFFICERS/KEY EMPLOYEES AGAINST THE ESTABLISHED GOALS FOR THE PRIOR YEAR AND DETERMINES THE ANNUAL SALARY INCREASE AND/OR BONUS BASED UPON THAT PROGRESS. SALARIES ARE REVIEWED AND COMPARED PERIODICALLY TO APPLICABLE COMPENSATION SURVEYS. THE CEO DETERMINES THE GOALS FOR THE UPCOMING YEAR IN ACCORDANCE WITH THE ORGANIZATION'S STRATEGIC GOALS. THE BOARD APPROVES THE ORGANIZATIONAL BUDGET WHICH INCLUDES THESE SALARY INCREASES.
FORM 990, PART VI, SECTION C, LINE 18PHOTOCOPIES OF THE FORM 990 ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG.
FORM 990, PART VI, SECTION C, LINE 19PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE.
FORM 990, PART XI, LINE 5:CHANGE IN VALUE OF INTEREST RATE SWAP AGREEMENT 86,969. CHANGE IN VALUE OF EQUITY IN FOUNDATION NET ASSETS 46,800. TOTAL TO FORM 990, PART XI, LINE 5: 133,769.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART VII, LINE 1:COMPENSATION PAID TO CHAIRMAN OF THE BOARD, DR. CALVIN SNIPES, IS PAID FOR MEDICAL SERVICES PROVIDED TO THE HOSPITAL. NO PART OF THE COMPENSATION IS PAID FOR SERVICES IN HIS CAPACITY AS A BOARD MEMBER.BOARD MEMBER COMPENSATION:

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITAL FOUNDATIONBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1PO BOX 188AddressLine1
CityPICKENSCity
StateSCState
ZIP Code29671ZIPCode
FieldValueIRS element (for citing)
EIN570943822EIN
Primary ActivitiesSUPPORT/FUNDRAISINGPrimaryActivities
Legal Domicile StateSCLegalDomicileState
Exempt Code Section501(C)(3)ExemptCodeSection
Public Charity Status7PublicCharityStatus

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITAL INCBusinessNameLine1
FieldValueIRS element (for citing)
Controlled Org1ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties1ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
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 Orgs1RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable

Name Of Other Organization NameOfOtherOrganization

FieldValueIRS element (for citing)
Business Name Line1CANNON MEMORIAL HOSPITAL FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Transaction TypeCTransactionType
Amount Involved40000AmountInvolved

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