TOMAH HEALTH COMMUNITY FOUNDATION INC: Form 990EZ, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- TOMAH HEALTH COMMUNITY FOUNDATION INC (EIN 39-1823757)
- Tax period
- 2011-10-01 to 2012-09-30
- Filed
- 2013-03-21
- IRS object ID
- 201310809349200401
- 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-03-21T07:27:27-05:00 | Timestamp |
| Tax Period End Date | 2012-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 411765929 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 NICOLLET MALL STE 1300 | AddressLine1 |
| City | MINNEAPOLIS | City |
| State | MN | State |
| ZIP Code | 554027033 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990EZ | ReturnType |
| Tax Period Begin Date | 2011-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391823757 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TOMAH MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | TOMA | NameControl |
| Phone | 6083722181 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | RAY HABELMAN JR | Name |
| Title | PRESIDENT | Title |
| Phone | 6083722181 | Phone |
| Date Signed | 2013-03-19 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | KIM HUNWARDSEN CPA | Name |
| PTIN | P00484560 | PTIN |
| Phone | 9529446166 | Phone |
| Date Prepared | 2013-03-19 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990-EZ IRS990EZ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Schedule B Not Required | X | ScheduleBNotRequired |
| Web Site | N/A | WebSite |
| Organization501c3 | X | Organization501c3 |
| Gross Receipts | 40813 | GrossReceipts |
| Info In Schedule O Part I | X | InfoInScheduleOPartI |
| Contributions Gifts Grants Etc | 27819 | ContributionsGiftsGrantsEtc |
| Investment Income | 8089 | InvestmentIncome |
| Gaming Gross Income | 638 | GamingGrossIncome |
| Fundraising Gross Income | 4267 | FundraisingGrossIncome |
| Special Events Direct Expenses | 5665 | SpecialEventsDirectExpenses |
| Special Events Net Income Loss | -760 | SpecialEventsNetIncomeLoss |
| Total Revenue | 35148 | TotalRevenue |
| Grants And Similar Amounts Paid | 7749 | GrantsAndSimilarAmountsPaid |
| Other Expenses Total | 156 | OtherExpensesTotal |
| Total Expenses | 7905 | TotalExpenses |
| Excess Or Deficit For Year | 27243 | ExcessOrDeficitForYear |
| Net Assets Or Fund Balances BOY | 412924 | NetAssetsOrFundBalancesBOY |
| Other Changes In Net Assets | 20378 | OtherChangesInNetAssets |
| Net Assets Or Fund Balances EOY | 460545 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part II | X | InfoInScheduleOPartII |
Cash Savings And Investments CashSavingsAndInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 412548 | BOY |
| EOY | 460545 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 376 | BOY |
| EOY | 0 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 412924 | BOY |
| EOY | 460545 | EOY |
Sum Of Total Liabilities SumOfTotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Net Assets Or Fund Balances NetAssetsOrFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 412924 | BOY |
| EOY | 460545 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Primary Exempt Purpose | SUPPORT OF TOMAH MEMORIAL HOSPITAL AND SURROUNDING COMMUNITY. | PrimaryExemptPurpose |
Program Service Accomplishment ProgramServiceAccomplishment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description Program Service Accom | THE MISSION OF TOMAH MEMORIAL HOSPITAL FOUNDATION IS TO SUPPORT THE COMMUNITY OF TOMAH AND THE HEALTHCARE PROVIDERS THAT SERVE ITS RESIDENTS. THE FOCUS OF ITS SUPPORT WILL BE COMMUNITY-BASED WELLNESS, FACILITY UPGRADES, AND THE DEVELOPMENT OF PROGRAMS THAT BENEFIT THE LOCAL HOSPITAL AND SURROUNDING COMMUNITIES. | DescriptionProgramServiceAccom |
| Grants And Allocations | 7749 | GrantsAndAllocations |
| Program Service Expenses | 7905 | ProgramServiceExpenses |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | 7905 | TotalProgramServiceExpenses |
Officer Director Trustee Key Empl OfficerDirectorTrusteeKeyEmpl (12 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | TitleTitle | Avg Hours Per Wk Devoted To PositionAvgHoursPerWkDevotedToPosition | CompensationCompensation | Contri To Empl Benefit Plans EtcContriToEmplBenefitPlansEtc | Expense Account Other AllowancesExpenseAccountOtherAllowances |
|---|---|---|---|---|---|---|---|---|
| RAY HABELMAN JR | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | PRESIDENT | 1.00 | 0 | 0 | 0 |
| RYAN STEELE | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | PRESIDENT UNTIL 3/2012 | 1.00 | 0 | 0 | 0 |
| PETER REICHARDT | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | VICE PRESIDENT | 1.00 | 0 | 0 | 0 |
| SANDRA HUMPHREY | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | SECRETARY | 1.00 | 0 | 0 | 0 |
| JENNIFER MUBARAK | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | SECRETARY UNTIL 3/2012 | 1.00 | 0 | 0 | 0 |
| MIKE MAYHEW | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | TREASURER | 1.00 | 0 | 0 | 0 |
| LAURA DAMROW | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR | 1.00 | 0 | 0 | 0 |
| BRIAN EIRSCHELE | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR | 1.00 | 0 | 0 | 0 |
| JENNIFER PARKER | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR | 1.00 | 0 | 0 | 0 |
| THERESE CONWAY | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR | 1.00 | 0 | 0 | 0 |
| LORINDA LANE | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR | 1.00 | 0 | 0 | 0 |
| GLORIA DIPPEN | ||||||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | DIRECTOR UNTIL 3/2012 | 1.00 | 0 | 0 | 0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part V | X | InfoInScheduleOPartV |
| Activities Not Previously Rpt | 0 | ActivitiesNotPreviouslyRpt |
| Made Changes To Orgnzng Etc Doc | 0 | MadeChangesToOrgnzngEtcDoc |
| Organization Had UBI | 0 | OrganizationHadUBI |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Organization Dissolved Etc | 0 | OrganizationDissolvedEtc |
| Direct Indirect Political Expend | 0 | DirectIndirectPoliticalExpend |
| Made Loans To From Officers | 0 | MadeLoansToFromOfficers |
| Tax Imposed Under IRC4911 | 0 | TaxImposedUnderIRC4911 |
| Tax Imposed Under IRC4912 | 0 | TaxImposedUnderIRC4912 |
| Tax Imposed Under IRC4955 | 0 | TaxImposedUnderIRC4955 |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTrans |
| Amount Of Tax Imposed On Org Mgr | 0 | AmountOfTaxImposedOnOrgMgr |
| Amount Of Tax Reimbursed By Org | 0 | AmountOfTaxReimbursedByOrg |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| States Where Copy Of Return Is Filed | WI | StatesWhereCopyOfReturnIsFiled |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JOSEPH ZEPS | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 6083740286 | TelephoneNumber |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Foreign Office | 0 | ForeignOffice |
| Maintain Any Donor Advised Funds | 0 | MaintainAnyDonorAdvisedFunds |
| Does Org Have Hospital | 0 | DoesOrgHaveHospital |
| Tanning Services Provided | 0 | TanningServicesProvided |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Engage Political Cmpgn Activities | 0 | EngagePoliticalCmpgnActivities |
| Engage In Lobbying Activities | 0 | EngageInLobbyingActivities |
| Operating School | 0 | OperatingSchool |
| Trnsfrs Exempt Non Char Related Org | 0 | TrnsfrsExemptNonCharRelatedOrg |
| Part VI Of Comp Of Highest Paid Empl | NONE | PartVIOfCompOfHighestPaidEmpl |
| Part VIA Hghst Paid Cntrct Prof Ser | NONE | PartVIAHghstPaidCntrctProfSer |
| Filed Schedule A | 1 | FiledScheduleA |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org509a2 | X | PubliclySupportedOrg509a2 |
Gifts Grants Contrib Received509 GiftsGrantsContribReceived509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 29264 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 29496 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 24807 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 23717 | CurrentTaxYearMinus1Year |
| Current Tax Year | 27819 | CurrentTaxYear |
| Total | 135103 | Total |
Gross Receipts From Admissions GrossReceiptsFromAdmissions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 6240 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 5270 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 4580 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 3329 | CurrentTaxYearMinus1Year |
| Current Tax Year | 4905 | CurrentTaxYear |
| Total | 24324 | Total |
Total509 Total509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 35504 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 34766 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 29387 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 27046 | CurrentTaxYearMinus1Year |
| Current Tax Year | 32724 | CurrentTaxYear |
| Total | 159427 | Total |
Amts Recd From Disqual Persons AmtsRecdFromDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus1 Year | 725 | CurrentTaxYearMinus1Year |
| Current Tax Year | 825 | CurrentTaxYear |
| Total | 1550 | Total |
Amts From Subst Contributors AmtsFromSubstContributors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Support From DQ Ps Etc SupportFromDQPsEtc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus1 Year | 725 | CurrentTaxYearMinus1Year |
| Current Tax Year | 825 | CurrentTaxYear |
| Total | 1550 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total509 | 157877 | PublicSupportTotal509 |
Gross Investment Income509 GrossInvestmentIncome509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 13571 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 10690 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7854 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 6517 | CurrentTaxYearMinus1Year |
| Current Tax Year | 8089 | CurrentTaxYear |
| Total | 46721 | Total |
Investment Income And UBTI InvestmentIncomeAndUBTI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 13571 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 10690 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7854 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 6517 | CurrentTaxYearMinus1Year |
| Current Tax Year | 8089 | CurrentTaxYear |
| Total | 46721 | Total |
Total Support Total TotalSupportTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 49075 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 45456 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 37241 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 33563 | CurrentTaxYearMinus1Year |
| Current Tax Year | 40813 | CurrentTaxYear |
| Total | 206148 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Percentage509 | 0.76580 | PublicSupportPercentage509 |
| Prior Year Support Percentage | 0.61100 | PriorYearSupportPercentage |
| Investment Income Percentage | 0.22660 | InvestmentIncomePercentage |
| Prior Yr Invest Income Percentage | 0.24590 | PriorYrInvestIncomePercentage |
| Thirty Three Percnt Tests CY509 | X | ThirtyThreePercntTestsCY509 |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | GOLF OUTING | NameOfEvent1 |
| Gross Receipts Event1 | 24432 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 20165 | CharitableContributionsEvent1 |
| Gross Revenue Event1 | 4267 | GrossRevenueEvent1 |
| Rent Facility Costs Event1 | 2010 | RentFacilityCostsEvent1 |
| Food And Beverage Event1 | 3655 | FoodAndBeverageEvent1 |
| Gross Receipts Total | 24432 | GrossReceiptsTotal |
| Charitable Contributions Total | 20165 | CharitableContributionsTotal |
| Gross Revenue Total Events | 4267 | GrossRevenueTotalEvents |
| Rent Facility Costs Total Events | 2010 | RentFacilityCostsTotalEvents |
| Food And Beverage Total Events | 3655 | FoodAndBeverageTotalEvents |
| Direct Expense Summary Events | 5665 | DirectExpenseSummaryEvents |
| Net Income Summary | -1398 | NetIncomeSummary |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| OTHER INVESTMENT INCOME | FORM 990-EZ, PART I, LINE 4 | INTEREST 3,562.. DIVIDENDS 4,527.. TOTAL INCLUDED ON FORM 990-EZ, LINE 4: 8,089. |
| OTHER EXPENSES | FORM 990-EZ, PART I, LINE 16 | DESCRIPTION: OFFICE EXPENSES. AMOUNT: 19. DESCRIPTION: NON-EVENT EXPENSES. AMOUNT: 137. TOTAL TO FORM 990-EZ, LINE 16: 156. |
| OTHER CHANGES IN NET ASSETS | FORM 990-EZ, PART I, LINE 20 | DESCRIPTION: UNREALIZED GAIN. AMOUNT: 20,378. |
| OTHER ASSETS | FORM 990-EZ, PART II, LINE 24 | DESCRIPTION: TOMAH HOSPITAL RECEIVABLE. BEG. OF YEAR AMOUNT: 376. END OF YEAR AMOUNT: 0. |
Transfer Prsnl Bnft Contracts Decl TransferPrsnlBnftContractsDecl
| Field | Value | IRS element (for citing) |
|---|---|---|
| Declaration | THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT. | Declaration |
Comments