AVITA HEALTH FOUNDATION: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- AVITA HEALTH FOUNDATION (EIN 20-0934451)
- Tax period
- 2011-07-01 to 2012-06-30
- Filed
- 2013-05-15
- IRS object ID
- 201341359349306074
- 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 | 2013-05-15T13:43:54-05:00 | Timestamp |
| Tax Period End Date | 2012-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 381357951 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PLANTE & MORAN PLLC | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 65 EAST STATE ST STE 600 | AddressLine1 |
| City | COLUMBUS | City |
| State | OH | State |
| ZIP Code | 43215 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 200934451 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GALION COMMUNITY HOSPITAL FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | GALI | NameControl |
| Phone | 4194684841 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 269 PORTLAND WAY SOUTH | AddressLine1 |
| City | GALION | City |
| State | OH | State |
| ZIP Code | 44833 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | D ERIC DRAIME | Name |
| Title | CFO | Title |
| Phone | 4194684841 | Phone |
| Date Signed | 2013-05-15 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BERNIE OSTROWSKI | Name |
| PTIN | P00366367 | PTIN |
| Phone | 6148493000 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | AVITA HEALTH FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | D ERIC DRAIME | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 269 PORTLAND WAY SOUTH | AddressLine1 |
| City | GALION | City |
| State | OH | State |
| ZIP Code | 44833 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 318387 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | N/A | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2004 | YearFormation |
| State Legal Domicile | OH | StateLegalDomicile |
| Activity Or Mission Description | SEE SCHEDULE OINSPIRE PHILANTHROPY AND PROVIDE FINANCIAL SUPPORT TO GALION COMMUNITY HOSPITAL IN WAYS THAT HAVE A POSITIVE IMPACT ON PATIENTS, EMPLOYEES, AND THE COMMUNITY. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 12 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 12 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 51374 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 289690 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 0 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 115145 | InvestmentIncomePriorYear |
| Investment Income Current Year | 712 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 0 | OtherRevenuePriorYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 166519 | TotalRevenuePriorYear |
| Total Revenue Current Year | 290402 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 166519 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 873 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 27128 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 0 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 155434 | OtherExpensePriorYear |
| Other Expenses Current Year | 78101 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 349081 | TotalExpensesPriorYear |
| Total Expenses Current Year | 78974 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -182562 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 211428 | RevenuesLessExpensesCY |
| Total Assets BOY | 372758 | TotalAssetsBOY |
| Total Assets EOY | 520722 | TotalAssetsEOY |
| Total Liabilities BOY | 109932 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 46468 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 262826 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 474254 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | INSPIRE PHILANTHROPY AND PROVIDE FINANCIAL SUPPORT TO GALION COMMUNITY HOSPITAL IN WAYS THAT HAVE A POSITIVE IMPACT ON PATIENTS, EMPLOYEES, AND THE COMMUNITY.THE PROCEEDS OF ALL FUNDRAISERS BY THE FOUNDATION ARE USED TO PROVIDE FINANCIAL SUPPORT TO GALION COMMUNITY HOSPITAL FOR EQUIPMENT AND SERVICES THAT WOULD HAVE A POSITIVE IMPACT ON THE PATIENTS, EMPLOYEES, AND THE COMMUNITY. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 70092 | Expense |
| Grants | 873 | Grants |
| Revenue | 0 | Revenue |
| Description | SUPPORT GALION COMMUNITY HOSPITAL AND SUBSIDIARY ORGANIZATIONS THAT PROMOTE HEALTH CARE IN CRAWFORD COUNTY, OHIO AND SURROUNDING COUNTIES. | Description |
| Total Program Service Expense | 70092 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 0 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 1 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 12 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 12 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 0 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | OH | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | D ERIC DRAIME | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 4194685501 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 269 PORTLAND WAY SOUTH | AddressLine1 |
| City | GALION | City |
| State | OH | State |
| ZIP Code | 44833 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (14 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| ERIC GEYER | ||||||
| CHAIR | 0.20 | X | X | 0 | 0 | 0 |
| KENNETH DAVIS | ||||||
| VICE CHAIR | 0.20 | X | X | 0 | 0 | 0 |
| DICK LEUTHOLD | ||||||
| SECRETARY/TREASURER | 0.20 | X | X | 0 | 0 | 0 |
| BOYD EPPERSON | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| MARGARET CAGLE | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| LINDA SCHIEFER | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| RICHARD HARER | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| DAVE SPRAW | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| JAMES W PRY | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| MARYLYN STRANG | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| DAWN RATLIFF | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| DOUG SCHILLING | ||||||
| DIRECTOR | 0.20 | X | 0 | 0 | 0 | |
| JERRY MORASKO | ||||||
| PRESIDENT/CEO | 0.20 | X | 0 | 256642 | 0 | |
| D ERIC DRAIME | ||||||
| CFO | 0.20 | X | 0 | 180628 | 0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 437270 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 0 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| All Other Contributions | 289690 | AllOtherContributions |
| Total Contributions | 289690 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 28697 | TotalRevenueColumn |
| Exclusion | $28,697 | ExclusionAmount |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 27985 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | -27985 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -27985 | TotalRevenueColumn |
| Exclusion | -$27,985 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 290402 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $712 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 873 | Total |
| Program Services | 873 | ProgramServices |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 66901 | Total |
| Program Services | 58873 | ProgramServices |
| Management And General | 8028 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5998 | Total |
| Program Services | 5278 | ProgramServices |
| Management And General | 720 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 87 | Total |
| Program Services | 87 | ProgramServices |
Other Expenses OtherExpenses (3 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBT EXPENSE | 4000 | 4000 | |
| BANK SERVICE CHARGES | 1102 | 970 | 132 |
| SPECIAL PROJECT COSTS | 13 | 11 | 2 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 78974 | Total |
| Program Services | 70092 | ProgramServices |
| Management And General | 8882 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 182324 | BOY |
| EOY | 363500 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 59556 | BOY |
| EOY | 26679 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 130878 | BOY |
| EOY | 130543 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 372758 | BOY |
| EOY | 520722 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 109932 | BOY |
| EOY | 46468 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 109932 | BOY |
| EOY | 46468 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 73111 | BOY |
| EOY | 235445 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 189715 | BOY |
| EOY | 238809 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 262826 | BOY |
| EOY | 474254 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 372758 | BOY |
| EOY | 520722 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | 211428 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org170b1 Avi | X | PubliclySupportedOrg170b1Avi |
Gifts Grants Contrib Received170 GiftsGrantsContribReceived170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 280870 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 17383 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 16104 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 51374 | CurrentTaxYearMinus1Year |
| Current Tax Year | 289690 | CurrentTaxYear |
| Total | 655421 | Total |
Total170 Total170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 280870 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 17383 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 16104 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 51374 | CurrentTaxYearMinus1Year |
| Current Tax Year | 289690 | CurrentTaxYear |
| Total | 655421 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Amounts Subst Contributors Total | 153306 | AmountsSubstContributorsTotal |
| Public Support Total170 | 502115 | PublicSupportTotal170 |
Gross Investment Income170 GrossInvestmentIncome170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 894 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 7 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 6 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 9468 | CurrentTaxYearMinus1Year |
| Current Tax Year | 28697 | CurrentTaxYear |
| Total | 39072 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Support | 694493 | TotalSupport |
| Public Support Pertcentage170 | 0.72300 | PublicSupportPertcentage170 |
| Public Support Pertcent Prior Year | 0.73530 | PublicSupportPertcentPriorYear |
| Thirty Three Percnt Tests CY170 | X | ThirtyThreePercntTestsCY170 |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (2 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| INTEREST RECEIVABLE | 423 |
| FUTURE CAPITAL IMPROVEMENTS BY BOARD OF TRUSTEES | 130120 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 130543 | TotalBookValueOtherAssets |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | Identifier |
| Return Reference | PART X: | ReturnReference |
| Explanation | THE INTERNAL REVENUE SERVICE HAS RULED THAT GCH, CHA, NCOFCC, BCH, FOUNDATION, AND HOMECARE MATTERS ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AVITA AND GCH ACQUISITION SUB HAVE APPLIED WITH THE INTERNAL REVENUE SERVICE FOR TAX-EXEMPT ORGANIZATION STATUS AS DEFINED UNDER SECTION 501(C)(3), WHICH IS PENDING AS OF JUNE 30, 2012. ACCORDINGLY, NO PROVISION FOR FEDERAL INCOME TAXES HAS BEEN MADE IN THE CONSOLIDATED FINANCIAL STATEMENTS. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF JUNE 30, 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO JUNE 30, 2009. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (2 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JERRY MORASKO | |||||||||||||
| 0 | 230142 | 0 | 26500 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 256642 | 0 | 0 |
| D ERIC DRAIME | |||||||||||||
| 0 | 158866 | 0 | 21762 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 180628 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | SUPPLEMENTAL INFORMATION | Identifier |
| Return Reference | PART III | ReturnReference |
| Explanation | PART I, LINE 3: A RELATED ORGANIZATION, GALION COMMUNITY HOSPITAL, USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -WRITTEN EMPLOYMENT CONTRACT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| Return ReferenceReturnReference | ExplanationExplanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | THE SOLE MEMBER OF THE CORPORATION SHALL, AT ALL TIMES, BE AVITA HEALTH SYSTEM. |
| FORM 990, PART VI, SECTION A, LINE 7A | MEMBERS OR DIRECTORS SHALL HAVE THE APPROVAL OF THE BOARD OF DIRECTORS OF AVITA HEALTH SYSTEM. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE MEMBER HAS THE RIGHT TO APPROVE OR RATIFY DECISIONS OF THE ORGANIZATION'S GOVERNING BODY, SUCH AS APPROVAL OF THE GOVERNING BODY'S ELECTION OR REMOVAL OF MEMBERS. |
| FORM 990, PART VI, SECTION A, LINE 8B | THE ORGANIZATION DOES NOT HAVE SUB-COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AND SENT TO THE EXECUTIVE COMMITTEE OF GALION COMMUNITY HOSPITAL'S BOARD FOR THEIR REVIEW PRIOR TO FILING. THE BOARD EXECUTIVE COMMITTEE APPROVES THE FORM 990 FOLLOWING REVIEW, AS AUTHORIZED BY THE FULL GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 12C | GALION COMMUNITY HOSPITAL HAS A CONFLICT OF INTEREST POLICY THAT COVERS ALL BOARD OF DIRECTORS AND OFFICERS OF THE CORPORATION. CONFLICT OF INTEREST SURVEYS ARE REVIEWED BY BOARD CHAIRMAN AND THE CEO TO ENSURE COMPLIANCE. VARIOUS RESTRICTIONS ARE IMPOSED ON INDIVIDUALS WITH POTENTIAL CONFLICTS OF INTEREST (I.E. INABILITY TO VOTE) UNTIL DECISION HAS BEEN MADE ON POTENTIAL CONFLICT. AVITA HEALTH FOUNDATION HAS ADOPTED THIS POLICY. |
| FORM 990, PART VI, SECTION B, LINE 15A | GALION COMMUNITY HOSPITAL'S PROCESS FOR DETERMINING COMPENSATION CONSISTED OF BOARD EXECUTIVE COMMITTEE REVIEW OF OHIO HOSPITAL ASSOCIATION COMPENSATION SURVEYS, AND THE COMMITTEE DETERMINES EXECUTIVE COMPENSATION BASED ON THIS COMPARABILITY DATA. CONTEMPORANEOUS MINUTES ARE KEPT OF MEETINGS HELD BY THE EXECUTIVE COMMITTEE REGARDING DECISIONS AND DELIBERATIONS OF THIS PROCESS. THIS PROCESS WAS LAST COMPLETED IN JUNE OF 2012 FOR 2013 COMPENSATION. |
| FORM 990, PART VI, SECTION C, LINE 18 | FORM 990 AND FORM 1023 ARE MADE AVAILABLE UPON REQUEST. |
| FORM 990, PART VI, SECTION C, LINE 19 | GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT AVAILABLE TO THE PUBLIC. |
| FORM 990, PART VII | ESTIMATE OF OFFICERS' ALLOCATION OF HOURS WORKED FOR RELATED TAX-EXEMPT ENTITIES: GALION COMMUNITY HOSPITAL: -JERRY MORASKO: 40 -D. ERIC DRAIME: 40 COMMUNITY HEALTH ASSOCIATES, INC.: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 NORTH CENTRAL OHIO FAMILY CARE CENTER: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 AVITA HEALTH SYSTEM: -JERRY MORASKO: .1 -D. ERIC DRAIME: .1 |
| FORM 990, PART XI, LINE 2C | THE ORGANIZATION HAS A FINANCE COMMITTEE WHICH OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (6 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrgControlledOrg | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|---|---|
| GALION COMMUNITY HOSPITAL | |||||||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 344451872 | HOSPITAL SERVICES | OH | 501(C)(3) | LINE 3 | AVITA HEALTH SYSTEM | 1 | |
| COMMUNITY HEALTH ASSOCIATES INC | |||||||||||
| 955 BUCYRUS ROAD | GALION | OH | 44833 | 341784017 | PHYSICIAN OFFICE | OH | 501(C)(3) | LINE 11A, I | GALION COMMUNITY HOSPITAL | 1 | |
| NORTH CENTRAL OHIO FAMILY CARE CENTER INC | |||||||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 341807906 | PHYSICIAN OFFICE | OH | 501(C)(3) | LINE 11A, I | GALION COMMUNITY HOSPITAL | 1 | |
| AVITA HEALTH SYSTEM | |||||||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 274385692 | HEALTHCARE | OH | 501(C)(3) | LINE 11A, I | 0 | N/A | |
| GCH AQUISITION SUB | |||||||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 383821803 | AQUISITION COMPANY | OH | 501(C)(3) | LINE 9 | GALION COMMUNITY HOSPITAL | 1 | |
| CRAWFORD COUNTY SHARED HEALTH SERVICES INC | |||||||||||
| 1220 NORTH MARKET STREET | GALION | OH | 44833 | 341484014 | HOME HEALTH & HOSPICE | OH | 501(C)(3) | LINE 9 | GALION COMMUNITY HOSPITAL | 1 | |
Form990 Schedule R Part III Form990ScheduleRPartIII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivityPrimaryActivity | Legal Domicile StateLegalDomicileState | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|
| GALION COMMUNITY PAIN MANAGEMENT LLC | |||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 300602607 | HOSPITAL SUPPORT | OH | N/A |
| GALION COMMUNITY VASCULAR SERVICES LLC | |||||||
| 269 PORTLAND WAY SOUTH | GALION | OH | 44833 | 611613817 | HOSPITAL SUPPORT | OH | N/A |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 1 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |