2013-05-15T13:43:54-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2011-07-01 200934451 GALION COMMUNITY HOSPITAL FOUNDATION GALI 4194684841 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME 4194684841 2013-05-15 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z AVITA HEALTH FOUNDATION D ERIC DRAIME 269 PORTLAND WAY SOUTH GALION OH 44833 318387 0 X N/A X 2004 OH 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. 12 12 0 0 0 0 51374 289690 0 0 115145 712 0 0 166519 290402 166519 873 27128 0 0 0 0 0 0 155434 78101 349081 78974 -182562 211428 372758 520722 109932 46468 262826 474254 X 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. 0 0 70092 873 0 SUPPORT GALION COMMUNITY HOSPITAL AND SUBSIDIARY ORGANIZATIONS THAT PROMOTE HEALTH CARE IN CRAWFORD COUNTY, OHIO AND SURROUNDING COUNTIES. 70092 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 OH X D ERIC DRAIME 4194685501 269 PORTLAND WAY SOUTH GALION OH 44833 X ERIC GEYER 0.20 X X 0 0 0 KENNETH DAVIS 0.20 X X 0 0 0 DICK LEUTHOLD 0.20 X X 0 0 0 BOYD EPPERSON 0.20 X 0 0 0 MARGARET CAGLE 0.20 X 0 0 0 LINDA SCHIEFER 0.20 X 0 0 0 RICHARD HARER 0.20 X 0 0 0 DAVE SPRAW 0.20 X 0 0 0 JAMES W PRY 0.20 X 0 0 0 MARYLYN STRANG 0.20 X 0 0 0 DAWN RATLIFF 0.20 X 0 0 0 DOUG SCHILLING 0.20 X 0 0 0 JERRY MORASKO 0.20 X 0 256642 0 D ERIC DRAIME 0.20 X 0 180628 0 0 437270 0 0 0 1 0 0 289690 289690 28697 28697 27985 -27985 -27985 -27985 290402 0 0 712 873 873 66901 58873 8028 5998 5278 720 87 87 BAD DEBT EXPENSE 4000 4000 BANK SERVICE CHARGES 1102 970 132 SPECIAL PROJECT COSTS 13 11 2 78974 70092 8882 0 182324 363500 59556 26679 130878 130543 372758 520722 109932 46468 109932 46468 X 73111 235445 189715 238809 262826 474254 372758 520722 211428 0 X X 0 1 1 X 0 X 280870 17383 16104 51374 289690 655421 280870 17383 16104 51374 289690 655421 153306 502115 894 7 6 9468 28697 39072 694493 0.72300 0.73530 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 INTEREST RECEIVABLE 423 FUTURE CAPITAL IMPROVEMENTS BY BOARD OF TRUSTEES 130120 130543 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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. 0 0 0 0 0 0 0 0 0 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 SUPPLEMENTAL INFORMATION PART III 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 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. 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 N/A 0 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 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0