2013-10-28T13:52:52-05:00 2012-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2012-01-01 391459276 APPLETON MEDICAL CENTER FOUNDATION INC APPL 9207386506 1818 N MEADE STREET APPLETON WI 54911 DEAN HIGH 9207386506 2013-10-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2013-10-15 2012 2016-02-25 16:41:14Z DEAN HIGH 1818 N MEADE STREET APPLETON WI 54911 1196933 0 X WWW.AMCFOUNDATION.ORG X 1983 WI ENHANCE THE HEALTH OF OUR COMMUNITIES. 17 12 0 60 0 0 507834 790656 0 0 -204930 317747 55113 55150 358017 1163553 172898 143984 0 0 245728 279378 0 0 244397 102504 88134 521130 511496 -163113 652057 10645212 12041669 50428 37905 10594784 12003764 X TO RAISE FUNDS AND CARRY OUT THE PURPOSES OF THE APPLETON MEDICAL CENTER, APPLETON, WI. THESE PURPOSES INCLUDE THE ENCOURAGEMENT OF EFFECTIVE SERVICES WITHIN AND AROUND APPLETON AND THE GREATER FOX VALLEY AREA BY PROVIDING SCHOLARSHIPS AND GRANTS TO ORGANIZATIONS THAT SUPPORT AMC'S PURPOSE. TO CREATE AND SUPPORT HOSPITAL HEALTH CARE INITIATIVES THROUGH FUNDING FOR THE APPLETON MEDICAL CENTER AND RELATED OTHER COMMUNITY HEALTH CARE PROVIDERS. 0 0 139484 139484 TO RAISE FUNDS AND CARRY OUT THE PURPOSES OF THE APPLETON MEDICAL CENTER, APPLETON, WI. THESE PURPOSES INCLUDE THE ENCOURAGEMENT OF EFFECTIVE SERVICES WITHIN AND AROUND APPLETON AND THE GREATER FOX VALLEY AREA BY PROVIDING SCHOLARSHIPS AND GRANTS TO ORGANIZATIONS THAT SUPPORT AMC'S PURPOSE. TO CREATE AND SUPPORT HOSPITAL HEALTH CARE INITIATIVES THROUGH FUNDING FOR THE APPLETON MEDICAL CENTER AND RELATED OTHER COMMUNITY HEALTH CARE PROVIDERS. 4500 4500 7 SCHOLARSHIPS WERE GRANTED TO INDIVIDUALS WHO ARE GOING INTO THE MEDICAL FIELD OF STUDY. 143984 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 17 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X JOSEPH W ENGELS 9208305971 PO BOX 8025 APPLETON WI 54911 ANDERLADAVID MD 1.00 43.00 X 0 308202 33534 BORENCLARK JR MD 1.00 40.00 X 0 237312 23611 BYTOFJOYCE 1.00 X 0 0 0 DUNGAR STEVE C MD 1.00 X 0 0 0 FULKERSONJAY 1.00 X 0 0 0 HIGH DEAN V 1.00 X X 0 0 0 OLSONTIM 1.00 41.00 X 0 448909 119293 RAYMICHAEL MDPHD 1.00 X 0 0 0 RIESTERJEFF 1.00 1.00 X 0 0 0 SCHAFFMEYER PASTOR ALAN 1.00 X 0 0 0 SCHUBBE PETER J 1.00 X 0 0 0 UEHLINGBARBARA 1.00 X X 0 0 0 WALSH CYRIL P 1.00 X X 0 0 0 WILSON JAMES R 1.00 X X 0 0 0 HUNTERJEFF 1.00 41.00 X 0 398506 139340 FROHNAMICHAEL 15.00 28.00 X X 87699 87702 21625 RUGLANDWALTER 1.00 X 0 0 0 87699 1480631 337403 0 0 1 0 0 420192 370464 790656 140877 140877 176870 0 176870 176870 176870 88530 33380 55150 55150 1163553 0 0 372897 139484 139484 4500 4500 98511 24628 73883 180867 45217 135650 6865 6865 18036 18036 877 877 6774 6774 -8228 -4114 -4114 3102 775 2327 1337 1337 PURCHASED SERVICES 35649 17825 17824 SUPPLIES 8971 2960 6011 MEMBERSHIPS/SUBSCRIPTIO 6094 3047 3047 UNCOLLECTIBLE PLEDGES 4693 4693 3964 1846 2118 511496 143984 123115 244397 1159318 1173565 238058 546981 9247836 10321123 10645212 12041669 50428 37905 50428 37905 X 5510535 6249218 3453019 4091410 1631230 1663136 10594784 12003764 10645212 12041669 652057 756923 0 X X 0 1 X 1 0 X 660549 243392 1306897 507834 790656 3509328 660549 243392 1306897 507834 790656 3509328 1888152 1621176 247961 235618 112227 98740 140877 835423 4344751 347095 0.37310 0.30190 X X APPLETON MEDICAL CENTER FOUNDATION (THE FOUNDATION) DID NOT MEET THE 33 1/3% PUBLIC SUPPORT TEST IN THE PRIOR YEAR. HOWEVER, PURSUANT TO TREASURY REG. 1.170A-9(F)(3), IT SATISFIES THE 10% FACTS AND CIRCUMSTANCES TEST. THE FOUNDATION MAINTAINS A CONTINUOUS AND BONA FIDE PROGRAM FOR THE SOLICITATION OF FUNDS FROM THE GENERAL PUBLIC. HOWEVER, IT RECEIVED PERIODIC SIGNIFICANT CONTRIBUTIONS FROM A RELATED ORGANIZATION, THEDACARE, INC., THAT IS A SECTION 509(A)(3) SUPPORTING ORGANIZATION AND THEREFORE NOT AN EXCLUDED PUBLICALLY SUPPORTED ORGANIZATION. THESE SIGNIFICANT CONTRIBUTIONS MADE DURING 2008 AND 2010 HAVE NOT BEEN VIEWED AS UNUSUAL GRANTS. WITHOUT THESE CONTRIBUTIONS, THE FOUNDATION EASILY SATISFIES THE 33 1/3% TEST. FURTHERMORE, DURING 2009 THE FOUNDATION CONTRIBUTED BACK TO THEDACARE ALMOST $635,000. BASED ON THESE FACTORS, THE FOUNDATION BELIEVES THAT IT IS PUBLICALLY-SUPPORTED AS DEFINED BY THE INTERNAL REVENUE CODE AND REGULATIONS THEREUNDER. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5185470 31906 71610 31094 5257892 5188828 54597 -14882 43073 5185470 5148663 3305 64028 27168 5188828 4876903 1370 287444 17054 5148663 5104609 7064 -234181 589 4876903 0.68370 0.31630 0.00000 0 0 0 X 1953856 756923 756923 1196933 -33380 -33380 1163553 544876 33380 33380 511496 0 511496 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE FOUNDATION HAS ADOPTED INVESTMENT AND SPENDING POLICIES FOR ENDOWMENT ASSETS THAT ATTEMPT TO PROVIDE A PREDICTABLE STREAM OF FUNDING TO PROGRAMS SUPPORTED BY ITS ENDOWMENT WHILE SEEKING TO MAINTAIN THE PURCHASING POWER OF THE ENDOWMENT ASSETS. ENDOWMENT ASSESTS INCLUDE THOSE ASSETS OF DONOR-RESTRICTED FUNDS THAT THE FOUNDATION MUST HOLD IN PERPETUITY OR FOR A DONOR-SPECIFIED PERIOD(S). UNDER THIS POLICY, AS APPROVED BY THE BOARD OF DIRECTORS, THE ENDOWMENT ASSETS ARE INVESTED IN A MANNER THAT IS INTENDED TO PRODUCE RESULTS THAT EXCEED THE PRICE AND YIELD RESULTS OF THE S & P 500 INDEX WHILE ASSUMING A MODERATE LEVEL OF INVESTMENT RISK. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE FOUNDATION IS A TAX-EXEMPT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE FOUNDATION IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE FOUNDATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE FOUNDATION RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2012 OR 2011. FEDERAL TAX RETURNS FOR THE YEARS ENDED 2009 AND BEYOND, REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES -33,380. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 33,380. HIGH FLYIN' GOLF OUTING 52357 52357 16752 3824 LAUGHTER IS THE BEST MEDICINE 36173 36173 983 2833 3035 1202 88530 88530 17735 2833 3035 5026 28629 59901 1 RURAL HEALTH INITIATIVE 100 COUNTY ROAD B SHAWANO WI 54166 208635695 501(C)(3) 46000 GENERAL OPERATIONS APPLETON MEDICAL CENTER INC 1818 NORTH MEADE STREET APPLETON WI 54911 390824015 501(C)(3) 30071 CANCER CARE SUPPORT, CARDIAC CARE SUPPORT, NURSING EDUCATION, AND COMMUNITY GARDENS THEDACARE INC PO BOX 8025 APPLETON WI 54912 391509362 501(C)(3) 16435 CHILD LEARNING CENTER AND ADULT MENTAL HEALTH 3 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION ONLY WRITES CHECKS OUT FOR GRANTS TO ORGANIZATIONS ONCE THE ITEM OR SERVICE HAS ALREADY BEEN RECEIVED BY THE ORGANIZATION. SCHOLARSHIP CHECKS ARE WRITTEN OUT TO THE COLLEGE AND THE RECIPIENT. X 0 1 X 0 1 0 0 0 0 0 0 0 ANDERLADAVID MD 0 305861 0 511 0 1830 0 14500 0 19034 0 341736 0 0 BORENCLARK JR MD 0 237120 0 192 0 0 0 15816 0 7795 0 260923 0 0 OLSONTIM 0 381644 0 58695 0 8570 0 106269 0 13024 0 568202 0 0 HUNTERJEFF 0 331109 0 55333 0 12064 0 103929 0 35411 0 537846 0 0 FROHNAMICHAEL 79176 79177 3299 3300 5224 5225 2666 2667 8146 8146 98511 98515 0 0 PART I, LINE 1B CLUB DUES ARE A TAXABLE BENEFIT OFFERED INFREQUENTLY ON A CASE BY CASE BASIS. THEY NEED TO BE APPROVED UNANIMOUSLY BY THE HIRING VICE PRESIDENT, THE HUMAN RESOURCES VICE PRESIDENT, AND THE CEO. PART I, LINE 3 THE ORGANIZATION RELIES ON THEDACARE, INC., A RELATED 501(C)(3) ORGANIZATION, TO ESTABLISH THE COMPENSATION FOR ITS EXECUTIVE DIRECTOR. THEDACARE, INC. USES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AS ITS METHODS FOR ESTABLISHING THE COMPENSATION FOR APPLETON MEDICAL CENTER FOUNDATION'S EXECUTIVE DIRECTOR. PART I, LINE 4B TIM OLSON IS ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF HIS BASE COMPENSATION. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTIONS 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVESTED IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. NOTHING WAS PAID OUT IN 2012. FORM 990, PART VI, SECTION A, LINE 6 APPLETON MEDICAL CENTER FOUNDATION, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THE ELECTION AND REMOVAL OF DIRECTORS REQUIRES THE APPROVAL OF THEDACARE,INC. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS SHALL NOT BE TAKEN WITHOUT THE APPROVAL OF THEDACARE, INC.: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. AMENDMENT OF THE BYLAWS 3. MERGER, CONSOLIDATION OR DISSOLUTION OF THIS CORPORATION 4. THE CREATION OF ANY SUBSIDIARIES OR AFFILIATES OF THIS CORPORATION FORM 990, PART VI, SECTION B, LINE 11 A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS E-MAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY THROUGH SURVEYS, WHICH ARE REVIEWED BY THE COMPLIANCE OFFICER AND COMMITTEE. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION PROCESS FOR TOP OFFICIALS OF THE ORGANIZATION IS MANAGED BY THEIR EMPLOYER FOR PAYROLL PURPOSES, THEDACARE, INC., A RELATED ORGANIZATION. MANAGEMENT OF THEDACARE, INC. DETERMINES A FAIR AND REASONABLE COMPENSATION FOR THESE INDIVIDUALS BASED ON MARKET AND COMPARABILITY DATA PROVIDED BY HUMAN RESOURCES. NO OTHER OFFICERS OF THE ORGANIZATION RECEIVE ANY COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL ARE AVAILABLE UPON REQUEST. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 HEALTHCARE WI 501(C)(3) LINE 11C, III-FI N/A 0 THEDA CLARK MEDICAL CENTER INC PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 NEW LONDON FAMILY MEDICAL CENTER INC 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 APPLETON MEDICAL CENTER INC PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 SHAWANO MEDICAL CENTER INC 309 N BARTLETTE STREET SHAWANO WI 54166 390807068 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 THEDA CLARK MEDICAL CENTER FOUNDATION INC PO BOX 8025 APPLETON WI 54912 311550056 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 0 WOLF RIVER AREA HEALTHCARE FOUNDATION INC 1405 MILL STREET NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 11A, I NEW LONDON FAMILY MEDICAL CENTER INC 0 GEORGE F PEABODY FOUNDATION INC PO BOX 2553 APPLETON WI 54912 391702534 FOUNDATION WI 501(C)(3) LINE 11A, I APPLETON MEDICAL CENTER INC 0 COMMUNITY HOSPICE FOUNDATION INC PO BOX 1534 APPLETON WI 54912 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 0 SHAWANO MEDICAL CENTER FOUNDATION INC 309 N BARTLETTE STREET SHAWANO WI 54166 391539117 FOUNDATION WI 501(C)(3) LINE 11A, I SHAWANO MEDICAL CENTER INC 0 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0