2012-03-13T05:19:55-05:00 2011-04-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2010-05-01 390807068 SHAWANO MEDICAL CENTER INC SHAW 9205262111 309 NORTH BARTLETTE STREET SHAWANO WI 54166 KENNETH MONGER 7155267310 2012-03-07 1 TERRI REXRODE CPA MST 9206620016 2012-03-07 2010 2016-02-24 21:20:13Z KENNETH MONGER 309 NORTH BARTLETTE STREET SHAWANO WI 54166 41996845 0 X WWW.SHAWANOMED.ORG X 1932 WI THE HOSPITAL OPERATES A 25-BED ACUTE CARE FACILITY AND PROVIDES COMPREHENSIVE MEDICAL, SURGICAL, EMERGENCY, AND OUTPATIENT SERVICES TO THE RESIDENTS OF SHAWANO COUNTY AND THE SURROUNDING AREA. THE HOSPITAL IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL (CAH) UNDER MEDICARE AND MEDICAID REGULATIONS. THE CAH DESIGNATION, WHICH ENABLES THE HOSPITAL TO RECEIVE REIMBURSEMENT UNDER COST-BASED METHODS FOR BOTH MEDICARE AND MEDICAID, LIMITS THE NUMBER OF STAFFED BEDS THE HOSPITAL MAY OPERATE TO 25. 12 9 434 57 0 0 146759 68243 40614827 41241240 393455 586486 25684 16929 41180725 41912898 0 0 0 0 20252893 22226754 0 0 0 20006848 21212242 40259741 43438996 920984 -1526098 56771383 59043182 15710901 18340958 41060482 40702224 X TO PROVIDE HIGH-QUALITY HEALTH CARE SERVICES IN A HEALING ENVIRONMENT. WE EMPOWER OUR PATIENTS AND COMMUNITY TO GET WELL AND STAY HEALTHY. 0 0 37834298 41241240 SHAWANO MEDICAL CENTER, INC. OPERATES A 25-BED ACUTE CARE FACILITY, WHICH PROVIDES LOCAL COMPREHENSIVE MEDICAL, SURGICAL, EMERGENCY, OUTPATIENT, AND HOSPICE SERVICES TO THE COMMUNITY. THE HOSPITAL PROVIDED CHARITY CARE TO 593 PATIENTS AT REDUCED OR NO-CHARGE FOR SERVICES FURNISHED UNDER THE HOSPITAL'S COMMUNITY CARE POLICY AGGREGATING $1,338,597. THE COST OF THESE SERVICES WAS $741,204. ALSO, UNCOMPENSATED HEALTHCARE COSTING $1,513,308 WAS PROVIDED TO 5,421 PATIENTS WHO WERE CLASSIFIED AS BAD DEBTS BECAUSE PATIENTS DID NOT PAY FOR ALL OR PART OF THE HEALTHCARE SERVICES PROVIDED. IN ADDITION, THE HOSPITAL PROVIDES AN IMPORTANT COMMUNITY BENEFIT BY PROVIDING CRITICAL HEALTHCARE LOCALLY. WITHOUT THE HOSPITAL, THIS CARE WOULD NOT BE AVAILABLE LOCALLY. THE HOSPITAL ALSO PROVIDED HEALTH EDUCATION PROGRAMS AND INFORMATION TO THE COMMUNITY AT AN AGGREGATE COST OF $44,505 37834298 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 11 0 1 434 1 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X KENNETH MONGER CFO 7155267310 309 NORTH BARTLETTE STREET SHAWANO WI 54166 X LARRY KLEMENT 2.00 X X 0 0 0 DICK KOEPPEN 2.00 X X 0 0 0 JERRY HENTGES 2.00 X X 0 0 0 PAULA WEGNER 2.00 X X 0 0 0 DR AMY SLAGLE 2.00 X 0 0 0 DR PETER KEENAN 2.00 X 0 0 0 GAIL MOESCH 2.00 X 0 0 0 JIM MEYER 2.00 X 0 0 0 RICK KANE 2.00 X 0 0 0 TIM OLSON 2.00 X X 0 412160 100567 BRIAN BURMEISTER 2.00 X X 0 284915 61721 DR MICHAEL WILLIAMS 2.00 X 0 366050 20111 DOROTHY J ERDMANN 40.00 X 0 0 0 KENNETH S MONGER 40.00 X 92212 0 6556 DR JEFFREY L MINIKEL 40.00 X 542940 0 15044 KSHAMATA SHALINI MD 40.00 X 175250 0 13865 DR RICHARD SARNWICK 35.00 X 191487 0 25668 DR ANN TOUSIGNANT 40.00 X 276528 0 25363 ROBERT L OSMER 32.00 X 335103 0 20773 VINCENT D STUDER 0.00 X 119236 0 16381 1732756 1063125 306049 12 1 1 0 BELLIN MEMORIAL HOSPITAL 744 S WEBSTER AVE POBOX 23400 GREEN BAY WI 54305 ER PHYSICIAN SERVICES 2254970 MCKESSON DRUG DC #8175 3003 AIRPORT ROAD LACROSSE WI 54603 PHARMACEUTICALS 1318121 THEDACARE PO BOX 8025 APPLETON WI 549128025 CRNA CONTRACTOR LABOR FEES 845769 UNIVERSAL HOSPITAL SDS 12-0940 PO BOX 86 MINNEAPOLIS MN 55486 BIOMEDICAL SERVICES AND IV DUMP RENTALS 744387 SHAWANO MUNICPAL UTILITIES 122 N SAWYER STREET SHAWANO WI 54166 UTILITIES 546143 29 26054 42189 68243 NET PATIENT REVENUES 621400 40148287 40148287 OTHER HOSPITAL SERVICE 621400 652968 652968 DIETARY SERVICES 621400 236419 236419 REHAB SERVICES 621400 203566 203566 41241240 261159 261159 77268 76594 674 674 674 323239 2088 323239 2088 325327 325327 23608 7353 16255 16255 41912898 41241240 0 603415 1643024 1643024 15739125 15155758 583367 332394 313795 18599 3311036 3046530 264506 1201175 1057034 144141 185003 185003 68712 68712 52759 40065 12694 157133 17819 139314 814429 736741 77688 51709 43923 7786 125782 87518 38264 583280 530785 52495 3275851 2978520 297331 187145 170302 16843 SUPPLIES 5083589 4648063 435526 PROFESSIONAL CONTRACTED 3031286 3031286 BAD DEBT EXPENSE (PATIE 2482939 2482939 CONTRACT LABOR 2345818 2345818 CONTRACTED SERVICES 1295458 1295458 1471349 1147402 323947 43438996 37834298 5604698 0 975 1125 5058546 11362104 4628559 4693324 1149776 1045802 291204 135814 60496217 31943317 30945135 28552900 14678894 13243611 0 18294 8502 56771383 59043182 3356196 7413846 11963756 10783164 390949 143948 15710901 18340958 X 40449038 40487466 611444 214758 41060482 40702224 56771383 59043182 X -1526098 1167840 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION HAS INDIRECT LOBBYING ACTIVITIES THROUGH THE PAYMENT OF WISCONSIN HOSPITAL ASSOCIATION (WHA) AND AMERICAN HOSPITAL ASSOCIATION (AHA) DUES. THE DUES PAID DURING 2010 WERE WHA - $18,522; AHA - $10,066. LOBBYING EXPENSES WERE APPROXIMATELY 15% OF THE DUES (WHA - $2,778; AHA $1,510). 1574028 1574028 37749268 16732591 21016677 1092925 572284 520641 19987204 14638442 5348762 92792 92792 28552900 INTEREST RATE SWAP AGREEMENTS 143948 143948 41912898 43438996 -1526098 980786 187054 1167840 -358258 41989492 76594 76594 41912898 0 41912898 43515590 76594 76594 43438996 0 43438996 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR UNCERTAIN TAX POSITIONS, THE HOSPITAL 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 HOSPITAL RECORDED NO ASSET OR LIABILITY FOR UNCERTAIN TAX POSITION IN 2011 OR 2010. FEDERAL AND STATE INCOME TAX RETURNS FOR 2010, 2009, AND 2008 REMAIN SUBJECT TO EXAMINATION BY MAJOR TAX JURISDICTIONS. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 76,594. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 76,594. PART XI, LINE 8 - OTHER: INTEREST RATE SWAP AGREEMENT ADJUSTMENT: 187,040 DECREASE IN TEMPORARILY RESTRICTED NET ASSETS: 396,686 NET ASSESTS RELEASED FROM RESTRICTION: 396,700 GOLF BENEFIT 14940 14940 5471 VARIOUS AUXILIARY 8668 8668 1882 0 23608 23608 7353 7353 16255 1 1 1 X 300.000000000000 1 X 275.000000000000 1 1 1 0 1 1 741204 741204 0.01810 8049066 7321793 727273 0.01780 8790270 7321793 1468477 0.03590 28330 28330 0.00070 46500 46500 0.00110 2840 2840 0.00010 77670 77670 0.00190 8867940 7321793 1546147 0.03780 1000 1000 0.00000 400 400 0.00000 1650 1650 0.00000 5200 5200 0.00010 8250 8250 0.00010 1 1374846 0 12989227 12860679 128548 X 1 1 1 1 SHAWANO MEDICAL CENTER INC

309 N BARTLETTE STREET SHAWANO WI 54166

X X X X SHAWANO MEDICAL CENTER INC 1 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 $ 2482939. PART II: COMMUNITY BUILDING AND COMMUNITY HEALTH PROMOTIONS STRESS THE GOALS SET BY HEALTHIEST WISCONSIN 2010. THESE INCLUDE SPORTS MEDICINE SERVICES FOR YOUTH SPORTS, SUPPORT FOR WALKING AND BIKING EVENTS, FREE EDUCATIONAL PROGRAMS INCLUDING A REGULAR DIABETES PROGRAM, HEALTH FAIRS, SUPPORT OF THE RURAL HEALTH INITIATIVE (A RURAL FARM/OUTREACH PROGRAM), A GENEROUS INCOME-BASED PAYMENT PROGRAM (COMMUNITY CARE), SUPPORT OF TECHNICAL AND COLLEGE HEALTH CARE PROGRAMS. PART III, LINE 4: THERE IS NOT A BAD DEBT EXPENSE FOOTNOTE IN THE ORGANIZATION'S FINANCIAL STATEMENTS. THE RATIONALE FOR INCLUDING OTHER BAD DEBT AMOUNTS IN COMMUNITY BENEFIT: PATIENTS ARE TRULY UNABLE TO PAY OUT-OF-POCKET LIABILITY BUT DID NOT COMPLETE THE PROCESS. IF THEY HAVE COMPLETED THE PAPERWORK, THEY WOULD HAVE QUALIFIED FOR CHARITY CARE.PART I, LINE 7: COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS REPORTED ABOVE WAS OBTAINED FROM THE 2011 MEDICARE COST REPORT "COST TO CHARGE" RATIO.SCHEDULE H, PART I, LINE 7 COLUMN (F): THE AMOUNT OF BAD DEBT REMOVED FROM THE DENOMINATOR IN CALCULATING THE PERCENTAGES WAS $2,482,939 PART III, LINE 8: THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS UNDER REVENUE RULING 69-645 STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY IMPLYING THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT.THE ELDERLY ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH HEALTHCARE ACCESS. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE SERVICES, CMS WOULD HAVE THE BURDEN OF PROVIDING THESE SERVICES. THE PATIENTS WOULD HAVE A VERY LONG TRAVEL TIME IF THEY HAD TO GO TO OTHER FACILITIES.COSTING METHODOLOGY USED TO DETERMINE THE AMOUNT OF MEDICARE ALLOWABLE COSTS REPORTED ABOVE WERE DERIVED FROM THE MEDICARE COST REPORT. PART III, LINE 9B: THE WRITTEN DEBT COLLECTION POLICY COVERS PRACTICES THAT WILL BE FOLLOWED FOR PATIENTS WHO ARE KNOW TO QUALIFY FOR FINANCIAL ASSISTANCE OR DISCOUNTED RATES. PART VI, LINE 2: SHAWANO MEDICAL CENTER, IN COOPERATION WITH THE SHAWANO COUNTY DEPARTMENT OF PUBLIC HEALTH, CONDUCTS HEALTH ASSESSMENTS OF THE COMMUNITY EVERY THREE YEARS. THE MOST RECENT WAS COORDINATED WITH THE HEALTHIEST WISCONSIN 2010 PROJECT. THE ASSESSMENT INVOLVES INPUT FROM A MULTI-DISCIPLINARY COMMUNITY TEAM AND FOCUS GROUPS. SHAWANO COUNTY DEPARTMENT OF PUBLIC HEALTH ORGANIZED THE DATA AND HELPED THE COMMITTEE SET PRIORITIES. PART VI, LINE 3: NEW PATIENTS TO OUR FACILITY ARE PROVIDED WITH 1. BROCHURE THAT ADDRESSES FREQUENTLY ASKED QUESTIONS ABOUT PATIENT INSURANCE AND FINANCIAL ARRANGEMENTS. THE BROCHURE COVERS OUR CHARITY CARE PROGRAM REQUIREMENTS AND ALSO INVITES PATIENTS TO CONTACT OUR PATIENT FINANCIAL COUNSELOR TO HELP IDENTIFY OTHER PROGRAMS FEDERAL, STATE OR LOCAL GOVERNMENT THAT PATIENTS MAY BE ELIGIBLE FOR. 2. CHARITY CARE PROGRAM APPLICATIONS ARE AVAILABLE TO ALL PATIENTS AT THE TIME OF REGISTRATION. 3. YEARLY A NOTICE OF AVAILABILITY OF COMMUNITY CARE FINANCIAL ASSISTANCE FOR THE UN-INSURED AND UNDER-INSURED IS PUBLISHED IN LOCAL AND SURROUNDING NEWSPAPERS. NOTICE IS PUBLISHED IN ACCORDANCE WITH REGULATION 42CFR 124.504 NOTICE OF AVAILABILITY OF UNCOMPENSATED SERVICES. PART VI, LINE 4: THE SHAWANO MEDICAL CENTER SERVICE AREA INCLUDES ABOUT 35,000 IN SHAWANO, MENOMINEE AND WAUPACA COUNTIES. PRIMARY SERVICE AREA INCLUDES SHAWANO, GRESHAM, CLINTONVILLE, KESHENA; SECONDARY SERVICE AREA INCLUDES BONDUEL, CECIL, MARION; TERTIARY SERVICE AREA INCLUDES TIGERTON, NEOPOST, AND GILLETT. THERE ARE NO OTHER HOSPITALS IN THE SERVICE AREA. A. THE EMERGENCY DEPARTMENT HANDLES OVER 20,000 VISITS PER YEAR B. ABOUT 400 BABIES ARE BORN AT SMC ANNUALLY. C. SMC IS A CRITICAL-ACCESS HOSPITAL D. SHAWANO MEDICAL CENTER SERVES MEDICALLY UNDERSERVED AREAS INCLUDING WESTERN SHAWANO COUNTY (60.0) AND MENOMINEE COUNTY (60.0). (MUA APPLIES TO AREAS WITH A SCORE OF 62 OR LESS FOR PRIMARY CARE SERVICES PER THE US DEPARTMENT TO HEALTH & HUMAN SERVICES). E. IN SHAWANO COUNTY, 11% OF THE POPULATION LIVES BELOW THE POVERTY LEVEL. COUNTY, 31.7% LIVES BELOW THE POVERTY LEVEL. PART VI, LINE 6: A.OUR BOARD OF TRUSTEES IS COMPRISED OF RESIDENTS WHO LIVE IN THE AREA BUT ARE NOT EMPLOYEES OF SMC. ADMINISTRATORS SERVE AS AD HOC MEMBERS ON THE BOARD.B.SMC HAS AN OPEN CAMPUS FOR PHYSICIANS; PRIVILEGES ARE EXTENDED TO PHYSICIANS FROM THEDACARE PHYSICIANS, BELLINHEALTH, AURORA HEALTH, MENOMINEE TRIBAL CLINIC AND OTHER AREA CLINICS.C.SURPLUS FUNDS HAVE BEEN USED FOR TECHNOLOGICAL IMPROVEMENTS INCLUDING AN IN-HOUSE MRI, SURGICAL EQUIPMENT (INCLUDING ORTHOPEDIC SURGICAL SUPPLIES), AND A COMPREHENSIVE ELECTRONIC MEDICAL RECORD UPGRADE. PART VI, LINE 7: SHAWANO MEDICAL CENTER, INC. ENTERED INTO A DEFINITIVE AFFILIATION AGREEMENT WITH THEDACARE, INC. ON JANUARY 30, 2011. AS PART OF A LARGER FAMILY, SHAWANO MEDICAL CENTER IS IN THE PROCESS OF ALIGNING WITH THEDACARE TO PROMOTE A HEALTHIER SHAWANO COMMUNITY. X X 1 0 0 0 0 0 0 0 0 TIM OLSON 0 322102 0 67348 0 22710 0 87350 0 13217 0 512727 0 0 BRIAN BURMEISTER 0 219678 0 48120 0 17117 0 48147 0 13574 0 346636 0 0 DR MICHAEL WILLIAMS 0 366050 0 0 0 0 0 7266 0 12845 0 386161 0 0 DR JEFFREY L MINIKEL 537641 0 0 0 5299 0 0 0 15044 0 557984 0 0 0 KSHAMATA SHALINI MD 85375 0 62097 0 27778 0 4073 0 9792 0 189115 0 0 0 DR RICHARD SARNWICK 189826 0 0 0 1661 0 5580 0 20088 0 217155 0 0 0 DR ANN TOUSIGNANT 273948 0 0 0 2580 0 5394 0 19969 0 301891 0 0 0 ROBERT L OSMER 316977 0 15000 0 3126 0 0 0 20773 0 355876 0 0 0 VINCENT D STUDER 42659 0 0 0 76577 0 2328 0 14053 0 135617 0 0 0 PART I, LINE 4A VINCENT D. STUDER $38,786.80, DR. KSHAMATA SHALINI $27,518.40. CITY OF SHAWANO WISCONSIN 390807068 2006-10-02 6000000 SEE SCHEDULE K SUPPLEMENTAL INFORMATION 0 0 0 6000000 6000000 2007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE K, PART 1, LINE A DESCRIPTION OF PURPOSE FINANCE THE EXPANSION, IMPROVEMENT AND EQUIPPING OF THE HOSPITAL FACILITY, SPECIFICALLY INCLUDING THE ADDITION OF ATTACHED CLINIC FACILITY FOR HOSPITAL BASED PHYSICIANS AND RENOVATIONS OF OUTPATIENT SURGICAL FACILITIES. DR AMY SLAGLE MEDICAL STAFF PRESIDENT - BOARD OF TRUSTEES 378142 PATIENT REFERRALS 0 REINHARTS FOODS JERRY HENTGES, A BOD MEMBER IS ALSO A MANAGER AT REINHARTS FOODS 167783 FOOD SUPPLIES 0 FORM 990, PART VI, SECTION A, LINE 4 ON 1/30/11 THEDA CARE BECAME THE SOLE CORPORATE MEMBER OF SHAWANO MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 6 OUR BOARD OF TRUSTEES IS COMPRISED OF RESIDENTS WHO LIVE IN THE AREA BUT ARE NOT EMPLOYEES OF SMC. ADMINISTRATORS SERVE AS AD HOC MEMBERS ON THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 ON 1/30/11 THEDA CARE BECAME THE SOLE CORPROATE MEMBER OF SHAWANO MEDICAL CENTER, INC. FORM 990, PART VI, SECTION A, LINE 7A OUR BOARD OF TRUSTEES IS COMPRISED OF RESIDENTS WHO LIVE IN THE AREA BUT ARE NOT EMPLOYEES OF SMC. ADMINISTRATORS SERVE AS AD HOC MEMBERS O THE BOARD. ON 1/31/11, THEDA CARE BECAME THE SOLE CORPORATE MEMBER AND THEY CAN ELECT AND REMOVE TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MUST BE COMPLETED ONLY BY THE MEMBER: MERGE OR CONSOLIDATE THE CORPORATION, SELL, LEASE, TRANSFER OR DISPOSE OF MATERIAL ASSETS, CAUSE THE ORGANIZATION TO ENTER INTO JOINT VENTURES OR AFFILIATIONS, AMEND THE ARTICLES OR BYLAWS, DEVELOP AND APPROVE THE CAPITAL AND OPERATING ANNUAL BUDGETS, AUTHORIZE AND MAKE CAPITAL EXPENDITURES, APPROVE THE STRATEGIC PLANS FROM YEAR TO YEAR, DEVELOP AND APPROVE THE SAFETY AND QUALITY PLAN, APPROVE THE DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION, HIRE AND TERMINATE THE PRESIDENT AND CEO, BORROW OR INCUR DEBT, APPOINT AUDITORS AND LEGAL COUNSEL, AND RETAIN INVESTMENT ADVISORS AND ESTABLISH INVESTMENT POLICIES. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS (BOD) IS GIVEN AN ELECTRONIC COPY FOR REVIEW. THE BOD HAS DELEGATED THE DETAIL REVIEW OF THE FORM 990 TO THE MANAGEMENT OF THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL CONFLICT OF INTEREST STATEMENTS ARE COMPLETED AND SIGNED BY EACH MEMBER OF THE BOARD OF TRUSTEES. CONFLICTS OF INTEREST DISCLOSED BY A MEMBER ARE REVIEWED BY THE ENTIRE BOARD OF TRUSTEES FOR APPROPRIATENESS AND RESOLUTION. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO IS REVIEWED AND APPROVED BY THE GOVERNING BODY. SURVEYS ARE UTILIZED TO DETERMINE BOTH CEO AND OTHER KEY EMPLOYEES' COMPENSATION. DOCUMENTATION IS KEPT WITH RESPECT TO THE DELIBERATION AND DECISIONS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION HAS DEEMED THAT ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. DETAIL OF HOURS WORKED FOR A RELATED ORGANIZATION FORM 990, PART VII TIM OLSON WORKED 40 HOURS FOR A RELATED ORGANIZATION. BRIAN BURMEISTER WORKED 40 HOURS FOR A RELATED ORGANIZATION. DR. MICHAEL WILLIAMS WORKED 40 HOURS FOR A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 980,786. INTEREST RATE SWAP AGREEMENT ADJUSTMENT 187,040. DECREASE IN TEMPORARILY RESTRICTED NET ASSETS -396,686. NET ASSETS RELEASED FROM RESTRICTION 396,700. TOTAL TO FORM 990, PART XI, LINE 5: 1,167,840. AUDITED FINANCIAL STATEMENTS FORM 990, PART XII, LINE 2C THE COMBINED FINANCIAL STATEMENTS OF SHAWANO MEDICAL CENTER, INC. AND AFFILIATE ARE AUDITED BY AN INDEPENDENT ACCOUNTANT. THE BOARD OF DIRECTORS FOR THE HOSPITAL IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF THE INDEPENDENT AUDITOR. SHAWANO MEDICAL CENTER FOUNDATION INC 309 N BARTLETTE STREET SHAWANO WI 54166 391539117 SUPPORT WI 11D LINE 11D, III-O N/A 0 THEDACARE 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 FUNCTIONALLY INTEGRATED WI 501(C)(3) LINE 3 N/A 0 APPLETON MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 THEDA CLARK MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 APPLETON MEDICAL CENTER FOUNDATION 1818 N MEADE APPLETON WI 54911 391459276 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 THEDA CLARK FOUNDATION 130 SECOND STREET NEENAH WI 54956 391550056 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 WOLF RIVER FOUNDATION 1405 MILL STREET NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 COMMUNITY HOSPICE FOUNDATION 1818 N MEADE APPLETON WI 54911 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 GEORGE PEABODY FOUNDATION PO BOX 2553 APPLETON WI 54912 391702534 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 NEW LONDON FAMILY MEDICAL CENTER 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54891 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SHAWANO MEDICAL CENTER FOUNDATION INC C 15000