2012-05-15T15:06:10-05:00 2011-06-30 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2010-07-01 200934451 GALION HEALTH FOUNDATION GALI 4194684841 269 PORTLAND WAY SOUTH GALION OH 44833 D ERIC DRAIME 4194684841 2012-05-14 1 BERNIE OSTROWSKI 6148493000 2010 2016-02-24 21:20:13Z GALION COMMUNITY HOSPITAL FOUNDATION D ERIC DRAIME 269 PORTLAND WAY SOUTH GALION OH 44833 166519 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. 11 11 0 0 0 0 7389 51374 0 0 21597 115145 0 0 28986 166519 48840 27128 0 0 3041 0 0 0 0 16675 155434 68556 182562 -39570 -16043 297928 372758 19059 109932 278869 262826 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 163910 27128 0 SUPPORT GALION COMMUNITY HOSPITAL AND SUBSIDIARY ORGANIZATIONS THAT PROMOTE HEALTH CARE IN CRAWFORD COUNTY, OHIO AND SURROUNDING COUNTIES. 163910 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 11 11 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 PAMELA FELLNER 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 JERRY MORASKO 0.20 X 0 223604 0 D ERIC DRAIME 0.20 X 0 115673 0 DOUG SCHILLING 0.20 X 0 0 0 0 339277 0 0 0 1 0 0 3927 47447 51374 106026 106026 9119 9119 9119 9119 166519 0 0 115145 27128 27128 58789 51734 7055 4200 3696 504 5128 4513 615 845 744 101 85613 75339 10274 BANK SERVICE CHARGES 623 548 75 SPECIAL PROJECT COSTS 176 155 21 MEMBER DUES 60 53 7 182562 163910 18652 0 182324 216415 81513 59556 0 130878 297928 372758 19059 109932 19059 109932 X 102175 73111 176694 189715 278869 262826 297928 372758 -16043 0 X X 0 1 1 X 0 X 482130 280870 17383 16104 51374 847861 482130 280870 17383 16104 51374 847861 208744 639117 10966 894 7 6 9468 21341 869202 0.73530 0.68620 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 INTEREST RECEIVABLE 90 FUTURE CAPITAL IMPROVEMENTS BY BOARD OF TRUSTEES 130788 130878 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE INTERNAL REVENUE SERVICE HAS RULED THAT GCH, CHA, NCOFCC, BCH, AND FOUNDATION ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AVITA AND GCH ACQUISITON 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, 2011. ACCORDINGLY, NO PROVISION FOR FEDERAL INCOME TAXES HAS BEEN MADE IN THE CONSOLIDATED FINANCIAL STATEMENTS. GCPM, GCVS, AND BCH PHYSICIAN CO., LLC ARE LIMITED LIABILITY COMPANIES THAT HAVE ELECTED TO BE TAXED AS PARTNERSHIPS. PARTNERSHIP INCOME OR LOSS IS NOT TAXES AT THE ENTITY LEVEL, BUT FLOWS THROUGH TO THE PARTNERS. THE SYSTEM'S SHARE OF THE TAXABLE INCOME MAY BE SUBJECT TO UNRELATED BUSINESS INCOME TAX. THERE WERE NO SIGNIFICANT PROVISIONS FOR INCOME TAX FOR 2011. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2008. 1 GALION COMMUNITY HOSPITAL 269 PORTLAND WAY SOUTH GALION OH 44833 344451872 501(C)(3) 27128 HOSPITAL RENOVATION GRANT 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAKES GRANTS TO RELATED EXEMPT ORGANIZATIONS TO FURTHER THEIR EXEMPT PURPOSES. 0 0 0 0 0 0 0 0 0 JERRY MORASKO 0 184600 0 35000 0 4004 0 0 0 0 0 223604 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: GALION HEALTH FOUNDATION RELIED ON A RELATED ORGANIZATION (GALION COMMUNITY HOSPITAL) THAT USED THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -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 GALION COMMUNITY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OR DIRECTORS SHALL HAVE THE APPROVAL OF THE BOARD OF DIRECTORS OF GALION COMMUNITY HOSPITAL. 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. GALION 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 PROCESSS. THIS PROCESS WAS LAST COMPLETED IN 2010. THIS PROCESS IS PERFORMED BY GALION COMMUNITY HOSPITAL FOR GALION HEALTH FOUNDATION'S EXECUTIVES. 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 NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC. FORM 990, PART VII ESTIMATE OF OFFICERS' ALLOCATION OF HOURS WORKED FOR GALION COMMUNITY HOSPITAL RELATED ENTITIES: GALION COMMUNITY HOSPITAL -JERRY MORASKO: 40 -D. ERIC DRAIME: 40 -ANDREW DANIELS: 0 COMMUNITY HEALTH ASSOCIATES, INC.: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 -ANDREW DANIELS: .2 NORTH CENTRAL OHIO FAMILY CARE CENTER: -JERRY MORASKO: .2 -D. ERIC DRAIME: .2 -ANDREW DANIELS: .2 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 0 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 ACQUISITION SUB 269 PORTLAND WAY SOUTH GALION OH 44833 383821803 ACQUISITION COMPANY OH 501(C)(3) LINE 9 GALION COMMUNITY HOSPITAL 0 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 GALION COMMUNITY HOSPITAL 0 0 GALION COMMUNITY VASCULAR SERVICES LLC 269 PORTLAND WAY SOUTH GALION OH 44833 611613817 HOSPITAL SUPPORT OH GALION COMMUNITY HOSPITAL 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 GALION COMMUNITY HOSPITAL O 107655 PAYROLL