2012-08-14T13:33:15-05:00 2011-09-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 200936376 WEST GEORGIA HEALTH FOUNDATION INC WEST 7068821411 1514 VERNON ROAD LAGRANGE GA 30240 PAUL PERROTTI 7068821411 2012-08-14 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z PAUL PERROTTI 1514 VERNON ROAD LAGRANGE GA 30240 1176733 0 X WWW.WGHEALTH.ORG X 2004 GA THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED EXCLUSIVELY FOR THE BENEFIT OF THE WEST GEORGIA MEDICAL CENTER, INC. AND ITS AFFILIATED ENTITIES. 14 8 3 87 0 0 476864 942399 0 0 259676 136866 0 9214 736540 1088479 1558369 351073 0 0 0 0 0 0 0 49342 80669 1607711 431742 -871171 656737 9558422 5721672 4757756 231833 4800666 5489839 NONE 0 0 304183 243783 TO PROVIDE FUNDS FOR SPECIFIC MEDICAL AND CANCER TREATING EQUIPMENT AND SUPPORT OF WEST GEORGIA MEDICAL CENTER. 90000 90000 TO PROVIDE SUPPORT TO WEST GEORGIA MEDICAL CENTER, INC. FOR OPERATING THE HOSPICE CENTER. 16290 16290 HELPING HANDS FAMILY ASSISTANCE PROGRAM - TO ASSIST PRESENT AND RETIRED WGHS EMPLOYEES AND HOSPITAL AUXILIARY VOLUNTEERS WITH FINANCIAL SUPPORT IN TIMES OF CRISIS. QUALIFYING HARDSHIPS INCLUDE CATASTROPHIC ILLNESS OR ACCIDENT SUFFERED BY A RECIPIENT OR AN UNINSURED LOSS TO A PRIMARY RESIDENCE CAUSED BY FIRE OR OTHER MAJOR ACCIDENT OR DISASTER. FROM OCTOBER 1, 2010 - SEPTEMBER 30, 2011, THE HELPING HANDS PROGRAMS HAS PROVIDED $16,290 IN ASSISTANCE TO 32 WEST GEORGIA HEALTH SYSTEM EMPLOYEES. 6040 1000 6040 1000 416513 1 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 2 0 1 3 1 0 0 0 0 0 1 1 0 0 0 0 X 14 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 GA X JENNY MYHAND WEST GEORGIA HEALTH 7068453157 1514 VERNON ROAD LAGRANGE GA 30240 WESLEY SMITH 1.00 X X 0 0 0 PATRICK CREWS 1010-211 1.00 X X 0 0 0 SANDY SIMMONS 211-911 1.00 X X 0 0 0 WAYNE ABBOTT 1.00 X X 0 0 0 GERALD FULKS 1.00 X X 0 470814 86210 HEATHER GRAHAM 1.00 X 0 0 0 RICK MALLORY 042011-092011 1.00 X 0 0 0 AIMEE THOMPSON MADDOX 1.00 X 0 52838 13390 KYLE CRAWFORD 1.00 X 0 0 0 WAYNE HUNTER 1.00 X 0 0 0 TERRY MCMILLAN 1.00 X 0 0 0 BEVERLY LUNDBERG 1.00 X 0 0 0 DR BRETT BOWIE 1.00 X 0 19150 0 DR JULIAN DUTTERA 1.00 X 0 20188 0 ELLEN HARRIS 1.00 X 0 0 0 DR DAVID MARTIN 1.00 X 0 100000 0 SUSAN FERGUSON 40.00 X X 0 52615 4842 CATHERINE WIGGINS 1.00 X 0 90568 44544 PAUL PERROTTI 1.00 X X 0 423168 40390 JOE RAGLAND 102010-042011 1.00 X 0 0 0 0 1229341 189376 0 0 1 0 0 101490 74486 766423 942399 169497 169497 32631 -32631 -32631 -32631 58922 101490 55623 3299 3299 MISCELLANEOUS 900099 5915 5915 5915 1088479 0 0 146080 333783 333783 17290 17290 13461 13461 1000 1000 952 184 768 BAD DEBT 62524 62524 CAMP DOGWOOD GRIEF CAMP 2732 2732 431742 416513 15229 0 539077 729236 288655 379291 8730690 4613145 9558422 5721672 9186 389 4748570 231444 4757756 231833 X 3888666 4577839 912000 912000 4800666 5489839 9558422 5721672 X 656737 32436 X 0 1 1 X 0 X 1328051 726312 748072 476864 1007236 4286535 1328051 726312 748072 476864 1007236 4286535 193822 4092713 454640 322117 219576 146610 136866 1279809 5566344 0.73530 0.76160 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4800666 945878 155841 412546 5489839 5264798 523813 647124 1635069 4800666 12371256 821933 -3776 7924615 5264798 0.19000 0.81000 0 0 0 DUE TO AFFILIATE 231444 231444 1088479 431742 656737 32436 32436 689173 1101719 32436 56789 89225 1012494 75985 75985 1088479 412546 56789 56789 355757 75985 75985 431742 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: NET ASSETS ARE RELEASED FROM RESTRICTIONS WHEN EXPENSES ARE INCURRED TO SATISFY THE RESTRICTED PURPOSES, BY PASSAGE OF TIME OR BY OCCURENCE OF SPECIFIC EVENTS. NET ASSETS RELEASED DURING THE YEAR WERE PRIMARILY FOR THE CONTRIBUTIONS AND SUPPORT OF CONSTRUCTION OF ADDITIONAL FACILITIES, SPECIFIC MEDICAL AND CANCER TREATMENT EQUIPMENT, AND THE HOSPICE PROGRAM OF LAGRANGE-TROUP COUNTY HOSPITAL AUTHORITY. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FOUNDATION HAS BEEN CLASSIFIED AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) AND HAS BEEN DETERMINED NOT TO BE A PRIVATE FOUNDATION UNDER SECTION 509(A). ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN INCLUDED IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE FOUNDATION HAS EVALUATED ITS TAX POSITIONS AND HAS DETERMINED THAT IT DOES NOT HAVE ANY MATERIAL UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF SEPTEMBER 30, 2011, AND 2010. FISCAL YEARS ENDING ON AND AFTER SEPTEMBER 30, 2008 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 55,623. DISCOUNT ON PLEDGES RECEIVABLE 1,166. PART XII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT FEES 13,461. BAD DEBT 62,524. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSES 55,623. DISCOUNT ON PLEDGES RECEVIABLE 1,166. PART XIII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT EXPENSES 13,461. BAD DEBT 62,524. GOLF TOURNAMENT 122781 83284 39497 9100 24208 2549 3639 POINSETTIA SALE 22649 12674 9975 9975 2 14982 5532 9450 2350 594 3208 160412 101490 58922 9100 24208 4899 594 16822 55623 3299 1 WEST GEORGIA MEDICAL CENTER INC 1514 VERNON ROAD LAGRANGE GA 30240 205497506 501(C)(3) 333783 HOSPITAL OPERATIONS 1 HELPING HANDS EMPLOYEE PROGRAM 32 16290 TUITION REIMBURSEMENT 1 1000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: FUNDS WERE USED TO SUPPORT WEST GEORGIA MEDICAL CENTER, INC., A RELATED 501(C)(3) ORGANIZATION AND OTHER AFFILIATED HEALTHCARE PROVIDERS. THE HELPING HANDS FAMILY ASSISTANCE PROGRAM IS AN EMPLOYEE EMERGENCY ASSISTANCE PROGRAM. X X 1 1 X X X X 0 1 0 0 0 0 0 0 0 GERALD FULKS 0 374356 0 96458 0 0 0 72819 0 13391 0 557024 0 0 PAUL PERROTTI 0 232685 0 42188 0 148295 0 29724 0 10666 0 463558 0 148295 PART I, LINE 1A THE ORGANIZATION PAYS MINOR SPOUSAL TRAVEL AND COUNTRY CLUB DUES FOR THE CEO ONLY. THESE ARE ADDED TO HIS TAXABLE COMPENSATION. PART I, LINE 4B EMPLOYER CONTRIBUTIONS TO THE 457(F) EXECUTIVE RETIREMENT PLAN INCLUDE $20,260 FOR PAUL PERROTTI AND $55,700 FOR GERALD FULKS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS WEST GEORGIA HEALTH SERVICES, INC. A RELATED 501(C)(3) ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A UPON A VACANCY, THE MEMBERS OF THE BOARD OF DIRECTORS SHALL BE APPOINTED BY THE BOARD OF DIRECTORS OF W. GA HEALTH SERVICES, INC. TO SERVE A TERM OF 4 YEARS AND UNTIL A SUCCESSOR HAS BEEN APPOINTED, OR UNTIL THE MEMBER'S EARLIER DEATH, RESIGNATION, OR REMOVAL. A DIRECTOR MAY SERVE UP TO TWO 4 YEAR SUCCESSIVE TERMS. ANY DIRECTOR MAY BE REMOVED, EITHER FOR OR WITHOUT CAUSE, BY THE BOARD OF DIRECTORS OF W. GA HEALTH SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7B THE DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO THE APPROVAL OF THE ORGANIZATIONS MEMBER THROUGH THE SELECTION AND OVERSIGHT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 WAS PROVIDED TO EACH BOARD MEMBER VIA E-MAIL PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANY DIRECTOR OF THE CORPORATION HAVING ANY POTENTIAL FINANCIAL INTEREST IN THE OUTCOME OF ANY DECISION THAT IS BEFORE THE BOARD OF DIRECTORS SHALL MAKE SUCH INTEREST APPARENT PRIOR TO THE DELIBERATIONS OR VOTE OF THE BOARD OF DIRECTORS ON THIS ISSUE, AND SAID DIRECTOR SHALL ABSTAIN FROM VOTING ON THIS ISSUE, AND ABSENT HIMSELF/HERSELF FROM THIS MEETING DURING DELIBERATIONS ON THIS ISSUE. THE NATURE OF ANY DIRECTOR'S POTENTIAL FINANCIAL INTEREST IN THE OUTCOME OF ANY BOARD DECISION SHALL BE DISCLOSED IN THE MINUTE BOOK OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 15 HUMAN RESOURCES MAKES COMPENSATION RECOMMENDATIONS BASED ON COMPARATIVE MARKET ANALYSIS WHICH IS THEN REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 32,436. LAGRANGE-TROUP COUNTY HOSPITAL AUTHORITY 1514 VERNON ROAD LAGRANGE GA 30240 562609278 HOSPITAL AUTHORITY GA 501(C)(3) LINE 3 N/A 0 VERNON WOODS RETIREMENT COMMUNITY INC 1514 VERNON ROAD LAGRANGE GA 30240 582575049 ASSISTED LIVING GA 501(C)(3) LINE 9 N/A 0 WEST GEORGIA HEALTH SERVICES INC 1514 VERNON ROAD LAGRANGE GA 30240 205497622 PARENT OF HEALTH SYSTEM GA 501(C)(3) LINE 11A, I N/A 0 WEST GEORGIA MEDICAL CENTER INC 1514 VERNON ROAD LAGRANGE GA 30240 205497506 HOSPITAL GA 501(C)(3) LINE 3 N/A 0 WEST GEORGIA HEALTH PHYSICIANS INC 1514 VERNON ROAD LAGRANGE GA 30240 275125341 PHYSICIAN PRACTICE GA WEST GEORIGA HEALTH SERVICES INC C 0 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0