2012-04-02T09:35:33-05:00 2011-06-30 CLARK SCHAEFER HACKETT & CO 2525 N LIMESTONE STREET SPRINGFIELD OH 45503 990 2010-07-01 310787073 MENTAL HEALTH SERVICES FOR CLARK AND MADISON COUNTIES INC MENT 9373992701 1345 NORTH FOUNTAIN BLVD SPRINGFIELD OH 45504 MARY BETH TAYLOR 9373999500 2012-03-31 1 DEVESH KAMAL CPA 9373992000 2012-03-31 2010 2016-02-24 21:20:13Z MARY BETH TAYLOR 1345 NORTH FOUNTAIN BLVD SPRINGFIELD OH 45504 14533342 0 X WWW.MHSCC.ORG X 1969 OH PROVIDES MENTAL AND BEHAVIORAL HEALTH SERVICES TO RESIDENTS OF CLARK AND MADISON COUNTIES OHIO. 20 20 288 0 0 0 6076093 6139730 7289590 7089266 115956 14568 941326 1223110 14422965 14466674 0 0 0 0 10601401 10450245 0 0 0 3182600 2845797 13784001 13296042 638964 1170632 12623127 13494291 4446967 4140423 8176160 9353868 X WE ARE A PRIVATE, NOT FOR PROFIT COMPREHENSIVE BEHAVIORAL HEALTHCARE SYSTEM DEDICATED TO SERVING INDIVIDUALS,FAMILIES, AND OUR COMMUNITY WITH HIGH QUALITY, COST EFFECTIVE CARE. OUR SERVICES ARE INTEGRATED WITH THE HEALTHCARE ENVIRONMENT. WE ARE CHARITABLE TO SERVE THOSE IN NEED WITHIN THE LIMITS OF OUR RESOURCES. 0 0 2579248 2319424 ADULT CARE, OR INPATIENT PSYCHIATRIC MENTAL HEALTH SERVICES SERVED 794 CLIENTS IN FISCAL YEAR 2011. 7613300 5465015 OUTPATIENT PSYCHIATRIC SERVICES SERVED 5,730 CLIENTS DURING THE FISCAL YEAR. 755410 492858 RESIDENTIAL SERVICES FOR CLIENTS WITH SEVERE MENTAL DISABILITIES WERE PROVIDED FOR 96 CLIENTS DURING THE FISCAL YEAR. 10947958 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 23 0 1 288 1 0 0 0 0 0 0 0 0 0 0 0 0 X 20 20 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X MARY BETH TAYLOR 9373999500 1345 NORTH FOUNTAIN BLVD SPRINGFIELD OH 45504 JACK SPENCER 3.00 X X 0 0 0 JERRY SIMONTON 3.00 X X 0 0 0 HEATHER CORBIN 3.00 X 0 0 0 GEORGE DEGENHART 3.00 X 0 0 0 ALEXIS EVANS 3.00 X 0 0 0 DEBBIE FINKES 3.00 X 0 0 0 HORTON HOBBS 3.00 X 0 0 0 JEFF HUGHES 3.00 X 0 0 0 DARRELL KITCHEN 3.00 X 0 0 0 LEE ANN LOPEZ 3.00 X 0 0 0 MARY LOU LOFTIS 3.00 X 0 0 0 DON LYNAM 3.00 X 0 0 0 CHARLIE RINEHART 3.00 X 0 0 0 DOUG SCHANTZ 3.00 X 0 0 0 SHAWN TAYLOR 3.00 X 0 0 0 TODD EADES 3.00 X 0 0 0 TERRI WYATT 3.00 X 0 0 0 LYNN ZECHMAN 3.00 X 0 0 0 SUE MCCLELLAND 3.00 X 0 0 0 TOM FRANZEN 3.00 X 0 0 0 JAMES PERRY PHD 40.00 X X 163938 0 19743 MARY BETH TAYLOR 40.00 X 101979 0 16561 DR MARK A SMITH 40.00 X X 265218 0 23702 DR KALPANA VISHNUPAD 40.00 X X 212032 0 22070 DR YIU-CHUNG CHANG 40.00 X X 201419 0 21535 944586 0 103611 7 0 1 0 SPRINGFIELD PSYCHIATRIC ASSOCIATES 3162 EL CAMINO DR SPRINGFIELD OH 45503 PHYSICIAN 107655 1 20882 6103648 15200 6139730 TITLE XIX MEDICAID 900099 4936416 4936416 PATIENT SERVICE REVENU 621300 1878816 1878816 RENTAL REVENUE FROM CL 623990 158371 158371 TITLE XX 900099 115663 115663 7089266 49647 49647 31589 66668 -35079 -35079 -35079 OTHER SERVICE REVENUE 621300 1223110 1223110 1223110 14466674 8277297 0 49647 944586 802898 141688 7427482 6311197 1116285 1505872 1254922 250950 572305 487227 85078 191209 100230 90979 705272 619007 86265 204631 175234 29397 214528 169449 45079 OPERATING EXPENSES 612042 412572 199470 PURCHASED SERVICES 448170 196021 252149 OPERATING SUPPLIES 251280 221561 29719 EQUIPMENT EXPENSES 118710 97685 21025 BAD DEBTS 99955 99955 13296042 10947958 2348084 0 5445945 6553733 3792562 3835167 2035823 2013587 6607 6812 277367 161632 5239150 4450575 1012114 788575 51709 58785 1000 76000 12623127 13494291 4415404 4110735 31563 29688 4446967 4140423 X 8176160 9353868 8176160 9353868 12623127 13494291 X 1170632 7076 X X 0 1 1 X 0 X 6988941 7560517 7599005 6076093 6139730 34364286 6988941 7560517 7599005 6076093 6139730 34364286 34364286 206484 230614 191932 115956 49647 794633 60653 1389234 1141233 941326 1188031 4720477 39879396 33126470 0.86170 0.86420 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 57000 57000 1524609 1061298 463311 1804011 1637852 166159 1589709 1518849 70860 263821 232576 31245 788575 14466674 13296042 1170632 7076 7076 1177708 14508829 7076 7076 14501753 -35079 -35079 14466674 13331121 35079 35079 13296042 0 13296042 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME FROM CERTAIN ACTIVITIES NOT DIRECTLY RELATED TO THE AGENCY'S TAX-EXEMPT PURPOSE IS SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. THOSE PROVISIONS CLARIFY THE ACCOUNTING AND RECOGNITION FOR INCOME TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN AGENCY'S ANNUAL REPORTING RETURNS. THE AGENCY'S REPORTING RETURNS ARE SUBJECT TO AUDIT BY FEDERAL AND STATE TAXING AUTHORITIES. OPEN AUDIT PERIODS ARE 2007-2009. NO INCOME TAX PROVISION HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS AS THE AGENCY HAS DETERMINED IT DOES NOT HAVE UNRELATED BUSINESS INCOME SUBJECT TO TAXATION. PART XII, LINE 4B - OTHER ADJUSTMENTS: LOSS ON SALE OF ASSETS -35,079. 1 1 1 X 175.000000000000 1 X 1 1 1 0 0 770090 664700 112390 0.00850 770090 664700 112390 0.00850 770090 664700 112390 0.00850 1 62385 1008287 1077804 -69517 X 1 1 1 1 MENTAL HEALTH SERVICES

1345 N FOUNTAIN BLVD SPRINGFIELD OH 45504

X 16 BED PSYCHIATRIC HOSPITAL MENTAL HEALTH SERVICES 1 0 1 1 175.000000000000 1 250.000000000000 1 X X 1 0 1 X 1 X X X X 1 X 0 0 PART VI, LINE 2: MENTAL HEALTH SERVICES OF CLARK AND MADISON COUNTIES, INC. SCREENS ALL PATIENTS FOR CHARITY CAREELIGIBILITY BASED ON THEIR INCOME AND CURRENT FEDERAL POVERTY LEVEL GUIDELINES. IN ADDITION, SELF-PAY PATIENTS AND PATIENTS WITH OUTSTANDING MEDICAL EXPENSES THAT EXCEED $5,000 ARE ELIGIBLE FOR A 30% DISCOUNT. IN RELATION TO THE NEEDS OF THE COMMUNITY, WE ALSO SEEK THE INPUT OF THE COMMUNITY DURING THE STRATEGIC PLANNING PROCESS BASED ON ACCUMULATED DATA AND FEEDBACK. FOR 2012, A COMMUNITY BENEFIT REPORT WILL BE PREPARED. PART VI, LINE 3: THE INPATIENT BILLING CLERK MEETS WITH THE PATIENT, THE PATIENTS FAMILY OR ANOTHER AUTHORIZED GUARDIAN OR REPRESENTATIVE TO DISCUSS CLIENT CARE PROGRAMS. IN ADDITION, WE HAVE A MEDICAID REFERRAL COUNSELOR WHO ASSISTS CLIENTS WITH COMPLETION OF MEDICAID AND PRESCRIPTION DRUG ASSISTANCE APPLICATIONS. PART VI, LINE 4: CLARK AND MADISON COUNTIES ARE LOCATED IN SOUTHWEST OHIO WITH AN AREA POPULATION OF APPROXIMATELY 181,000. THE PERCENTAGE OF HOUSEHOLDS UNDER THE FEDERAL POVERTY GUIDELINES IS 15%. THE CLIENTS THAT WE SERVE ARE TYPICALLY ELIGIBLE FOR MEDICAID, MEDICARE OR OTHER FEDERAL ASSISTANCE PROGRAMS. THIS ELIGIBILITY IS USUALLY A FUNCTION OF OUR CLIENTS PSYCHIATRIC DISABILTIIES. X X X 0 0 0 0 0 0 0 0 0 JAMES PERRY PHD 163938 0 0 0 0 0 0 0 19743 0 183681 0 0 0 DR MARK A SMITH 265218 0 0 0 0 0 0 0 23702 0 288920 0 0 0 DR KALPANA VISHNUPAD 212032 0 0 0 0 0 0 0 22070 0 234102 0 0 0 DR YIU-CHUNG CHANG 201419 0 0 0 0 0 0 0 21535 0 222954 0 0 0 MENTAL HEALTH RECOVERY BOARD OF CLARK GREENE AND MADISON COUNTIES DEFERRED LOAN FOR HOUSING FOR MENTALLY ILL X 75000 29688 0 1 1 YUI-CHUNG CHAN SALARY ADVANCE X 20000 0 1 1 29688 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEES AUDIT COMMITTEE REVIEWS THE FORM 990 AND APPROVES IT BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD OF TRUSTEES REVIEW THE CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS AND COMPLETE SURVEY AND STATEMENT OF UNDERSTANDING. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD REFERENCES VARIOUS INDUSTRY COMPENSATION STUDIES AND SALARY SCHEDULES OF COMPARABLE ORGANIZATIONS. THE HUMAN RESOURCES DIRECTOR REPORTS TO THE BOARD OF TRUSTEES REGARDING MATTERS OF COMPENSATION LEVELS AND RESULTS OF SUCH STUDIES. FORM 990, PART VI, SECTION C, LINE 18 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON WRITTEN REQUEST OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 FORM 1023 AND FORM 990 ARE MADE AVAILABLE FOR PUBLIC INSPECTION UPON WRITTEN REQUEST OF THE ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 7,076. THE ORGANIZATION DID NOT CHANGE ITS ACCEPTANCE PROCEDURES FOR THE FINANCIAL STATEMENTS FROM THE PRIOR PERIOD METHOD. MANAGEMENT REVIEWS THE AUDITED FINANCIAL STATEMENTS AND PRESENTS THEM TO THE BOARD FOR APPROVAL. CLEANERS EXTRAORDINAIRE INC 112 LOHNES AVE SPRINGFIELD OH 45504 311110016 JOB TRAINING FOR INDIVIDUALS WITH DISABILITES OH 501(C)(3) 170(B)(1)(A)(VI) N/A 0 RESOURCE CENTER APARTMENTS INC 601 N FOUNTAIN AVE SPRINGFIELD OH 45503 311307922 AFFORDABLE HOUSING FOR THE DISABLED OH 501(C)(3) 170(B)(1)(A)(VI) N/A 0 RESTAN CORP 601 N FOUNTAIN AVE SPRINGFIELD OH 45503 311368099 AFFORDABLE HOUSING FOR THE DISABLED OH 501(C)(3) 509(A)(2) N/A 0 JANI-TURF MAINTENENCE SERVICE INC 112 LOHNES AVE SPRINGFIELD OH 45504 311331268 JANITORIAL AND PROPERTY MAINTENECE SERVICES OH N/A C 5698 104644 1.00000 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 JANI-TURF MAINTENANCE SERVICES INC L 119217 CLEANERS EXTRAORDINAIRE INC L 41789 RESOURCE CENTER APARTMENTS INC P 4600 RESTAN CORP K 600 THE RETURN FOR MENTAL HEAL SERVICES OF CLARK AND MADISON COUNTIES, INC. IS BEING FILED BETWEEN MARCH 1, 2012 AND MARCH 30, 2012, AS DIRECTED BY THE IRS IN NOTICE 2012-4, BECAUSE ELECTRONIC FILING WAS NOT AVAILABLE JANUARY 1, 2012 THROUGH FEBRUARY 29, 2012. I AM REQUESTING THAT PENALTIES BE WAIVED BECAUSE IT WOULD BE INEQUITABLE TO IMPOSE A PENALTY ON US DUE TO THE UNUSUAL CIRCUMSTANCES REQUIRING US TO DELAY THE FILING OF THIS RETURN.