2012-11-15T11:52:01-06:00 2011-12-31 420714325 MCGLADREY LLP PO BOX 5946 MADISON WI 537050946 990 2011-01-01 391459276 APPLETON MEDICAL CENTER FOUNDATION INC APPL 9207386506 1818 NORTH MEADE STREET APPLETON WI 54911 DEAN HIGH 9207386506 2012-11-08 1 JAMES G GRAHAM P00006111 6088332612 2011 2016-02-24 21:20:13Z DEAN HIGH 1818 NORTH MEADE STREET APLETON WI 54911 4843728 0 X WWW.AMCFOUNDATION.ORG X 1983 WI ENHANCE THE HEALTH OF OUR COMMUNITIES. 17 12 0 40 0 0 1306897 507834 0 0 -1166440 -204930 78896 55113 219353 358017 298700 172898 0 0 248609 245728 0 0 232529 90726 102504 638035 521130 -418682 -163113 10807039 10645212 28782 50428 10778257 10594784 ENHANCE THE HEALTH OF OUR COMMUNITIES. 0 0 154898 154898 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. 18000 18000 15 SCHOLARSHIPS WERE GRANTED TO INDIVIDUALS WHO ARE GOING INTO THE MEDICAL FIELD OF STUDY. 172898 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 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 17 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X X JOSEPH W ENGELS 9208305971 122 E COLLEGE AVENUE PO BOX 8025 APPLETON WI 549128025 JOYCE BYTOF 1.00 X 0 0 0 STEVE DUNGAR MD 1.00 X 0 0 0 JAY FULKERSON 1.00 X 0 0 0 BARBARA UEHLING 1.00 X X 0 0 0 CYRIL WALSH MD 1.00 X X 0 0 0 PETER SCHUBBE DC 1.00 X 0 0 0 DIANE ABRAHAM 16.00 X X 29284 29284 1753 DEAN HIGH 1.00 X X 0 0 0 JEFF RIESTER 1.00 X X 0 0 0 JAMES R WILSON 1.00 X X 0 0 0 TIM OLSON 1.00 X 0 433618 99752 DAVID B ANDERLA MD 1.00 X 0 312073 23150 PASTOR ALAN SCHAFFMEYER 1.00 X 0 0 0 MICHAEL FROHNA 16.00 X X 36415 36415 8531 KATHRYN CORREIA 1.00 X 0 521673 96773 65699 1333063 229959 0 0 1 0 0 14450 493384 900 507834 98741 98741 4146870 4450541 -303671 -303671 -303671 90283 35170 55113 55113 358017 0 0 -149817 154898 154898 18000 18000 70841 17710 53131 174887 43722 131165 18036 18036 7843 7843 266 266 2259 565 1694 125 125 PURCHASED SERVICES 18132 9066 9066 PRINTING 13952 13952 SOFTWARE 13636 6818 6818 SUPPLIES 12566 4147 8419 15689 7671 8018 521130 172898 115703 232529 1118964 1084736 135269 238058 9552806 9322418 10807039 10645212 28782 50428 28782 50428 X 5872842 5510535 3328782 3453019 1576633 1631230 10778257 10594784 10807039 10645212 X -163113 -20360 X X 0 1 1 X 0 X 273121 660549 243392 1306897 507834 2991793 273121 660549 243392 1306897 507834 2991793 1579637 1412156 990640 247961 235618 112227 98740 1685186 4676979 0.30190 0.17720 X APPLETON MEDICAL CENTER FOUNDATION (THE FOUNDATION) DOES NOT MEET THE 33 1/3% PUBLIC SUPPORT TEST FOR THE CURRENT OR PRIOR YEAR (AS CORRECTED). 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 PUBLICLY 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. IF THESE CONTRIBUTIONS WERE NETTED, THE CURRENT YEAR PUBLIC SUPPORT PERCENTAGE WOULD BE 44.23%. BASED ON THESE FACTORS, THE FOUNDATION BELIEVES THAT IT IS PUBLICLY-SUPPORTED AS DEFINED BY THE INTERNAL REVENUE CODE AND REGULATIONS THEREUNDER. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5188828 54597 -14882 43073 5185470 5148663 3305 64028 27168 5188828 4876903 1370 287444 17054 5148663 5104609 7064 -234181 589 4876903 0.68540 0.31460 0 0 0 358017 521130 -163113 -20360 -20360 -183473 372827 -20360 35170 14810 358017 0 358017 556300 35170 35170 521130 0 521130 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 ASSETS 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: THE FOUNDATION FOLLOWS FASB GUIDANCE ON INCOME TAXES, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, WHICH ADDRESSES THE DETERMINATION OF WHETHER TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED IN THE FINANCIAL STATEMENTS. UNDER THIS GUIDANCE, THE FOUNDATION MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. EXAMPLES OF TAX POSITIONS INCLUDE THE TAX-EXEMPT STATUS OF THE FOUNDATION, AND VARIOUS POSITIONS RELATED TO THE POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME. THE TAX BENEFITS RECOGNIZED IN THE FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50 PERCENT LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. AT DECEMBER 31, 2011 AND 2010, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS LIABILITIES. THE FOUNDATION FILES FORM 990 IN THE U.S. FEDERAL JURISDICTION. TAX RETURNS FILED BY THE FOUNDATION ARE GENERALLY OPEN FOR EXAMINATION FOR THE YEARS 2008 THROUGH 2011. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE 35,170. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE 35,170. HIGH FLYING GOLF OUTING 63613 63613 318 17623 4836 LAUGHTER IS THE BEST MEDICINE 26670 26670 612 3682 4158 90283 90283 930 21305 8994 31229 59054 1 APPLETON SCHOOL DISTRICT 122 EAST COLLEGE AVENUE SUITE 1A APPLETON WI 54911 396000710 3 27000 AFTER SCHOOL ENRICHMENT FOR NEEDY CHILDREN UNIVERSITY OF WI OSHKOSH 800 ALGOMA BLVD OSHKOSH WI 54901 391805963 3 60000 LIVING HEALTHY COMMUNITY CLINIC RURAL HEALTH INITIATIVE 100 COUNTRY ROAD B SHAWANO WI 54166 208635695 3 30000 GENERAL OPERATIONS APPLETON MEDICAL CENTER INC 1818 NORTH MEADE ST APPLETON WI 54911 390824015 3 37898 GLASSWORK, COMMUNITY GARDENS, FLOWERS FOR CANCER PATIENTS 4 SCHOLARSHIPS 15 18000 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: PROCEDURES FOR MONITORING THE USE OF GRANT FUNDS: 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 0 1 0 0 0 0 0 0 0 TIM OLSON 0 344649 0 62541 0 26428 0 86550 0 13202 0 533370 0 0 DAVID B ANDERLA MD 0 310705 0 356 0 1012 0 9350 0 13800 0 335223 0 0 KATHRYN CORREIA 0 399343 0 108695 0 13635 0 82372 0 14401 0 618446 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 KATHRYN CORREIA AND TIM OLSON ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THEIR BASE COMPENSATION. THIS 457(F) SUPPLEMENTAL BENFIT 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 2011. X 1 900 FMV 0 0 0 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 EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C ENFORCEMENT OF CONFLICTS POLICY: 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -20,360. FORM 990, PART XII, LINE 2C THERE WERE NO CHANGES FROM THE PRIOR YEAR THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54912 391509362 HEALTHCARE WI 501(C)(3) LINE 11C, III-FI THEDACARE INC 0 APPLETON MEDICAL CENTER INC 1818 NORTH MEADE ST APPLETON WI 54911 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 THEDA CLARK MEDICAL CENTER INC 130 SECOND ST NEENAH WI 54956 311550056 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 GEORGE F PEABODY FOUNDATION INC PO BOX 2553 APPLETON WI 54912 391702534 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 0 COMMUNITY HOSPICE FOUNDATION INC 1818 NORTH MEADE ST APPLETON WI 54911 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 0 NEW LONDON FAMILY MEDICAL CENTER INC 1405 MILL ST NEW LONDON WI 54961 390869788 HSOPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54891 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 THEDA CLARK MEDICAL CENTER FOUNDATION INC 130 SECOND ST NEENAH WI 54956 390830664 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 0 WOLF RIVER AREA HEALTHCARE FOUNDATION 1405 MILL ST NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 11B, II THEDACARE INC 0 SHAWANO MEDICAL CENTER INC 309 N BARTLETTE ST SHAWANO WI 54166 390807068 MEDICAL WI 501(C)(3) LINE 3 THEDACARE INC 0 SHAWANO MEDICAL CENTER FOUNDATION INC N6192 WOLF RIVER ROAD SHAWANO WI 54166 391539117 FOUNDATION WI 501(C)(3) LINE 11D, III-O THEDACARE INC 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0