2012-08-01T10:49:46-05:00 2011-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST SUITE 600 COLUMBUS OH 43215 990 2011-01-01 331031454 BERGER HEALTH FOUNDATION BERG 7404208209 600 N PICKAWAY STREET CIRCLEVILLE OH 43113 THOMAS SCHERER 7404208209 2012-07-23 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z LARRY HALM 600 N PICKAWAY STREET CIRCLEVILLE OH 43113 996370 0 X WWW.BERGERFOUNDATION.ORG X 2002 OH BERGER HEALTH FOUNDATION ACHIEVES ITS MISSION THROUGH A VARIETY OF ENDEAVORS. IT'S FUNDRAISING EFFORTS PROVIDE PROGRAM SUPPORT FOR BERGER HOSPICE AND CIRCLE OF CARING FAITH-IN-ACTION PROGRAMS; PROVIDE BUILDING AND EQUIPMENT UPGRADES FOR BERGER HEALTH SYSTEM: AND HEALTHCARE SCHOLARSHIPS AND OTHER PROGRAMS TO PROMOTE ENHANCED NURSING CARE AND QUALITY INITIATIVE THAT BENEFIT PATIENT CARE AND ENHANCE COMMUNITY RESOURCES. ALL FUNDS RAISED ARE USED TO ASSIST IN MEETING HEALTH RELATED NEEDS OF THE COMMUNITY. 14 8 2 11 0 0 865225 878569 0 0 4422 3713 53779 70779 923426 953061 656367 599260 0 0 142831 154316 0 0 95069 367480 90074 1166678 843650 -243252 109411 1902614 2019118 68283 259503 1834331 1759615 THE MISSION OF BERGER HEALTH FOUNDATION IS TO ENCOURAGE, RECEIVE AND BE RESPONSIBLE FOR CHARITABLE GIFTS THAT SUPPORT THE DEVELOPMENT AND HEALTH-RELATED SERVICES AT BERGER HEALTH SYSTEM FOR THE RESIDENTS OF PICKAWAY COUNTY AND THE SURROUNDING AREA. 0 0 53720 0 0 RAINBOW FUND - BRADLEY CANCER CENTER PATIENT SUPPORT 74069 0 0 HOSPITAL HANNAN FUND - COMMUNITY SUPPORT 50000 0 0 HOSPICE 452334 452334 0 452334 452334 630123 1 1 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 2 1 0 0 0 0 0 1 1 0 0 0 0 X 14 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X THOMAS SCHERER 7404208002 1180 N COURT ST CIRCLEVILLE OH 43113 X CHARLES BRADLEY 1.00 X X 0 0 0 JON VEITH 1.00 X X 0 218999 16375 TODD STEVENS 1.00 X X 0 0 0 GUNHILD LONG 1.00 X X 0 19125 450 JEAN DROSTE 1.00 X 0 0 0 NELSON EMBREY 1.00 X 0 0 0 DORIS GILLESPIE 1.00 X 0 0 0 MIKE HESS 1.00 X 0 0 0 DIANE HILL 1.00 X 0 0 0 PATRICIA HUGHEY 1.00 X 0 66019 16139 ANGELA KLETT 1.00 X 0 0 0 CONNIE LEWIS 1.00 X 0 0 0 ROBERT SNEED 1.00 X 0 0 0 SUSAN STRAWSER 1.00 X 0 69640 25668 DAVID PAUGH 2.50 X 0 143998 36666 LARRY HALM 40.00 X 97502 0 20539 97502 517781 115837 0 0 1 0 0 27025 460001 391543 878569 3713 3713 11287 11287 11287 11287 102801 27025 43309 59492 59492 953061 0 0 74492 520969 520969 78291 78291 124396 24879 24879 74638 17952 3590 5386 8976 1084 217 325 542 464 93 139 232 10420 2084 3126 5210 200 200 40257 37093 3164 2307 2307 29219 29219 13952 13952 4139 4139 843650 630123 118458 95069 633101 672737 336908 386430 52345 0 30400 3032 1413 385967 385967 385967 439661 551092 21200 21479 1902614 2019118 68283 259503 68283 259503 X 1448364 1373648 385967 385967 0 0 1834331 1759615 1902614 2019118 X 109411 -184127 X X 0 1 0 X 0 X 161509 250919 261399 734230 878569 2286626 161509 250919 261399 734230 878569 2286626 486145 1800481 8108 9233 21824 18335 15000 72500 66014 146212 93561 102801 408588 2767714 334393 0.65050 0.71960 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 114868 30 0 0 0 114898 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.12940 0.87060 0 0 385967 385967 385967 OTHER INVESTMENTS 551092 F 551092 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: APPROXIMATELY $100,000 OF THE ENDOWMENT IS PERMANTELY RESTRICTED AND TO BE USED FOR NURSING EDUCATION. IN ADDITION, $14,000 OF THE ENDOWMENT IS BOARD DESIGNATED AND TO BE USED FOR CONTINUING EDUCATION FOR WOMEN IN THE HEALTH FIELD. GOLF OUTING 99644 22000 77644 20621 14204 LADIES NIGHT OUT 30182 5025 25157 5837 2647 129826 27025 102801 26458 16851 43309 59492 1 BERGER HOSPITAL 600 N PICKAWAY ST CIRCLEVILLE OH 43113 316400103 GOVERNMENTAL HOSPITA 472029 N/A N/A TRANSFER OF CASH FOR VARIOUS DONATIONS RECEIVED. MARY VIRGINIA CRITES HANNAN PARK 104 EAST FRANKLIN STREET CIRCLEVILLE OH 43113 311777036 501(C)3 10000 N/A N/A TRANSFER OF DONATIONS PLEDGED TO PARK. 2 CASH ASSISTANCE 801 78291 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE BOARD OF DIRECTORS ROUTINELY APPROVES TRANSFERS TO BERGER HOSPITAL FOR PURCHASES OF MEDICAL SUPPLIES/EQUIPMENT THAT ARE MADE THROUGHOUT THE YEAR. IN ADDITION, THE BOARD OF DIRECTORS APPROVES THE DISTRIBUTION OF FUNDS TO ORGANIZATIONS IN THE COMMUNITY IN ORDER TO HELP PROMOTE AND ENHANCE THE SURROUNDING AREA. X X X 0 0 0 0 0 0 0 0 0 JON VEITH 0 218999 0 0 0 0 0 0 0 16375 0 235374 0 0 DAVID PAUGH 0 143998 0 0 0 0 0 20160 0 16506 0 180664 0 0 HEALTH CARE LOGISTICS INC CONNIE LEWIS IS A BOARD MEMBER OF BHF AND PRESIDENT OF HCL. 17758 HEALTH CARE LOGISTICS, INC. IS ONE OF THE LARGER SPONSORS FOR BERGER HEALTH FOUNDATION'S GOLF CLASSIC EACH YEAR. THERE WERE VARIOUS TRANSACTIONS DURING THE YEAR BETWEEN BHF AND HCL INVOLVING GOLF APPAREL. 0 FORM 990, PART VI, SECTION A, LINE 6 BERGER HEALTH FOUNDATION IS ORGANIZED AS A COMPONENT UNIT OF BERGER HEALTH SYSTEM, THE PARENT ORGANIZATION AND SOLE VOTING MEMBER FOR THE CONSOLIDATED GROUP. FORM 990, PART VI, SECTION A, LINE 7A BERGER HEALTH FOUNDATION BOARD OF DIRECTORS ARE CONFIRMED BY BERGER HEALTH SYSTEM'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE 2011 FORM 990 IS REVIEWED FOR COMPLETENESS AND ACCURACY BY THE VP OF FINANCE, EXECUTIVE DIRECTOR OF BERGER HEALTH FOUNDATION, AND CEO OF BERGER HEALTH SYSTEM. THE FORM 990 IS PROVIDED TO AND REVIEWED BY THE BOARD PRIOR TO FILING THE RETURN WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THEIR CONFLICT OF INTEREST POLICY BY DISTRIBUTING ANNUAL QUESTIONNAIRES TO THE BOARD MEMBERS, DIRECTORS, AND OFFICERS. IF THE SITUATION ARISES, NEW BOARD MEMBERS WILL COMPLETE THE CONFLICT OF INTEREST QUESTIONNAIRE WHEN THEY FIRST JOIN AS WELL. THE QUESTIONNAIRES MUST BE SIGNED AND RETURNED TO BE REVIEWED BY BERGER HEALTH FOUNDATION'S BOARD OF DIRECTORS BEFORE BEING FURTHER REVIEWED BY THE PRESIDENT/CEO OF BERGER HEALTH SYSTEM. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE RESPECTIVE BOARDS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A CONFLICTS OF INTEREST STATEMENT BY A BOARD MEMBER, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE BOARD MEMBER, THE BOARD SHALL REVIEW THE MATTER TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE CONFLICTED BOARD MEMBER SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE BOARD CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, BOARD MEMBERS SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE RESPECTIVE BOARDS FOR DISCUSSION AND VOTE. THE CONFLICTED BOARD MEMBER MAY NOT BE PRESENT AND MUST ABSTAIN FROM VOTING WHEN THE VOTE IS TAKEN. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S COMPENSATION FOR THE EXECUTIVE DIRECTOR AND OTHER OFFICERS IS DETERMINED BY THE USE OF OHA SURVEYS. THE COMPENSATION OF THE PRESIDENT/CEO OF BERGER HOSPITAL IS REVIEWED AND APROVED BY THE BOARD OF DIRECTORS OF BERGER HOSPITAL. THE EXECUTIVE DIRECTOR'S COMPENSATION IS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS AND THE CEO OF BERGER HOSPITAL. THE CFO AND SECRETARY'S COMPENSATION IS REVIEWED AND APPROVED BY THE PRESIDENT/CEO OF BERGER HOSPITAL. DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATION AND DECISIONS IS KEPT CONTEMPORANEOUSLY IN THE CONTRACTS FOR THE OFFICERS AND IN THE MINUTES OF THE BOARD MEETINGS FOR THE PRESIDENT/CEO; THIS PROCESS WAS LAST COMPLETED IN 2011. 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. FORM 990, PART VII: ESTIMATE OF OFFICERS' ALLOCATION OF HOURS WORKED FOR BERGER HEALTH FOUNDATION RELATED ENTITIES: PICKAWAY PROFESSIONAL SERVICES: -JON VEITH 40 HOURS BERGER HEALTH SYSTEM: -GUNHILD LONG 40 HOURS -PATRICIA HUGHEY 40 HOURS -SUSAN STRAWSER 40 HOURS -DAVID PAUGH 40 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: TRANSFER OUT OF BHFV'S NET ASSETS TO BE REPORTED ON FORM 1120 -184,127. TOTAL TO FORM 990, PART XI, LINE 5: -184,127. FORM 990, PART XII, LINE 2C: BERGER HEALTH SYSTEM ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF THE INDEPEDENT ACCOUNTANT. BERGER HOSPITAL 600 N PICKAWAY ST CIRCLEVILLE OH 43113 316400103 ACUTE CARE HOSPITAL OH GOVERNMENTAL HOSPITA N/A N/A 0 PICKAWAY HEALTH SERVICES 600 N PICKAWAY ST CIRCLEVILLE OH 43113 311438107 PHYSICIAN GROUP OH 501(C)(3) LINE 11A, I BERGER HOSPITAL 1 BERGER HEALTH SYSTEM 600 N PICKAWAY ST CIRCLEVILLE OH 43113 262545110 INACTIVE ACUTE CARE HOSPITAL OH 501(C)(3) LINE 3 N/A 0 BERGER ACUTE SERVICES LLC 332 CONGRESS PARK DR DAYTON OH 45459 451450450 MEDICAL SERVICES OH BERGER HEALTH FOUNDATION VENTURES RELATED -52561 108311 0 0 0.60000 PICKAWAY DIALYSIS CENTER LLC 66 CHERRY HILL DRIVE BEVERLY MA 01915 562614118 DIALYSIS MA BERGER HEALTH FOUNDATION VENTURES RELATED 135972 127974 0 1 0.19000 PICKAWAY PROFESSIONAL SERVICES INC 600 N PICKAWAY ST CIRCLEVILLE OH 43113 611408162 ANESTHESIOLOGISTS OH N/A C BERGER HEALTH FOUNDATION VENTURES 1204 N COURT ST CIRCLEVILLE OH 43113 412218009 MEDICAL SERVICES OH N/A C 121707 206293 1.00000 0 1 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 BERGER HOSPITAL B 472029 CASH TRANSACTION BERGER HOSPITAL C 460001 CASH TRANSACTION