2011-03-14T14:13:11-05:00 2010-07-31 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2009-08-01 371193348 Carlinville Area Hospital Foundation CARL 2178543141 20733 North Broad Street Carlinville IL 62626 Kenneth Reid 2178543141 2011-03-08 1 Carmen Krantz 5635561790 2009 2016-02-24 21:20:13Z X Kenneth Reid 20733 North Broad Street Carlinville IL 62626 1968149 0 X www.cahcare.com X 1944 IL Support primary and emergency health care services for persons living in the Carlinville area 14 14 0 14 0 0 1566748 1841615 0 58335 51585 -3613 -4009 1621470 1889191 1537934 5086304 0 0 47000 532 68916 21448 97517 1606382 5184353 15088 -3295162 6002850 2896485 117883 6002850 2778602 The purpose of the Foundation is to help support the availability of primary and emergency health care services for those persons living in the Carlinville area. 0 0 5113827 5086304 0 Carlinville Area Hospital Foundation was established to support persons living in the Carlinville Area. Many small and rural communities face the threat of losing access to health care due to cuts in payment, especially through government programs such as Medicare and Medicaid. The residents of the communities served by Carlinville Area Hospital deserve the availability of a hospital which can meet as many of their needs as possible in a quality, cost-effective and convenient manner.1. September 18, 2009; Annual Fundraising Golf Tournament 2. July 25th 2010: Ribbon Cutting Ceremony for New Facility3. Raised an additional $ 560,000 in contributions and pledges for the new facilityDuring fiscal year 2010 Carlinville Area Hospital Foundation also provided funding to Carlinville Area Hospital in the amount of $5,086,304 for the building of a new hospital. The Foundation also provided $20,000 in funding to support a general surgeon. 5113827 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 14 14 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 IL X Greg Ward 2178543141 20733 North Broad Street Carlinville IL 62626 X Richard Walden 0.50 X X 0 0 0 James Ashworth 0.50 X X 0 0 0 Betty Star 0.50 X X 0 0 0 Tammy Dugan 0.50 X X 0 0 0 Steven Boente DMD 0.30 X 0 0 0 Kenneth Breitwiser 0.30 X 0 0 0 Don B Denby Jr 0.30 X 0 0 0 Peggy Denby 0.30 X 0 0 0 Alice Drury 0.30 X 0 0 0 Charlene Genta 0.30 X 0 0 0 Elisabeth Herndon 0.30 X 0 0 0 Ralph March 0.30 X 0 0 0 Dennis Pickrel 0.30 X 0 0 0 Ed Tawfall 0.30 X 0 0 0 Dawn Cherry 0.30 X 0 0 0 Brent Davis 0.30 X 0 0 0 Mary Jo Reichmann 0.30 X 0 0 0 Kenneth Reid 1.00 X 0 180345 12624 Greg Ward 1.00 X 0 122846 8599 0 303191 21223 0 0 1 0 0 16012 1825603 1841615 64060 64060 58373 70848 -12475 -12475 -12475 4101 16012 8110 -4009 -4009 1889191 0 0 47576 5086304 5086304 532 532 1610 1610 20000 20000 2500 2500 65884 65884 Doubtful pledges 7494 7494 Miscellaneous expense 29 29 5184353 5113827 1610 68916 4430929 239812 1226610 2276169 268566 380504 76745 0 6002850 2896485 0 117883 0 117883 X 200580 254258 5802270 2524344 6002850 2778602 6002850 2896485 X 0 1 0 X 0 X X X 0 0 0 Carlinville Area Hospital Association 370645239 3 1 5086304 Middle Macoupin Healthcare Systems 371193396 11a 1 0 2 5086304 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 Due to affiliate 117883 117883 Part X: Description of Uncertain Tax Positions Under FIN 48: The Organization has adopted the provisions of FASB Accounting Standards Codification Topic ASC 740-10 (previously Financial Interpretation No. 48, Accounting for the Uncertainty in Income Taxes) on August 1, 2009. The implementation of this standard had no impact on the consolidated financial statements. As of both the date of adoption, and as of July 31, 2010, the unrecognized tax benefit accrual was zero. The Organization will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. The Organization is no longer subject to Federal or state tax examinations by tax authorities for years before 2006. Golf Outing 20113 16012 4101 1400 1500 1878 2223 1109 20113 16012 4101 1400 1500 1878 2223 1109 8110 -4009 1 Carlinville Area Hospital Association 20733 North Broad Street Carlinville IL 62626 370645239 501(c)(3) 5086304 Provide assistance for improved acute and preventative health care benefits and general surgeon funding 1 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Carlinville Area Hospital Foundation's purpose is to support primary and emergency health care services for persons living in the Carlinville area and in particular Carlinville Area Hospital Association. The Foundation is a supporting organization of the Hospital and all grants and support are given to the Hospital to assist in their exempt purpose of providing health care services. The Hospital provides the Foundation with proofs of purchase to ensure the money is used appropriately. 0 0 0 0 0 0 0 0 0 Kenneth Reid 0 180345 0 0 0 0 0 7214 0 5410 0 192969 0 0 Supplemental Information Part III Part I, Question 3: Carlinville Area Hospital Foundation does not pay compensation to Kenneth Reid, CEO. This individual is an employee of Brim Healthcare Inc., an unrelated management company. Carlinville Area Hospital Association, a related organization, pays management fees for his services at the Hospital. Carlinville Area Hospital Association and Brim Healthcare, Inc. use these methods to determine his compensation. Supplemental Information Part III Part II: Kenneth Reid is an employee of Brim Healthcare Inc., an unrelated management company. Carlinville Area Hospital Association pays management fees to Brim Healthcare Inc. for his services provided to the Hospital. Cash 2010-06-30 5086304 370645239 Carlinville Area Hospital Association 20733 North Broad Street Carlinville IL 62626 501(c)(3) 0 0 0 0 Form 990, Part VI, Section A, line 2 Don B. Denby, Jr. and Elisabeth Herndon have a family relationship. Richard Walden, Chairman, and James Ashworth, Vice Chairman, have a business relationship. Form 990, Part VI, Section A, line 6 Carlinville Area Hospital Foundation has one member, Middle Macoupin Health Care Systems. Form 990, Part VI, Section A, line 7a The Member has the exclusive right and power to designate two of its directors to serve as directors of the Foundation and to appoint all persons to or remove them from the Board of Directors except vacancies on the Board caused by death, resignation or removal shall be filled at any meeting by a majority vote of the remaining Directors. Form 990, Part VI, Section A, line 7b The Member has the exclusive right and power to approve or reject the following proposed actions prior to the Board of Directors taking any action on: 1. the annual operating budget, capital budget, long-range plan and any action which will result in a substantial change in the expenditures or revenue forecast in any such plan or budget; 2. the undertaking of or substantive amendments to a contractual obligation in excess of $250,000, or the guaranteeing of an obligation in excess of $250,000; 3. the purchase, lease, transfer, mortgage or sale of any asset or property with a value in excess of $250,000, except with respect to transactions specified and previously approved within the capital budget; 4. any plan of construction or remodeling involving an expenditure in excess of $250,000 except with respect to transactions specified and previously approved within the capital budget; 5. any borrowing; 6. any application for a government grant; 7. any general plan for the solicitation of charitable contributions or the solicitation or acceptance as a gift of any real property or any interest; 8. any amendments to these Bylaws and any amendment or restatement of the Articles of Incorporation; any proposal to adopt Articles of Dissolution, Merger or Consolidation; 9. any selection, removal or change in the compensation or other terms of employment of the Corporation's operating officers; 10. any substantial change in employee fringe benefits or personnel policies; and 11. any other matters as may be required by law to be submitted to the Member or as to which the Member determines, by resolution, that submission is advisable. Form 990, Part VI, Section B, line 11 The Form 990 will be distributed to the governing body before it is filed. The CEO, CFO, and Director of Finance of Carlinville Area Hospital Association, a related organization, review the Form 990. Form 990, Part VI, Section B, line 12c Any duality of interest or possible conflict of interest on the part of any board member shall be disclosed to the other members of the board and made a matter of record through an annual procedure and also when the interest becomes a matter of board action. Any board member having a duality of interest or possible conflict of interest on any matter shall not vote or use his or her personal influence on the matter. The minutes of the meeting shall reflect the disclosure, the abstention from voting, and the quorum situation. Any new member of the board will be advised of this policy upon entering on the duties of office. The board members complete and sign the conflict of interest form yearly. The forms are reviewed by the Chairman of the Board and if a potential conflict is identified the Chairman of the Board follows up. Form 990, Part VI, Section B, Line 15: The CEO and CFO are not compensated by Carlinville Area Hospital Foundation. The CEO and CFO are compensated by an unrelated management company through Carlinville Area Hospital Association, a related organization, for services provided to the Hospital. The unrelated management company and the Hospital use these methods to determine compensation. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are not available to the public. However, financial information is available through the public disclosure copy of the 990. Form 990, Part XI, Line 2C: Carlinville Area Hospital Association, a related organization, is responsible for oversight of the audit. Form 990, Page 7, Part VII The CEO, Kenneth Reid, and CFO, Greg Ward, were employees of Brim Healthcare Inc. The reportable compensation reported on Form 990, Part VII and Schedule J was paid to Brim Healthcare Inc. by Carlinville Area Hospital Association, a related organization, for CEO and CFO services provided to Carlinville Area Hospital Association. The services provided by Kenneth Reid and Greg Ward for Carlinville Area Hospital Foundation are not compensated. Form 990, Page 7, Part VII The following individual devoted time providing services to the following related organizations. Carlinville Area Hospital Association, a related organization. Kenneth Reid, CEO 40 hours per week Greg Ward, CFO 40 hours per week Richard Walden .5 hours per week Ralph March .5 hours per week Middle Macoupin Healthcare Systems Kenneth Reid, CEO .25 hours per week Richard Walden .25 hours per week Form 990, Part VI, Section A, Line 1a: The Board of Directors appoints three or more Directors to serve with the President on the Executive Committee. The Executive Committee has power and authority to manage and control the business and affairs of the Foundation as the Board of Directors. In no event should the Executive Committee exercise those powers to amend the Articles of Incorporation or Bylaws, sell, transfer or otherwise dispose of substantially all of the Foundation's assets, or adopt Articles of Merger or Consolidation. Form 990, Schedule A, Part I, line 11i: The support of Middle Macoupin is provided through Carlinville Area Hospital Foundation providing grants to Carlinville Area Hospital Association. Carlinville Area Hospital Association 20733 North Broad Street Carlinville IL 62626 370645239 Provision of health care services IL 501(c)(3) 3 N/A Middle Macoupin Healthcare Systems 20733 North Broad Street Carlinville IL 62626 371193396 Provide support and benefit Carlinville Area Hospital Association IL 501(c)(3) 11a N/A 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0