2011-02-07T11:30:21-06:00 2010-06-30 Tyler Simms & StSauveur CPAS PC 19 Morgan Drive Lebanon NH 03766 990 2009-07-01 020226774 SPEARE MEMORIAL HOSPITAL SPEA 6032382231 16 HOSPITAL ROAD PLYMOUTH NH 03264 MICHELLE MCEWEN 6035361120 2011-01-18 1 W JAY SIMMS 6036530044 2009 2016-02-24 21:20:13Z MICHELLE MCEWEN 16 Hospital Road Plymouth NH 03264 48483151 0 X SPEAREHOSPITAL.COM X 1899 NH TO PROVIDE INPATIENT, OUTPATIENT AND PHYSICIAN HEALTH CARE SERVICES 13 12 435 0 0 0 189652 178498 41969714 46319533 495884 418915 422596 371777 43077846 47288723 310000 0 20871457 21156458 0 131549 22172159 26462902 43043616 47929360 34230 -640637 50826054 55545738 19627662 24116856 31198392 31428882 To maintain a hospital and other such institutions within the State of New Hampshire, with facilities that include medical services to provide for the diagnosis and treatment of patients that may require inpatient, outpatient, emergency care and other pursuits designed to promote the general health of the community. SMH does not discriminate relative to race, religion or national origin, ability to pay and will assure that all patients receive the same level of care through quality assessment monitoring and improvement activities. 0 0 42263887 46319533 SMH IS A 25-BED ACUTE-CARE HOSPITAL THAT PROVIDES INPATIENT AND OUTPATIENT SERVICES TO THE SURROUNDING COMMUNITY. 42263887 1 1 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 37 0 1 435 1 0 0 0 0 0 1 1 0 0 0 0 0 0 13 12 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 NH X X Kathleen Beriau- Accounting Supervisor 6032382106 SPEARE MEMORIAL HOSPITAL PLYMOUTH NH 03264 Michelle mcewen 40.00 X X 216909 0 39003 William crangle 1.00 X X 0 0 0 Colleen brickley 1.00 X X 0 0 0 Brian chalmers 1.00 X X 0 0 0 Eldwin wixson 1.00 X 0 0 0 Susan Karkheck 1.00 X X 0 0 0 Stanley Lee Freeman 1.00 X X 0 0 0 Quentin Blaine 1.00 X 0 0 0 Clint hutchins 1.00 X 0 0 0 William Larsen 1.00 X X 0 0 0 Alison Ritz 1.00 X 0 0 0 David Talbot 1.00 X 0 0 0 Ronald Sibley 1.00 X 0 0 0 Peter G Kritikos 40.00 X 115816 0 17974 RICHARD F WERKOWSKI 40.00 X 0 0 0 Joseph CASEY md 40.00 X 308925 0 47856 Timothy lyons MD 40.00 X 318800 0 36213 Michael P Giovan MD 40.00 X 436729 0 56772 James P KorenJr MD 40.00 X 258578 0 33111 Victor Gennaro MD 40.00 X 415817 0 56733 2071574 0 287662 30 0 1 0 HARVEY CONSTRUCTION CORP OF NH 10 HARVEY ROAD BEDFORD NH 03110 CONSTRUCTION 2079566 LAVALLEE BRENSINGER ARCHITECTS 155 DOW STREET SUITE 400 MANCHESTER NH 03101 ARCHITECTS 211519 2 1570 101840 75088 178498 NET PATIENT REVENUE 624100 45953913 45953913 Other Operating Revenu 900099 365620 365620 46319533 369309 369309 41726 41726 41726 41726 1231012 1174414 6992 56598 -6992 49606 49606 32472 1570 13022 19450 19450 PHARMACY INCOME 446110 165766 165766 CAFETERIA INCOME 722210 144835 144835 310601 47288723 46319533 0 790692 310000 310000 347250 347250 14705494 12451772 2189496 64226 1215604 1023708 186616 5280 3628516 3037122 575729 15665 1259594 1045349 208853 5392 50196 50196 37748 37748 56282 56282 90624 87909 2715 4575941 4382740 155260 37941 916523 855444 61079 110036 73657 35637 742 33402 33402 729892 729892 2411382 2411382 BAD DEBT 4208573 4208573 PHYSICIAN FEES & WAGES 4010476 4010476 PURCHASED SERVICES 3190036 2898456 290329 1251 PROVIDER TAX STATE OF N 2104910 2104910 COST OF DRUGS 1947927 1947927 1988954 684570 1303332 1052 47929360 42263887 5533924 131549 6321459 4078242 32594 9402 5883728 5923440 3123536 2590151 719056 717164 439352 408230 43012777 17154499 22612783 25858278 9264388 11660773 1650759 3221560 778399 1078498 50826054 55545738 2148068 2782948 13060000 16815000 366140 1221045 4053454 3297863 19627662 24116856 X 30530379 30908631 451788 279026 216225 241225 31198392 31428882 50826054 55545738 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9138 9138 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: SPEARE MEMORIAL HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF SPEARE MEMORIAL HOSPITAL AND THE OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSE. SPEARE MEMORIAL HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITES. 9404573 1518080 986474 11909127 10511233 60500 -1162894 4266 9404573 0.98000 0.02000 0.00050 0 0 564517 564517 27041780 7895350 19146430 920517 311421 609096 14485963 8947728 5538235 25858278 BOND FUNDS 3221560 F 3221560 OTHER CURRENT LIABILITIES 2160771 EST. THIRD-PARTY PAYER SETTLEMENTS 801666 Related Party Note Payable 335426 3297863 47288723 47929360 -640637 796265 74862 871127 230490 46464248 156699 156699 46307549 56282 924892 981174 47288723 46888885 0 46888885 56282 984193 1040475 47929360 Part V, Line 4: Description of Intended Use of Endowment Funds: THE ENDOWMENT FUND IS USED TO SUPPORT OPERATIONS OF THE HOSPITAL. Part XI, Line 8 - Other Adjustments: BAD DEBT EXPENSE ON MSHC RECEIVABLE: 59301. RESTRICTED CONTRIBUTIONS: 25000. Restricted pledge loss: -9439. Part XII, Line 2d - Other Adjustments: Net Assets released from Restrictions: 156699. Part XII, Line 4b - Other Adjustments: grant expense: 310000. BAD DEBT EXPENSE ON MSHC RECEIVABLE: -59301. FORGIVENESS OF DEBT INCOME: 674193. Part XIII, Line 4b - Other Adjustments: grant expense: 310000. FORGIVENESS ON DEBT INCOME: 674193. Golf Tournament 34042 1570 32472 528 1170 10104 1220 34042 1570 32472 528 1170 10104 1220 13022 19450 1 1 1 X 1 X 225.000000000000 1 1 0 1 1 3788006 2104910 1683096 0.03850 3618961 2720933 898028 0.02050 14694220 14065861 628359 0.01440 22101187 18891704 3209483 0.07340 87643 0 87643 0.00200 4203 0 4203 0.00010 214936 0 214936 0.00490 215661 0 215661 0.00490 522443 522443 0.01190 22623630 18891704 3731926 0.08530 1 2693487 32798 14065861 16698927 -2633066 X 1 1 NA Speare Memorial Hospital

16 Hospital Road Plymouth NH 03264

X X X X Part III, Line 8: 100% OF THE SHORTFALL FROM MEDICARE SHOULD BE CONSIDERED A COMMUNITY BENEFIT. THE SERVICES PROVIDED TO MEDICARE PATIENTS ARE THE SAME SERVICES THAT ARE PROVIDED TO SELF-PAY PATIENTS WHO PAY SPEARE MEMORIAL HOSPITAL SLIGHTLY DISCOUNTED CHARGES. THE COMMUNITY BENEFIT AMOUNT IS CALCULATED BY SUBTRACTING THE MEDICARE PAYMENTS AND PATIENT COINSURANCE AND DEDUCTIBLE PAYMENTS FROM THE MEDICARE CHARGES. Part III, Line 9b: speare Memorial Hospital has both a collections policy, and a charity care policy that describes charity eligibility and steps to be completed before a patient's account is written off to bad debt. Part VI, Line 2: Information gathering through surveys, focus groups, community representation, public forums, input from health care providers, industry leaders, outside consultants,AND analysis of internal data and external data provided by Hospital Associations, Payers, etc. Part VI, Line 3: Patients are educated at time of registration or through educational materials that are distributed through THE HOSPITAL'S website or by community outreach.Speare MEMORIAL Hospital is a member of a community health network that provides assistance, support,and education relating to eligibility assistance. Part VI, Line 4: Speare Memorial Hospital is located in the mountain and lakes region of New Hampshire and primarly serves constituents in Grafton County. Grafton County population size is approximately 86,000 within its 40 distinct municipalities. Part VI, Line 6: Speare MEMORIAL HOSPITAL provides prescription drug assistance, primary-care clincs, multiple support groups, patient education programs, school dental program, etc. and haS affliations and partnerships with many community organizations. NH 0 MID-STATE HEALTH CENTER 101 BOULDER POINT DRIVE NO 1 PLYMOUTH NH 03264 020487172 501 (C)(3) 310000 FMV COMMUNITY BENEFIT GRANT 1 1 X X X X X 0 0 0 0 0 0 0 0 0 Michelle mcewen 216909 0 0 0 0 0 16692 0 22311 0 255912 0 0 0 Joseph CASEY md 308925 0 0 0 0 0 25545 0 22311 0 356781 0 0 0 Timothy lyons MD 318800 0 0 0 0 0 13326 0 22887 0 355013 0 0 0 Michael P Giovan MD 436729 0 0 0 0 0 33885 0 22887 0 493501 0 0 0 James P KorenJr MD 258578 0 0 0 0 0 10800 0 22311 0 291689 0 0 0 Victor Gennaro MD 415817 0 0 0 0 0 33846 0 22887 0 472550 0 0 0 NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 64461TCH5 2004-11-01 13520000 CONSTRUCTION AND RENOVATION PROJECT 0 0 NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY 020279866 64461TCH5 2010-05-19 4000000 CONSTRUCTION AND RENOVATION PROJECT 0 0 13520000 978181 318768 13201232 2007 0 0 0 1 4000000 58963 3941037 2010 0 0 0 1 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 2 The community relations director is the spouse of a board member. Form 990, Part VI, Section A, line 6 The provisions of SMH governing documents provides the board of directors is comprised of association members. Form 990, Part VI, Section A, line 7a The association members elect the board members Form 990, Part VI, Section B, line 11 The FORM 990 is reviewed by the hospital CFO, THE President/CEO, and THE Finance Committee with THE full board of Directors. The FORM 990 is THEN signed and filed. Form 990, Part VI, Section B, line 12c Annual compliance form completed by each member of the board Form 990, Part VI, Section B, line 15a Compensation for the CEO is determined via a compensation committee, compensation survey or study, comparison of other organizations 990 information, board approval and written employment contact. Form 990, Part VI, Section C, line 19 Upon request SPEARE MEMORIAL AT BOULDER POINT Boulder Point Dr PLYMOUTH NH 03264 263888977 REAL ESTATE NH 501(c)(3) Line 9 SPEARE MEMORIAL HOSPITAL PLYMOUTH HOSPITAL PROFESSIONAL BUILDING 19 AVERY STREET PLYMOUTH NH 03264 020366565 PROFESSIONAL RENTAL SPACE NH C 1.00000 SPEARE HEALTH NETWORK LLC 16 HOSPITAL ROAD PLYMOUTH NH 03264 043372339 PHYSICIAN/HOSPITAL ORGANIZATION NH C 25659 0.50000 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 SPEARE MEMORIAL AT BOULDER POINT-LEASES ALL OF ITS SPACE TO SMH J