GASTON MEMORIAL HOSPITAL FOUNDATION INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- GASTON MEMORIAL HOSPITAL FOUNDATION INC (EIN 56-1479699)
- Tax period
- 2009-07-01 to 2010-06-30
- Filed
- 2011-04-06
- IRS object ID
- 201130969349300403
- Schema version
- 2009v1.7
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-04-06T08:44:03-05:00 | Timestamp |
| Tax Period End Date | 2010-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DIXON HUGHES PLLC | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 500 Ridgefield Court | AddressLine1 |
| City | Asheville | City |
| State | NC | State |
| ZIP Code | 28806 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 561479699 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GASTON MEMORIAL HOSPITAL FOUNDATION INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | GAST | NameControl |
| Phone | 7048342000 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2525 COURT DRIVE PO BOX 1747 | AddressLine1 |
| City | GASTONIA | City |
| State | NC | State |
| ZIP Code | 280531747 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | DAVID O'CONNOR | Name |
| Title | CFO | Title |
| Phone | 7048342000 | Phone |
| Date Signed | 2011-03-29 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Amy Bibby | Name |
| Phone | 8282542254 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | DAVID O'CONNOR | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2525 COURT DRIVE PO BOX 1747 | AddressLine1 |
| City | GASTONIA | City |
| State | NC | State |
| ZIP Code | 280531747 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 2356788 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | WWW.CAROMONT.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1985 | YearFormation |
| State Legal Domicile | NC | StateLegalDomicile |
| Activity Or Mission Description | To provide exceptional health care to the communities we serve. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 3 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 2 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 1628015 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 774819 | ContributionsGrantsCurrentYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 227135 | InvestmentIncomePriorYear |
| Investment Income Current Year | 242605 | InvestmentIncomeCurrentYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 1855150 | TotalRevenuePriorYear |
| Total Revenue Current Year | 1017424 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 1025820 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 480778 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 1807 | OtherExpensePriorYear |
| Other Expenses Current Year | 9195 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 1027627 | TotalExpensesPriorYear |
| Total Expenses Current Year | 489973 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 827523 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 527451 | RevenuesLessExpensesCY |
| Total Assets BOY | 8377524 | TotalAssetsBOY |
| Total Assets EOY | 11182026 | TotalAssetsEOY |
| Total Liabilities BOY | 140000 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 70000 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 8237524 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 11112026 | NetAssetsOrFundBalancesEOY |
| Mission Description | To provide exceptional healthcare to the communities we serve. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 480949 | Expense |
| Grants | 480778 | Grants |
| Revenue | 3035347 | Revenue |
| Description | SEE SCHEDULE O.The Gaston Memorial Hospital Foundation (a subsidiary of CaroMont Health) was established in 1985. In addition to the Foundation utilizing its investment earnings for donations, CaroMont Health donates up to 10% of its operating income to the GMH Foundation each year. Gaston Memorial Hospital Foundation actively supports Gaston Family Health Services (GFHS), a private non-profit corporation providing medical and dental services to the uninsured and underinsured population of Gaston County. During fiscal year 2010, the Foundation donated $480,778 to help cover the cost of their physicians. This clinic is important to assuring that the uninsured and underinsured have access to health care in Gaston County. CaroMont Health is committed to assisting GFHS in providing for these patients who might otherwise go without primary care services. | Description |
| Total Program Service Expense | 480949 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 1 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 1 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 3 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 2 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Other Website | X | OtherWebsite |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DAVID O'CONNOR | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7048342000 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2525 COURT DRIVE | AddressLine1 |
| City | GASTONIA | City |
| State | NC | State |
| ZIP Code | 28054 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| No Listed Persons Compensated | X | NoListedPersonsCompensated |
Form990 Part VII Section A Form990PartVIISectionA (10 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer |
|---|---|---|---|---|---|---|
| James R Beam | ||||||
| Chairman | 1.00 | X | 0 | 0 | 0 | |
| Mary Frances Forrester | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| David Allen Smith | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| James Howard Jr | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Mickey Price | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Sheila Reilley | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Wayne F Shovelin | ||||||
| CEO through Sept. | 1.00 | 0 | 1972052 | 712653 | X | |
| Valinda L Rutledge | ||||||
| CEO AS OF OCT. | 1.00 | 0 | 257892 | 43500 | X | |
| David O'Connor | ||||||
| CFO/Asst. Treasurer | 1.00 | 0 | 579283 | 174861 | X | |
| Maria Long | ||||||
| VP General Counsel/Asst. S | 1.00 | 0 | 355765 | 121619 | X | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 3164992 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 1052633 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Related Organizations | 23519 | RelatedOrganizations |
| All Other Contributions | 751300 | AllOtherContributions |
| Total Contributions | 774819 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 262328 | TotalRevenueColumn |
| Exclusion | $262,328 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 1319641 | Securities |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 1339364 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -19723 | Securities |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -19723 | TotalRevenueColumn |
| Exclusion | -$19,723 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1017424 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $242,605 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 480778 | Total |
| Program Services | 480778 | ProgramServices |
Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9024 | Total |
| Management And General | 9024 | ManagementAndGeneral |
Other Expenses OtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | OTHER EXPENSE | Description |
| Total | 171 | Total |
| Program Services | 171 | ProgramServices |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 489973 | Total |
| Program Services | 480949 | ProgramServices |
| Management And General | 9024 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3 | BOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8145279 | BOY |
| EOY | 10163963 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 191555 | BOY |
| EOY | 267078 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 40687 | BOY |
| EOY | 750985 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8377524 | BOY |
| EOY | 11182026 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 140000 | BOY |
| EOY | 70000 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 140000 | BOY |
| EOY | 70000 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8196837 | BOY |
| EOY | 10361040 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 40687 | BOY |
| EOY | 750986 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8237524 | BOY |
| EOY | 11112026 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8377524 | BOY |
| EOY | 11182026 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org170b1 Avi | X | PubliclySupportedOrg170b1Avi |
Gifts Grants Contrib Received170 GiftsGrantsContribReceived170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1795062 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1547946 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7205 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1553180 | CurrentTaxYearMinus1Year |
| Current Tax Year | 774819 | CurrentTaxYear |
| Total | 5678212 | Total |
Total170 Total170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1795062 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1547946 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7205 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1553180 | CurrentTaxYearMinus1Year |
| Current Tax Year | 774819 | CurrentTaxYear |
| Total | 5678212 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Amounts Subst Contributors Total | 572790 | AmountsSubstContributorsTotal |
| Public Support Total170 | 5105422 | PublicSupportTotal170 |
Gross Investment Income170 GrossInvestmentIncome170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 979834 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1023903 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 377967 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 463406 | CurrentTaxYearMinus1Year |
| Current Tax Year | 262328 | CurrentTaxYear |
| Total | 3107438 | Total |
Other Income170 OtherIncome170
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus1 Year | 74835 | CurrentTaxYearMinus1Year |
| Total | 74835 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Support | 8860485 | TotalSupport |
| Public Support Pertcentage170 | 0.57620 | PublicSupportPertcentage170 |
| Public Support Pertcent Prior Year | 0.63620 | PublicSupportPertcentPriorYear |
| Thirty Three Percnt Tests CY170 | X | ThirtyThreePercntTestsCY170 |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 40686 | BeginningOfYearBalance |
| Contributions | 750000 | Contributions |
| Investment Earnings Or Losses | -39463 | InvestmentEarningsOrLosses |
| Grants Or Scholarships | 238 | GrantsOrScholarships |
| End Of Year Balance | 750985 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 30235 | BeginningOfYearBalance |
| Contributions | 15043 | Contributions |
| Investment Earnings Or Losses | -1785 | InvestmentEarningsOrLosses |
| Grants Or Scholarships | 2807 | GrantsOrScholarships |
| End Of Year Balance | 40686 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 1.00000 | BoardDesignatedEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (3 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| CANCER FOUNDATION FUND | 6513 |
| MACKIE SCHOLARSHIP FUND | 36119 |
| SHOVELIN SCHOLARSHIP FUND | 708353 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 750985 | TotalBookValueOtherAssets |
| Total Revenue | 1017424 | TotalRevenue |
| Total Expenses | 489973 | TotalExpenses |
| Excess Or Deficit For Year | 527451 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 329128 | NetUnrealizedGLOnInvestments |
| Other | $2,017,923 | OtherAmount |
| Total Adjustments | 2347051 | TotalAdjustments |
| Excess Or Deficit Per FS | 2874502 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 2874502 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | 329128 | NetUnrealizedGainsInvestments |
| Other Revenues | 2017923 | OtherRevenues |
| Revenue Not Rptd F990 | 2347051 | RevenueNotRptdF990 |
| Revenue Subtotal | 527451 | RevenueSubtotal |
| Other Revenues Not Included | 489973 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 489973 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 1017424 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 0 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 0 | ExpensesSubtotal |
| Other Expenses Not Included | 489973 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 489973 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 489973 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part V, Line 4: | Description of Intended Use of Endowment Funds: | THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS AND CANCER ASSISTANCE. |
| Part XI, Line 8 - Other Adjustments: | EQUITY TRANSFER: 2017923. | |
| Part XII, Line 2d - Other Adjustments: | TRANFER OF EQUITY FROM HOSPITAL: 2017923. | |
| Part XII, Line 4b - Other Adjustments: | EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS: 489973. | |
| Part XIII, Line 4b - Other Adjustments: | EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS: 489973. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 1 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GASTON FAMILY HEALTH SERVICES | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 991 WEST HUDSON BOULEVARD | AddressLine1 |
| City | GASTONIA | City |
| State | NC | State |
| ZIP Code | 28054 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 581958398 | EINOfRecipient |
| IRC Section | 501(C)(3) | IRCSection |
| Amount Of Cash Grant | 480778 | AmountOfCashGrant |
| Purpose Of Grant | FEDERALLY QUALIFIED HEALTH DEPARTMENT OFFERING MEDICAL CARE TO LOW INCOME RESIDENTS OF GASTON COUNTY | PurposeOfGrant |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Nbr Of501 C3 And Govt Grants | 1 | TotalNbrOf501C3AndGovtGrants |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Procedure for Monitoring Grants in the U.S.: | Identifier |
| Return Reference | Part I, Line 2: | ReturnReference |
| Explanation | Schedule I, Part I, Line 2: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Independent Consultant | X | IndependentConsultant |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 1 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 1 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 1 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (4 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Wayne F Shovelin | |||||||||||||
| 0 | 642828 | 0 | 394994 | 0 | 934230 | 0 | 577417 | 0 | 135236 | 0 | 2684705 | 0 | 922287 |
| Valinda L Rutledge | |||||||||||||
| 0 | 145002 | 0 | 112500 | 0 | 390 | 0 | 31876 | 0 | 11624 | 0 | 301392 | 0 | 0 |
| David O'Connor | |||||||||||||
| 0 | 311111 | 0 | 121980 | 0 | 146192 | 0 | 135558 | 0 | 39303 | 0 | 754144 | 0 | 132040 |
| Maria Long | |||||||||||||
| 0 | 204730 | 0 | 71010 | 0 | 80025 | 0 | 91731 | 0 | 29888 | 0 | 477384 | 0 | 78135 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation |
|---|---|
| Part I, Line 4a | Wayne F. Shovelin, CEO participates in a Supplemental Salary Continuation Retirement Plan. Gross payments for 2010 were $5,914,998. Please refer to the Schedule O disclosure for Part VI, Section B, Line 15 for more detail. |
| Part I, Line 6 | Certain CaroMont Medical Group Inc. Physician's Compensation packages are based on the individual physician's net results from operations as calculated based soley on his/her net charges less his/her allocable share of clinic overhead costs. Executive Incentive Compensation Plan for all key employees based on the achievement of annual Business Objectives and Financial Performance of the consolidated system. Manager Incentive Plan based on consolidated corporate and individual performance goals. |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (4 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section B, line 11 | The organization's Form 990 is reviewed by the Audit Finance Investment Committee of the Board of Directors prior to presentation to the full Board before the Form is filed with the IRS. |
| Form 990, Part VI, Section B, line 12c | Each applicable employee and director shall fully and truthfully complete a questionnaire concerning potential and actual conflicts of interest annually. Such questionnaire shall identify the employee's obligation to immediately make the President aware in writing of any potential or actual conflicts on interest as they may arise and contain said employee's agreement to abide by all terms and conditions of this policy as a condition of retaining their position. Such questionnaires shall be reviewed annually by the Vice President/General Counsel and the Corporate Compliance Officer. The President shall make the Board of Directors aware of any actual conflicts of interest. |
| Form 990, Part VI, Section B, line 15 | The CEO, CFO/Assistant Treasurer and General Counsel/Assistant Secretary are compensated for their services by CaroMont Health, Inc. The compensation of all CaroMont executives for each year is established by the Compensation Committee of the CaroMont Health Board of Directors, based on guidance and opinions provided by an independent, third-party compensation consultant. Board members who serve on the Compensation Committee are independent and free of any conflict of interest. Any Compensation Committee member who develops a conflict of interest during his/her term with respect to the discussion of any executive's compensation leaves the meeting and does not participate in the discussion or decision-making by the remaining independent members of the Compensation Committee. The Compensation Committee retains jurisdiction over the total compensation package for executives and reviews executive benefits and perquisites as well as total cash compensation. Compensation for the CEO is established through a process of dialogue with the CEO, comparison with comparable market data and determination by the Compensation Committee of acceptable salary range and percentile ranking. All compensation decisions for the CEO are recommended by the Compensation Committee and approved by the Board of Directors. Compensation for all other executives is established through a process of dialogue between the CEO and the executive, comparison with comparable market data and determination by the CEO of acceptable salary range and percentile ranking. All compensation decisions for executives are recommended by the CEO and approved by the Compensation Committee. Full collected compensation information and any compensation opinions provided during these processes will be kept with the Compensation Committee or Board minutes, as applicable. In 2009, the Board of Directors, by and through the Compensation Committee, conducted two detailed reviews of the retirement benefit to be paid to its retiring CEO. In conducting these reviews, the Compensation Committee worked through an evaluation of the retiring CEO's performance during his 33-year tenure with the organization. The Compensation Committee concluded that in the areas of finance and quality measures, the retiring CEO's performance consistently exceeded expectations and has positioned CaroMont Health as a leader in the region. His performance in the area of patient satisfaction has, in the mission-critical area of emergency services, exceeded the Board of Director's expectations. Overall, and over the arc of his career at CaroMont, the retiring CEO's leadership has led CaroMont Health from a mere community hospital into a regional healthcare powerhouse. The Committee concluded that his leadership had outperformed the region and fulfilled the community's desire to keep its healthcare system under local control, thereby justifying his retirement payment as fair and reasonable compensation for outstanding performance. |
| Form 990, Part VI, Section C, line 19 | At this time, the organization's governing documents and conflict of interest policy are not made available to the public. The organization's financial statements are made available upon request. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (6 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|
| CaroMont Health | |||||||||
| 2525 Court Drive | Gastonia | NC | 28054 | 581636959 | MEDICAL SERVICES | NC | 501(c)(3) | Line 11B, II | N/A |
| CaroMont Health Services | |||||||||
| 2526 Court Drive | Gastonia | NC | 28054 | 561455630 | OUTPATIENT SERVICES | NC | 501(c)(3) | Line 3 | N/A |
| CaroMont Medical Group Inc | |||||||||
| 2528 Court Drive | Gastonia | NC | 28054 | 561479712 | MEDICAL GROUP | NC | 501(c)(3) | Line 9 | N/A |
| Hospice of Gaston County Inc | |||||||||
| 2529 Court Drive | Gastonia | NC | 28054 | 581341530 | Hospice Care | NC | 501(c)(3) | Line 7 | N/A |
| Gaston Memorial Hospital Inc | |||||||||
| 2530 Court Drive | Gastonia | NC | 28054 | 560619359 | HOSPITAL | NC | 501(c)(3) | Line 3 | N/A |
| Gaston Emergency Physicians Inc | |||||||||
| 2531 Court Drive | Gastonia | NC | 28054 | 562209423 | Supporting Organization | NC | 501(c)(3) | Line 11A, I | N/A |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
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