FORT MEMORIAL HOSPITAL FOUNDATION INC: Form 990, tax year 2022
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- Organization
- FORT MEMORIAL HOSPITAL FOUNDATION INC (EIN 39-1397028)
- Tax period
- 2022-10-01 to 2023-09-30
- Filed
- 2024-08-07
- IRS object ID
- 202412209349301476
- Schema version
- 2022v5.0
- 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) |
|---|---|---|
| Return | 2024-08-07T14:15:12-05:00 | ReturnTs |
| Tax Period End | 2023-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 390758449 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 170 N RADNOR-CHESTER RD SUITE 200 | AddressLine1Txt |
| City | RADNOR | CityNm |
| State Abbreviation | PA | StateAbbreviationCd |
| ZIP | 19087 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2022-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391397028 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MEMORIAL HOSPITAL FOUNDATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FORT | BusinessNameControlTxt |
| Phone | 9205685000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 535381998 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JAMES NELSON | PersonNm |
| Person Title | ASSISTANT TREASURER | PersonTitleTxt |
| Phone | 9205685000 | PhoneNum |
| Signature | 2024-07-29 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IRS Responsible Prty Info Curr | 0 | IRSResponsiblePrtyInfoCurrInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | SOLOMON MARDAKHAEV | PreparerPersonNm |
| PTIN | P01806552 | PTIN |
| Phone | 6105653930 | PhoneNum |
| Preparation | 2024-07-16 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2022 | TaxYr |
| Build TS | 2024-08-08 14:25:15Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JAMES NELSON | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 535381998 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $542,667 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | N/A | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1981 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Volunteers | 11 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $153,621 | PYContributionsGrantsAmt |
| CY Contributions Grants | $97,185 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $0 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $0 | CYProgramServiceRevenueAmt |
| PY Investment Income | $176,692 | PYInvestmentIncomeAmt |
| CY Investment Income | $236,821 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $330,313 | PYTotalRevenueAmt |
| CY Total Revenue | $334,006 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $112,191 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $83,575 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $0 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $0 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $53,327 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $46,367 | PYOtherExpensesAmt |
| CY Other Expenses | $53,327 | CYOtherExpensesAmt |
| PY Total Expenses | $158,558 | PYTotalExpensesAmt |
| CY Total Expenses | $136,902 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $171,755 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $197,104 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $7,976,529 | TotalAssetsBOYAmt |
| Total Assets EOY | $8,979,321 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $125,637 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $141,747 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $7,850,892 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $8,837,574 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $54,075 | ExpenseAmt |
| Grant | $54,075 | GrantAmt |
| Revenue | $0 | RevenueAmt |
| Desc | FORT MEMORIAL HOSPITAL FOUNDATION WAS CREATED FOR THE SOLE BENEFIT OF FORT HEALTHCARE. FOUR AREAS OF STRATEGIC FOCUS GUIDE OUR FUNDRAISING AND GRANTING PROCESS. BENEVOLENT CARE INCLUDES PROGRAM FUNDING TO ASSIST PATIENTS WHO CANNOT AFFORD CARE. PROVIDING EXCEPTIONAL CARE INCLUDES FUNDING FOR EQUIPMENT, TECHNOLOGY AND SERVICES THAT ENHANCE THE QUALITY OF CARE AND PATIENT SATISFACTION. LIVING HEALTHIER INCLUDES SERVICES FOCUSED ON COMMUNITY WELLNESS INITIATIVES. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $29,500 | ExpenseAmt |
| Grant | $29,500 | GrantAmt |
| Revenue | $0 | RevenueAmt |
| Desc | ADVANCING CAREERS IN HEALTHCARE INCLUDES SCHOLARSHIPS AND TRAINING FOR EMPLOYEES. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $83,575 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | 0 | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | Yes (1) | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 5 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | Yes (1) | QuidProQuoContributionsInd |
| Quid Pro Quo Contri Discl | Yes (1) | QuidProQuoContriDisclInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JAMES NELSON | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9205685000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 535381998 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (11 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|---|---|
| MICHAEL ANDERSON MD | |||||||
| BOARD MEMBER | 1.00 | 40.00 | Yes (X) | $0 | $1,595,636 | $44,201 | |
| MICHAEL WALLACE | |||||||
| SENIOR ADVISOR | 1.00 | 40.00 | Yes (X) | $0 | $637,198 | $45,607 | |
| MARY BECK METZGER | |||||||
| SECRETARY | 1.00 | 40.00 | Yes (X) | $0 | $65,927 | $15,750 | Yes (X) |
| DONALD WILLIAMS MD | |||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $29,479 | $1,406 | ||
| CAROL BURROWS | |||||||
| PRESIDENT | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| ROY BUDLONG | |||||||
| BOARD MEMBER | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |
| ANDY DIDION | |||||||
| BOARD MEMBER | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |
| JAMES FITZPATRICK PHD | |||||||
| BOARD MEMBER | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |
| CHRISTI OTT | |||||||
| BOARD MEMBER | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |
| THOMAS VINZ | |||||||
| BOARD MEMBER | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |
| JAMES NELSON | |||||||
| ASSISTANT TREASURER | 1.00 | 40.00 | $0 | $363,506 | $45,461 | Yes (X) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $0 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $2,691,746 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $152,425 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
| Cntrct Rcvd Greater Than100 K | 0 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $97,185 | AllOtherContributionsAmt |
| Total Contributions | $97,185 | TotalContributionsAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $154,752 | TotalRevenueColumnAmt |
| Exclusion | $154,752 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $290,730 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $208,661 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $82,069 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $82,069 | TotalRevenueColumnAmt |
| Exclusion | $82,069 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $334,006 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $0 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $236,821 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $54,075 | TotalAmt |
| Program Services | $54,075 | ProgramServicesAmt |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,500 | TotalAmt |
| Program Services | $29,500 | ProgramServicesAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,235 | TotalAmt |
| Fundraising | $41,235 | FundraisingAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,147 | TotalAmt |
| Fundraising | $1,147 | FundraisingAmt |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,945 | TotalAmt |
| Fundraising | $10,945 | FundraisingAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $136,902 | TotalAmt |
| Program Services | $83,575 | ProgramServicesAmt |
| Management And General | $0 | ManagementAndGeneralAmt |
| Fundraising | $53,327 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $367,754 | BOYAmt |
| EOY | $362,431 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,608,775 | BOYAmt |
| EOY | $8,616,890 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,976,529 | BOYAmt |
| EOY | $8,979,321 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $52,079 | BOYAmt |
| EOY | $68,189 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $73,558 | BOYAmt |
| EOY | $73,558 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $125,637 | BOYAmt |
| EOY | $141,747 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,532,471 | BOYAmt |
| EOY | $8,504,644 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $318,421 | BOYAmt |
| EOY | $332,930 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,850,892 | BOYAmt |
| EOY | $8,837,574 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,976,529 | BOYAmt |
| EOY | $8,979,321 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $197,104 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $789,578 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | Yes (X) | SupportingOrganization509a3Ind |
| Supporting Org Type1 | Yes (X) | SupportingOrgType1Ind |
| Supported Organizations | 1 | SupportedOrganizationsCnt |
Supported Org Information SupportedOrgInformationGrp
Supported Organization Name SupportedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390286215 | EIN |
| Organization Type | 3 | OrganizationTypeCd |
| Governing Document Listed | Yes (1) | GoverningDocumentListedInd |
| Support | $54,075 | SupportAmt |
| Other Support | $0 | OtherSupportAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supported Organizations Total | 1 | SupportedOrganizationsTotalCnt |
| Support Sum | $54,075 | SupportSumAmt |
| Other Support Sum | $0 | OtherSupportSumAmt |
Form990 Sch A Supporting Org Form990SchASupportingOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Listed By Name Governing Doc | Yes (1) | ListedByNameGoverningDocInd |
| Suprt Org No IRS Determination | 0 | SuprtOrgNoIRSDeterminationInd |
| Supported Org Section C456 | 0 | SupportedOrgSectionC456Ind |
| Supported Org Not Organized US | 0 | SupportedOrgNotOrganizedUSInd |
| Organization Change Suprt Org | 0 | OrganizationChangeSuprtOrgInd |
| Support Non Supported Org | 0 | SupportNonSupportedOrgInd |
| Payment Substantial Contribtr | 0 | PaymentSubstantialContribtrInd |
| Loan Disqualified Person | 0 | LoanDisqualifiedPersonInd |
| Controlled Disqualified Prsn | 0 | ControlledDisqualifiedPrsnInd |
| Disqualified Prsn Controll Int | 0 | DisqualifiedPrsnControllIntInd |
| Disqualified Prsn Ownr Int | 0 | DisqualifiedPrsnOwnrIntInd |
| Excess Business Holdings Rules | 0 | ExcessBusinessHoldingsRulesInd |
| Contribution Controller | 0 | ContributionControllerInd |
| Contribution Family | 0 | ContributionFamilyInd |
| Contribution35 Controlled | 0 | Contribution35ControlledInd |
Form990 Sch A Type1 Suprt Org Form990SchAType1SuprtOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Power Appoint Majority Dir Trst | Yes (1) | PowerAppointMajorityDirTrstInd |
| Operate Benefit Non Suprt Org | 0 | OperateBenefitNonSuprtOrgInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| 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) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $0 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | GIFT ANNUITY DONOR RESERVES | Desc |
| Amt | $73,558 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $73,558 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $1,123,584 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $789,578 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | $789,578 | RevenueNotReportedAmt |
| Revenue Subtotal | $334,006 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $334,006 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $136,902 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $136,902 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $136,902 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | FORT MEDICAL GROUP PROVIDES FOR INCOME TAXES ON A LIABILITY METHOD WHEREBY DEFERRED TAX ASSETS ARE RECOGNIZED FOR DEDUCTIBLE TEMPORARY DIFFERENCES, OPERATING LOSSES, AND TAX CREDIT CARRYFORWARDS AND DEFERRED TAX LIABILITIES ARE RECOGNIZED FOR TAXABLE TEMPORARY DIFFERENCES. BOTH ARE CALCULATED USING ENACTED TAX RATES WHEN THE DIFFERENCES ARE REALIZED OR SETTLED. TEMPORARY DIFFERENCES ARE THE DIFFERENCES BETWEEN THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND THEIR TAX BASES. DEFERRED TAX ASSETS ARE REDUCED BY A VALUATION ALLOWANCE WHEN, IN THE OPINION OF MANAGEMENT, IT IS MORE LIKELY THAN NOT THAT SOME PORTION OR ALL OF THE DEFERRED TAX ASSETS WILL NOT BE REALIZED. THE FINAL TAX RETURN FOR FMG WAS FILED AS OF JANUARY 1, 2022 SINCE FMG WAS MERGED INTO THE HOSPITAL AS OF THIS DATE. ALL NET OPERATING LOSS CARRYFORWARDS FROM FMG HAVE BEEN RELINQUISHED AS OF THE DATE OF THE MERGER. | ExplanationTxt |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable
Recipient Business Name RecipientBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53538 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient EIN | 390286215 | RecipientEIN |
| IRC Section | 501 (C)(3) | IRCSectionDesc |
| Cash Grant | $54,075 | CashGrantAmt |
| Non Cash Assistance | $0 | NonCashAssistanceAmt |
| Purpose Of Grant | HOSPITAL SUPPORT | PurposeOfGrantTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 1 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Grants Other Asst To Indiv In US GrantsOtherAsstToIndivInUSGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Type | SCHOLARSHIPS | GrantTypeTxt |
| Recipient | 22 | RecipientCnt |
| Cash Grant | $29,500 | CashGrantAmt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 2: | FormAndLineReferenceDesc |
| Explanation | THE FORT MEMORIAL HOSPITAL FOUNDATION (FMHF) PROVIDES PHILANTHROPIC FUNDING TO FORT HEALTHCARE (FHC) TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. FMHF GRANTS ARE ALIGNED WITH FHC'S STRATEGIC GOALS, SUPPORT OPERATIONAL EXCELLENCE AND HELP FHC ADOPT INNOVATIVE TECHNOLOGY AND PATIENT CARE PRACTICES. THE FOUNDATION HAS CHOSEN FOUR PRIORITIES FOR FUNDING. PROPOSALS FOR FUNDING MUST FIT WITHIN ONE OF THESE FOCUS AREAS; BENEVOLENT CARE, KEEPING YOUR FAMILY HEALTHY, PROVIDE THE BEST HEALTH CARE POSSIBLE, EDUCATE PEOPLE FOR CAREERS IN HEALTHCARE. DEPARTMENTS RECEIVING GRANTS ARE RESPONSIBLE TO REPORT THE USE OF FUNDS, OUTCOMES AND ANECDOTAL STORIES THAT ILLUSTRATE THE IMPACT OF THE GRANT. REPORTING REQUIREMENTS WILL BE DETERMINED COLLABORATIVELY PRIOR TO A FINAL FUNDING DECISION. THE SCHOLARSHIP CRITERIA ARE DETERMINED BY AGREEMENT WITH THE DONOR AT THE TIME OF THEIR CONTRIBUTION. THE FOUNDATION HAS TWO CATEGORIES OF DOCUMENTATION FOR THE SCHOLARSHIPS: 1) SCHOLARSHIPS ESTABLISHED THROUGH A TRUST OR ESTATE DOCUMENT; 2) SCHOLARSHIPS ESTABLISHED BY LIVING DONORS FOR WHICH THERE IS WRITTEN GUIDANCE. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (3 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MICHAEL ANDERSON MD | ||||||||||||||
| BOARD MEMBER | $0 | $627,061 | $0 | $408,271 | $0 | $560,304 | $0 | $12,839 | $0 | $31,362 | $0 | $1,639,837 | $0 | $0 |
| MICHAEL WALLACE | ||||||||||||||
| SENIOR ADVISOR | $0 | $463,044 | $0 | $167,455 | $0 | $6,699 | $0 | $12,200 | $0 | $33,407 | $0 | $682,805 | $0 | $0 |
| JAMES NELSON | ||||||||||||||
| ASSISTANT TREASURER | $0 | $273,841 | $0 | $84,208 | $0 | $5,457 | $0 | $12,200 | $0 | $33,261 | $0 | $408,967 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. BOARD MEMBERS WITH A CONFLICT OF INTEREST ABSTAIN FROM VOTING ON THE MATTERS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 41,235. TOTAL EXPENSES 41,235. |
Schedule R IRS990ScheduleR
Id Disregarded Entities IdDisregardedEntitiesGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PAIN CENTERS OF WISCONSIN - FORT ATKINSON LLC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1604 MADISON AVENUE | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53538 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 900777376 | EIN |
| Primary Activities | HEALTH CARE SERVICES | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Total Income | $445,366 | TotalIncomeAmt |
| End Of Year Assets | $938,957 | EndOfYearAssetsAmt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1Txt |
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53538 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390286215 | EIN |
| Primary Activities | HEALTH CARE | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 3 | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORTCARE INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1Txt |
| City | FORT ATKINSON | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53538 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391725831 | EIN |
| Primary Activities | PREFERRED PROVIDER ORGANIZATION | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Entity Type | C | EntityTypeTxt |
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |