Indian Stream Health Center Inc: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- Indian Stream Health Center Inc (EIN 20-0999212)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-08-09
- IRS object ID
- 202212219349301216
- Schema version
- 2021v4.2
- 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 | 2022-08-09T11:42:32-05:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 010523282 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Berry Dunn McNeil & Parker LLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1000 Elm Street 4th Floor | AddressLine1Txt |
| City | Manchester | CityNm |
| State Abbreviation | NH | StateAbbreviationCd |
| ZIP | 03101 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 200999212 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Indian Stream Health Center Inc | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | INDI | BusinessNameControlTxt |
| Phone | 6032378336 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 141 Corliss Lane | AddressLine1Txt |
| City | Colebrook | CityNm |
| State Abbreviation | NH | StateAbbreviationCd |
| ZIP | 03756 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Matthew Streeter | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 6033265610 | PhoneNum |
| Signature | 2022-08-05 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | Matthew | PersonFirstNm |
| Person Last | Streeter | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Barbara J McGuan CPA | PreparerPersonNm |
| PTIN | P00219457 | PTIN |
| Phone | 6036697337 | PhoneNum |
| Preparation | 2022-08-05 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 0 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Final Return | Yes (X) | FinalReturnInd |
| Principal Officer | Matthew Streeter | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 141 Corliss Lane | AddressLine1Txt |
| City | Colebrook | CityNm |
| State Abbreviation | NH | StateAbbreviationCd |
| ZIP | 03756 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $5,675,031 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.indianstream.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2005 | FormationYr |
| Legal Domicile State | NH | LegalDomicileStateCd |
| Activity Or Mission | To provide excellent preventive, acute, and wellness-focused health care to residents within the organization's service area regardless of patient's ability to pay. We will focus our resources to maximize the quality of life of area residents in a cost-effective and efficient manner. | ActivityOrMissionDesc |
| Contract Termination | Yes (X) | ContractTerminationInd |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 61 | TotalEmployeeCnt |
| Total Volunteers | 10 | TotalVolunteersCnt |
| Total Gross UBI | $52,330 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $3,160,613 | PYContributionsGrantsAmt |
| CY Contributions Grants | $3,217,361 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $2,753,251 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $2,439,756 | CYProgramServiceRevenueAmt |
| PY Investment Income | $1,557 | PYInvestmentIncomeAmt |
| CY Investment Income | $689 | CYInvestmentIncomeAmt |
| PY Other Revenue | $10,725 | PYOtherRevenueAmt |
| CY Other Revenue | $17,225 | CYOtherRevenueAmt |
| PY Total Revenue | $5,926,146 | PYTotalRevenueAmt |
| CY Total Revenue | $5,675,031 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $3,722,077 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $2,676,022 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $2,214,790 | PYOtherExpensesAmt |
| CY Other Expenses | $2,810,121 | CYOtherExpensesAmt |
| PY Total Expenses | $5,936,867 | PYTotalExpensesAmt |
| CY Total Expenses | $5,486,143 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$10,721 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $188,888 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $2,959,451 | TotalAssetsBOYAmt |
| Total Assets EOY | $0 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $1,107,890 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $0 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,851,561 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $0 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To provide excellent preventive, acute, and wellness-focused health care to residents within the organization's service area regardless of patient's ability to pay. We will focus our resources to maximize the quality of life of area residents in a cost-effective and efficient manner. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | Yes (1) | SignificantChangeInd |
| Expense | $4,179,836 | ExpenseAmt |
| Revenue | $2,456,981 | RevenueAmt |
| Desc | Provide primary health care to the residents of the Colebrook, NH region and ensure a transition at the closing of the merger for primary care and pharmacy operations to UCVH and its affiliates. | Desc |
| Total Program Service Expenses | $4,179,836 | 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 | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | 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 | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | 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 | Yes (1) | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 7 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 61 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| 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 | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | 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 | Yes (1) | LocalChaptersInd |
| Policies Reference Chapters | Yes (1) | PoliciesReferenceChaptersInd |
| 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 | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | NH | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Matthew Streeter | PersonNm |
| Phone | 6033265610 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8 Clover Lane | AddressLine1Txt |
| City | Whitefield | CityNm |
| State Abbreviation | NH | StateAbbreviationCd |
| ZIP | 03598 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (14 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|
| Gail Fisher | ||||||
| President | 8.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Suzanne Phinney | ||||||
| Vice President | 3.00 | Yes (X) | $0 | $0 | $0 | |
| David Thatcher | ||||||
| Treasurer | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Mike Burtnick | ||||||
| Secretary | 3.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Myriam Beauchesne | ||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Sharon Belleville | ||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Margaret Fitzgerald | ||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Linda Lomasney | ||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Frank Sawicki | ||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Amber Dodge | ||||||
| Past Director | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Sergio Zullich | ||||||
| CEO | 40.00 | Yes (X) | $205,647 | $0 | $30,850 | |
| Arthur Nichols | ||||||
| Interim CFO | 32.00 | Yes (X) | $58,630 | $0 | $190 | |
| Jose Zirena | ||||||
| Past CFO | 40.00 | Yes (X) | $90,068 | $0 | $13,810 | |
| Greg Culley | ||||||
| Past CEO | 40.00 | Yes (X) | $23,239 | $0 | $0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $377,584 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $44,850 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 1 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Sheenan Phinney Bass & Green PA | |||||
| 28 State Street 22nd Floor | Boston | MA | 02109 | Legal Services | $508,003 |
| Locums Tenens | |||||
| PO Box 405547 | Atlanta | GA | 303845547 | Locums Tenens Providers | $270,048 |
| EHRlang LLC | |||||
| 70 Saint Nicholas Ave | Worcester | MA | 01606 | IT Service Desk, Admin, and Application | $161,280 |
| Barton Associates Inc | |||||
| PO Box 417844 | Boston | MA | 022417844 | Locums Tenens Providers | $119,981 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $3,217,361 | GovernmentGrantsAmt |
| Total Contributions | $3,217,361 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt |
|---|---|---|---|---|
| Pharmacy Revenue | 624100 | $1,332,625 | $1,280,295 | $52,330 |
| Net Patient Service Re | 624100 | $966,297 | $966,297 | |
| Nursing Services | 624100 | $140,834 | $140,834 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $2,439,756 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $689 | TotalRevenueColumnAmt |
| Exclusion | $689 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Other Income | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $17,225 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $17,225 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $17,225 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $5,675,031 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $2,404,651 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $52,330 | UnrelatedBusinessRevenueAmt |
| Exclusion | $689 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $422,734 | TotalAmt |
| Management And General | $422,734 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,899,853 | TotalAmt |
| Program Services | $1,822,190 | ProgramServicesAmt |
| Management And General | $77,663 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $35,569 | TotalAmt |
| Program Services | $34,522 | ProgramServicesAmt |
| Management And General | $1,047 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $153,205 | TotalAmt |
| Program Services | $152,377 | ProgramServicesAmt |
| Management And General | $828 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $164,661 | TotalAmt |
| Program Services | $131,729 | ProgramServicesAmt |
| Management And General | $32,932 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $499,832 | TotalAmt |
| Management And General | $499,832 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $30,316 | TotalAmt |
| Management And General | $30,316 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $780,666 | TotalAmt |
| Program Services | $667,872 | ProgramServicesAmt |
| Management And General | $112,794 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,516 | TotalAmt |
| Program Services | $12,412 | ProgramServicesAmt |
| Management And General | $3,104 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $39,703 | TotalAmt |
| Program Services | $31,763 | ProgramServicesAmt |
| Management And General | $7,940 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $71,642 | TotalAmt |
| Program Services | $57,314 | ProgramServicesAmt |
| Management And General | $14,328 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $172,125 | TotalAmt |
| Program Services | $137,700 | ProgramServicesAmt |
| Management And General | $34,425 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,231 | TotalAmt |
| Program Services | $5,785 | ProgramServicesAmt |
| Management And General | $1,446 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,509 | TotalAmt |
| Program Services | $12,407 | ProgramServicesAmt |
| Management And General | $3,102 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $214,435 | TotalAmt |
| Program Services | $171,548 | ProgramServicesAmt |
| Management And General | $42,887 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $46,720 | TotalAmt |
| Program Services | $37,376 | ProgramServicesAmt |
| Management And General | $9,344 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (2 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Pharmacy Costs | $858,498 | $858,498 | |
| Other Expenses | $57,928 | $46,343 | $11,585 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,486,143 | TotalAmt |
| Program Services | $4,179,836 | ProgramServicesAmt |
| Management And General | $1,306,307 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $170,606 | BOYAmt |
| EOY | $0 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $251,561 | BOYAmt |
| EOY | $0 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $56,653 | BOYAmt |
| EOY | $0 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $245,071 | BOYAmt |
| EOY | $0 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Rcvbl From Disqualified Prsn RcvblFromDisqualifiedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $107,672 | BOYAmt |
| EOY | $0 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $51,688 | BOYAmt |
| EOY | $0 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $0 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $0 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,076,200 | BOYAmt |
| EOY | $0 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $0 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,959,451 | BOYAmt |
| EOY | $0 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $245,512 | BOYAmt |
| EOY | $0 | EOYAmt |
Grants Payable GrantsPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $34,086 | BOYAmt |
| EOY | $0 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $656,598 | BOYAmt |
| EOY | $0 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $171,694 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,107,890 | BOYAmt |
| EOY | $0 | 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 | $1,851,561 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,851,561 | BOYAmt |
| EOY | $0 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,959,451 | BOYAmt |
| EOY | $0 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $188,888 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$2,040,449 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| 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) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org509a2 | Yes (X) | PubliclySupportedOrg509a2Ind |
Gifts Grants Contris Rcvd509 GiftsGrantsContrisRcvd509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $2,266,573 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $2,030,828 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $2,371,856 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $3,160,613 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $3,217,361 | CurrentTaxYearAmt |
| Total | $13,047,231 | TotalAmt |
Gross Receipts Admissions GrossReceiptsAdmissionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $4,386,429 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $3,912,820 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $3,719,613 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $2,692,451 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $2,387,426 | CurrentTaxYearAmt |
| Total | $17,098,739 | TotalAmt |
Total509 Total509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $6,653,002 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $5,943,648 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $6,091,469 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $5,853,064 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $5,604,787 | CurrentTaxYearAmt |
| Total | $30,145,970 | TotalAmt |
Amounts Rcvd Dsqlfy Person AmountsRcvdDsqlfyPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
Substantial Contributors Amt SubstantialContributorsAmtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
Subst And Dsqlfy Prsns Tot SubstAndDsqlfyPrsnsTotGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total509 | $30,145,970 | PublicSupportTotal509Amt |
Gross Investment Income509 GrossInvestmentIncome509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $1,706 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $980 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $9,150 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $10,632 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $689 | CurrentTaxYearAmt |
| Total | $23,157 | TotalAmt |
Investment Income And UBTI InvestmentIncomeAndUBTIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $1,706 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $980 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $9,150 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $10,632 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $689 | CurrentTaxYearAmt |
| Total | $23,157 | TotalAmt |
Net Income From Other UBI NetIncomeFromOtherUBIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus3 Years | $126,175 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $48,377 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $62,450 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $0 | CurrentTaxYearAmt |
| Total | $237,002 | TotalAmt |
Other Income509 OtherIncome509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $71,870 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $85,844 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $14,015 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year | $17,225 | CurrentTaxYearAmt |
| Total | $188,954 | TotalAmt |
Total Support Calendar Year TotalSupportCalendarYearGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $6,726,578 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $6,156,647 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $6,163,011 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $5,926,146 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $5,622,701 | CurrentTaxYearAmt |
| Total | $30,595,083 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support CY509 | 0.98530 | PublicSupportCY509Pct |
| Public Support PY509 | 0.98400 | PublicSupportPY509Pct |
| Investment Income CY | 0.00080 | InvestmentIncomeCYPct |
| Investment Income PY | 0.00080 | InvestmentIncomePYPct |
| Thirty Thr Pct Suprt Tests CY509 | Yes (X) | ThirtyThrPctSuprtTestsCY509Ind |
Form990 Schedule A Part VI Form990ScheduleAPartVIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Schedule A, Part III, Line 12, Explanation of Other Income: | FormAndLineReferenceDesc |
| Explanation | Other Income - 2017 Amount: $ 71,870. 2018 Amount: $ 85,844. 2019 Amount: $ 14,015. 2021 Amount: $ 17,225. | ExplanationTxt |
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 |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $5,675,031 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $5,675,031 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $5,675,031 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $5,486,143 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $5,486,143 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $5,486,143 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part X, Line 2: | FormAndLineReferenceDesc |
| Explanation | The Organization is a public charity under Section 501(c)(3) of the Internal Revenue Code (Code). As a public charity, the Organization is exempt from state and federal income taxes on income earned in accordance with its tax-exempt purpose. Unrelated business income is subject to state and federal income tax. Management has evaluated the Organization's tax positions and concluded that the Organization has no unrelated business income or uncertain tax positions that require adjustment to the financial statements. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| 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 | Yes (1) | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Sergio Zullich | PersonNm |
| Title | CEO | TitleTxt |
| Base Compensation Filing Org | $172,591 | BaseCompensationFilingOrgAmt |
| Compensation Based On Rltd Orgs | $0 | CompensationBasedOnRltdOrgsAmt |
| Bonus Filing Organization | $20,000 | BonusFilingOrganizationAmount |
| Bonus Related Organizations | $0 | BonusRelatedOrganizationsAmt |
| Other Compensation Filing Org | $13,056 | OtherCompensationFilingOrgAmt |
| Other Compensation Rltd Orgs | $0 | OtherCompensationRltdOrgsAmt |
| Deferred Compensation Flng Org | $5,173 | DeferredCompensationFlngOrgAmt |
| Deferred Comp Rltd Orgs | $0 | DeferredCompRltdOrgsAmt |
| Nontaxable Benefits Filing Org | $25,677 | NontaxableBenefitsFilingOrgAmt |
| Nontaxable Benefits Rltd Orgs | $0 | NontaxableBenefitsRltdOrgsAmt |
| Total Compensation Filing Org | $236,497 | TotalCompensationFilingOrgAmt |
| Total Compensation Rltd Orgs | $0 | TotalCompensationRltdOrgsAmt |
| Comp Report Prior990 Filing Org | $0 | CompReportPrior990FilingOrgAmt |
| Comp Report Prior990 Rltd Orgs | $0 | CompReportPrior990RltdOrgsAmt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 7 | FormAndLineReferenceDesc |
| Explanation | Due to the vacancy in the CEO position in February 2021 and the expected merger of Indian Stream Health Center near the end of 2021, Sergio Zullich, Pharmacy Director, was appointed to assume the CEO role, continuing to serve in a leadership role in the pharmacy. Mr. Zullich's CEO agreement provided he would be paid $15,000 and $5,000 bonuses upon completion of a specified number of months in his CEO role. He was paid those bonuses upon completion of the required months of serving in the CEO role. | ExplanationTxt |
Schedule N IRS990ScheduleN
Liquidation Of Assets Table LiquidationOfAssetsTableGrp
Liquidation Of Assets Detail LiquidationOfAssetsDetail (14 entries)
| Assets Distri Or Expnss PaidAssetsDistriOrExpnssPaidDesc | DistributionDistributionDt | Fair Market Value Of AssetFairMarketValueOfAssetAmt | Method Of FMV DeterminationMethodOfFMVDeterminationTxt | EINEIN | Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | IRC SectionIRCSectionTxt |
|---|---|---|---|---|---|---|---|---|---|
| Upper Connecticut Valley Hospital | |||||||||
| Cash & Cash Equivalents | 2021-12-31 | $921,913 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Grants receivable | 2021-12-31 | $25,892 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Patients Accounts Receivable | 2021-12-31 | $640,076 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Inventory - Pharmacy | 2021-12-31 | $128,769 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Prepaid Expenses | 2021-12-31 | $84,863 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Land | 2021-12-31 | $60,000 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Building, net of accumluated depreciation | 2021-12-31 | $1,355,772 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Building Improvements, net of accumulated depreciation | 2021-12-31 | $50,774 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Leasehold Improvements, net of accumulated depreciation | 2021-12-31 | $165,402 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Furniture & Fixtures, net of accumulated depreciation | 2021-12-31 | $11,578 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Computers & Equipment, net of accumulated depreciation | 2021-12-31 | $218,875 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Accounts payable and accrued expenses assumed | 2021-12-31 | -$135,133 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Deferred revenue and refundable advances assumed | 2021-12-31 | -$798,736 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Upper Connecticut Valley Hospital | |||||||||
| Long-term debt assumed | 2021-12-31 | -$689,596 | Value at time of sale | 020276210 | 181 Corliss Lane | Colebrook | NH | 03576 | 501(c)3 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Director Of Successor | Yes (1) | DirectorOfSuccessorInd |
| Employee Of Successor | 0 | EmployeeOfSuccessorInd |
| Owner Of Successor | 0 | OwnerOfSuccessorInd |
| Receive Compensation | 0 | ReceiveCompensationInd |
| Assets Distributed | Yes (1) | AssetsDistributedInd |
| Required To Notify AG | Yes (1) | RequiredToNotifyAGInd |
| Attorney General Notified | Yes (1) | AttorneyGeneralNotifiedInd |
| Liabilities Paid | 0 | LiabilitiesPaidInd |
| Bonds Outstanding | 0 | BondsOutstandingInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 2e: | FormAndLineReferenceDesc |
| Explanation | Person(s) Involved: David Thatcher and Gail Fisher both became Directors on the UCVH Board of Directors. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part III, line 3 | On December 31, 2021, the Organization merged with and into Upper Connecticut Valley Hospital Association, Inc. (UCVH), upon which time the separate corporate existence of the Organization ceased and UCVH continued its corporate existence as the surviving corporation, with all of the estate, assets, property, rights, privileges, immunities, powers and franchises of the Organization vesting in UCVH as the surviving corporation, all pursuant to an Agreement and Plan of Merger agreed to by both parties and approved by the State of New Hampshire Department of Justice, Charitable Trust Unit. |
| Form 990, Part VI, Section B, line 11b | The form 990 has historically been reviewed by the finance committee before filing. Because Indian Stream Health Center (ISHC) was acquired by Upper Connecticut Valley Hospital (UCVH) and ceased operations on 12/31/21, the 2021 form 990 will be reviewed by the Interim Financial Analyst and Interim CFO of ISHC in place at ISHC as of 12/31/21 and by the CFO of North Country Health (parent organization of acquiring organization UCVH). The Form will be provided to the entire UCVH Board prior to filing. |
| Form 990, Part VI, Section B, line 12c | Indian Stream Health Center Inc. requires their board members to annually sign a form stating what other organizations they were involved in. The board members are not allowed to vote on issues if they pertain to another organization the board member is involved with. |
| Form 990, Part VI, Section B, line 15 | Historically, the Board of Directors of Indian Stream Health Center, Inc. checked salary information from other FQHCs and review the Form 990s of the other nonprofits to obtain comparability information for the officers' salaries. The organization also participated in NACHC's salary survey. Because of the expected merger of ISHC into UCVH at year end, no new comparative surveys were conducted in 2021. |
| Form 990, Part VI, Section C, line 19 | Organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. |
| Form 990, Part IX, line 11g | Other professional fees: Program service expenses 667,872. Management and general expenses 112,794. Fundraising expenses 0. Total expenses 780,666. |
| Form 990, Part XI, line 9: | Net Asset transfer to Upper Connecticut Valley Hospital -2,040,449. |
| Form 990, Part XII, line 2c | The health center has not changed its oversight process for the audit of its financial statements or its selection process of its independent accountant during the year, except that final audited financial statements were presented to the acquiring organization's (UCVH) board of directors. |