2020-08-13T08:33:24-05:00 2019-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2018-10-01 391397028 FORT MEMORIAL HOSPITAL FOUNDATION INC FORT 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 JAMES NELSON ASSISTANT TREASURER 9205685000 2020-08-11 1 TERRI REXRODE CPA MST P00096513 9206620016 2020-08-11 184.97.211.65 2020-08-11 14:23:08 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 7D2FE2EA17AC540A2D29D4112E82844D375299C1 2018 2020-09-22 18:59:49Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 3382889 0 X N/A X 1981 WI 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. 7 5 0 9 0 0 67107 99559 0 0 171755 485485 0 0 238862 585044 60403 52998 0 0 0 0 0 0 316292 268777 316292 329180 369290 -90318 215754 7746444 7610383 107406 112222 7639038 7498161 X 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. 0 0 24948 24948 0 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. 28050 28050 0 ADVANCING CAREERS IN HEALTHCARE INCLUDES SCHOLARSHIPS AND TRAINING FOR EMPLOYEES. 52998 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 5 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 7 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 ROY BUDLONG BOARD MEMBER 1.00 3.00 X 0 0 0 JAMES FITZPATRICK PHD BOARD MEMBER 1.00 3.00 X 0 0 0 JAY SMITH BOARD MEMBER 1.00 3.00 X 0 0 0 THOMAS VINZ BOARD MEMBER 1.00 3.00 X 0 0 0 MICHAEL WALLACE BOARD MEMBER 1.00 40.00 X 0 545465 41117 JACKQUELYN WITT-SPOERL BOARD MEMBER 1.00 X 0 0 0 CAROL BURROWS PRESIDENT 1.00 X X 0 0 0 DR EDWIN FISCHER VICE PRESIDENT (THRU 12/31/18) 1.00 X X 0 0 0 MARY BECK METZGER SECRETARY 1.00 40.00 X X 0 57229 13836 MICHAEL RUMPF TREASURER (THRU 12/31/18) 1.00 3.00 X X 0 0 0 JAMES NELSON ASSISTANT TREASURER 1.00 40.00 X 0 292717 41117 0 895411 96070 0 0 1 0 0 99559 99559 144251 144251 3139079 2797845 341234 341234 341234 585044 0 0 485485 X 24948 24948 28050 28050 292540 292540 563 563 298 298 7081 7081 DUES AND MEMBERSHIPS 2028 2028 EDUCATION 310 310 13472 13472 369290 52998 0 316292 76653 331459 8992 5261 6586513 7273663 1074286 0 7746444 7610383 33848 38664 73558 73558 107406 112222 X 7327274 7161157 311764 337004 7639038 7498161 7746444 7610383 215754 -356631 0 X X 0 1 X 1 0 X X 1 FORT HEALTHCARE INC 390286215 3 1 24948 0 1 24948 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 GIFT ANNUITY DONOR RESERVES 73558 73558 X PART X, LINE 2: 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. 1 FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 390286215 501 (C)(3) 24948 HOSPITAL EQUIPMENT 1 0 SCHOLARSHIPS 31 28050 PART I, LINE 2: 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. 0 0 0 0 0 0 0 0 0 MICHAEL WALLACE BOARD MEMBER 0 413388 0 116220 0 15857 0 11000 0 30117 0 586582 0 0 JAMES NELSON ASSISTANT TREASURER 0 242076 0 46105 0 4536 0 11000 0 30117 0 333834 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE 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 OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 7,806. TOTAL EXPENSES 7,806. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 284,734. TOTAL EXPENSES 284,734. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 390286215 HEALTH CARE WI 501(C)(3) LINE 3 N/A 0 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI N/A C 1 FORTCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI N/A C 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0