TRICOUNTY MEMORIAL FOUNDATION INC: Form 990, tax year 2019
View the entire original 990 at ProPublica ↗
- Organization
- TRICOUNTY MEMORIAL FOUNDATION INC (EIN 30-0093022)
- Tax period
- 2019-01-01 to 2019-12-31
- Filed
- 2020-11-16
- IRS object ID
- 202003219349306430
- Schema version
- 2019v5.1
- 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 | 2020-11-16T10:43:31-06:00 | ReturnTs |
| Tax Period End | 2019-12-31 | 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 | 1502 LONDON ROAD SUITE 200 | AddressLine1Txt |
| City | DULUTH | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55812 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2019-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 300093022 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL FOUNDATION INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | TRI- | BusinessNameControlTxt |
| Phone | 7155384361 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DAN KLIDZEJS | PersonNm |
| Person Title | FINANCE ADMINISTRATOR, (TCMH) | PersonTitleTxt |
| Phone | 7155384361 | PhoneNum |
| Signature | 2020-11-11 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MICHAEL J PETERSON CPA | PreparerPersonNm |
| PTIN | P01833529 | PTIN |
| Phone | 2187224705 | PhoneNum |
| Preparation | 2020-11-11 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 71.13.38.61 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2020-11-11 | IPDt |
| IP Tm | 16:34:26 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2019 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | DAN KLIDZEJS | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $47,101 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY/FOUNDATION | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2001 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | TRI-COUNTY MEMORIAL FOUNDATION, INC. EXISTS TO SUPPORT THE MISSION OF TRI-COUNTY MEMORIAL HOSPITAL, INC. WHICH IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Volunteers | 7 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $33,293 | PYContributionsGrantsAmt |
| CY Contributions Grants | $38,573 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $27,645 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $0 | CYProgramServiceRevenueAmt |
| PY Investment Income | $4,469 | PYInvestmentIncomeAmt |
| CY Investment Income | $6,262 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $2,266 | CYOtherRevenueAmt |
| PY Total Revenue | $65,407 | PYTotalRevenueAmt |
| CY Total Revenue | $47,101 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $31,730 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $9,043 | 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 | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $23,036 | PYOtherExpensesAmt |
| CY Other Expenses | $15,345 | CYOtherExpensesAmt |
| PY Total Expenses | $54,766 | PYTotalExpensesAmt |
| CY Total Expenses | $24,388 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $10,641 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $22,713 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $435,908 | TotalAssetsBOYAmt |
| Total Assets EOY | $820,329 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $0 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $359,377 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $435,908 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $460,952 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TRI-COUNTY MEMORIAL FOUNDATION, INC. EXISTS TO SUPPORT THE MISSION OF TRI-COUNTY MEMORIAL HOSPITAL, INC. WHICH IS TO DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $24,388 | ExpenseAmt |
| Grant | $9,043 | GrantAmt |
| Revenue | $0 | RevenueAmt |
| Desc | TRI-COUNTY MEMORIAL FOUNDATION, INC. PROVIDES SUPPORT TRI-COUNTY MEMORIAL HOSPITAL, INC., COMMUNITY ORGANIZATIONS, AND INDIVIDUALS TO FURTHER THE PURPOSE OF HEALTH AND EDUCATIONAL NEEDS. TRI-COUNTY MEMORIAL HOSPITAL, INC. PROVIDES HEALTH SERVICES TO THEIR LOCAL AREAS. THE SERVICE AREA IS ABOUT A 25-MILE RADIUS AROUND THE FACILITY AND INCLUDES ABOUT 15,000 INDIVIDUALS. TRI-COUNTY MEMORIAL FOUNDATION, INC. PROVIDES SUPPORT TO TRI-COUNTY HOSPITAL, CLINICS, ASSISTED LIVING, AND NURSING HOME. AT TIMES, EQUIPMENT IS PURCHASED TO SUPPORT THE HOSPITAL, CLINICS, ASSISTED LIVING, AND NURSING HOME. DURING THE PERIOD JANUARY 1, 2019 THROUGH DECEMBER 31, 2019, $3,000 IN SCHOLARSHIPS WERE GRANTED TO STUDENTS IN THE AREA PURSUING CAREERS IN MEDICAL FIELDS. | Desc |
| Total Program Service Expenses | $24,388 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | 0 | 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 | 0 | 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 | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | 0 | 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 | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 0 | 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 | 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 | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | 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 | Yes (1) | 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 | 0 | ConflictOfInterestPolicyInd |
| Whistleblower Policy | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | 0 | 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | DAN KLIDZEJS | PersonNm |
| Phone | 7155384361 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| No Listed Persons Compensated | Yes (X) | NoListedPersonsCompensatedInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (8 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt |
|---|---|---|---|---|---|---|---|
| FRED BOE | |||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| WANDA CARTRETTE | |||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| GLEN JOHNSON | |||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| DAVE PIENTOK | |||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| RACHEL RISBERG | |||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| KURT JOHNSON | |||||||
| CHAIRMAN | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| K ROGER GILBERT | |||||||
| VICE CHAIRMAN | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | |
| DAN KLIDZEJS | |||||||
| FINANCE ADMINISTRATOR | 1.00 | $0 | $0 | $0 | Yes (X) | 40.00 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $0 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $0 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
| Cntrct Rcvd Greater Than100 K | 0 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $38,573 | AllOtherContributionsAmt |
| Total Contributions | $38,573 | TotalContributionsAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $6,262 | TotalRevenueColumnAmt |
| Exclusion | $6,262 | ExclusionAmt |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,266 | TotalRevenueColumnAmt |
| Exclusion | $2,266 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $2,266 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $47,101 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $0 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $8,528 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,043 | TotalAmt |
| Program Services | $6,043 | ProgramServicesAmt |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,000 | TotalAmt |
| Program Services | $3,000 | ProgramServicesAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $111 | TotalAmt |
| Program Services | $111 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,057 | TotalAmt |
| Program Services | $11,057 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | MISCELLANEOUS EXPENSES | Desc |
| Total | $4,177 | TotalAmt |
| Program Services | $4,177 | ProgramServicesAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,388 | TotalAmt |
| Program Services | $24,388 | ProgramServicesAmt |
| Management And General | $0 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $433,208 | BOYAmt |
| EOY | $820,329 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,700 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $435,908 | BOYAmt |
| EOY | $820,329 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $359,377 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $359,377 | 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 | $324,080 | BOYAmt |
| EOY | $346,793 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $111,828 | BOYAmt |
| EOY | $114,159 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $435,908 | BOYAmt |
| EOY | $460,952 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $435,908 | BOYAmt |
| EOY | $820,329 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $22,713 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $2,331 | 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) |
|---|---|---|
| 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 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390704510 | EIN |
| Organization Type | 3 | OrganizationTypeCd |
| Governing Document Listed | Yes (1) | GoverningDocumentListedInd |
| Support | $0 | SupportAmt |
| Other Support | $0 | OtherSupportAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supported Organizations Total | 1 | SupportedOrganizationsTotalCnt |
| Support Sum | $0 | 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 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 | DUE TO TRI COUNTY MEMORIAL HOSPITAL | Desc |
| Amt | $359,377 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $359,377 | TotalLiabilityAmt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | THE SOLE MEMBER OF THE CORPORATION SHALL BE TRI COUNTY MEMORIAL HOSPITAL, INC. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE RETURN IS REVIEWED BY THE BOARD OF DIRECTORS PRIOR TO FILING. |
| FORM 990, PART VI, SECTION C, LINE 19 | TRI-COUNTY MEMORAL FOUNDATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. |
| FORM 990, PART XI, LINE 9: | NET ASSETS RELEASED FOR RESTRICTIONS 3,831. TEMPORARY RESTRICTED CONTRIBUTIONS -1,500. |
| FORM 990, PART XII, LINE 2C, OVERSIGHT OF THE AUDIT: | THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS BY AN INDEPENDENT ACCOUNTANT. THE BOARD OF DIRECTORS GIVES THE FINAL APPROVAL OF THE AUDIT FIRM AND AUDIT REPORTS AND TAKES TIME ANNUALLY TO MEET WITH THE AUDITORS WITHOUT MANAGEMENT PRESENT. THERE WAS NO CHANGE TO THIS PROCESS DURING THE FILING PERIOD. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390704510 | EIN |
| Primary Activities | HOSPITAL | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 3 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 | 0 | 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 | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |