ARCHBOLD MEDICAL GROUP INC: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- ARCHBOLD MEDICAL GROUP INC (EIN 26-2988454)
- Tax period
- 2016-10-01 to 2017-09-30
- Filed
- 2018-08-08
- IRS object ID
- 201802209349301470
- Schema version
- 2016v3.1
- 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 | 2018-08-08T16:11:56-04:00 | ReturnTs |
| Tax Period End | 2017-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 580914992 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DRAFFIN & TUCKER LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 71309 | AddressLine1Txt |
| City | ALBANY | CityNm |
| State Abbreviation | GA | StateAbbreviationCd |
| ZIP | 317081309 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 262988454 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ARCHBOLD MEDICAL GROUP INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | ARCH | BusinessNameControlTxt |
| Phone | 2292282880 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | P O BOX 620 | AddressLine1Txt |
| City | THOMASVILLE | CityNm |
| State Abbreviation | GA | StateAbbreviationCd |
| ZIP | 317990620 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | J PERRY MUSTIAN | PersonNm |
| Person Title | PRESIDENT/CEO | PersonTitleTxt |
| Phone | 2292282880 | PhoneNum |
| Signature | 2018-08-15 | SignatureDt |
| Discuss With Paid Preparer | Yes (true) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JACQUELINE G ATKINS | PreparerPersonNm |
| PTIN | P00861721 | PTIN |
| Phone | 2298837878 | PhoneNum |
| Preparation | 2018-08-02 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | J PERRY MUSTIAN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | P O BOX 1018 | AddressLine1Txt |
| City | THOMASVILLE | CityNm |
| State Abbreviation | GA | StateAbbreviationCd |
| ZIP | 317990620 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $20,121,601 | GrossReceiptsAmt |
| Group Return For Affiliates | false | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | N/A | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2008 | FormationYr |
| Legal Domicile State | GA | LegalDomicileStateCd |
| Activity Or Mission | TO PROVIDE QUALIFIED HEALTH CARE PROFESSIONALS TO PERFORM HEALTH CARE SERVICES ESSENTIAL TO THE PREVENTION AND TREATMENT OF DISEASE FOR THE BENEFIT OF ALL INDIVIDUALS IN ITS SERVICE AREA. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 2 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| CY Contributions Grants | $0 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $17,435,731 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $17,553,748 | CYProgramServiceRevenueAmt |
| CY Investment Income | $0 | CYInvestmentIncomeAmt |
| PY Other Revenue | $3,521,491 | PYOtherRevenueAmt |
| CY Other Revenue | $2,567,853 | CYOtherRevenueAmt |
| PY Total Revenue | $20,957,222 | PYTotalRevenueAmt |
| CY Total Revenue | $20,121,601 | CYTotalRevenueAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $28,945,687 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $29,514,982 | CYSalariesCompEmpBnftPaidAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,197,667 | PYOtherExpensesAmt |
| CY Other Expenses | $11,594,034 | CYOtherExpensesAmt |
| PY Total Expenses | $38,143,354 | PYTotalExpensesAmt |
| CY Total Expenses | $41,109,016 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$17,186,132 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$20,987,415 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $6,766,773 | TotalAssetsBOYAmt |
| Total Assets EOY | $6,591,747 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $79,297,310 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $100,109,699 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | -$72,530,537 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | -$93,517,952 | NetAssetsOrFundBalancesEOYAmt |
| Mission | TO PROVIDE QUALIFIED HEALTH CARE PROFESSIONALS TO PERFORM HEALTH CARE SERVICES ESSENTIAL TO THE PREVENTION AND TREATMENT OF DISEASE FOR THE BENEFIT OF ALL INDIVIDUALS IN ITS SERVICE AREA. | MissionDesc |
| Significant New Program Srvc | false | SignificantNewProgramSrvcInd |
| Significant Change | false | SignificantChangeInd |
| Expense | $35,194,214 | ExpenseAmt |
| Revenue | $20,121,601 | RevenueAmt |
| Desc | HEALTH CARE SERVICES ESSENTIAL TO THE PREVENTION AND TREATMENT OF DISEASE FOR THE BENEFIT OF ALL INDIVIDUALS IN ITS SERVICE AREA, ESTABLISH AND PROMOTE HEALTH EDUCATION PROGRAMS FOR PATIENTS AND THE PUBLIC. | Desc |
| Total Program Service Expenses | $35,194,214 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (true) | DescribedInSection501c3Ind |
| Schedule B Required | false | ScheduleBRequiredInd |
| Political Campaign Acty | false | PoliticalCampaignActyInd |
| Lobbying Activities | false | LobbyingActivitiesInd |
| Subject To Proxy Tax | false | SubjectToProxyTaxInd |
| Donor Advised Fund | false | DonorAdvisedFundInd |
| Conservation Easements | false | ConservationEasementsInd |
| Collections Of Art | false | CollectionsOfArtInd |
| Credit Counseling | false | CreditCounselingInd |
| Temp Or Permanent Endowments | false | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (true) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | false | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | false | ReportProgramRelatedInvstInd |
| Report Other Assets | false | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (true) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (true) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | false | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (true) | ConsolidatedAuditFinclStmtInd |
| School Operating | false | SchoolOperatingInd |
| Foreign Office | false | ForeignOfficeInd |
| Foreign Activities | false | ForeignActivitiesInd |
| More Than5000 K To Org | false | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividualsInd |
| Professional Fundraising | false | ProfessionalFundraisingInd |
| Fundraising Activities | false | FundraisingActivitiesInd |
| Gaming Activities | false | GamingActivitiesInd |
| Operate Hospital | false | OperateHospitalInd |
| Grants To Organizations | false | GrantsToOrganizationsInd |
| Grants To Individuals | false | GrantsToIndividualsInd |
| Schedule J Required | Yes (true) | ScheduleJRequiredInd |
| Tax Exempt Bonds | false | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | false | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | false | PYExcessBenefitTransInd |
| Loan Outstanding | false | LoanOutstandingInd |
| Grant To Related Person | false | GrantToRelatedPersonInd |
| Business Rln With Org Mem | false | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | false | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | false | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | false | DeductibleNonCashContriInd |
| Deductible Art Contribution | false | DeductibleArtContributionInd |
| Terminate Operations | false | TerminateOperationsInd |
| Partial Liquidation | false | PartialLiquidationInd |
| Disregarded Entity | false | DisregardedEntityInd |
| Related Entity | Yes (true) | RelatedEntityInd |
| Related Organization Ctrl Ent | false | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | false | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | false | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (true) | ScheduleORequiredInd |
| IRP Document | 0 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | false | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | false | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | false | TaxablePartyNotificationInd |
| Nondeductible Contributions | false | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | false | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | false | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | false | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | false | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 2 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (true) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | false | DelegationOfMgmtDutiesInd |
| Change To Org Documents | false | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (true) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (true) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (true) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (true) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (true) | MinutesOfCommitteesInd |
| Officer Mailing Address | false | OfficerMailingAddressInd |
| Local Chapters | false | LocalChaptersInd |
| Form990 Provided To Gvrn Body | false | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (true) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (true) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (true) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (true) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (true) | DocumentRetentionPolicyInd |
| Compensation Process CEO | false | CompensationProcessCEOInd |
| Compensation Process Other | false | CompensationProcessOtherInd |
| Investment In Joint Venture | false | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | GA | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | GREG HEMBREE | PersonNm |
| Phone | 2292282853 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 915 GORDON AVENUE | AddressLine1Txt |
| City | THOMASVILLE | CityNm |
| State Abbreviation | GA | StateAbbreviationCd |
| ZIP | 31792 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (19 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | Former Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd |
|---|---|---|---|---|---|---|---|---|---|
| J PERRY MUSTIAN | |||||||||
| PRESIDENT/CE | 6.00 | 45.00 | Yes (X) | Yes (X) | $0 | $3,197,177 | $256,910 | ||
| GERALD N KADIS MD | |||||||||
| VICE CHAIRMA | 40.00 | Yes (X) | Yes (X) | $1,120,939 | $0 | $19,430 | |||
| EDWARD L HALL MD | |||||||||
| PAST TRUSTEE | 40.00 | Yes (X) | $633,786 | $0 | $30,535 | ||||
| LORRAINE WILLIAMS MD | |||||||||
| TRUSTEE | 40.00 | Yes (X) | $492,381 | $0 | $17,990 | ||||
| JOHNNY BELENCHIA MD | |||||||||
| TRUSTEE | 40.00 | Yes (X) | $489,110 | $0 | $22,145 | ||||
| CHARLES D HIGHTOWER | |||||||||
| PAST SEC/TRE | 6.00 | 45.00 | Yes (X) | $0 | $484,898 | $27,265 | |||
| GREG HEMBREE | |||||||||
| SEC/TREAS; C | 6.00 | 45.00 | Yes (X) | Yes (X) | $0 | $19,904 | $0 | ||
| MARTA JONES TURNER | |||||||||
| CHAIRMAN | 1.00 | 2.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| MARK PARKER | |||||||||
| TRUSTEE | 1.00 | 2.00 | Yes (X) | $0 | $0 | $0 | |||
| WALLACE GOODMAN | |||||||||
| PAST TRUSTEE | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| DANIEL E AUTRY SR | |||||||||
| PAST CHAIRMA | 1.00 | 3.00 | Yes (X) | $0 | $0 | $0 | |||
| GRADY RAMSEY | |||||||||
| VICE PRESIDE | 40.00 | 2.00 | Yes (X) | $203,009 | $0 | $33,410 | |||
| BRYAN E JONES | |||||||||
| ASST VICE PR | 40.00 | 2.00 | Yes (X) | $0 | $0 | $0 | |||
| CRAIG A FREDERICKS MD | |||||||||
| PHYSICIAN | 40.00 | $961,134 | $0 | $29,210 | Yes (X) | ||||
| BYRON SIZEMORE MD | |||||||||
| PHYSICIAN | 40.00 | $753,391 | $0 | $18,610 | Yes (X) | ||||
| RAUL G SANTOS MD | |||||||||
| PHYSICIAN | 40.00 | $739,471 | $0 | $16,780 | Yes (X) | ||||
| DARYL O CRENSHAW MD | |||||||||
| PHYSICIAN | 40.00 | 1.00 | $738,926 | $0 | $21,020 | Yes (X) | |||
| CHRISTOPHER DANIELS MD | |||||||||
| PHYSICIAN | 40.00 | $715,716 | $0 | $8,830 | Yes (X) | ||||
| DANIEL E AUTRY JR | |||||||||
| ASST VICE PR | 40.00 | $106,310 | $0 | $3,647 | Yes (X) | ||||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $6,954,173 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $3,701,979 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $505,782 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 52 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | Yes (true) | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (true) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | false | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| DELTA LOCUM TENENS LLC | |||||
| 1755 WITTINGTON PLACE SUITE 175 | DALLAS | TX | 75234 | LOCUM TENENS | $1,124,325 |
| WEATHERBY LOCUMS INC | |||||
| P O BOX 972633 | DALLAS | TX | 75397 | LOCUM TENENS | $813,838 |
| CARDIOLOGY CONSULTANTS OF SOUTH GA | |||||
| 100 MIMOSA DRIVE SUITE 2L | THOMASVILLE | GA | 317926678 | PROF FEES | $812,149 |
| CERNER HEALTH SERVICES INC | |||||
| P O BOX 959167 | ST LOUIS | MO | 63195 | SOFTWARE MAINT | $420,064 |
| NEXTGEN HEALTHCARE | |||||
| 18111 VON KARMAN AVE | IRVINE | CA | 92612 | SOFTWARE MAINT | $121,566 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 5 | CntrctRcvdGreaterThan100KCnt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PATIENT SERVICE REVENUE | Desc |
| Business | 623000 | BusinessCd |
| Total Revenue Column | $17,553,748 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $17,553,748 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $17,553,748 | TotalProgramServiceRevenueAmt |
Other Revenue Misc OtherRevenueMiscGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MANAGEMENT FEES | 623990 | $1,953,140 | $1,953,140 |
| DIRECTOR FEES | 623990 | $494,283 | $494,283 |
| MISCELLANEOUS INCOME | 623990 | $120,430 | $120,430 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $2,567,853 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $20,121,601 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $20,121,601 | RelatedOrExemptFuncIncomeAmt |
| 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 | $3,062,732 | TotalAmt |
| Program Services | $2,826,314 | ProgramServicesAmt |
| Management And General | $236,418 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $109,958 | TotalAmt |
| Management And General | $109,958 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,768,122 | TotalAmt |
| Program Services | $21,169,155 | ProgramServicesAmt |
| Management And General | $1,598,967 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $280,960 | TotalAmt |
| Program Services | $274,102 | ProgramServicesAmt |
| Management And General | $6,858 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,293,210 | TotalAmt |
| Program Services | $3,063,597 | ProgramServicesAmt |
| Management And General | $229,613 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,671,312 | TotalAmt |
| Management And General | $1,671,312 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,800 | TotalAmt |
| Management And General | $15,800 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,387,872 | TotalAmt |
| Program Services | $5,171,954 | ProgramServicesAmt |
| Management And General | $215,918 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,275 | TotalAmt |
| Program Services | $3,275 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $560,130 | TotalAmt |
| Program Services | $315,653 | ProgramServicesAmt |
| Management And General | $244,477 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $541,630 | TotalAmt |
| Management And General | $541,630 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $885,265 | TotalAmt |
| Program Services | $384,825 | ProgramServicesAmt |
| Management And General | $500,440 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $83,500 | TotalAmt |
| Program Services | $44,295 | ProgramServicesAmt |
| Management And General | $39,205 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $312,250 | TotalAmt |
| Program Services | $312,250 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $771,838 | TotalAmt |
| Program Services | $335,518 | ProgramServicesAmt |
| Management And General | $436,320 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $679,105 | TotalAmt |
| Program Services | $621,215 | ProgramServicesAmt |
| Management And General | $57,890 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| RECRUITMENT | $278,626 | $278,579 | $47 |
| MEDICAL SUPPLIES | $278,574 | $278,574 | |
| REPAIRS & MAINTENANCE | $62,032 | $59,330 | $2,702 |
| MISCELLANEOUS | $29,734 | $29,734 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $33,091 | TotalAmt |
| Program Services | $25,844 | ProgramServicesAmt |
| Management And General | $7,247 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,109,016 | TotalAmt |
| Program Services | $35,194,214 | ProgramServicesAmt |
| Management And General | $5,914,802 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $109,931 | BOYAmt |
| EOY | $614,923 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,164,511 | BOYAmt |
| EOY | $1,752,928 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $644,398 | BOYAmt |
| EOY | $701,311 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $194,297 | BOYAmt |
| EOY | $50,888 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $7,143,933 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $3,672,236 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,653,636 | BOYAmt |
| EOY | $3,471,697 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,766,773 | BOYAmt |
| EOY | $6,591,747 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,169,184 | BOYAmt |
| EOY | $2,925,964 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $77,128,126 | BOYAmt |
| EOY | $97,183,735 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $79,297,310 | BOYAmt |
| EOY | $100,109,699 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$72,530,537 | BOYAmt |
| EOY | -$93,517,952 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -$72,530,537 | BOYAmt |
| EOY | -$93,517,952 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,766,773 | BOYAmt |
| EOY | $6,591,747 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | -$20,987,415 | ReconcilationRevenueExpnssAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | Yes (true) | AccountantCompileOrReviewInd |
Acct Compile Or Review Basis AcctCompileOrReviewBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FS Audited | Yes (true) | 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 (true) | AuditCommitteeInd |
| Federal Grant Audit Required | false | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $140,680 | OtherCostOrOtherBasisAmt |
| Book Value | $140,680 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $373,661 | OtherCostOrOtherBasisAmt |
| Depreciation | $84,691 | DepreciationAmt |
| Book Value | $288,970 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,700,909 | OtherCostOrOtherBasisAmt |
| Depreciation | $561,455 | DepreciationAmt |
| Book Value | $1,139,454 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,928,683 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,026,090 | DepreciationAmt |
| Book Value | $1,902,593 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $3,471,697 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | DUE TO RELATED PARTIES | Desc |
| Amt | $97,183,735 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $97,183,735 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE D, PAGE 3, PART X | FormAndLineReferenceDesc |
| Explanation | EXCERPT FROM CONSOLIDATED PARENT ORGANIZATION AUDITED FINANCIAL STATEMENTS. THE MEDICAL CENTER, WITH THE EXCEPTION OF ARCHBOLD MEDICAL ENTERPRISES, INC., IS A NOT-FOR-PROFIT CORPORATION THAT HAS BEEN RECOGNIZED AS TAX- EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE MEDICAL CENTER APPLIES ACCOUNTING POLICIES THAT PRESCRIBE WHEN TO RECOGNIZE AND HOW TO MEASURE THE CONSOLIDATED FINANCIAL STATEMENT EFFECTS OF INCOME TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON ITS INCOME TAX RETURNS. THESE RULES REQUIRE MANAGEMENT TO EVALUATE THE LIKELIHOOD THAT, UPON EXAMINATION BY THE RELEVANT TAXING JURISDICTIONS, THOSE INCOME TAX POSITIONS WOULD BE SUSTAINED. BASED ON THAT EVALUATION, THE MEDICAL CENTER ONLY RECOGNIZES THE MAXIMUM BENEFIT OF EACH INCOME TAX POSITION THAT IS MORE THAN 50% LIKELY OF BEING SUSTAINED. TO THE EXTENT THAT ALL OR A PORTION OF THE BENEFITS OF AN INCOME TAX POSITION ARE NOT RECOGNIZED, A LIABILITY WOULD BE RECOGNIZED FOR THE UNRECOGNIZED BENEFITS, ALONG WITH ANY INTEREST AND PENALTIES THAT WOULD RESULT FROM DISALLOWANCE OF THE POSITION. SHOULD ANY SUCH PENALTIES AND INTEREST BE INCURRED, THEY WOULD BE RECOGNIZED AS OPERATING EXPENSES. BASED ON THE RESULTS OF MANAGEMENTS EVALUATION, NO LIABILITY IS RECOGNIZED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS FOR UNRECOGNIZED INCOME TAX POSITIONS. FURTHER, NO INTEREST OR PENALTIES HAVE BEEN ACCRUED OR CHARGED TO EXPENSE AS OF SEPTEMBER 30, 2017 AND 2016 OR FOR THE YEARS THEN ENDED. THE MEDICAL CENTERS TAX RETURNS ARE SUBJECT TO POSSIBLE EXAMINATION BY THE TAXING AUTHORITIES. FOR FEDERAL INCOME TAX PURPOSES, THE TAX RETURNS ESSENTIALLY REMAIN OPEN FOR POSSIBLE EXAMINATION FOR A PERIOD OF THREE YEARS AFTER THE RESPECTIVE FILING DEADLINES OF THOSE RETURNS. (THE MEDICAL CENTER REFERS TO ARCHBOLD MEDICAL CENTER, INC., THE PARENT CORPORATION.) | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | false | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (true) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | false | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | false | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | false | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | false | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | false | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | false | AnyNonFixedPaymentsInd |
| Initial Contract Exception | false | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (13 entries)
| TitleTitleTxt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| J PERRY MUSTIAN | |||||||||||||
| PRESIDENT/CEO | $610,115 | $177,050 | $2,410,012 | $242,900 | $14,010 | $3,454,087 | $2,390,936 | ||||||
| GERALD N KADIS MD | |||||||||||||
| VICE CHAIRMAN | $1,081,142 | $34,801 | $4,996 | $18,550 | $880 | $1,140,369 | |||||||
| EDWARD L HALL MD | |||||||||||||
| PAST TRUSTEE | $441,564 | $188,590 | $3,632 | $19,875 | $10,660 | $664,321 | |||||||
| LORRAINE WILLIAMS MD | |||||||||||||
| TRUSTEE | $446,698 | $45,683 | $10,600 | $7,390 | $510,371 | ||||||||
| JOHNNY BELENCHIA MD | |||||||||||||
| TRUSTEE | $320,157 | $167,600 | $1,353 | $8,135 | $14,010 | $511,255 | |||||||
| CHARLES D HIGHTOWER | |||||||||||||
| PAST SEC/TREAS; CFO | $335,495 | $102,765 | $46,638 | $19,875 | $7,390 | $512,163 | $39,780 | ||||||
| GRADY RAMSEY | |||||||||||||
| VICE PRESIDENT | $159,267 | $42,500 | $1,242 | $19,576 | $13,834 | $236,419 | |||||||
| CRAIG A FREDERICKS MD | |||||||||||||
| PHYSICIAN | $948,808 | $9,059 | $3,267 | $18,550 | $10,660 | $990,344 | |||||||
| BYRON SIZEMORE MD | |||||||||||||
| PHYSICIAN | $605,808 | $147,088 | $495 | $7,950 | $10,660 | $772,001 | |||||||
| RAUL G SANTOS MD | |||||||||||||
| PHYSICIAN | $551,190 | $186,152 | $2,129 | $15,900 | $880 | $756,251 | |||||||
| DARYL O CRENSHAW MD | |||||||||||||
| PHYSICIAN | $552,599 | $185,832 | $495 | $10,600 | $10,420 | $759,946 | |||||||
| CHRISTOPHER DANIELS MD | |||||||||||||
| PHYSICIAN | $615,000 | $100,270 | $446 | $7,950 | $880 | $724,546 | |||||||
| DANIEL E AUTRY JR | |||||||||||||
| ASST VICE PRESIDENT | $105,996 | $314 | $3,647 | $109,957 | |||||||||
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| SCHEDULE J, PAGE 1, PART I, LINE 3 | THE FILING ORGANIZATION RELIES ON THE METHODS USED BY ARCHBOLD MEDICAL CENTER, INC. (AMC), THE SOLE MEMBER, TO ESTABLISH COMPENSATION OF THE CEO AND EXECUTIVE OFFICERS. COMPENSATION DETERMINATION BY AMC INCLUDES AN INDEPENDENT COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT AND SURVEYS, AS WELL AS BOARD APPROVAL. THESE METHODS ARE WELL DOCUMENTED. |
| SCHEDULE J, PAGE 1, PART I, LINE 4 | J. PERRY MUSTIAN 0 227,000 0 GRADY RAMSEY 0 13,600 0 |
| SCHEDULE J, PART III | THE IRS RULES & REGULATIONS REQUIRE THAT CERTAIN NON-CURRENT, NON-CASH ITEMS ARE REPORTED IN PART II OF FORM 990 REGARDLESS OF THE CURRENT BENEFIT TO THE EMPLOYEE. THESE SAME RULES, IN SOME CASES, REQUIRE THE COMPENSATION AND BENEFITS TO BE REPORTED TWICE IN PART II, ONCE WHEN THE ENTITY ACCRUES FOR A FUTURE PAYMENT AND ONCE WHEN THE PAYMENT IS ACTUALLY MADE TO THE EMPLOYEE. THEREFORE, AN EMPLOYEE'S STATED TOTAL COMPENSATION AND BENEFITS REPORTED ON PART II ARE SUBSTANTIALLY HIGHER THAN THE ACTUAL CASH COMPENSATION RECEIVED IN THE CURRENT YEAR. AMOUNTS REPORTED AS BENEFITS INCLUDE AMOUNTS FOR LIFE INSURANCE, HEALTH INSURANCE, THRIFT PLAN CONTRIBUTIONS, AND PENSION CONTRIBUTIONS. BENEFITS RELATED TO PENSION AND RETIREMENT PLANS REFLECT AMOUNTS ACCUMULATED, BUT NOT PAID, TO THE INDIVIDUAL IN RECOGNITION OF TOTAL YEARS OF EMPLOYMENT, NOT JUST THE CURRENT YEAR. SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN A FEW OF AMC'S TOP EXECUTIVES PARTICIPATE IN A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) WHICH IS ACCRUED BUT UNFUNDED IN AN AMOUNT WHICH, WHEN ADDED TO OTHER SOURCES OF RETIREMENT INCOME, WILL AFFORD A RETIREMENT INCOME AT A TARGETED PERCENTAGE OF PRE-RETIREMENT COMPENSATION. THE SERP IS A NON-QUALIFIED RETIREMENT PLAN. AMC 457(F) RETIREMENT PLAN CERTAIN EXECUTIVES WHO ARE NOT ELIGIBLE FOR THE SERP MAY BE ELIGIBLE TO PARTICIPATE IN A 457(F) PLAN TO HELP THEM ACCUMULATE FUNDS FOR THEIR LONG TERM FINANCIAL NEEDS. THE ORGANIZATION MAY CONTRIBUTE A PERCENTAGE OF BASE SALARY INTO AN INDIVIDUAL EXECUTIVES ACCOUNT IF THE ORGANIZATION MEETS CERTAIN FINANCIAL TARGETS. THE ORGANIZATION OWNS ANY PLAN ASSETS UNTIL THEY ARE PAID TO THE EMPLOYEE AND ALL FUNDS ARE SUBJECT TO A SUBSTANTIAL RISK OF FORFEITURE. VESTING BEGINS AT AGE 55 WITH FIVE YEARS OF SERVICE AT A RATE OF 90% AND THEN INCREASES TO 100% AT AGE 60. PAYMENTS ARE MADE ANNUALLY UPON VESTING. BONUS AWARDS: OFFICERS AND PHYSICIANS ARE AWARDED BONUSES/INCENTIVES CONTINGENT IN PART ON MEETING MANAGEMENT-BY-OBJECTIVE INCENTIVE PLAN GOALS AND EXCESS OF REVENUE OVER EXPENSES. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PAGE 6, PART VI, LINE 2 | DANIEL AUTRY JR DANIEL AUTRY SR VP BOARD MEMBER FAMILY RELATIONSHIP |
| FORM 990, PAGE 6, PART VI, LINE 6 | ARCHBOLD MEDICAL CENTER, INC. (AMC) IS THE SOLE MEMBER OF THE ORGANIZATION WITH RIGHTS TO ELECT MEMBERS OF THE GOVERNING BODY, APPROVE SIGNIFICANT DECISIONS OF THE GOVERNING BODY AND RECEIVE A SHARE OF THE ORGANIZATION'S NET ASSETS UPON THE ORGANIZATION'S DISSOLUTION. |
| FORM 990, PAGE 6, PART VI, LINE 7A | AMC, THE SOLE MEMBER OF ARCHBOLD MEDICAL GROUP, HAS POWER TO APPOINT, ELECT, REPLACE OR REMOVE THE TRUSTEES OF THE GOVERNING BODY. ADDITIONALLY THE CEO AND CFO OF JOHN D. ARCHBOLD MEMORIAL HOSPITAL, A RELATED ORGANIZATION, SHALL SERVE AS EX-OFFICIO MEMBERS OF THE BOARD WITH THE POWER TO VOTE. |
| FORM 990, PAGE 6, PART VI, LINE 7B | THE FILING ORGANIZATION'S GOVERNING BODY MUST SEEK APPROVAL IN WRITING FROM THE SOLE MEMBER, AMC, FOR OPERATING AND CAPITAL BUDGETS, EXPENDITURES OR COMMITMENTS THAT EXCEED 10,000, ASSET SALES AND DISPOSITIONS, PLAN OF DISSOLUTION OF THE ORGANIZATION, ETC. |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE ORGANIZATION'S CFO PRESENTED THE FORM 990 TO TRUSTEES IN ATTENDANCE DURING THE BOARD MEETING PRIOR TO FILING THE RETURN WITH THE IRS. THE TRUSTEES HAD THE OPPORTUNITY TO ASK QUESTIONS AND MAKE COMMENTS. A COPY OF THE RETURN WAS MADE AVAILABLE TO THOSE BOARD MEMBERS WHO WERE UNABLE TO ATTEND THE MEETING. |
| FORM 990, PAGE 6, PART VI, LINE 12C | ON AN ANNUAL BASIS, THE ORGANIZATION DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE AND DISCLOSURE STATEMENT TO EACH TRUSTEE. THIS QUESTIONNAIRE INCLUDES QUESTIONS RELATED TO FINANCIAL INTERESTS, OUTSIDE INTERESTS OR ACTIVITIES, AND GIFTS, MEALS, AND ENTERTAINMENT. IN ADDITION TO DISCLOSING ANY APPLICABLE INFORMATION ON THE QUESTIONNAIRE, THE TRUSTEE ACKNOWLEDGES THAT (S)HE HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ, UNDERSTANDS, AND AGREES TO COMPLY WITH IT, AND UNDERSTANDS THAT THE ORGANIZATION IS A CHARITABLE ORGANIZATION AND THAT IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. RESPONSES ARE SUMMARIZED AND COLLECTIVELY REVIEWED BY THE AUDIT & COMPLIANCE COMMITTEE OF AMC, THE SOLE MEMBER. DURING EACH BOARD MEETING, THE CHAIRMAN INQUIRES IF ANY TRUSTEE HAS AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST RELATED TO ANY AGENDA ITEM. IF THE TRUSTEE DISCLOSES ANY SUCH INTEREST, THE TRUSTEE IS EXCUSED FROM THE MEETING WHILE THE DETERMINATION AS TO WHETHER AN ACTUAL CONFLICT OF INTEREST EXISTS IS DISCUSSED AND VOTED UPON BY DISINTERESTED MEMBERS OF THE BOARD OR COMMITTEE. IF INVITED TO DO SO, THE TRUSTEE WITH A POTENTIAL CONFLICT MAY RESPOND TO QUESTIONS PUT FORTH BY FELLOW DISINTERESTED TRUSTEES REGARDING ANY PROPOSED TRANSACTION OR ARRANGEMENT. THE MINUTES OF THE BOARD AND ALL COMMITTEES WITH BOARD-DELEGATED POWERS WILL RECORD THE NAME OF ANY INTERESTED PERSON/TRUSTEE WHO DISCLOSED OR WAS FOUND TO HAVE A FINANCIAL INTEREST IN CONNECTION WITH A TRANSACTION OR ARRANGEMENT RESULTING IN AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST, THE NATURE OF THE FINANCIAL INTEREST, ANY ACTION TAKEN TO DETERMINE WHETHER A CONFLICT OF INTEREST WAS PRESENT, AND THE BOARD'S OR COMMITTEE'S DECISION AS TO WHETHER A CONFLICT OF INTEREST IN FACT EXISTED; AND THE NAMES OF THE PERSONS WHO WERE PRESENT FOR DISCUSSIONS AND VOTES RELATED TO THE TRANSACTION OR ARRANGEMENT, THE CONTENT OF THE DISCUSSIONS, AND A RECORD OF ANY VOTES TAKEN IN CONNECTION THEREWITH. |
| FORM 990, PAGE 6, PART VI, LINE 19 | NO DOCUMENTS ARE OR WILL BE MADE AVAILABLE TO THE PUBLIC. |
| FORM 990, PART VII | DANIEL AUTRY JR IS EMPLOYED AS AN ASSISTANT VICE PRESIDENT FOR THE FILING ORGANIZATION AND IS THE SON OF BOARD MEMBER DANIEL AUTRY SR. HIS COMPENSATION, HOWEVER, IS PAID DIRECTLY BY A RELATED ORGANIZATION AND IS REIMBURSED BY AMG. DANIEL AUTRY SR RESIGNED HIS POSITION AS BOARD MEMBER DURING THE FISCAL YEAR 2017. |
| FORM 990, PART IX, LINE 11G | PROFESSIONAL FEES 3,713,856 0 0 PURCHASED SERVICES 1,458,098 215,918 0 TOTAL 5,171,954 215,918 0 |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (6 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Business Name Line2DirectControllingEntityName/BusinessNameLine2Txt |
|---|---|---|---|---|---|---|---|---|---|---|---|
| ARCHBOLD MEDICAL CENTER INC | |||||||||||
| P O BOX 1018 | THOMASVILLE | GA | 317991018 | 581552650 | H/C MGMT | GA | 501C3 | 12C | NA | false | |
| JOHN D ARCHBOLD MEM HOSPITAL INC | |||||||||||
| P O BOX 1018 | THOMASVILLE | GA | 317991018 | 580566121 | ACUTE CARE | GA | 501C3 | 3 | AMC | false | ARCHBOLD MEDICAL CENTER INC |
| ARCHBOLD FOUNDATION INC | |||||||||||
| PO BOX 620 | THOMASVILLE | GA | 317990620 | 581559677 | FOUNDATION | GA | 501C3 | 12B | AMC | false | ARCHBOLD MEDICAL CENTER INC |
| ARCHBOLD HEALTH SERVICES INC | |||||||||||
| PO BOX 620 | THOMASVILLE | GA | 317990620 | 581376434 | HEALTHCARE | GA | 501C3 | 10 | AMC | false | ARCHBOLD MEDICAL CENTER INC |
| CCSG INC | |||||||||||
| 915 GORDON AVENUE | THOMASVILLE | GA | 317926614 | 473501366 | MED CLINIC | GA | 501C3 | 3 | AMG | Yes (true) | |
| AMGIR INC | |||||||||||
| 915 GORDON AVENUE | THOMASVILLE | GA | 317926614 | 821188691 | MED CLINIC | GA | 501C3 | 3 | AMG | Yes (true) | |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ARCHBOLD MEDICAL ENTERPRISES | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 400 OLD ALBANY ROAD | AddressLine1Txt |
| City | THOMASVILLE | CityNm |
| State Abbreviation | GA | StateAbbreviationCd |
| ZIP | 31792 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 581494513 | EIN |
| Primary Activities | HEALTHCARE | PrimaryActivitiesTxt |
| Legal Domicile State | GA | LegalDomicileStateCd |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | false | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | false | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | false | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | false | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | Yes (true) | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | false | DivRelatedOrganizationInd |
| Asset Sale To Other Org | false | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | false | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | false | AssetExchangeInd |
| Rental Of Facilities To Oth Org | false | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | Yes (true) | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | Yes (true) | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (true) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (true) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (true) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (true) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (true) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | false | TransferToOtherOrgInd |
| Transfer From Other Org | false | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (6 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| CCSG INC | ||
| D | $3,356,533 | G/L BALANCE |
| AMGIR INC | ||
| D | $313,768 | G/L BALANCE |
| CCSG INC AMGIR INC | ||
| N | AMOUNT INDETERMINABLE | |
| CCSG INC AMGIR INC | ||
| P | AMOUNT INDETERMINABLE | |
| CCSG INC AMGIR INC | ||
| O | AMOUNT INDETERMINABLE | |
| CCSG INC AMGIR INC | ||
| Q | AMOUNT INDETERMINABLE | |