TRICOUNTY MEMORIAL FOUNDATION INC: Form 990EZ, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- TRICOUNTY MEMORIAL FOUNDATION INC (EIN 30-0093022)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-11-15
- IRS object ID
- 201733199349201458
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-11-15T08:30:38-06:00 | ReturnTs |
| Tax Period End | 2016-12-31 | 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 | 3703 Oakwood Hills Pkwy | AddressLine1Txt |
| City | Eau Claire | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54701 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990EZ | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | 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 | JONI OLSON | PersonNm |
| Person Title | CEO, tri-county memorial hospital | PersonTitleTxt |
| Phone | 7155384361 | PhoneNum |
| Signature | 2017-11-13 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | PAUL M TRACZEK CPA | PreparerPersonNm |
| PTIN | P01368830 | PTIN |
| Phone | 7158323407 | PhoneNum |
| Preparation | 2017-11-13 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 216.54.158.12 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-11-13 | IPDt |
| IP Tm | 15:09:43 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 28CD8CEAA75BD86222655C2FDB3DC3905C47D94D | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2017-02-10 21:41:12Z | BuildTS |
Form 990-EZ IRS990EZ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Schedule B Not Required | Yes (X) | ScheduleBNotRequiredInd |
| Website Address | www.gundersenhealth.org/tri-county/foundation | WebsiteAddressTxt |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Gross Receipts | $50,220 | GrossReceiptsAmt |
| Info In Schedule O Part I | Yes (X) | InfoInScheduleOPartIInd |
| Contributions Gifts Grants Etc | $17,655 | ContributionsGiftsGrantsEtcAmt |
| Program Service Revenue | $27,805 | ProgramServiceRevenueAmt |
| Investment Income | $4,760 | InvestmentIncomeAmt |
| Total Revenue | $50,220 | TotalRevenueAmt |
| Grants And Similar Amounts Paid | $18,299 | GrantsAndSimilarAmountsPaidAmt |
| Fees And Other Pymt To Ind Cntrct | $3,653 | FeesAndOtherPymtToIndCntrctAmt |
| Total Expenses | $21,952 | TotalExpensesAmt |
| Excess Or Deficit For Year | $28,268 | ExcessOrDeficitForYearAmt |
| Net Assets Or Fund Balances BOY | $398,570 | NetAssetsOrFundBalancesBOYAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Net Assets Or Fund Balances EOY | $426,838 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part II | Yes (X) | InfoInScheduleOPartIIInd |
Cash Savings And Investments CashSavingsAndInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $399,724 | BOYAmt |
| EOY | $429,919 | EOYAmt |
Form990 Total Assets Form990TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $399,724 | BOYAmt |
| EOY | $429,919 | EOYAmt |
Sum Of Total Liabilities SumOfTotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,154 | BOYAmt |
| EOY | $3,081 | EOYAmt |
Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $398,570 | BOYAmt |
| EOY | $426,838 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Primary Exempt Purpose | TRI-COUNTY MEMORIAL FOUNDATION, INC. EXISTS TO SUPPORT THE MISSION OF TRI-COUNTY MEMORIAL HOSPITAL, INC. IN THE COMMUNITIES AND SURROUNDING AREAS WHICH ARE SERVICED BY TRI-COUNTY MEMORIAL HOSPITAL, INC. | PrimaryExemptPurposeTxt |
Program Srvc Accomplishment ProgramSrvcAccomplishmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description Program Srvc Accom | TRI-COUNTY MEMORIAL HOSPITAL, INC. PROVIDES SERVICES TO ALL MEMBERS OF THE PUBLIC WHO NEED MEDICAL SERVICES. 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 THE HOSPITAL AND NURSING HOME IN NEEDED AREAS. AT TIMES, EQUIPMENT IS PURCHASED TO SUPPORT THE HOSPITAL AND NURSING HOME AND OFTEN THERE ARE SCHOLARSHIPS PROVIDED TO MEET HEALTHCARE TRAINING AND EDUCATION NEEDS. DURING THE PERIOD JANUARY 1, 2016 THROUGH DECEMBER 31, 2016, $5,200 IN SCHOLARSHIPS WERE GRANTED TO STUDENTS IN THE AREA PURSUING CAREERS IN MEDICAL FIELDS AND $1,393 WAS DONATED TO AN EMPLOYEE MISSION TRIP TO NICARAGUA. IN ADDITION, $4,000 WAS GRANTED TO FOUR LOCAL FOOD PANTRIES, AND $2,712 WAS DONATED TO THE RELAY FOR LIFE. | DescriptionProgramSrvcAccomTxt |
| Grants And Allocations | $18,299 | GrantsAndAllocationsAmt |
| Program Service Expenses | $18,299 | ProgramServiceExpensesAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $18,299 | TotalProgramServiceExpensesAmt |
Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (8 entries)
| TitleTitleTxt | Average Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRt | CompensationCompensationAmt | Employee Benefit ProgramEmployeeBenefitProgramAmt | Expense Account Other AllwncExpenseAccountOtherAllwncAmt |
|---|---|---|---|---|
| KURT JOHNSON | ||||
| Chairman | 0.50 | $0 | $0 | $0 |
| KATHY KULIG | ||||
| TRUSTEE | 0.50 | $0 | $0 | $0 |
| LInda Baxa | ||||
| TRUSTEE | 0.50 | $0 | $0 | $0 |
| K ROGER GILBERT | ||||
| Vice Chairman | 0.50 | $0 | $0 | $0 |
| Dave Pientok | ||||
| TRUSTEE | 0.50 | $0 | $0 | $0 |
| Wanda Cartrette | ||||
| TrusTEE | 0.50 | $0 | $0 | $0 |
| Duane Byom | ||||
| TrustEE | 0.50 | $0 | $0 | $0 |
| BRIAN THEILER | ||||
| President/CEO | 0.50 | $0 | $0 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part V | Yes (X) | InfoInScheduleOPartVInd |
| Activities Not Previously Rpt | 0 | ActivitiesNotPreviouslyRptInd |
| Chg Made To Orgnzng Doc Not Rpt | 0 | ChgMadeToOrgnzngDocNotRptInd |
| Organization Had UBI | 0 | OrganizationHadUBIInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Organization Dissolved Etc | 0 | OrganizationDissolvedEtcInd |
| Direct Indirect Pltcl Expend | $0 | DirectIndirectPltclExpendAmt |
| Made Loans To From Officers | 0 | MadeLoansToFromOfficersInd |
| Tax Imposed Under IRC4911 | $0 | TaxImposedUnderIRC4911Amt |
| Tax Imposed Under IRC4912 | $0 | TaxImposedUnderIRC4912Amt |
| Tax Imposed Under IRC4955 | $0 | TaxImposedUnderIRC4955Amt |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| Tax Imposed On Organization Mgr | $0 | TaxImposedOnOrganizationMgrAmt |
| Tax Reimbursed By Organization | $0 | TaxReimbursedByOrganizationAmt |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Roxane Schleich | PersonNm |
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) |
|---|---|---|
| Phone | 7155384361 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Donor Advised Fnds | 0 | DonorAdvisedFndsInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Tanning Services Provided | 0 | TanningServicesProvidedInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| School Operating | 0 | SchoolOperatingInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Part VI Of Comp Of Hghst Pd Empl | NONE | PartVIOfCompOfHghstPdEmplTxt |
| Part VI Hghst Pd Cntrct Prof Srvc | NONE | PartVIHghstPdCntrctProfSrvcTxt |
| Filed Schedule A | Yes (1) | FiledScheduleAInd |
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 | $4,994 | SupportAmt |
| Other Support | $0 | OtherSupportAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supported Organizations Total | 1 | SupportedOrganizationsTotalCnt |
| Support Sum | $4,994 | 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 O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990-EZ, Part I, Line 4 - Other Investment Income | Description: INTEREST INCOME. Amount: 4,760. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: SCHOLARSHIPS TO INDIVIDUALS. Grantee Name: N/A. Property Description: SCHOLARSHIP. Amount Given: 6,593. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: Donation for property and equipment purchases. Grantee Name: Tri-County Memorial Hospital. Grantee Address: 18601 Lincoln Street WHITEHALL, WI 54773. Grantee Relationship: Related Party. Property Description: Hospital Equipment. Amount Given: 4,994. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: Food Pantry Operation Donations. Grantee Name: City of Blair. Grantee Address: 122 South Urberg Avenue Blair, WI 54616. Property Description: Food Pantry Operations. Amount Given: 1,000. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: RELAY FOR LIFE DONATION. Grantee Name: Relay for Life of Trempealeau County. Property Description: Cancer Research. Amount Given: 2,712. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: Food Pantry Operation Donations. Grantee Name: City of Arcadia. Grantee Address: 1358 Hillview Drive Arcadia, WI 54612. Property Description: Food Pantry Operations. Amount Given: 1,000. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: Food Pantry Operation Donations. Grantee Name: City of Whitehall. Grantee Address: 36124 Sunset Boulevard WhiteHALL, WI 54773. Property Description: Food Pantry Operations. Amount Given: 1,000. |
| Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts Paid | Activity Classification: Food Pantry Operation Donations. Grantee Name: City of Independence. Grantee Address: 23688 Adams Street Independence, WI 54747. Property Description: Food Pantry Operations. Amount Given: 1,000. Total included on Form 990-EZ, line 10: 18,299. |
| Form 990-EZ, Part II, Line 26 - Other Liabilities | Description: ACCOUNTS PAYABLE - DUE TO HOSPITAL. Beg. of Year Amount: 1,154. End of Year Amount: 3,081. |
Transfer Prsnl Bnft Contracts Decl TransferPrsnlBnftContractsDecl
| Field | Value | IRS element (for citing) |
|---|---|---|
| Declaration | The organization did not, during the year, receive any funds, directly,or indirectly, to pay premiums on a personal benefit contract.The organization, did not, during the year, pay any premiums, directly,or indirectly, on a personal benefit contract. | DeclarationDesc |