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TRICOUNTY MEMORIAL FOUNDATION INC: Form 990EZ, tax year 2015

View the entire original 990 at ProPublica ↗

Organization
TRICOUNTY MEMORIAL FOUNDATION INC (EIN 30-0093022)
Tax period
2015-01-01 to 2015-12-31
Filed
2016-11-15
IRS object ID
201613209349205001
Schema version
2015v2.1
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

FieldValueIRS element (for citing)
Return2016-11-15T14:36:33-06:00ReturnTs
Tax Period End2015-12-31TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

FieldValueIRS element (for citing)
Preparer Firm EIN390758449PreparerFirmEIN

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1Wipfli LLPBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line13703 Oakwood Hills PkwyAddressLine1Txt
CityEau ClaireCityNm
State AbbreviationWIStateAbbreviationCd
ZIP54701ZIPCd
FieldValueIRS element (for citing)
Return Type990EZReturnTypeCd
Tax Period Begin2015-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN300093022EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1TRI-COUNTY MEMORIAL FOUNDATION INCBusinessNameLine1Txt
FieldValueIRS element (for citing)
Business Name ControlTRI-BusinessNameControlTxt
Phone7155384361PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line118601 LINCOLN STREETAddressLine1Txt
CityWHITEHALLCityNm
State AbbreviationWIStateAbbreviationCd
ZIP54773ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
Personbrian theilerPersonNm
Person TitleCeo, tri-county memorial hospitalPersonTitleTxt
Phone7155384361PhoneNum
Signature2016-11-15SignatureDt
Discuss With Paid PreparerYes (1)DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonPAUL M TRACZEK CPAPreparerPersonNm
PTINP01368830PTIN
Phone7158323407PhoneNum
Preparation2016-11-15PreparationDt
FieldValueIRS element (for citing)
Tax2015TaxYr
Build TS2017-02-10 21:41:12ZBuildTS

Form 990-EZ IRS990EZ

FieldValueIRS element (for citing)
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Schedule B Not RequiredYes (X)ScheduleBNotRequiredInd
Website Addresswww.gundersenhealth.org/tri-county/foundationWebsiteAddressTxt
Organization501c3Yes (X)Organization501c3Ind
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Gross Receipts$86,748GrossReceiptsAmt
Info In Schedule O Part IYes (X)InfoInScheduleOPartIInd
Contributions Gifts Grants Etc$7,686ContributionsGiftsGrantsEtcAmt
Program Service Revenue$74,464ProgramServiceRevenueAmt
Investment Income$4,598InvestmentIncomeAmt
Total Revenue$86,748TotalRevenueAmt
Grants And Similar Amounts Paid$56,240GrantsAndSimilarAmountsPaidAmt
Fees And Other Pymt To Ind Cntrct$3,259FeesAndOtherPymtToIndCntrctAmt
Total Expenses$59,499TotalExpensesAmt
Excess Or Deficit For Year$27,249ExcessOrDeficitForYearAmt
Net Assets Or Fund Balances BOY$371,321NetAssetsOrFundBalancesBOYAmt
Other Changes In Net Assets$0OtherChangesInNetAssetsAmt
Net Assets Or Fund Balances EOY$398,570NetAssetsOrFundBalancesEOYAmt
Info In Schedule O Part IIYes (X)InfoInScheduleOPartIIInd

Cash Savings And Investments CashSavingsAndInvestmentsGrp

FieldValueIRS element (for citing)
BOY$371,321BOYAmt
EOY$399,724EOYAmt

Form990 Total Assets Form990TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$371,321BOYAmt
EOY$399,724EOYAmt

Sum Of Total Liabilities SumOfTotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$1,154EOYAmt

Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp

FieldValueIRS element (for citing)
BOY$371,321BOYAmt
EOY$398,570EOYAmt
FieldValueIRS element (for citing)
Info In Schedule O Part IIIYes (X)InfoInScheduleOPartIIIInd
Primary Exempt PurposeTRI-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

FieldValueIRS element (for citing)
Description Program Srvc AccomTRI-COUNTY MEMORIAL HOSPITAL, INC. PROVIDES SERVICES TO ALL MEMBERS OF THE PUBLIC WHO NEED MEDICAL SERVICES. THE SERVICES 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, 2015 THROUGH DECEMBER 31, 2015, $3,200 IN SCHOLARSHIPS WERE GRANTED TO STUDENTS IN THE AREA PURSUING CAREERS IN MEDICAL FIELDS.DescriptionProgramSrvcAccomTxt
Grants And Allocations$56,240GrantsAndAllocationsAmt
Program Service Expenses$56,240ProgramServiceExpensesAmt
FieldValueIRS element (for citing)
Total Program Service Expenses$56,240TotalProgramServiceExpensesAmt

Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (8 entries)

TitleTitleTxtAverage Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRtCompensationCompensationAmtEmployee Benefit ProgramEmployeeBenefitProgramAmtExpense Account Other AllwncExpenseAccountOtherAllwncAmt
KURT JOHNSON
Chairman0.50$0$0$0
KATHY KULIG
TRUSTEE0.50$0$0$0
LInda Baxa
TRUSTEE0.50$0$0$0
K ROGER GILBERT
Vice Chairman0.50$0$0$0
Dave Pientok
TRUSTEE0.50$0$0$0
Wanda Cartrette
TrusTEE0.50$0$0$0
Duane Byom
TrustEE0.50$0$0$0
Brian Theiler
President/CEO0.50$0$0$0
FieldValueIRS element (for citing)
Info In Schedule O Part VYes (X)InfoInScheduleOPartVInd
Activities Not Previously Rpt0ActivitiesNotPreviouslyRptInd
Chg Made To Orgnzng Doc Not Rpt0ChgMadeToOrgnzngDocNotRptInd
Organization Had UBI0OrganizationHadUBIInd
Subject To Proxy Tax0SubjectToProxyTaxInd
Organization Dissolved Etc0OrganizationDissolvedEtcInd
Direct Indirect Pltcl Expend$0DirectIndirectPltclExpendAmt
Made Loans To From Officers0MadeLoansToFromOfficersInd
Tax Imposed Under IRC4911$0TaxImposedUnderIRC4911Amt
Tax Imposed Under IRC4912$0TaxImposedUnderIRC4912Amt
Tax Imposed Under IRC4955$0TaxImposedUnderIRC4955Amt
Engaged In Excess Benefit Trans0EngagedInExcessBenefitTransInd
Tax Imposed On Organization Mgr$0TaxImposedOnOrganizationMgrAmt
Tax Reimbursed By Organization$0TaxReimbursedByOrganizationAmt
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTransInd

Books In Care Of Detail BooksInCareOfDetail

FieldValueIRS element (for citing)
PersonRoxane SchleichPersonNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line118601 LINCOLN STREETAddressLine1Txt
CityWHITEHALLCityNm
State AbbreviationWIStateAbbreviationCd
ZIP54773ZIPCd
FieldValueIRS element (for citing)
Phone7155384361PhoneNum
FieldValueIRS element (for citing)
Foreign Financial Account0ForeignFinancialAccountInd
Foreign Office0ForeignOfficeInd
Donor Advised Fnds0DonorAdvisedFndsInd
Operate Hospital0OperateHospitalInd
Tanning Services Provided0TanningServicesProvidedInd
Related Organization Ctrl Ent0RelatedOrganizationCtrlEntInd
Political Campaign Acty0PoliticalCampaignActyInd
Lobbying Activities0LobbyingActivitiesInd
School Operating0SchoolOperatingInd
Trnsfr Exmpt Non Chrtbl Rltd Org0TrnsfrExmptNonChrtblRltdOrgInd
Part VI Of Comp Of Hghst Pd EmplNONEPartVIOfCompOfHghstPdEmplTxt
Part VI Hghst Pd Cntrct Prof SrvcNONEPartVIHghstPdCntrctProfSrvcTxt
Filed Schedule AYes (1)FiledScheduleAInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3Yes (X)SupportingOrganization509a3Ind
Supporting Org Type1Yes (X)SupportingOrgType1Ind
Supported Organizations1SupportedOrganizationsCnt

Supported Org Information SupportedOrgInformationGrp

Supported Organization Name SupportedOrganizationName

FieldValueIRS element (for citing)
Business Name Line1TRI-COUNTY MEMORIAL HOSPITAL INCBusinessNameLine1Txt
FieldValueIRS element (for citing)
EIN390704510EIN
Organization Type3OrganizationTypeCd
Governing Document ListedYes (1)GoverningDocumentListedInd
Support$53,040SupportAmt
Other Support$0OtherSupportAmt
FieldValueIRS element (for citing)
Supported Organizations Total1SupportedOrganizationsTotalCnt
Support Sum$53,040SupportSumAmt
Other Support Sum$0OtherSupportSumAmt

Form990 Sch A Supporting Org Form990SchASupportingOrgGrp

FieldValueIRS element (for citing)
Listed By Name Governing DocYes (1)ListedByNameGoverningDocInd
Suprt Org No IRS Determination0SuprtOrgNoIRSDeterminationInd
Supported Org Section C4560SupportedOrgSectionC456Ind
Supported Org Not Organized US0SupportedOrgNotOrganizedUSInd
Organization Change Suprt Org0OrganizationChangeSuprtOrgInd
Support Non Supported Org0SupportNonSupportedOrgInd
Payment Substantial Contribtr0PaymentSubstantialContribtrInd
Loan Disqualified Person0LoanDisqualifiedPersonInd
Controlled Disqualified Prsn0ControlledDisqualifiedPrsnInd
Disqualified Prsn Controll Int0DisqualifiedPrsnControllIntInd
Disqualified Prsn Ownr Int0DisqualifiedPrsnOwnrIntInd
Excess Business Holdings Rules0ExcessBusinessHoldingsRulesInd
Contribution Controller0ContributionControllerInd
Contribution Family0ContributionFamilyInd
Contribution35 Controlled0Contribution35ControlledInd

Form990 Sch A Type1 Suprt Org Form990SchAType1SuprtOrgGrp

FieldValueIRS element (for citing)
Power Appoint Majority Dir TrstYes (1)PowerAppointMajorityDirTrstInd
Operate Benefit Non Suprt Org0OperateBenefitNonSuprtOrgInd

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (4 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
Form 990-EZ, Part I, Line 4 - Other Investment IncomeDescription: INTEREST INCOME. Amount: 4,598.
Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts PaidActivity Classification: SCHOLARSHIPS TO INDIVIDUALS. Grantee Name: N/A. Property Description: SCHOLARSHIP. Amount Given: 3,200.
Form 990-EZ, Part I, Line 10 - Grants and Similar Amounts PaidActivity 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: 53,040. Total included on Form 990-EZ, line 10: 56,240.
Form 990-EZ, Part II, Line 26 - Other LiabilitiesDescription: ACCOUNTS PAYABLE - DUE TO HOSPITAL. Beg. of Year Amount: 0. End of Year Amount: 1,154.

Transfer Prsnl Bnft Contracts Decl TransferPrsnlBnftContractsDecl

FieldValueIRS element (for citing)
DeclarationThe 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