2016-08-15T11:30:21-05:00 2015-09-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2014-10-01 391397028 FORT MEMORIAL HOSPITAL FOUNDATION FORT 9205685157 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 JAMES NELSON VP OF FISCAL SERVICES 9205685157 2016-08-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2016-08-15 2014 2016-12-15 16:53:06Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 1884610 0 X N/A X 1981 WI THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. 11 8 0 8 0 0 105946 79343 0 0 639258 363875 0 0 745204 443218 39298 67034 0 0 0 0 0 0 21943 222861 216328 262159 283362 483045 159856 6936391 6550095 153609 122877 6782782 6427218 X THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. 0 0 33189 33189 0 THE FOUNDATION WAS CREATED FOR THE BENEFIT OF FORT HEALTHCARE, INC 33845 33845 0 SCHOLARSHIPS 67034 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 5 0 0 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE FORT ATKINSON WI 53538 ROY BUDLONG BOARD MEMBER 1.00 X 0 0 0 SHARON SCHMELING BOARD MEMBER 1.00 X 0 0 0 RICHARD TELFER BOARD MEMBER 1.00 X 0 0 0 MARY ELLEN VINZ BOARD MEMBER 1.00 X 0 0 0 MICHAEL WALLACE BOARD MEMBER 1.00 40.00 X 0 358279 38275 JACKQUELYN WITT BOARD MEMBER 1.00 X 0 0 0 CAROL WARD KNOX PRESIDENT 1.00 40.00 X X 0 0 0 DEAN JOHNSON VICE PRESIDENT 1.00 40.00 X X 0 0 0 DONALD WILLIAMS MD SECRETARY 1.00 40.00 X X 0 267559 35958 MICHAEL RUMPF TREASURER 1.00 40.00 X X 0 0 0 JAMES NELSON ASSISTANT TREASURER 1.00 40.00 X X 0 207560 37591 0 833398 111824 0 0 1 0 0 79343 79343 111558 111558 1693709 1441392 252317 252317 252317 443218 0 0 363875 X 33189 33189 33845 33845 173374 173374 3095 3095 1164 1164 12060 12060 FUNDRAISING EXPENSES 21943 21943 DUES AND MEMBERSHIPS 1179 1179 3513 3513 283362 67034 194385 21943 178496 97075 6483 11520 8475 0 6156118 5845192 586819 596308 6936391 6550095 67957 33133 85652 89744 153609 122877 X 6515921 6165452 266861 261766 6782782 6427218 6936391 6550095 159856 -515420 0 X X 0 1 X 1 0 X X 1 FORT HEALTHCARE 390286215 3 1 17275 0 1 17275 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 CERTIFICATES OF DEPOSIT 354301 F MONEY MARKET FUNDS 242007 F 596308 GIFT ANNUITY DONOR RESERVES 73558 DUE TO RELATED PARTY 16186 89744 -72202 -515420 -515420 443218 0 443218 283362 0 283362 0 283362 1 FORT HEALTHCARE INC 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 390286215 501 (C)(3) 33189 HOSPITAL EQUIPMENT 1 0 SCHOLARSHIPS 23 33845 PART I, LINE 2: THE FORT MEMORIAL HOSPITAL FOUNDATION (FMHF) PROVIDES PHILANTHROPIC FUNDING TO FORT HEALTHCARE (FHC) TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. FMHF GRANTS ARE ALIGNED WITH FHC'S STRATEGIC GOALS, SUPPORT OPERATIONAL EXCELLENCE AND HELP FHC ADOPT INNOVATIVE TECHNOLOGY AND PATIENT CARE PRACTICES. THE FOUNDATION HAS CHOSEN FOUR PRIORITIES FOR FUNDING. PROPOSALS FOR FUNDING MUST FIT WITHIN ONE OF THESE FOCUS AREAS; BENEVOLENT CARE, KEEPING YOUR FAMILY HEALTHY, PROVIDE THE BEST HEALTH CARE POSSIBLE, EDUCATE PEOPLE FOR CAREERS IN HEALTHCARE. DEPARTMENTS RECEIVING GRANTS ARE RESPONSIBLE TO REPORT THE USE OF FUNDS, OUTCOMES AND ANECDOTAL STORIES THAT ILLUSTRATE THE IMPACT OF THE GRANT. REPORTING REQUIREMENTS WILL BE DETERMINED COLLABORATIVELY PRIOR TO A FINAL FUNDING DECISION. 0 0 0 0 0 0 0 0 0 MICHAEL WALLACE BOARD MEMBER 0 346637 0 0 0 11642 0 10400 0 27875 0 396554 0 0 DONALD WILLIAMS MD SECRETARY 0 229142 0 35231 0 3186 0 8692 0 27266 0 303517 0 0 JAMES NELSON ASSISTANT TREASURER 0 206577 0 0 0 983 0 8326 0 29265 0 245151 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. BOARD MEMBERS WITH A CONFLICT OF INTEREST ABSTAIN FROM VOTING ON THE MATTERS. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 14,704. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 14,704. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 158,670. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 158,670. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. FORT HEALTHCARE INC 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 390286215 HEALTH CARE WI 501(C)(3) LINE 3 N/A 1 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI N/A C 1 FORT CARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI N/A C 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0