TRICOUNTY MEMORIAL FOUNDATION INC: Form 990EZ, tax year 2014

View the entire original 990 at ProPublica ↗

Organization: TRICOUNTY MEMORIAL FOUNDATION INC (EIN 30-0093022)
Tax period: 2014-01-01 to 2014-12-31
Filed: 2015-11-16
IRS object ID: 201523209349203312
Schema version: 2014v5.0
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
Form 990-EZ
Schedule A
Schedule O
Transfer Prsnl Bnft Contracts Decl

Return header ReturnHeader

Field	Value	IRS element (for citing)
Return	2015-11-16T12:46:21-06:00	ReturnTs
Tax Period End	2014-12-31	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 PARKWAY	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	2014-01-01	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	BRIAN THEILER	PersonNm
Person Title	CEO, TRI-COUNTY MEMORIAL HOSPITAL	PersonTitleTxt
Phone	7155384361	PhoneNum
Signature	2015-11-13	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	2015-11-13	PreparationDt

Field	Value	IRS element (for citing)
Tax	2014	TaxYr
Build TS	2016-02-25 16:41:14Z	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	$56,578	GrossReceiptsAmt
Info In Schedule O Part I	Yes (X)	InfoInScheduleOPartIInd
Contributions Gifts Grants Etc	$8,870	ContributionsGiftsGrantsEtcAmt
Program Service Revenue	$44,979	ProgramServiceRevenueAmt
Investment Income	$2,729	InvestmentIncomeAmt
Total Revenue	$56,578	TotalRevenueAmt
Grants And Similar Amounts Paid	$30,800	GrantsAndSimilarAmountsPaidAmt
Fees And Other Pymt To Ind Cntrct	$3,469	FeesAndOtherPymtToIndCntrctAmt
Total Expenses	$34,269	TotalExpensesAmt
Excess Or Deficit For Year	$22,309	ExcessOrDeficitForYearAmt
Net Assets Or Fund Balances BOY	$349,012	NetAssetsOrFundBalancesBOYAmt
Other Changes In Net Assets	$0	OtherChangesInNetAssetsAmt
Net Assets Or Fund Balances EOY	$371,321	NetAssetsOrFundBalancesEOYAmt

Cash Savings And Investments CashSavingsAndInvestmentsGrp

Field	Value	IRS element (for citing)
BOY	$349,012	BOYAmt
EOY	$371,321	EOYAmt

Form990 Total Assets Form990TotalAssetsGrp

Field	Value	IRS element (for citing)
BOY	$349,012	BOYAmt
EOY	$371,321	EOYAmt

Sum Of Total Liabilities SumOfTotalLiabilitiesGrp

Field	Value	IRS element (for citing)
BOY	$0	BOYAmt
EOY	$0	EOYAmt

Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp

Field	Value	IRS element (for citing)
BOY	$349,012	BOYAmt
EOY	$371,321	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 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, 2014 THROUGH DECEMBER 31, 2014, $4,800 IN SCHOLARSHIPS WERE GRANTED TO STUDENTS IN THE AREA PURSUING CAREERS IN MEDICAL FIELDS. IN ADDITION, THE FOUNDATION ALSO DONATED $1,000 EACH TO FOUR SEPARATE LOCAL FOOD PANTRIES.	DescriptionProgramSrvcAccomTxt
Grants And Allocations	$30,800	GrantsAndAllocationsAmt
Program Service Expenses	$34,269	ProgramServiceExpensesAmt

Field	Value	IRS element (for citing)
Total Program Service Expenses	$34,269	TotalProgramServiceExpensesAmt

Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (7 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
JOHN 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

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	OrganizationTypeDesc
Governing Document Listed	Yes (1)	GoverningDocumentListedInd
Support	$22,000	SupportAmt
Other Support	$0	OtherSupportAmt

Field	Value	IRS element (for citing)
Supported Organizations Total	1	SupportedOrganizationsTotalCnt
Support Sum	$22,000	SupportSumAmt

Form990 Sch A Supporting Org Form990SchASupportingOrgGrp

Field	Value	IRS element (for citing)
Listed By Name Governing Doc	0	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

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp (2 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
SECTION A, LINE 1:	TRI-COUNTY MEMORIAL HOSPITAL, INC. (HOSPITAL) IS THE SOLE CORPORATE MEMBER OF TRI-COUNTY MEMORIAL FOUNDATION, INC. (FOUNDATION). THEY HAVE HAD A HISTORIC AND CONTINUING RELATIONSHIP. THE HOSPITAL MAINTAINS CONTROL OVER THE FOUNDATION AND IS LISTED AS THE SOLE CORPORATE MEMBER WITH RESERVE POWERS IN THE GOVERNING DOCUMENTS OF THE FOUNDATION.
SECTION A, LINE 6:	IN ADDITION TO PROVIDING $22,000 OF GRANTS TO TRI-COUNTY MEMORIAL HOSPITAL, INC., THE SUPPORT INCLUDED $4,800 FOR SCHOLARSHIPS TO AREA HIGH SCHOOL GRADUATES PURSUING HIGHER EDUCATION IN HEALTHCARE RELATED FIELDS AND $4,000 TO LOCAL FOOD PANTRY ORGANIZATIONS TO SUPPORT THE HEALTH OF THE LOCAL COMMUNITY. THESE DONATIONS ARE PART OF THE SAME CHARITABLE CLASS OR PURPOSE OF TRI-COUNTY MEMORIAL HOSPITAL, INC. IF IT WERE NOT FOR THE FOUNDATION PROVIDING THESE DONATIONS, TRI-COUNTY MEMORIAL HOSPITAL, INC. WOULD PROVIDE THESE DIRECTLY.

Form And Line ReferenceFormAndLineReferenceDesc

ExplanationExplanationTxt

SECTION A, LINE 1:

TRI-COUNTY MEMORIAL HOSPITAL, INC. (HOSPITAL) IS THE SOLE CORPORATE MEMBER OF TRI-COUNTY MEMORIAL FOUNDATION, INC. (FOUNDATION). THEY HAVE HAD A HISTORIC AND CONTINUING RELATIONSHIP. THE HOSPITAL MAINTAINS CONTROL OVER THE FOUNDATION AND IS LISTED AS THE SOLE CORPORATE MEMBER WITH RESERVE POWERS IN THE GOVERNING DOCUMENTS OF THE FOUNDATION.

SECTION A, LINE 6:

IN ADDITION TO PROVIDING $22,000 OF GRANTS TO TRI-COUNTY MEMORIAL HOSPITAL, INC., THE SUPPORT INCLUDED $4,800 FOR SCHOLARSHIPS TO AREA HIGH SCHOOL GRADUATES PURSUING HIGHER EDUCATION IN HEALTHCARE RELATED FIELDS AND $4,000 TO LOCAL FOOD PANTRY ORGANIZATIONS TO SUPPORT THE HEALTH OF THE LOCAL COMMUNITY. THESE DONATIONS ARE PART OF THE SAME CHARITABLE CLASS OR PURPOSE OF TRI-COUNTY MEMORIAL HOSPITAL, INC. IF IT WERE NOT FOR THE FOUNDATION PROVIDING THESE DONATIONS, TRI-COUNTY MEMORIAL HOSPITAL, INC. WOULD PROVIDE THESE DIRECTLY.

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (7 entries)

Form And Line ReferenceFormAndLineReferenceDesc	ExplanationExplanationTxt
FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME	DESCRIPTION: INTEREST INCOME. AMOUNT: 2,729.
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: SCHOLARSHIPS TO INDIVIDUALS. GRANTEE NAME: N/A. PROPERTY DESCRIPTION: SCHOLARSHIP. AMOUNT GIVEN: 4,800.
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: 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.
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: 22,000. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 30,800.

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