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      <GovernmentGrants>33198</GovernmentGrants>
      <TotalContributions>418619</TotalContributions>
      <ProgramServiceRevenue>
        <Description>Patient &amp; resident revenue</Description>
        <BusinessCode>622110</BusinessCode>
        <TotalRevenueColumn>23577348</TotalRevenueColumn>
        <RelatedOrExemptFunctionIncome>23577348</RelatedOrExemptFunctionIncome>
      </ProgramServiceRevenue>
      <ProgramServiceRevenue>
        <Description>Supporting revenue</Description>
        <BusinessCode>900099</BusinessCode>
        <TotalRevenueColumn>659000</TotalRevenueColumn>
        <RelatedOrExemptFunctionIncome>659000</RelatedOrExemptFunctionIncome>
      </ProgramServiceRevenue>
      <TotalProgramServiceRevenue>24236348</TotalProgramServiceRevenue>
      <InvestmentIncome>
        <TotalRevenueColumn>193549</TotalRevenueColumn>
        <ExclusionAmount>193549</ExclusionAmount>
      </InvestmentIncome>
      <GrossRents>
        <Real>33078</Real>
      </GrossRents>
      <LessRentalExpenses>
        <Real>0</Real>
      </LessRentalExpenses>
      <RentalIncomeOrLoss>
        <Real>33078</Real>
      </RentalIncomeOrLoss>
      <NetRentalIncomeOrLoss>
        <TotalRevenueColumn>33078</TotalRevenueColumn>
        <ExclusionAmount>33078</ExclusionAmount>
      </NetRentalIncomeOrLoss>
      <LessCostOthBasisSalesExpenses>
        <Other>1503</Other>
      </LessCostOthBasisSalesExpenses>
      <GainOrLoss>
        <Other>-1503</Other>
      </GainOrLoss>
      <NetGainOrLossInvestments>
        <TotalRevenueColumn>-1503</TotalRevenueColumn>
        <ExclusionAmount>-1503</ExclusionAmount>
      </NetGainOrLossInvestments>
      <TotalRevenue>
        <TotalRevenueColumn>24880091</TotalRevenueColumn>
        <RelatedOrExemptFunctionIncome>24236348</RelatedOrExemptFunctionIncome>
        <UnrelatedBusinessRevenue>0</UnrelatedBusinessRevenue>
        <ExclusionAmount>225124</ExclusionAmount>
      </TotalRevenue>
      <InfoInScheduleOPartIX>X</InfoInScheduleOPartIX>
      <GrantsToDomesticIndividuals>
        <Total>11111</Total>
        <ProgramServices>11111</ProgramServices>
      </GrantsToDomesticIndividuals>
      <CompCurrentOfficersDirectors>
        <Total>1182427</Total>
        <ProgramServices>898972</ProgramServices>
        <ManagementAndGeneral>283455</ManagementAndGeneral>
      </CompCurrentOfficersDirectors>
      <OtherSalariesAndWages>
        <Total>9897507</Total>
        <ProgramServices>9244617</ProgramServices>
        <ManagementAndGeneral>623677</ManagementAndGeneral>
        <Fundraising>29213</Fundraising>
      </OtherSalariesAndWages>
      <PensionPlanContributions>
        <Total>81100</Total>
        <ProgramServices>71039</ProgramServices>
        <ManagementAndGeneral>10061</ManagementAndGeneral>
      </PensionPlanContributions>
      <OtherEmployeeBenefits>
        <Total>940306</Total>
        <ProgramServices>866745</ProgramServices>
        <ManagementAndGeneral>73561</ManagementAndGeneral>
      </OtherEmployeeBenefits>
      <PayrollTaxes>
        <Total>699234</Total>
        <ProgramServices>634275</ProgramServices>
        <ManagementAndGeneral>61650</ManagementAndGeneral>
        <Fundraising>3309</Fundraising>
      </PayrollTaxes>
      <FeesForServicesLegal>
        <Total>5426</Total>
        <ManagementAndGeneral>5426</ManagementAndGeneral>
      </FeesForServicesLegal>
      <FeesForServicesAccounting>
        <Total>67210</Total>
        <ManagementAndGeneral>67210</ManagementAndGeneral>
      </FeesForServicesAccounting>
      <FeesForServicesOther>
        <Total>4179678</Total>
        <ProgramServices>3824208</ProgramServices>
        <ManagementAndGeneral>351768</ManagementAndGeneral>
        <Fundraising>3702</Fundraising>
      </FeesForServicesOther>
      <Advertising>
        <Total>122867</Total>
        <ProgramServices>92077</ProgramServices>
        <Fundraising>30790</Fundraising>
      </Advertising>
      <OfficeExpenses>
        <Total>1076407</Total>
        <ProgramServices>864975</ProgramServices>
        <ManagementAndGeneral>208284</ManagementAndGeneral>
        <Fundraising>3148</Fundraising>
      </OfficeExpenses>
      <Occupancy>
        <Total>398881</Total>
        <ProgramServices>398881</ProgramServices>
      </Occupancy>
      <Travel>
        <Total>65949</Total>
        <ProgramServices>60227</ProgramServices>
        <ManagementAndGeneral>5722</ManagementAndGeneral>
      </Travel>
      <ConferencesMeetings>
        <Total>44159</Total>
        <ProgramServices>34292</ProgramServices>
        <ManagementAndGeneral>9692</ManagementAndGeneral>
        <Fundraising>175</Fundraising>
      </ConferencesMeetings>
      <Interest>
        <Total>286002</Total>
        <ProgramServices>48003</ProgramServices>
        <ManagementAndGeneral>237999</ManagementAndGeneral>
      </Interest>
      <DepreciationDepletion>
        <Total>1712639</Total>
        <ProgramServices>1712639</ProgramServices>
      </DepreciationDepletion>
      <Insurance>
        <Total>177769</Total>
        <ProgramServices>43200</ProgramServices>
        <ManagementAndGeneral>134569</ManagementAndGeneral>
      </Insurance>
      <OtherExpenses>
        <Description>Medical supplies</Description>
        <Total>1298776</Total>
        <ProgramServices>1298776</ProgramServices>
      </OtherExpenses>
      <OtherExpenses>
        <Description>Provision for bad debts</Description>
        <Total>696000</Total>
        <ProgramServices>696000</ProgramServices>
      </OtherExpenses>
      <OtherExpenses>
        <Description>Grant expenditures</Description>
        <Total>25337</Total>
        <ProgramServices>17897</ProgramServices>
        <ManagementAndGeneral>7440</ManagementAndGeneral>
      </OtherExpenses>
      <OtherExpenses>
        <Description>Quality assurance tax</Description>
        <Total>13815</Total>
        <ProgramServices>13815</ProgramServices>
      </OtherExpenses>
      <AllOtherExpenses>
        <Total>444</Total>
        <ManagementAndGeneral>444</ManagementAndGeneral>
      </AllOtherExpenses>
      <TotalFunctionalExpenses>
        <Total>22983044</Total>
        <ProgramServices>20831749</ProgramServices>
        <ManagementAndGeneral>2080958</ManagementAndGeneral>
        <Fundraising>70337</Fundraising>
      </TotalFunctionalExpenses>
      <SavingsAndTempCashInvestments>
        <BOY>2193808</BOY>
        <EOY>1127698</EOY>
      </SavingsAndTempCashInvestments>
      <AccountsReceivable>
        <BOY>2884473</BOY>
        <EOY>2916960</EOY>
      </AccountsReceivable>
      <InventoriesForSaleOrUse>
        <BOY>305757</BOY>
        <EOY>402773</EOY>
      </InventoriesForSaleOrUse>
      <PrepaidExpensesDeferredCharges>
        <BOY>55471</BOY>
        <EOY>56856</EOY>
      </PrepaidExpensesDeferredCharges>
      <LandBuildingsEquipmentBasis>26389604</LandBuildingsEquipmentBasis>
      <LandBldgEquipmentAccumDeprec>12914236</LandBldgEquipmentAccumDeprec>
      <LandBuildingsEquipmentBasisNet>
        <BOY>14503660</BOY>
        <EOY>13475368</EOY>
      </LandBuildingsEquipmentBasisNet>
      <InvestmentsPubTradedSecurities>
        <BOY>4698377</BOY>
        <EOY>6048340</EOY>
      </InvestmentsPubTradedSecurities>
      <InvestmentsOtherSecurities>
        <EOY>701847</EOY>
      </InvestmentsOtherSecurities>
      <InvestmentsProgramRelated>
        <BOY>4784</BOY>
        <EOY>22730</EOY>
      </InvestmentsProgramRelated>
      <OtherAssetsTotal>
        <BOY>57107</BOY>
        <EOY>387481</EOY>
      </OtherAssetsTotal>
      <TotalAssets>
        <BOY>24703437</BOY>
        <EOY>25140053</EOY>
      </TotalAssets>
      <AccountsPayableAccruedExpenses>
        <BOY>1569197</BOY>
        <EOY>1789999</EOY>
      </AccountsPayableAccruedExpenses>
      <DeferredRevenue>
        <BOY>416826</BOY>
        <EOY>322510</EOY>
      </DeferredRevenue>
      <TaxExemptBondLiabilities>
        <BOY>5105914</BOY>
        <EOY>4301414</EOY>
      </TaxExemptBondLiabilities>
      <MortNotesPyblSecuredInvestProp>
        <BOY>1562130</BOY>
        <EOY>1045980</EOY>
      </MortNotesPyblSecuredInvestProp>
      <OtherLiabilities>
        <BOY>426032</BOY>
        <EOY>0</EOY>
      </OtherLiabilities>
      <TotalLiabilities>
        <BOY>9080099</BOY>
        <EOY>7459903</EOY>
      </TotalLiabilities>
      <FollowSFAS117>X</FollowSFAS117>
      <UnrestrictedNetAssets>
        <BOY>15506678</BOY>
        <EOY>17563490</EOY>
      </UnrestrictedNetAssets>
      <PermanentlyRestrictedNetAssets>
        <BOY>116660</BOY>
        <EOY>116660</EOY>
      </PermanentlyRestrictedNetAssets>
      <TotalNetAssetsFundBalances>
        <BOY>15623338</BOY>
        <EOY>17680150</EOY>
      </TotalNetAssetsFundBalances>
      <TotalLiabNetAssetsFundBalances>
        <BOY>24703437</BOY>
        <EOY>25140053</EOY>
      </TotalLiabNetAssetsFundBalances>
      <ReconcilationRevenueExpenses>1897047</ReconcilationRevenueExpenses>
      <ReconciliationUnrealizedInvest>159765</ReconciliationUnrealizedInvest>
      <ReconcilationOtherChanges>0</ReconcilationOtherChanges>
      <MethodOfAccountingAccrual>X</MethodOfAccountingAccrual>
      <AccountantCompileOrReview>0</AccountantCompileOrReview>
      <FSAudited>1</FSAudited>
      <FSAuditedBasis>
        <FinancialStatementConsolidated>X</FinancialStatementConsolidated>
      </FSAuditedBasis>
      <AuditCommittee>1</AuditCommittee>
      <FederalGrantAuditRequired>0</FederalGrantAuditRequired>
    </IRS990>
    <IRS990ScheduleA documentId="RetDoc1039100001">
      <Hospital170b1Aiii>X</Hospital170b1Aiii>
    </IRS990ScheduleA>
    <IRS990ScheduleB documentId="RetDoc1234500001">
      <ContributorInfo>
        <ContributorNumber>RESTRICTED</ContributorNumber>
        <ContributorNameBusiness>
          <BusinessNameLine1>RESTRICTED</BusinessNameLine1>
        </ContributorNameBusiness>
        <ContributorAddressUS>
          <AddressLine1>RESTRICTED</AddressLine1>
          <AddressLine2>RESTRICTED</AddressLine2>
          <City>RESTRICTED</City>
          <State>RESTRICTED</State>
          <ZIPCode>RESTRICTED</ZIPCode>
        </ContributorAddressUS>
        <AggregateContributions>RESTRICTED</AggregateContributions>
      </ContributorInfo>
    </IRS990ScheduleB>
    <IRS990ScheduleD documentId="RetDoc1040000001">
      <CurrentYear>
        <BeginningOfYearBalance>1627963</BeginningOfYearBalance>
        <InvestmentEarningsOrLosses>7635</InvestmentEarningsOrLosses>
        <OtherExpenditures>9104</OtherExpenditures>
        <EndOfYearBalance>1626494</EndOfYearBalance>
      </CurrentYear>
      <CurrentYearMinus1Year>
        <BeginningOfYearBalance>1628126</BeginningOfYearBalance>
        <InvestmentEarningsOrLosses>14308</InvestmentEarningsOrLosses>
        <OtherExpenditures>14471</OtherExpenditures>
        <EndOfYearBalance>1627963</EndOfYearBalance>
      </CurrentYearMinus1Year>
      <CurrentYearMinus2Years>
        <BeginningOfYearBalance>1617150</BeginningOfYearBalance>
        <InvestmentEarningsOrLosses>46377</InvestmentEarningsOrLosses>
        <OtherExpenditures>35401</OtherExpenditures>
        <EndOfYearBalance>1628126</EndOfYearBalance>
      </CurrentYearMinus2Years>
      <CurrentYearMinus3Years>
        <BeginningOfYearBalance>1617150</BeginningOfYearBalance>
        <InvestmentEarningsOrLosses>33261</InvestmentEarningsOrLosses>
        <OtherExpenditures>33261</OtherExpenditures>
        <EndOfYearBalance>1617150</EndOfYearBalance>
      </CurrentYearMinus3Years>
      <CurrentYearMinus4Years>
        <BeginningOfYearBalance>1617150</BeginningOfYearBalance>
        <InvestmentEarningsOrLosses>13589</InvestmentEarningsOrLosses>
        <OtherExpenditures>13589</OtherExpenditures>
        <EndOfYearBalance>1617150</EndOfYearBalance>
      </CurrentYearMinus4Years>
      <PermanentEndowmentEOYBalance>1.00000</PermanentEndowmentEOYBalance>
      <EndowmentsHeldByUnrelatedOrgs>0</EndowmentsHeldByUnrelatedOrgs>
      <EndowmentsHeldByRelatedOrgs>0</EndowmentsHeldByRelatedOrgs>
      <Land>
        <OtherCostOrOtherBasis>63494</OtherCostOrOtherBasis>
        <BookValue>63494</BookValue>
      </Land>
      <Buildings>
        <InvestmentCostOrOtherBasis>151876</InvestmentCostOrOtherBasis>
        <OtherCostOrOtherBasis>16817743</OtherCostOrOtherBasis>
        <Depreciation>7021181</Depreciation>
        <BookValue>9948438</BookValue>
      </Buildings>
      <Equipment>
        <OtherCostOrOtherBasis>7978360</OtherCostOrOtherBasis>
        <Depreciation>5455709</Depreciation>
        <BookValue>2522651</BookValue>
      </Equipment>
      <OtherLandBuildings>
        <OtherCostOrOtherBasis>1378131</OtherCostOrOtherBasis>
        <Depreciation>437346</Depreciation>
        <BookValue>940785</BookValue>
      </OtherLandBuildings>
      <TotalOfBookValueLandBuildings>13475368</TotalOfBookValueLandBuildings>
      <FootnoteInPartXIII>X</FootnoteInPartXIII>
      <Form990ScheduleDPartXIII>
        <Identifier>Description of Intended Use of Endowment Funds:</Identifier>
        <ReturnReference>Part V, Line 4:</ReturnReference>
        <Explanation>Endowment funds with the income to be used for repairs and maintenance and capital improvements. Funds which can be loaned to the general fund for operating needs and a fund with the distributions to be used for the benefit of Virginia Gay Health Care Foundation.</Explanation>
      </Form990ScheduleDPartXIII>
      <Form990ScheduleDPartXIII>
        <Identifier>Description of Uncertain Tax Positions Under FIN 48:</Identifier>
        <ReturnReference>Part X, Line 2:</ReturnReference>
        <Explanation>The Hospital is organized as an Iowa nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred.</Explanation>
      </Form990ScheduleDPartXIII>
    </IRS990ScheduleD>
    <IRS990ScheduleH documentId="RetDoc1041500001">
      <CharityCarePolicy>1</CharityCarePolicy>
      <WrittenPolicy>1</WrittenPolicy>
      <PolicyAppliedToAllHospitals>X</PolicyAppliedToAllHospitals>
      <FPGReferenceFreeCare>1</FPGReferenceFreeCare>
      <Pcent200>X</Pcent200>
      <FPGReferenceDiscountedCare>1</FPGReferenceDiscountedCare>
      <Pcent350>X</Pcent350>
      <FreeDiscCareMedicallyIndigent>1</FreeDiscCareMedicallyIndigent>
      <AmountsBudgetedForCharityCare>1</AmountsBudgetedForCharityCare>
      <ExpensesExceededBudget>0</ExpensesExceededBudget>
      <AnnualCommunityBenefitReport>1</AnnualCommunityBenefitReport>
      <ReportPublicallyAvailable>1</ReportPublicallyAvailable>
      <CharityCareAtCost>
        <TotalCommunityBenefitExpense>243000</TotalCommunityBenefitExpense>
        <NetCommunityBenefitExpense>243000</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.01090</PercentOfTotalExpense>
      </CharityCareAtCost>
      <UnreimbursedMedicaid>
        <TotalCommunityBenefitExpense>144452</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>144452</DirectOffsettingRevenue>
      </UnreimbursedMedicaid>
      <TotalCharityCare>
        <TotalCommunityBenefitExpense>387452</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>144452</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>243000</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.01090</PercentOfTotalExpense>
      </TotalCharityCare>
      <CommunityHealthServices>
        <PersonsServed>10375</PersonsServed>
        <TotalCommunityBenefitExpense>52964</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>3945</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>49019</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.00220</PercentOfTotalExpense>
      </CommunityHealthServices>
      <HealthProfessionsEducation>
        <PersonsServed>6</PersonsServed>
        <TotalCommunityBenefitExpense>6020</TotalCommunityBenefitExpense>
        <NetCommunityBenefitExpense>6020</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.00030</PercentOfTotalExpense>
      </HealthProfessionsEducation>
      <SubsidizedHealthServices>
        <TotalCommunityBenefitExpense>4149792</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>4100172</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>49620</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.00220</PercentOfTotalExpense>
      </SubsidizedHealthServices>
      <CashAndInKindContributions>
        <PersonsServed>350</PersonsServed>
        <TotalCommunityBenefitExpense>5535</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>250</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>5285</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.00020</PercentOfTotalExpense>
      </CashAndInKindContributions>
      <TotalOtherBenefits>
        <PersonsServed>10731</PersonsServed>
        <TotalCommunityBenefitExpense>4214311</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>4104367</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>109944</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.00490</PercentOfTotalExpense>
      </TotalOtherBenefits>
      <TotalCommunityBenefits>
        <PersonsServed>10731</PersonsServed>
        <TotalCommunityBenefitExpense>4601763</TotalCommunityBenefitExpense>
        <DirectOffsettingRevenue>4248819</DirectOffsettingRevenue>
        <NetCommunityBenefitExpense>352944</NetCommunityBenefitExpense>
        <PercentOfTotalExpense>0.01580</PercentOfTotalExpense>
      </TotalCommunityBenefits>
      <BadDebtExpenseReported>1</BadDebtExpenseReported>
      <BadDebtExpenseAmount>696000</BadDebtExpenseAmount>
      <AmountAttributableTo>0</AmountAttributableTo>
      <AmountReimbursedByMedicare>6315740</AmountReimbursedByMedicare>
      <CostOfCareReimbursedByMedicare>6166773</CostOfCareReimbursedByMedicare>
      <MedicareSurplusOrShortfall>148967</MedicareSurplusOrShortfall>
      <CostingMethodologyUsed>
        <Other>X</Other>
      </CostingMethodologyUsed>
      <WrittenDebtCollectionPolicy>1</WrittenDebtCollectionPolicy>
      <ProvisionForCharityCare>1</ProvisionForCharityCare>
      <NumberOfHospitalFacilities>1</NumberOfHospitalFacilities>
      <Form990ScheduleHPartVSectionA>
        <FacilityNumber>1</FacilityNumber>
        <Name>
          <BusinessNameLine1>Virginia Gay Hospital Inc</BusinessNameLine1>
        </Name>
        <Address>
          <AddressLine1>502 N 9th Avenue</AddressLine1>
          <City>Vinton</City>
          <State>IA</State>
          <ZIPCode>523492254</ZIPCode>
        </Address>
        <LicensedHospital>X</LicensedHospital>
        <GeneralMedicalAndSurgical>X</GeneralMedicalAndSurgical>
        <CriticalAccessHospital>X</CriticalAccessHospital>
        <Er24Hours>X</Er24Hours>
        <Other>3 provider based rural health clinics</Other>
      </Form990ScheduleHPartVSectionA>
      <Form990ScheduleHPartVSectionB>
        <HospitalFacilityName>
          <BusinessNameLine1>Virginia Gay Hospital Inc</BusinessNameLine1>
        </HospitalFacilityName>
        <HospitalFacilityNumber>1</HospitalFacilityNumber>
        <CHNAConducted>1</CHNAConducted>
        <CommunityDefinition>X</CommunityDefinition>
        <CommunityDemographics>X</CommunityDemographics>
        <ExistingResources>X</ExistingResources>
        <HowDataObtained>X</HowDataObtained>
        <CommunityHealthNeeds>X</CommunityHealthNeeds>
        <OtherHealthIssues>X</OtherHealthIssues>
        <IdentifyingProcess>X</IdentifyingProcess>
        <ConsultingProcess>X</ConsultingProcess>
        <NeedsAssessmentConducted>12</NeedsAssessmentConducted>
        <TakeIntoAccount>1</TakeIntoAccount>
        <OtherFacilities>0</OtherFacilities>
        <CHNAWidelyAvailable>1</CHNAWidelyAvailable>
        <OwnWebsite>X</OwnWebsite>
        <OnRequest>X</OnRequest>
        <AdoptImplementStrategy>X</AdoptImplementStrategy>
        <ExecuteImplementStrategy>X</ExecuteImplementStrategy>
        <PrioritizeHealthNeeds>X</PrioritizeHealthNeeds>
        <PrioritizeServices>X</PrioritizeServices>
        <OtherNeedsAddressed>X</OtherNeedsAddressed>
        <AllNeedsAddressed>1</AllNeedsAddressed>
        <OrganizationIncurExciseTax>0</OrganizationIncurExciseTax>
        <EligibilityCriteriaExplained>1</EligibilityCriteriaExplained>
        <UsesFPGFree>1</UsesFPGFree>
        <FPGFreePercent>200.000000000000</FPGFreePercent>
        <UsesFPGDiscounted>1</UsesFPGDiscounted>
        <FPGDiscountPercent>350.000000000000</FPGDiscountPercent>
        <ExplainsBasis>1</ExplainsBasis>
        <IncomeLevel>X</IncomeLevel>
        <MedicalIndigency>X</MedicalIndigency>
        <MedicaidMedicare>X</MedicaidMedicare>
        <ExplainsApplicationMethod>1</ExplainsApplicationMethod>
        <IncludesPublicityMeasures>1</IncludesPublicityMeasures>
        <AvailableOnRequest>X</AvailableOnRequest>
        <OtherPublicity>X</OtherPublicity>
        <ActionsOnNonpayment>1</ActionsOnNonpayment>
        <CollectionActivities>0</CollectionActivities>
        <NotifyUponAdmission>X</NotifyUponAdmission>
        <NotifiedAllPatients>X</NotifiedAllPatients>
        <DocumentedDetermination>X</DocumentedDetermination>
        <NondiscrimEmergencyCarePolicy>1</NondiscrimEmergencyCarePolicy>
        <MedicareRate>X</MedicareRate>
        <AmountsGenerallyBilled>0</AmountsGenerallyBilled>
        <GrossCharges>0</GrossCharges>
      </Form990ScheduleHPartVSectionB>
      <Form990ScheduleHPartVSectionC>
        <NumberOfOtherFacilities>3</NumberOfOtherFacilities>
        <OtherFacilities>
          <Name>
            <BusinessNameLine1>Virginia Gay Nursing &amp; Rehab</BusinessNameLine1>
          </Name>
          <Address>
            <AddressLine1>502 N 9th Avenue</AddressLine1>
            <City>Vinton</City>
            <State>IA</State>
            <ZIPCode>52349</ZIPCode>
          </Address>
          <FacilityType>Intermediate care facility</FacilityType>
        </OtherFacilities>
        <OtherFacilities>
          <Name>
            <BusinessNameLine1>Virginia Gay Hospital Home Health Agency</BusinessNameLine1>
          </Name>
          <Address>
            <AddressLine1>309 1st Avenue</AddressLine1>
            <City>Vinton</City>
            <State>IA</State>
            <ZIPCode>52349</ZIPCode>
          </Address>
          <FacilityType>Skilled nursing care</FacilityType>
        </OtherFacilities>
        <OtherFacilities>
          <Name>
            <BusinessNameLine1>Atkins Family Medical Clinic</BusinessNameLine1>
          </Name>
          <Address>
            <AddressLine1>401 Cardinal Avenue</AddressLine1>
            <City>Atkins</City>
            <State>IA</State>
            <ZIPCode>52206</ZIPCode>
          </Address>
          <FacilityType>Physician clinic</FacilityType>
        </OtherFacilities>
      </Form990ScheduleHPartVSectionC>
      <Form990ScheduleHPartVI>
        <Explanation>Part I, Line 3c: Discount Current Year's Federal FPI for Family size100% Family income is less or equal to 200% of FPIG80% Family income is 201% to 225% of FPIG60% Family income is 226% to 250% of FPIG40% Family income is 251% to 300% of FPIG20% Family income is 301% to 350% of FPIG0% Family income is greater than 350% of FPIG</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part I, Line 6a: The community benefit report is available upon request.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio which addresses all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services, health professions education, and cash and in-kind contributions to community groups, lines 7e, 7f, and 7i are reported based on costs reported in the general ledger. The cost for subsidized health services on line 7g was determined using the Medicare cost report.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part I, L7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $696,000.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part III, Line 4: Prior to any account being classified as bad debt, all payments are applied including contractual allowances and discounts, and every effort is made with the patient in an attempt to collect the outstanding balance. Payments on accounts that were written off as bad debt reduces bad debt expense in the current year. Virginia Gay Hospital continues to serve patients in emergency situations even after the patients have generated significant bad debt.Virginia Gay Hospital monitors the level of charity care it provides. Virginia Gay Hospital has several procedures in place to determine which patients would qualify for charity even if the applications are not completed. Therefore, the Hospital feels confident that no amount of bad debt expense is attributable to patients eligible under the organization's financial assistance policy. The footnote to the Organization's financial statements can be found on pages 8 and 9 of the attached audited financial statements.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part III, Line 8: Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part III, Line 9b: For patients who are known to qualify for charity care or financial assistance and who qualify for 100% discount, there will be no collection efforts. If a patient qualifies for a partial write-off of their bill, any personal portion due that is delinquent would follow the same collection procedures as other patients. Virginia Gay Hospital tries to identify patients who are uninsured or under-insured and patients who meet the presumptive eligibility criteria. Acceptable programs are: the Food Stamp program, Mothers and Children (MAC), Iowa Family Planning Network (IFPN), Medically Needy Program, Limited eligibility, County relief programs, and deceased patients with no known estate. If a patient qualifies for assistance after their account has already been sent to collections, all collection efforts cease immediately and all credit issues are reversed. If a patient enters into an extended payment plan, Virginia Gay Hospital will not impose wage garnishments, or liens on primary residences, will not send unpaid bills to outside collection agencies, and will cease all collection efforts, as long as the patient complies with their payment agreement, or contacts Virginia Gay Hospital with changed financial information.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Virginia Gay Hospital, Inc.</Identifier>
        <Explanation>Part V, Section B, Line 3: Public health and hospital representatives from the counties of Buchanan, Delaware, Benton, Jones, Iowa, Johnson and Cedar were invited to serve on a steering committee to help guide the CHNA process from start to finish. Special attention was paid to recruiting diverse subsets of the population to help accurately identify the most critical issues in the area.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Virginia Gay Hospital, Inc.</Identifier>
        <Explanation>Part V, Section B, Line 5c: The Organization's Community Health Needs Assessment can be found at www.myvghinc.com.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Virginia Gay Hospital, Inc.</Identifier>
        <Explanation>Part V, Section B, Line 6i: Virginia Gay Hospital has adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to the Hospital's website at www.myvghinc.com.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Virginia Gay Hospital, Inc.</Identifier>
        <Explanation>Part V, Section B, Line 7: The needs assessment identified needs that are being addressed by other organizations in the community. Teen pregnancy and sexual health is being addressed by the Vinton-Shellsburg school district. Mental health was also an area identified as a need in relation to high school students and this is also referred to school districts and area mental health providers.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Virginia Gay Hospital, Inc.</Identifier>
        <Explanation>Part V, Section B, Line 14g: A summary of the policy and financial assistance information is posted in the emergency, admitting and waiting rooms, admissions and business offices, included with patient bills and information is available on our website.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part VI, Line 2: The Hospital provides staff to attend Community Coalitions and Advisory Committees which are focused on specific populations and/or community health issues. Examples of the committees include: The Benton County Provider Coalition, the Area Agency on Aging Task Force and the Emergency Preparedness/Disaster Recovery Coalition. These coalitions meet regularly throughout the year and review resources as well as problems that are identified.Virginia Gay Hospital staff participate annually in the community needs assessment process for public health.The target area for the community Health Needs Assessment (CHNA) as identified by the Linn County hospitals included an eight county region of Linn and its contiguous counties (Buchanan, Delaware, Benton, Jones, Iowa, Johnson and Cedar). Public health and hospital representatives from each county were invited to serve on a steering committee to help guide the CHNA process from start to finish. Special attention was paid to recruiting diverse subsets of the population to help accurately identify the most critical issues in the area. Following the collection of all the statistical data, each health indicator was analyzed by comparing it regionally, to the state average rate, and national rates to determine the community's priority health concerns. Obesity/chronic disease, cancer, substance abuse, mental health and sexual health were found as health concerns that needed to be addressed. The CHNA is posted on our website to comply with the 501r requirements and can be viewed in its entirety at www.myvghinc.com.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part VI, Line 3: Virginia Gay Hospital is committed to providing charity care to persons who have healthcare needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay for medically necessary care based on their individual financial situation. Virginia Gay Hospital strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. Patients are expected to cooperate with Virginia Gay Hospital's procedures for obtaining charity care or other forms of payment of financial assistance, and to contribute to the cost of their care based on their individual ability to pay. The charity care policy includes all departments of the facility, including the Vinton Family Medical Clinic, the Urbana Family Medical Clinic, the Van Horne Family Medical Clinic, and the Nursing and Rehab. The Virginia Gay Hospital Home Health Agency has a separate financial assistance procedure, due to their Public Health role in the community.Notification about charity care is available by the publication of notices in patient bills, posting of notices in emergency rooms, admitting and registration departments, the Business Office, and other public places the Hospital may elect. Information is also included on the facility website, and in the patient information packets. A request for charity may be made by the patient or a family member, close friend or associate of the patient, subject to the applicable privacy laws.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part VI, Line 4: Virginia Gay Hospital is a Critical access hospital serving an estimated population of 27,000. Virginia Gay Hospital is located in Vinton, Iowa, the county seat of Benton County. Vinton has a population of approximately 5,200 people. The closest hospitals are located 37 miles away in Cedar Rapids, Iowa. Virginia Gay Hospital currently operates three separate clinics; one clinic is located on the hospital campus in Vinton, another clinic is located in the rural town of Van Horne, Iowa which is 15 miles from Vinton and the other clinic is located in the rural community of Urbana, 13 miles from Vinton. The Hospital and clinics serve a large number of Medicare and Medicaid patients that represent admissions and registrations of 40% and 8% respectively. The median household income in 2010 was $55,810 and 6.8% of the population was below the poverty level. Manufacturing is the largest industry in the area and the recession has had a heavy impact on Vinton and Benton County and unemployment rates are up as a result.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Explanation>Part VI, Line 5: Virginia Gay Hospital is proudly recognized as having one of the lowest costs per stay rates in the state of Iowa. The Hospital offers twenty-five beds in an acute care setting with state of the art technology and professional services. Virginia Gay Hospital also offers 24 hour acute care, short term skilled nursing services, radiology, respiratory care, cardio-pulmonary rehabilitation, physical therapy, occupational therapy, speech therapy, laboratory services, surgical services, outpatient clinics and emergency care. In addition, our staff has contributed multiple hours providing uncompensated time in areas such as family/parenting/sibling education, medical expertise for the schools athletic teams, health fairs, information and referrals to community services, safety classes, sports physicals and many other uncompensated services. Requirements of the IRS community benefit standard for tax-exempt organizations are integral to the Hospital's larger charitable mission of improving health and quality of life. Specifically, Virginia Gay Hospital is governed by an independent board including community leaders, physicians, consumer representatives, business experts and clinical healthcare experts who reside in our primary service area. The Board has a history of commitment to acting with the highest integrity and has been proactively evaluating opportunities to voluntarily adopt governance best practices to ensure the organization continues to operate with the highest of integrity for the benefit of the community. To meet the needs of our community, the Hospital extends privileges to medical staff that are qualified through licensure in the state of Iowa. Excess funds are reinvested and used for patient care and facility upgrades.Virginia Gay's Home Health Agency offers a variety of services to all ages in the rural population of Benton County. The Hospital also offers such services as skilled and non- skilled service home care, blood pressure checks, and group teaching classes such as cardiopulmonary resuscitation (CPR), Advanced Life Support (ALS) and Pediatric Advanced Life Support (PALS). In addition, Virginia Gay Hospital, through its integrated network of providers, provides non-emergency services to the community it serves. It makes these services accessible to the community through participation in government programs like Medicare and Medicaid and by offering assistance through their Financial assistance program. Virginia Gay Hospital's Financial Assistance Policy provides discounted and free services to patients who lack the resources to be fully responsible for the health care they receive. The Financial Assistance Policy is designed to ensure the entire community served by the Hospital has access to needed healthcare services. Virginia Gay Hospital takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad health needs of the community. It strives to identify community needs beyond basic healthcare, respond to them, aiming to make a positive, life-enhancing difference in the community. Contributing to Community Education: The nursing staff and Home Health Agency nurses participate in county wide community health fairs. These events provide information and guidelines to those in need of Medical information.Preventive Care a Priority: The Hospital has taken steps to enhance preventive care for people of all ages by ensuring that those who come here for preventive care receive the screenings and recommendations appropriate to their personal and family history.</Explanation>
      </Form990ScheduleHPartVI>
      <Form990ScheduleHPartVI>
        <Identifier>Reports Filed With States</Identifier>
        <ReturnReference>Part VI, Line 7</ReturnReference>
        <Explanation>IA</Explanation>
      </Form990ScheduleHPartVI>
    </IRS990ScheduleH>
    <IRS990ScheduleI documentId="RetDoc1041900001">
      <RecordsMaintained>1</RecordsMaintained>
      <Form990ScheduleIPartIII>
        <TypeOfGrant>Academic support to nursing students</TypeOfGrant>
        <NumberOfRecipients>9</NumberOfRecipients>
        <AmountOfCashGrant>9000</AmountOfCashGrant>
      </Form990ScheduleIPartIII>
      <Form990ScheduleIPartIII>
        <TypeOfGrant>Student loan repayment</TypeOfGrant>
        <NumberOfRecipients>2</NumberOfRecipients>
        <AmountOfCashGrant>2111</AmountOfCashGrant>
      </Form990ScheduleIPartIII>
      <Form990ScheduleIPartIV>
        <Identifier>Procedure for Monitoring Grants in the U.S.:</Identifier>
        <ReturnReference>Part I, Line 2:</ReturnReference>
        <Explanation>Schedule I, Part I, Line 2: Interested high school seniors entering the field of health care must complete an application. A Committee of the Hospital Board reviews the applications, selects the recipients, and forwards the applications to the full Board for their review and selection. The checks are written to the recipient and the school to ensure appropriate use of the funds.</Explanation>
      </Form990ScheduleIPartIV>
      <Form990ScheduleIPartIV>
        <Identifier>Schedule I, Part III:</Identifier>
        <Explanation>The number of recipients is the actual number of students receiving a scholarship or student loan repayment assistance.</Explanation>
      </Form990ScheduleIPartIV>
    </IRS990ScheduleI>
    <IRS990ScheduleJ documentId="RetDoc1042400001">
      <CompensationCommittee>X</CompensationCommittee>
      <CompensationSurvey>X</CompensationSurvey>
      <BoardOrCommitteeApproval>X</BoardOrCommitteeApproval>
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      <Form990ScheduleJPartII>
        <NamePerson>Dr Brian Meeker DO</NamePerson>
        <Title>Director</Title>
        <BaseCompensationFilingOrg>558944</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
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        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Dr Mark Dearden DO</NamePerson>
        <Title>Director</Title>
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      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Michael Riege</NamePerson>
        <Title>CEO</Title>
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        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Dr Michelle Elgin DO</NamePerson>
        <Title>Physician</Title>
        <BaseCompensationFilingOrg>177846</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
        <BonusFilingOrg>0</BonusFilingOrg>
        <BonusRelatedOrgs>0</BonusRelatedOrgs>
        <OtherCompensationFilingOrg>0</OtherCompensationFilingOrg>
        <OtherCompensationRelatedOrgs>0</OtherCompensationRelatedOrgs>
        <DeferredCompFilingOrg>1389</DeferredCompFilingOrg>
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        <NontaxableBenefitsFilingOrg>13476</NontaxableBenefitsFilingOrg>
        <NontaxableBenefitsRelatedOrgs>0</NontaxableBenefitsRelatedOrgs>
        <TotalCompensationFilingOrg>192711</TotalCompensationFilingOrg>
        <TotalCompensationRelatedOrgs>0</TotalCompensationRelatedOrgs>
        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Michele Burnes</NamePerson>
        <Title>Physician Assistant</Title>
        <BaseCompensationFilingOrg>254574</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
        <BonusFilingOrg>0</BonusFilingOrg>
        <BonusRelatedOrgs>0</BonusRelatedOrgs>
        <OtherCompensationFilingOrg>0</OtherCompensationFilingOrg>
        <OtherCompensationRelatedOrgs>0</OtherCompensationRelatedOrgs>
        <DeferredCompFilingOrg>2369</DeferredCompFilingOrg>
        <DeferredCompRelatedOrgs>0</DeferredCompRelatedOrgs>
        <NontaxableBenefitsFilingOrg>16091</NontaxableBenefitsFilingOrg>
        <NontaxableBenefitsRelatedOrgs>0</NontaxableBenefitsRelatedOrgs>
        <TotalCompensationFilingOrg>273034</TotalCompensationFilingOrg>
        <TotalCompensationRelatedOrgs>0</TotalCompensationRelatedOrgs>
        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Rita Taylor-Stewart</NamePerson>
        <Title>Physician Assistant</Title>
        <BaseCompensationFilingOrg>250781</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
        <BonusFilingOrg>0</BonusFilingOrg>
        <BonusRelatedOrgs>0</BonusRelatedOrgs>
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        <OtherCompensationRelatedOrgs>0</OtherCompensationRelatedOrgs>
        <DeferredCompFilingOrg>2369</DeferredCompFilingOrg>
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        <NontaxableBenefitsFilingOrg>4229</NontaxableBenefitsFilingOrg>
        <NontaxableBenefitsRelatedOrgs>0</NontaxableBenefitsRelatedOrgs>
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        <TotalCompensationRelatedOrgs>0</TotalCompensationRelatedOrgs>
        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Dr Gene Lariviere MD</NamePerson>
        <Title>Surgeon</Title>
        <BaseCompensationFilingOrg>342239</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
        <BonusFilingOrg>0</BonusFilingOrg>
        <BonusRelatedOrgs>0</BonusRelatedOrgs>
        <OtherCompensationFilingOrg>0</OtherCompensationFilingOrg>
        <OtherCompensationRelatedOrgs>0</OtherCompensationRelatedOrgs>
        <DeferredCompFilingOrg>5100</DeferredCompFilingOrg>
        <DeferredCompRelatedOrgs>0</DeferredCompRelatedOrgs>
        <NontaxableBenefitsFilingOrg>16586</NontaxableBenefitsFilingOrg>
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        <TotalCompensationFilingOrg>363925</TotalCompensationFilingOrg>
        <TotalCompensationRelatedOrgs>0</TotalCompensationRelatedOrgs>
        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
      <Form990ScheduleJPartII>
        <NamePerson>Dr Margaret Mangold MD</NamePerson>
        <Title>Physician</Title>
        <BaseCompensationFilingOrg>298821</BaseCompensationFilingOrg>
        <CompBasedOnRelatedOrgs>0</CompBasedOnRelatedOrgs>
        <BonusFilingOrg>0</BonusFilingOrg>
        <BonusRelatedOrgs>0</BonusRelatedOrgs>
        <OtherCompensationFilingOrg>0</OtherCompensationFilingOrg>
        <OtherCompensationRelatedOrgs>0</OtherCompensationRelatedOrgs>
        <DeferredCompFilingOrg>2262</DeferredCompFilingOrg>
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        <NontaxableBenefitsFilingOrg>18353</NontaxableBenefitsFilingOrg>
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        <TotalCompensationRelatedOrgs>0</TotalCompensationRelatedOrgs>
        <CompReportPrior990FilingOrg>0</CompReportPrior990FilingOrg>
        <CompReportPrior990RelatedOrgs>0</CompReportPrior990RelatedOrgs>
      </Form990ScheduleJPartII>
    </IRS990ScheduleJ>
    <IRS990ScheduleK documentId="RetDoc1053100001">
      <Form990ScheduleKPartI>
        <BondReferenceCd>A</BondReferenceCd>
        <IssuerName>
          <BusinessNameLine1>City of Vinton Iowa</BusinessNameLine1>
        </IssuerName>
        <IssuerEIN>426005303</IssuerEIN>
        <DateIssued>2008-02-28</DateIssued>
        <IssuePrice>6800000</IssuePrice>
        <DescriptionOfPurpose>New patient unit, emergency, physical/occupational therapy, &amp; imaging dept</DescriptionOfPurpose>
        <Defeased>0</Defeased>
        <OnBehalfOfIssuer>0</OnBehalfOfIssuer>
        <PoolFinancing>0</PoolFinancing>
      </Form990ScheduleKPartI>
      <Form990ScheduleKPartII>
        <BondReferenceCd>A</BondReferenceCd>
        <AmountRetired>2498586</AmountRetired>
        <TotalProceeds>6800000</TotalProceeds>
        <OtherSpentProceeds>6800000</OtherSpentProceeds>
        <YearOfSubstCompletion>2010</YearOfSubstCompletion>
        <CurrentRefunding>0</CurrentRefunding>
        <AdvanceRefunding>0</AdvanceRefunding>
        <FinalAllocationMade>1</FinalAllocationMade>
        <AdequateBooksAndRecdsMaintaind>1</AdequateBooksAndRecdsMaintaind>
      </Form990ScheduleKPartII>
      <Form990ScheduleKPartIII>
        <BondReferenceCd>A</BondReferenceCd>
        <OwningBondFinancedProperty>0</OwningBondFinancedProperty>
        <AnyLeaseArrangements>0</AnyLeaseArrangements>
        <MngmentCntrctBondFinancdPrprty>0</MngmentCntrctBondFinancdPrprty>
        <AnyResearchAgreements>0</AnyResearchAgreements>
        <PrcntgePrvtBusinessUseByOthers>0.00000</PrcntgePrvtBusinessUseByOthers>
        <PercentageOfPrvtBusinessReUBI>0.00000</PercentageOfPrvtBusinessReUBI>
        <TotalPrivateBusinessUse>0.00000</TotalPrivateBusinessUse>
        <BondIssMeetPrvtSecurityPayTest>0</BondIssMeetPrvtSecurityPayTest>
        <ChangeInUseBondFinancedProp>0</ChangeInUseBondFinancedProp>
        <NonQualifiedBondRemedProcdrs>1</NonQualifiedBondRemedProcdrs>
      </Form990ScheduleKPartIII>
      <Form990ScheduleKPartIV>
        <BondReferenceCd>A</BondReferenceCd>
        <Form8038TFiled>0</Form8038TFiled>
        <RebateNotDueYet>0</RebateNotDueYet>
        <ExceptionToRebate>0</ExceptionToRebate>
        <NoRebateDue>1</NoRebateDue>
        <VariableRateIssue>0</VariableRateIssue>
        <HedgeIdentifiedInBooksAndRecds>0</HedgeIdentifiedInBooksAndRecds>
        <GrossProceedsInvestedInGIC>0</GrossProceedsInvestedInGIC>
        <GrossProceedsInvested>0</GrossProceedsInvested>
        <WrittenProcToMonitorReqs>0</WrittenProcToMonitorReqs>
      </Form990ScheduleKPartIV>
      <Form990ScheduleKPartV>
        <BondReferenceCd>A</BondReferenceCd>
        <ProcToUndertkCorrectiveAction>1</ProcToUndertkCorrectiveAction>
      </Form990ScheduleKPartV>
      <Form990ScheduleKPartVI>
        <Identifier>Schedule K Part IV, Arbitrage, Line 2c</Identifier>
        <ReturnReference>Date Rebate Computation Performed</ReturnReference>
        <Explanation>Issuer Name: City of Vinton, Iowa Date the Rebate Computation was Performed: 04/26/2011</Explanation>
      </Form990ScheduleKPartVI>
      <Form990ScheduleKPartVI>
        <Identifier>Schedule K, Part IV, Line 2c:</Identifier>
        <Explanation>All proceeds had been spent as of 4/26/2011. Since no proceeds have arisen since, it is not necessary to do any future arbitrage calculations.</Explanation>
      </Form990ScheduleKPartVI>
    </IRS990ScheduleK>
    <IRS990ScheduleO documentId="RetDoc1044400001">
      <GeneralExplanation>
        <Identifier>New Program Services</Identifier>
        <ReturnReference>Form 990, Part III, line 2</ReturnReference>
        <Explanation>Atkins Clinic opened in August 2012. This is a free-standing clinic and will be a rural health clinic in FY 2014.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section A, line 1</ReturnReference>
        <Explanation>The Executive Committee consists of the officers of the Board of Directors. The Executive Committee has the power to transact all regular business of the Hospital during the period between the meetings of the Governing Board, subject to any prior limitation imposed by the Governing Board and with the understanding that all matters of major importance will be referred to the Governing Board. The Executive Committee must submit to the Governing Board at its last meeting before the end of the fiscal year, a budget showing the expected receipts, income, and expense for the coming year. Minutes of the Executive Committee meetings must be submitted to the Board, and its actions are subject to approval or disapproval at the next regular board meeting.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section A, line 2</ReturnReference>
        <Explanation>John Ketchen, Vice Chair of the Board, and Mark Mossman, Chair of the Board, have a business relationship. Mark Mossman, David Vermedahl, John Ketchen, all board members, Michael Riege, CEO, and Julia Meadows, CFO, have a business relationship.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section A, line 7a</ReturnReference>
        <Explanation>One of the Directors of the Board is the Mayor of the city of Vinton, Iowa. Two Directors are appointed by the Mayor and approved by the City Council of the City of Vinton for such terms as the City Council determines. One of these appointments is a physician in active practice and a resident of Benton County, Iowa. The second Director appointed by the City of Vinton is a resident of Benton County, Iowa.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section B, line 11</ReturnReference>
        <Explanation>The Form 990 is distributed to the Board members prior to filing. The 990 is reviewed by the Hospital's CEO and CFO.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section B, line 12c</ReturnReference>
        <Explanation>Any director, officer, key employee, Medical Staff member or committee member having an existing or potential interest in a contract or other transaction presented to the Board of Directors for deliberation, authorization, approval, or ratification, or any such person who reasonably believes such an interest exists in another person should make a prompt disclosure of the interest to the Board or committee prior to its acting on such contract or transaction. The interested party is required to disclose the nature and extent of his/her interest and any relevant and material facts known to him/her about the contract or transaction which might reasonably be construed to be adverse to the organization's interest. The Board requires annual statements from officers, directors, key employees, and key members of the Medical Staff. The body to which such disclosure is made determines, by majority vote, whether the disclosure shows that the non-voting and non-participation provisions below must be observed. If so, such persons should not vote on, nor use his/her personal influence on, nor participate (other than to present factual information or to respond to questions) in the discussions or deliberations with respect to such contract or transaction. Such persons may not be counted in determining the existence of a quorum at any meeting where the contract or transaction is under discussion or is being voted upon. The minutes of the meeting reflect the disclosure made and, where applicable, the abstention from voting and participation and whether a quorum was present.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section B, line 15</ReturnReference>
        <Explanation>The Board Wage &amp; Salary Committee and full board reviews compensation increases for the CEO based on annual evaluations and the IHA Salary Survey. Comparisons to state averages are used. Substantiation of the deliberation and decision is documented in the Board minutes. The process is completed annually and was last completed in May 2013. The CEO determines compensation for the CFO and key employees, with approval from the Board Wage &amp; Salary committee and full Board, based on annual performance evaluations and the IHA Salary Survey. Contemporaneous substantiation of the deliberation and decision is provided for any actions taken regarding compensation. The process is completed annually and was last completed in May 2013.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <ReturnReference>Form 990, Part VI, Section C, line 19</ReturnReference>
        <Explanation>The Organization's governing documents, conflict of interest policy, and financial statements are not available to the public. Financial information is available through the public disclosure copy of the 990.</Explanation>
      </GeneralExplanation>
      <GeneralExplanation>
        <Identifier>Other Fees</Identifier>
        <ReturnReference>Form 990, Part IX, line 11g</ReturnReference>
        <Explanation>Repairs, maintenance and lease expense: Program service expenses 761,055. Management and general expenses 36,003. Fundraising expenses 1,972. Total expenses 799,030. Purchased services: Program service expenses 3,061,153. Management and general expenses 315,765. Fundraising expenses 1,730. Total expenses 3,378,648. Recruitment: Program service expenses 2,000. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,000.</Explanation>
      </GeneralExplanation>
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