2014-02-13T15:25:21-06:00 2013-06-30 310800053 CLARK SCHAEFER HACKETT & CO 14 E MAIN STREET SUITE 500 SPRINGFIELD OH 45502 990 2012-07-01 310787073 MENTAL HEALTH SERVICES FOR CLARK AND MADISON COUNTIES INC MENT 9373992701 474 N YELLOW SPRINGS ST SPRINGFIELD OH 45504 MARY BETH TAYLOR 9373999500 2014-02-13 1 DEVESH KAMAL CPA P00201226 9373992000 2014-02-13 2012 2015-11-30 17:44:51Z MARY BETH TAYLOR 474 N YELLOW SPRINGS ST SPRINGFIELD OH 45504 14203253 0 X WWW.MHSCC.ORG X 1969 OH PROVIDES MENTAL AND BEHAVIORAL HEALTH SERVICES TO RESIDENTS OF CLARK AND MADISON COUNTIES OHIO. 18 16 283 0 0 0 4145915 4700152 9757400 8499269 34342 15048 0 988784 13937657 14203253 0 0 0 0 10235021 9647547 0 0 0 2945355 3178599 13180376 12826146 757281 1377107 14501030 19667506 4405498 8180114 10095532 11487392 X WE ARE A PRIVATE, NOT FOR PROFIT COMPREHENSIVE BEHAVIORAL HEALTHCARE SYSTEM DEDICATED TO SERVING INDIVIDUALS,FAMILIES, AND OUR COMMUNITY WITH HIGH QUALITY, COST EFFECTIVE CARE. OUR SERVICES ARE INTEGRATED WITH THE HEALTHCARE ENVIRONMENT. WE ARE CHARITABLE TO SERVE THOSE IN NEED WITHIN THE LIMITS OF OUR RESOURCES. 0 0 2605821 2239629 ADULT CARE, OR INPATIENT PSYCHIATRIC MENTAL HEALTH SERVICES SERVED 794 CLIENTS IN FISCAL YEAR 2013. 6912029 7045802 OUTPATIENT PSYCHIATRIC SERVICES SERVED 5,730 CLIENTS DURING THE FISCAL YEAR. 649739 202622 RESIDENTIAL SERVICES FOR CLIENTS WITH SEVERE MENTAL DISABILITIES WERE PROVIDED FOR 96 CLIENTS DURING THE FISCAL YEAR. 10167589 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 29 0 1 283 1 0 0 0 0 0 0 0 0 0 0 0 0 X 18 16 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X MARY BETH TAYLOR 9373999500 474 N YELLOW SPRINGS STREET SPRINGFIELD OH 45504 JAMES PERRY PHD 40.00 X X 165687 0 17220 DARRELL KITCHEN 3.00 X X 0 0 0 SHAWN TAYLOR 3.00 X X 0 0 0 RICK BRODERICK 3.00 X 0 0 0 GEORGE DEGENHART 3.00 X 0 0 0 ALEXIS EVANS COMER 3.00 X 0 0 0 TOM FRANZEN 3.00 X 0 0 0 HORTON HOBBS 3.00 X 0 0 0 JEFF HUGHES 3.00 X 0 0 0 MARILYN KREIDER 3.00 X 0 0 0 LEE ANN LOPEZ 3.00 X 0 0 0 SUE MCCLELLAND 3.00 X 0 0 0 CHARLIE RINEHART 3.00 X 0 0 0 DOUG SCHANTZ 3.00 X 0 0 0 JERRY SIMONTON 3.00 X 0 0 0 BRIAN SMITH 3.00 X 0 0 0 TERRI WYATT 3.00 X 0 0 0 DR MARK A SMITH 40.00 X X 262331 0 20107 MARRY BETH TAYLOR 40.00 X 95713 0 15140 DR KALPANA VISHNUPAD 40.00 X 210561 0 18794 DR YIU-CHUNG CHANG 40.00 X 193383 0 18409 927675 0 89670 4 0 1 0 SPRINGFIELD PSYCHIATRIC ASSOCIATION 3162 EL CAMINO RD SPRINGFIELD OH 45503 PHYSICIAN 118085 1 10701 4432527 256924 4700152 TITLE XIX MEDICAID 900099 5375371 5375371 PATIENT SERVICE REVENUES 621300 1826680 1826680 MEDICAID PAYBACK 900099 1019979 1019979 RENTAL REVENUE FROM CLIENT SUPPOR 623990 158093 158093 TITLE XX 900099 119146 119146 8499269 15048 15048 OTHER SERVICE REVENUE 621300 988784 988784 988784 14203253 9488053 0 15048 932577 737988 194589 7011322 5918473 1092849 1164139 960740 203399 539509 445245 94264 188087 85347 102740 660440 575334 85106 160004 136022 23982 217212 146413 70799 OPERATING EXPENSES 690130 356709 333421 PURCHASED SERVICES 659204 269001 390203 OPERATING SUPPLIES 372636 342085 30551 EQUIPMENT EXPENSES 131608 94954 36654 99278 99278 12826146 10167589 2658557 0 5703660 5324719 2906037 1625196 2157798 2002960 7653 7004 179927 172322 15342898 4866515 3501786 10476383 43169 57922 1000 1000 14501030 19667506 4327685 4601100 50000 3553076 27813 25938 4405498 8180114 X 10095532 11487392 10095532 11487392 14501030 19667506 1377107 14753 0 X X 0 1 X 1 0 X 7599005 6076093 6139730 4145915 4700152 28660895 7599005 6076093 6139730 4145915 4700152 28660895 28660895 191932 115956 49647 34342 15048 406925 1141233 941326 1188031 1836521 988784 6095895 35163715 32781405 0.81510 0.82480 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1560377 1560377 9633358 1169312 8464046 1823992 1795827 28165 2109709 1706000 403709 215462 195376 20086 10476383 X 14218006 14753 14753 14203253 0 14203253 12826146 0 12826146 0 12826146 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: INCOME FROM CERTAIN ACTIVITIES NOT DIRECTLY RELATED TO THE AGENCY'S TAX-EXEMPT PURPOSE IS SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME. THOSE PROVISIONS CLARIFY THE ACCOUNTING AND RECOGNITION FOR INCOME TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN AGENCY'S ANNUAL REPORTING RETURNS. THE AGENCY'S REPORTING RETURNS ARE SUBJECT TO AUDIT BY FEDERAL AND STATE TAXING AUTHORITIES. OPEN AUDIT PERIODS ARE 2009-2011. NO INCOME TAX PROVISION HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS AS THE AGENCY HAS DETERMINED IT DOES NOT HAVE UNRELATED BUSINESS INCOME SUBJECT TO TAXATION. 1 1 1 X 175.000000000000 1 X 1 1 1 0 1 1 1079744 748711 331033 0.02580 1079744 748711 331033 0.02580 1079744 748711 331033 0.02580 1 92047 782324 861486 -79162 X 1 1 1 1 MENTAL HEALTH SERVICES

474 N YELLOW SPRINGS STREET SPRINGFIELD OH 45504

X 16 BED PSYCHIATRIC HOSPITAL MENTAL HEALTH SERVICES 1 1 X X X X X X X X X 12 1 0 1 X X X X 1 0 1 1 175.000000000000 1 250.000000000000 1 X X X 1 1 X X 1 0 X X X 1 X 0 0 PART I, LINE 3C: MENTAL HEALTH SERVICES OF CLARK AND MADISON COUNTIES, INC. SCREENS ALL PATIENTS FOR CHARITY CAREELIGIBILITY BASED ON THEIR INCOME AND CURRENT FEDERAL POVERTY LEVEL GUIDELINES. IN ADDITION, SELF-PAY PATIENTS AND PATIENTS WITH OUTSTANDING MEDICAL EXPENSES THAT EXCEED $5,000 ARE ELIGIBLE FOR A 30% DISCOUNT. MENTAL HEALTH SERVICES PART V, SECTION B, LINE 14G: THE BILLING CLERK PROVIDES INFORMATION TO PATIENTS ON OUR CHARITY CARE PROGRAMS. PART VI, LINE 2: IN RELATION TO THE NEEDS OF THE COMMUNITY, WE ALSO SEEK THE INPUT OF THE COMMUNITY DURING THE STRATEGIC PLANNING PROCESS BASED ON ACCUMULATED DATA AND FEEDBACK. FOR 2012, A COMMUNITY NEEDS ASSESSMENT WAS PERFORMED AS PART OF OUR STRATEGIC PLANNING PROCESS USING FOCUS GROUPS OF OUR CLIENTS AND COMMUNITY MEMBERS TO IDENTIFY PROGRAMMING NEEDS. PART VI, LINE 3: THE INPATIENT BILLING CLERK MEETS WITH THE PATIENT, THE PATIENTS FAMILY OR ANOTHER AUTHORIZED GUARDIAN OR REPRESENTATIVE TO DISCUSS CLIENT CARE PROGRAMS. IN ADDITION, WE HAVE A MEDICAID REFERRAL COUNSELOR WHO ASSISTS CLIENTS WITH COMPLETION OF MEDICAID AND PRESCRIPTION DRUG ASSISTANCE APPLICATIONS. PART VI, LINE 4: CLARK AND MADISON COUNTIES ARE LOCATED IN SOUTHWEST OHIO WITH AN AREA POPULATION OF APPROXIMATELY 181,000. THE PERCENTAGE OF HOUSEHOLDS UNDER THE FEDERAL POVERTY GUIDELINES IS 15%. THE CLIENTS THAT WE SERVE ARE TYPICALLY ELIGIBLE FOR MEDICAID, MEDICARE OR OTHER FEDERAL ASSISTANCE PROGRAMS. THIS ELIGIBILITY IS USUALLY A FUNCTION OF OUR CLIENTS PSYCHIATRIC DISABILTIIES. X X X 0 0 0 0 0 0 0 0 0 JAMES PERRY PHD 165687 0 0 0 0 0 0 0 17220 0 182907 0 0 0 DR MARK A SMITH 262331 0 0 0 0 0 0 0 20107 0 282438 0 0 0 DR KALPANA VISHNUPAD 210561 0 0 0 0 0 0 0 18794 0 229355 0 0 0 DR YIU-CHUNG CHANG 193383 0 0 0 0 0 0 0 18409 0 211792 0 0 0 A CLARK COUNTY OHIO 316000132 999999999 2011-12-28 5000000 CONSTRUCTING INPATIENT AND OUTPATIENT FACILITY FOR MENTAL HEALTH SERVICES 0 0 0 A 5000000 50000 3503076 1446924 2013 0 0 0 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 A 0 PART III, LINE 9; PART IV, LINE 7; AND PART V: MENTAL HEALTH SERVICES FOR CLARK AND MADISON COUNTIES, INC. IS CURRENTLY IN THE PROCESS OF ESTABLISHING WRITTEN PROCEDURES (A) TO ENSURE THAT ALL NON-QUALIFIED BONDS OF AN ISSUE ARE REMEDIATED IN ACCORDANCE WITH REGULATIONS SECTIONS 1.141-12 AND 1.145-2, (B) TO MONITOR THE REQUIREMENTS OF SECTION 148 OF THE INTERNAL REVENUE CODE, AND (C) TO ENSURE THAT VIOLATIONS OF FEDERAL TAX REQUIREMENTS ARE TIMELY IDENTIFIED AND CORRECTED THROUGH THE VOLUNTARY CLOSING AGREEMENT PROGRAM IF SELF-REMEDIATION IS NOT AVAILABLE UNDER APPLICABLE REGULATIONS. ACCORDINGLY, IT EXPECTS THAT IT WILL BE ABLE TO CHECK "YES" FOR THESE ITEMS IN ITS 2014 SCHEDULE K FILING. MENTAL HEALTH RECOVERY BOARD OF CLARK GREENE AND MADISON COUNTIES DEFERRED LOAN FOR HOUSING FOR MENTALLY ILL X 75000 25938 0 1 1 25938 FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF TRUSTEES AUDIT COMMITTEE REVIEWS THE FORM 990 AND APPROVES IT BEFORE FILING. FORM 990, PART VI, SECTION B, LINE 12C BOARD OF TRUSTEES REVIEW THE CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS AND COMPLETE SURVEY AND STATEMENT OF UNDERSTANDING. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD REFERENCES VARIOUS INDUSTRY COMPENSATION STUDIES AND SALARY SCHEDULES OF COMPARABLE ORGANIZATIONS. THE HUMAN RESOURCES DIRECTOR REPORTS TO THE BOARD OF TRUSTEES REGARDING MATTERS OF COMPENSATION LEVELS AND RESULTS OF SUCH STUDIES. FORM 990, PART VI, SECTION C, LINE 18 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON WRITTEN REQUEST OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 FORM 1023 AND FORM 990 ARE MADE AVAILABLE FOR PUBLIC INSPECTION UPON WRITTEN REQUEST OF THE ORGANIZATION. THE ORGANIZATION DID NOT CHANGE ITS ACCEPTANCE PROCEDURES FOR THE FINANCIAL STATEMENTS FROM THE PRIOR PERIOD METHOD. MANAGEMENT REVIEWS THE AUDITED FINANCIAL STATEMENTS AND PRESENTS THEM TO THE BOARD FOR APPROVAL. CLEANERS EXTRAORDINAIRE INC 112 LOHNES AVE SPRINGFIELD OH 45504 311110016 JOB TRAINING FOR INDIVIDUALS WITH DISABILITES OH 501(C)(3) 170(B)(1)(A)(VI) N/A 0 RESOURCE CENTER APARTMENTS INC 601 N FOUNTAIN AVE SPRINGFIELD OH 45503 311307922 AFFORDABLE HOUSING FOR THE DISABLED OH 501(C)(3) 170(B)(1)(A)(VI) N/A 0 RESTAN CORP 601 N FOUNTAIN AVE SPRINGFIELD OH 45503 311368099 AFFORDABLE HOUSING FOR THE DISABLED OH 501(C)(3) 509(A)(2) N/A 0 JANI-TURF MAINTENENCE SERVICE INC 112 LOHNES AVE SPRINGFIELD OH 45504 311331268 JANITORIAL AND PROPERTY MAINTENECE SERVICES OH N/A C 2725 98418 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 JANI-TURF MAINTENANCE SERVICES INC M 28694 CLEANERS EXTRAORDINAIRE INC M 115715 RESOURCE CENTER APARTMENTS INC Q 4600 RESTAN CORP L 5046