TRICOUNTY MEMORIAL FOUNDATION INC: Form 990EZ, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- TRICOUNTY MEMORIAL FOUNDATION INC (EIN 30-0093022)
- Tax period
- 2011-07-01 to 2012-06-30
- Filed
- 2013-02-06
- IRS object ID
- 201300379349200220
- Schema version
- 2011v1.2
- 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-02-06T13:46:04-06:00 | Timestamp |
| Tax Period End Date | 2012-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 3703 OAKWOOD HILLS PARKWAY | AddressLine1 |
| City | EAU CLAIRE | City |
| State | WI | State |
| ZIP Code | 54701 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990EZ | ReturnType |
| Tax Period Begin Date | 2011-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 300093022 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL FOUNDATION INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | TRI- | NameControl |
| Phone | 7155384361 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1 |
| City | WHITEHALL | City |
| State | WI | State |
| ZIP Code | 54773 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BRIAN THEILER | Name |
| Title | CHIEF EXECUTIVE OFFICER | Title |
| Phone | 7155384361 | Phone |
| Date Signed | 2013-01-23 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | PAUL M TRACZEK CPA | Name |
| PTIN | P01368830 | PTIN |
| Phone | 7158323407 | Phone |
| Date Prepared | 2013-01-23 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990-EZ IRS990EZ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Schedule B Not Required | X | ScheduleBNotRequired |
| Web Site | HTTP://WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY/FOUNDAT | WebSite |
| Organization501c3 | X | Organization501c3 |
| Gross Receipts | 35789 | GrossReceipts |
| Info In Schedule O Part I | X | InfoInScheduleOPartI |
| Contributions Gifts Grants Etc | 3138 | ContributionsGiftsGrantsEtc |
| Program Service Revenue | 21173 | ProgramServiceRevenue |
| Investment Income | 11478 | InvestmentIncome |
| Total Revenue | 35789 | TotalRevenue |
| Grants And Similar Amounts Paid | 6625 | GrantsAndSimilarAmountsPaid |
| Fees And Oth Pymt To Ind Contractors | 141 | FeesAndOthPymtToIndContractors |
| Total Expenses | 6766 | TotalExpenses |
| Excess Or Deficit For Year | 29023 | ExcessOrDeficitForYear |
| Net Assets Or Fund Balances BOY | 307154 | NetAssetsOrFundBalancesBOY |
| Other Changes In Net Assets | 0 | OtherChangesInNetAssets |
| Net Assets Or Fund Balances EOY | 336177 | NetAssetsOrFundBalancesEOY |
Cash Savings And Investments CashSavingsAndInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 307154 | BOY |
| EOY | 336177 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 307154 | BOY |
| EOY | 336177 | EOY |
Sum Of Total Liabilities SumOfTotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 0 | EOY |
Net Assets Or Fund Balances NetAssetsOrFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 307154 | BOY |
| EOY | 336177 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| 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. | PrimaryExemptPurpose |
Program Service Accomplishment ProgramServiceAccomplishment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description Program Service 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 FISCAL YEAR 2012, $2,625 IN SCHOLARSHIPS WERE GRANTED TO STUDENTS IN THE AREA PURSUING CAREERS IN MEDICAL FIELDS. THE FOUNDATION ALSO DONATED $1,000 EACH TO FOUR SEPARATE LOCAL FOOD PANTRIES DURING THE FISCAL YEAR. | DescriptionProgramServiceAccom |
| Grants And Allocations | 6625 | GrantsAndAllocations |
| Program Service Expenses | 6766 | ProgramServiceExpenses |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | 6766 | TotalProgramServiceExpenses |
Officer Director Trustee Key Empl OfficerDirectorTrusteeKeyEmpl (9 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | TitleTitle | Avg Hours Per Wk Devoted To PositionAvgHoursPerWkDevotedToPosition | CompensationCompensation | Contri To Empl Benefit Plans EtcContriToEmplBenefitPlansEtc | Expense Account Other AllowancesExpenseAccountOtherAllowances |
|---|---|---|---|---|---|---|---|---|
| MAYNARD CLIPPER | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | CHAIRMAN | 0.50 | 0 | 0 | 0 |
| PATTI DOCKENDORFF | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TREASURER | 0.50 | 0 | 0 | 0 |
| JILL BERG | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | SECRETARY | 0.50 | 0 | 0 | 0 |
| KURT JOHNSON | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | VICE CHAIRMAN | 0.50 | 0 | 0 | 0 |
| JOHN KULIG | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TRUSTEE | 0.50 | 0 | 0 | 0 |
| LINDA BAXA | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TRUSTEE | 0.50 | 0 | 0 | 0 |
| K ROGER GILBERT | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TRUSTEE | 0.50 | 0 | 0 | 0 |
| MARY LOU DEJNO | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TRUSTEE | 0.50 | 0 | 0 | 0 |
| ALAN ROBERTSON | ||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | TRUSTEE | 0.50 | 0 | 0 | 0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part V | X | InfoInScheduleOPartV |
| Activities Not Previously Rpt | 0 | ActivitiesNotPreviouslyRpt |
| Made Changes To Orgnzng Etc Doc | 0 | MadeChangesToOrgnzngEtcDoc |
| Organization Had UBI | 0 | OrganizationHadUBI |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Organization Dissolved Etc | 0 | OrganizationDissolvedEtc |
| Direct Indirect Political Expend | 0 | DirectIndirectPoliticalExpend |
| Made Loans To From Officers | 0 | MadeLoansToFromOfficers |
| Tax Imposed Under IRC4911 | 0 | TaxImposedUnderIRC4911 |
| Tax Imposed Under IRC4912 | 0 | TaxImposedUnderIRC4912 |
| Tax Imposed Under IRC4955 | 0 | TaxImposedUnderIRC4955 |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTrans |
| Amount Of Tax Imposed On Org Mgr | 0 | AmountOfTaxImposedOnOrgMgr |
| Amount Of Tax Reimbursed By Org | 0 | AmountOfTaxReimbursedByOrg |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| States Where Copy Of Return Is Filed | WI | StatesWhereCopyOfReturnIsFiled |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | DAN KLIDZEJS | NamePerson |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1 |
| City | WHITEHALL | City |
| State | WI | State |
| ZIP Code | 54773 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7155384361 | TelephoneNumber |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Foreign Office | 0 | ForeignOffice |
| Maintain Any Donor Advised Funds | 0 | MaintainAnyDonorAdvisedFunds |
| Does Org Have Hospital | 0 | DoesOrgHaveHospital |
| Tanning Services Provided | 0 | TanningServicesProvided |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Engage Political Cmpgn Activities | 0 | EngagePoliticalCmpgnActivities |
| Engage In Lobbying Activities | 0 | EngageInLobbyingActivities |
| Operating School | 0 | OperatingSchool |
| Trnsfrs Exempt Non Char Related Org | 0 | TrnsfrsExemptNonCharRelatedOrg |
| Part VI Of Comp Of Highest Paid Empl | NONE | PartVIOfCompOfHighestPaidEmpl |
| Part VIA Hghst Paid Cntrct Prof Ser | NONE | PartVIAHghstPaidCntrctProfSer |
| Filed Schedule A | 1 | FiledScheduleA |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | X | SupportingOrganization509a3 |
| Supporting Org509a3 Type1 | X | SupportingOrg509a3Type1 |
| Certification Checkbox | X | CertificationCheckbox |
| Contrib By Controlling Individual | 0 | ContribByControllingIndividual |
| Contribution By Related Party | 0 | ContributionByRelatedParty |
| Contrib By35 Controlled Entity | 0 | ContribBy35ControlledEntity |
Supported Org Information SupportedOrgInformation
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390704510 | EIN |
| Type Of Organization | 3 | TypeOfOrganization |
| Listed In Governing Doc | 1 | ListedInGoverningDoc |
| Organized In US | 1 | OrganizedInUS |
| Amount | $0 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Number Of Supported Orgs | 1 | TotalNumberOfSupportedOrgs |
| Sum Of Amounts | 0 | SumOfAmounts |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (6 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| OTHER INVESTMENT INCOME | FORM 990-EZ, PART I, LINE 4 | INTEREST INCOME 11,478.. |
| GRANTS AND SIMILAR AMOUNTS PAID | FORM 990-EZ, PART I, LINE 10 | 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. |
| GRANTS AND SIMILAR AMOUNTS PAID | FORM 990-EZ, PART I, LINE 10 | ACTIVITY CLASSIFICATION: SCHOLARSHIPS TO INDIVIDUALS. GRANTEE NAME: N/A. PROPERTY DESCRIPTION: SCHOLARSHIP. AMOUNT GIVEN: 2,625. |
| GRANTS AND SIMILAR AMOUNTS PAID | FORM 990-EZ, PART I, LINE 10 | 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. |
| GRANTS AND SIMILAR AMOUNTS PAID | FORM 990-EZ, PART I, LINE 10 | 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. |
| GRANTS AND SIMILAR AMOUNTS PAID | FORM 990-EZ, PART I, LINE 10 | 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. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 6,625. |
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. | Declaration |