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JAY COUNTY HOSPITAL AUXILIARY INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
JAY COUNTY HOSPITAL AUXILIARY INC (EIN 35-2139245)
Tax period
2012-01-01 to 2012-12-31
Filed
2013-05-15
IRS object ID
201301359349300610
Schema version
2012v2.1
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

FieldValueIRS element (for citing)
Timestamp2013-05-15T06:49:34-05:00Timestamp
Tax Period End Date2012-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN201695613EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1BOLLENBACHER & ASSOCIATES LLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1215 E PEARL ST PO BOX 702AddressLine1
CityPORTLANDCity
StateINState
ZIP Code47371ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN352139245EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1JAY COUNTY HOSPITAL AUXILIARY INCBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlJAYCNameControl
Phone2607261878Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1500 W VOTAWAddressLine1
CityPORTLANDCity
StateINState
ZIP Code47371ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameCONNIE FEARName
TitleDIRECTOR OF VOLUNTEER SERVICESTitle
Phone2607261878Phone
Date Signed2013-05-14DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameSCOTT A BOLLENBACHER CPAName
PTINP00401897PTIN
Phone2607264207Phone
Date Prepared2013-05-14DatePrepared
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonCONNIE FEARNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1500 W VOTAWAddressLine1
CityPORTLANDCity
StateINState
ZIP Code47371ZIPCode
FieldValueIRS element (for citing)
Gross Receipts103867GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteN/AWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation2001YearFormation
State Legal DomicileINStateLegalDomicile
Activity Or Mission DescriptionTHE JAY COUNTY HOSPITAL AUXILIARY IS A NOT-FOR-PROFIT ORGANIZATION WHOSE PRIMARY PURPOSE IS TO OPERATE EXCLUSIVELY FOR THE BENEFIT OF THE JAY COUNTY HOSPITAL. FUNCTIONS OF THE ORGANIZATION INCLUDE SPONSORSHIP OF HOSPITAL BUILDINGS, EQUIPMENT, PROJECTS AND PROGRAMS TO IMPROVE PATIENT CARE, AND PROMOTION OF THE HOSPITAL'S PROGRAMS.ActivityOrMissionDescription
Nbr Voting Members Governing Body15NbrVotingMembersGoverningBody
Nbr Independent Voting Members15NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Nbr Volunteers168TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year4288ContributionsGrantsPriorYear
Contributions Grants Current Year9272ContributionsGrantsCurrentYear
Program Service Revenue Prior Year25441ProgramServiceRevenuePriorYear
Program Service Revenue CY30ProgramServiceRevenueCY
Investment Income Prior Year-38854InvestmentIncomePriorYear
Investment Income Current Year1485InvestmentIncomeCurrentYear
Other Revenue Prior Year20263OtherRevenuePriorYear
Other Revenue Current Year23005OtherRevenueCurrentYear
Total Revenue Prior Year11138TotalRevenuePriorYear
Total Revenue Current Year33792TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year5919GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY1290GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year0SalariesEtcPriorYear
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year34613OtherExpensePriorYear
Other Expenses Current Year23267OtherExpensesCurrentYear
Total Expenses Prior Year40532TotalExpensesPriorYear
Total Expenses Current Year24557TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-29394RevenuesLessExpensesPriorYear
Revenues Less Expenses CY9235RevenuesLessExpensesCY
Total Assets BOY208853TotalAssetsBOY
Total Assets EOY222814TotalAssetsEOY
Total Liabilities BOY0TotalLiabilitiesBOY
Total Liabilities EOY0TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY208853NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY222814NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTHE JAY COUNTY HOSPITAL AUXILIARY IS A NOT-FOR-PROFIT ORGANIZATION WHOSE PRIMARY PURPOSE IS TO OPERATE EXCLUSIVELY FOR THE BENEFIT OF THE JAY COUNTY HOSPITAL. FUNCTIONS OF THE ORGANIZATION INCLUDE SPONSORSHIP OF HOSPITAL BUILDINGS, EQUIPMENT, PROJECTS AND PROGRAMS TO IMPROVE PATIENT CARE, AND PROMOTION OF THE HOSPITAL'S PROGRAMS.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense24557Expense
Grants1290Grants
Revenue17307Revenue
DescriptionTHE JAY COUNTY HOSPITAL AUXILIARY IS A NOT-FOR-PROFIT ORGANIZATION WHOSE PRIMARY PURPOSE IS TO OPERATE EXCLUSIVELY FOR THE BENEFIT OF THE JAY COUNTY HOSPITAL. FUNCTIONS OF THE ORGANIZATION INCLUDE SPONSORSHIP OF HOSPITAL BUILDINGS, EQUIPMENT, PROJECTS AND PROGRAMS TO IMPROVE PATIENT CARE, AND PROMOTION OF THE HOSPITAL'S PROGRAMS.Description
Total Program Service Expense24557TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets1ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities1FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required0ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity0RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members15NbrVotingGoverningBodyMembers
Number Independent Voting Members15NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO0CompensationProcessCEO
Compensation Process Other0CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledINStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1JAY COUNTY HOSPITAL AUXILARYBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number2607261878TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1500 W VOTAW STAddressLine1
CityPORTLANDCity
StateINState
ZIP Code47371ZIPCode
FieldValueIRS element (for citing)
No Listed Persons CompensatedXNoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (15 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficer
CINDA MIXON
MEMBER0.00X000
ROSE FENNING
MEMBER0.00X000
GAIL FRANKS
MEMBER0.00X000
KAREN GORE
MEMBER0.00X000
VERA HEFFNER
MEMBER0.00X000
RACHEL STULTZ
MEMBER0.00X000
JACKIE GRADY
MEMBER0.00X000
GEORGE HORN
MEMBER0.00X000
TAMMY HORN
MEMBER0.00X000
JOAN KELLY
MEMBER0.00X000
DOLLY SNODGRASS
PRESIDENT ELECT0.00000X
CAROLE LEONHARD
PRESIDENT0.00000X
EMILY STEVESON
RECORDING SECRETARY0.00000X
EVA WYRICK
CORRESPONDING SECRETARY0.00000X
ZOLA HIDAY
TREASURER0.00000X
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation0TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K0TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources
Number Of Contractors GT100 K0NumberOfContractorsGT100K
Membership Dues272MembershipDues
All Other Contributions9000AllOtherContributions
Noncash Contributions4000NoncashContributions
Total Contributions9272TotalContributions

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionMISCELLANEOUS INCOMEDescription
Business Code900000BusinessCode
Total Revenue Column30TotalRevenueColumn
Related Or Exempt Function Income30RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue30TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column1485TotalRevenueColumn
Exclusion$1,485ExclusionAmount
FieldValueIRS element (for citing)
Gross Income Fundraising Events16145GrossIncomeFundraisingEvents
Fundraising Direct Expenses10417FundraisingDirectExpenses

Net Income From Fundraising Events NetIncomeFromFundraisingEvents

FieldValueIRS element (for citing)
Total Revenue Column5728TotalRevenueColumn
Exclusion$5,728ExclusionAmount
FieldValueIRS element (for citing)
Gross Sales Of Inventory76935GrossSalesOfInventory
Cost Of Goods Sold59658CostOfGoodsSold

Net Income Or Loss NetIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column17277TotalRevenueColumn
Related Or Exempt Function Income17277RelatedOrExemptFunctionIncome

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column33792TotalRevenueColumn
Related Or Exempt Function Income17307RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$7,213ExclusionAmount

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total1290Total
Program Services1290ProgramServices

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total4330Total
Program Services4330ProgramServices

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total857Total
Program Services857ProgramServices

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total643Total
Program Services643ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total2153Total
Program Services2153ProgramServices

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServices
MISCELLANEOUS EXPENSES84458445
RENT40004000
ADVERTISING16751675
ANNUAL DINNER992992

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total172Total
Program Services172ProgramServices

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total24557Total
Program Services24557ProgramServices
Management And General0ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY95014BOY
EOY106645EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY44696BOY
EOY0EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY17110BOY
EOY19883EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis48861LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec10881LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY2672BOY
EOY37980EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY49361BOY
EOY58306EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY208853BOY
EOY222814EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY159492BOY
EOY164507EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY4842BOY
EOY13788EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY44519BOY
EOY44519EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY208853BOY
EOY222814EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY208853BOY
EOY222814EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses9235ReconcilationRevenueExpenses
Reconciliation Unrealized Invest4726ReconciliationUnrealizedInvest
Reconcilation Other Changes0ReconcilationOtherChanges
Method Of Accounting CashXMethodOfAccountingCash
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement SeparateXFinancialStatementSeparate
FieldValueIRS element (for citing)
Audit Committee1AuditCommittee
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis48861OtherCostOrOtherBasis
Depreciation10881Depreciation
Book Value37980BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings37980TotalOfBookValueLandBuildings

Other Assets OtherAssets

FieldValueIRS element (for citing)
DescriptionPORTLAND FOUNDATION SCHOLARSHIP FUNDDescription
Book Value58306BookValue
FieldValueIRS element (for citing)
Total Book Value Other Assets58306TotalBookValueOtherAssets
Tot Revenue Etc Audited Fincl Stmt38519TotRevenueEtcAuditedFinclStmt
Net Unrealized Gains Investments4727NetUnrealizedGainsInvestments
Revenue Not Rptd F9904727RevenueNotRptdF990
Revenue Subtotal33792RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form99033792TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt24557TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal24557ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99024557TotalExpensesPerForm990

Schedule G IRS990ScheduleG

Events Information EventsInformation

FieldValueIRS element (for citing)
Name Of Event1CELEBRATION OF LIGHTSNameOfEvent1
Gross Receipts Event17802GrossReceiptsEvent1
Gross Revenue Event17802GrossRevenueEvent1
Other Direct Expenses Event14691OtherDirectExpensesEvent1
Name Of Event2BOOK SALENameOfEvent2
Gross Receipts Event26357GrossReceiptsEvent2
Gross Revenue Event26357GrossRevenueEvent2
Other Direct Expenses Event25441OtherDirectExpensesEvent2
Total Number Of Other Events1TotalNumberOfOtherEvents
Gross Receipts Other Events1986GrossReceiptsOtherEvents
Gross Revenue Other Events1986GrossRevenueOtherEvents
Other Direct Expenses Other Events285OtherDirectExpensesOtherEvents
Gross Receipts Total16145GrossReceiptsTotal
Gross Revenue Total Events16145GrossRevenueTotalEvents
Other Direct Expenses Total Events10417OtherDirectExpensesTotalEvents
Direct Expense Summary Events10417DirectExpenseSummaryEvents
Net Income Summary5728NetIncomeSummary

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (3 entries)

Return ReferenceReturnReferenceExplanationExplanation
FORM 990, PART VI, SECTION B, LINE 11THE BOARD OF DIRECTORS REVIEWS THE TAX RETURN BEFORE IT IS FILED
FORM 990, PART VI, SECTION B, LINE 12CANNUAL CONFLICT OF INTEREST POLICY STATEMENTS ARE SIGNED BY EACH BOARD MEMBER. THESE ARE THEN REVIEWED BY THE BOARD OF DIRECTORS TO ENSURE COMPLIANCE.
FORM 990, PART VI, SECTION C, LINE 19GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST.