2013-05-15T13:38:12-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE STREET SUITE 600 COLUMBUS OH 43215 990 2011-07-01 314379491 HOLZER HOSPITAL FOUNDATION HOLZ 7404465060 100 JACKSON PIKE GALLIPOLIS OH 45631 KENNETH PAYNE 7404465060 2013-05-13 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z SEE SCHEDULE O KENNETH PAYNE 100 JACKSON PIKE GALLIPOLIS OH 45631 122786653 0 X WWW.HOLZER.ORG X 1910 OH TO ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE. 16 2 1259 26 225631 -3633 151053 137421 115428440 117432970 175814 94314 1543831 1537482 117299138 119202187 44359 57600 0 0 45891037 51087561 0 0 0 70283349 68076089 116218745 119221250 1080393 -19063 87049156 87492950 28220286 25396143 58828870 62096807 X WE WILL ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 97336689 57600 117541764 SEE SCHEDULE OTHE HOSPITAL ACCEPTS ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. A PATIENT IS CLASSIFIED AS A CHARITY PATIENT BY REFERENCE TO CERTAIN ESTABLISHED POLICIES OF THE HOSPITAL. IN ASSESSING A PATIENT'S INABILITY TO PAY, THE HOSPITAL COMPARES INCURRED CHARGES WITH GENERALLY RECOGNIZED POVERTY INCOME LEVELS AND THE PATIENT'S FINANCIAL RESOURCES. BECAUSE THE HOSPITAL DOES NOT EXPECT TO RECEIVE PAYMENT FOR AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT SERVICE REVENUES. CHARITY CARE PROVIDED, BASED ON ESTABLISHED RATES, WAS APPROXIMATELY $8,350,124 AND $7,268,562 IN FISCAL 2012 AND 2011 RESPECTIVELY. CONSISTENT WITH ITS MISSION, THE HOSPITAL PROVIDES COMMUNITY SERVICES INTENDED TO BENEFIT THE UNDERSERVED AND ENHANCE THE HEALTH STATUS OF THE COMMUNITY. THE HOSPITAL OPERATES A 24 HOUR PER DAY, 7 DAY PER WEEK EMERGENCY ROOM PROVIDING CARE TO ALL PATIENTS. THE HOSPITAL OPERATES HOLZER HOSPICE. CONTINUING EDUCATION, CERTIFICATION PROGRAMS, AND INFORMATIONAL SEMINARS ARE CONDUCTED FOR BOTH HOSPITAL AND MEDICAL STAFF. HEALTH FAIRS ARE CONDUCTED AT NO CHARGE. ADDITIONALLY, THE HOSPITAL'S MOBILE UNIT IS TAKEN TO COMMUNITY EVENTS TO PERFORM FREE SCREENINGS, AND DISPENSE EDUCATIONAL MATERIALS. HOSPITAL STAFF ALSO RESPONDS TO REQUESTS FROM EMPLOYERS AND COMMUNITY GROUPS, ALONG WITH SENIOR CITIZEN CENTERS, FOR SCREENINGS AND INFORMATIONAL PROGRAMS. EDUCATIONAL SUPPORT GROUPS, SUCH AS DIABETES AND CANCER, AND AN EDUCATIONAL GROUP MEETING FOR STROKES, ARE SPONSORED BY THE HOSPITAL. THE HOSPITAL'S MEETING ROOMS ARE MADE AVAILABLE TO ORGANIZATIONS AT NO CHARGE FOR HEALTH-RELATED PROGRAMMING AND MEETINGS. ADDITIONALLY, CIVIC AND PROFESSIONAL ORGANIZATIONS ARE INVITED TO THE HOSPITAL REGULARLY FOR PROGRAMS THAT ARE EDUCATIONAL AND INFORMATIONAL ON HEALTH CARE SERVICES AS DEVELOPED. SPEAKERS FROM THE HOSPITAL STAFF ARE AVAILABLE AND RESPOND TO SPEAKING INVITATIONS FOR GROUPS AND ORGANIZATIONS IN THE HOSPITAL'S SERVICE AREA. THE HOSPITAL OFFERS MANY SERVICES TO THE COMMUNITY AT NOMINAL OR NO CHARGE, INCLUDING BLOOD PRESSURE AND BLOOD SUGAR SCREENINGS, CHOLESTEROL CHECKS, HEMOGLOBIN, PULSE OXIMETRY, PROSTATE CHECKS, BONE DENSITY, AND TUMOR REGISTRY. THE PEDIATRIC UNIT WORKS IN CONJUNCTION WITH THE GALLIA COUNTY HEALTH DEPARTMENT IN PROMOTING FREE IMMUNIZATIONS. THE HOSPITAL ALSO PROVIDES EDUCATIONAL PROGRAMS AND SCREENINGS, AND DISCOUNTS AT THE HOSPITAL'S GIFT SHOP, CAFETERIA, AND PHARMACY IN CONJUNCTION WITH ITS MAXWELL 50 PROGRAM. ASSISTANCE IS ALSO PROVIDED TO SENIOR CITIZENS AND OTHER PATIENTS AND THEIR FAMILIES WITH THE SUBMISSIONS OF FORMS FOR INSURANCE, FINANCIAL COUNSELING, AND APPLICATION TO THE MEDICARE AND MEDICAID PROGRAMS FOR HEALTH SERVICE COVERAGE. COSTS ASSOCIATED WITH THESE PROGRAMS ARE INCLUDED IN THE HOSPITAL'S EXPENSES. 97336689 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 52 0 1 1259 1 1 1 0 0 0 0 1 1 0 0 0 0 X 16 2 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X KENNETH PAYNE 7404465060 100 JACKSON PIKE GALLIPOLIS OH 45631 X BRENT SAUNDERS 0.80 X X 306199 0 3531 WAYNE MUNRO MD 13.00 X X 576417 0 36729 JAMES R PHILLIPPE 28.00 X X 291832 0 11361 ALAN A STOCKMEISTER 0.80 X X 0 16000 0 RYAN SMITH 0.80 X X 0 16000 0 STEVE CHAPMAN CPA 0.80 X X 0 15500 0 DANNY HOLSCHUH 0.80 X 0 15750 0 LARRY KIDD 0.80 X X 0 16250 0 M SUZANNE MIZE MD 0.80 X 0 208423 32080 PAUL M REED 0.80 X 0 11250 0 GARY ROACH 0.80 X 0 15750 0 BASHAR ATAI MD 0.80 X 0 260909 0 BRAD MUNN 0.80 X 0 0 0 THOMAS TOPE 0.80 X 0 188527 0 NIRMAL DUTTA MD 0.80 X 0 69150 0 JUDGE ROBERT GRILLO 0.80 X 0 0 0 KENNETH PAYNE 25.00 X 260363 0 0 JOHN V VIALL MD 40.00 X 156642 0 0 LEE SALTZGABER MD 40.00 X 225470 0 0 JOHN ALLEN 40.00 X 157520 0 0 THERESA S SIMON 40.00 X 145692 0 0 GERALDE VALLEE 40.00 X 179089 0 0 2299224 833509 83701 28 0 1 0 HOLZER CLINIC 90 JACKSON PIKE GALLIPOLIS OH 45631 PHYSICIANS 7718916 PLANTE & MORAN PLLC 67400 NORTHWESTERN HIGHWAY SOUTHFIELD MI 48034 ACCOUNTANTS 1127956 EXECUTIVE HEALTH RESOURCES INC PO BOX 822688 PHILADELPHIA PA 191822688 E H R COMPLIANCE SERVICES 419171 VITALIZE CONSULTING SOLUTIONS 248 MAIN STREET SUITE 101 READING MA 01867 CONSULTING 290470 I PATH LLC 2857 MANLEY ROAD MAUMEE OH 43537 PATHOLOGIST 278394 12 20001 106796 10624 137421 NET PATIENT SERVICES 622110 115796822 115796822 HCAP 622110 1314093 1314093 LIFELINE INCOME 622110 292627 292627 RENTAL INCOME 531120 29428 29428 117432970 110395 110395 197315 57967 139348 139348 139348 3455688 20112 3460530 31351 -4842 -11239 -16081 -16081 21460 20001 34618 -13158 -13158 CAFETERIA SALES 722320 959540 59116 900424 LAUNDRY INCOME 812300 177775 133706 44069 GIFT SHOP SALES 900099 119122 119122 154855 108794 32809 13252 1411292 119202187 117541764 225631 1297371 56600 56600 1000 1000 2622525 2622525 35056149 27659302 7396847 3119521 2461302 658219 7060237 5570527 1489710 3229129 2547783 681346 975457 975457 232587 232587 47608 47608 28300240 22204368 6095872 20485103 19819747 665356 49764 39045 10719 1926600 1733940 192660 654222 513303 140919 593026 533723 59303 5264324 4737892 526432 711623 640461 71162 BAD DEBTS 6064310 6064310 FRANCHISE FEE 1406290 1406290 HOLZER CARDIAC LLC 899055 899055 BOND ISSUE EXPENSES 176439 176439 289441 271602 17839 119221250 97336689 21884561 0 62214 85864 9097399 9099566 10482625 11665131 18179 0 998229 920399 2185234 2214919 1288150 1244411 139691272 108237050 29050022 31454222 10669686 7012508 23197418 23795930 87049156 87492950 15521322 16836674 0 -19017 6031142 2016233 5513921 4707498 1153901 1854755 28220286 25396143 X 58642470 61910407 186400 186400 58828870 62096807 87049156 87492950 X -19063 3287001 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1931 1931 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF DUES PAID TO THE OHIO HOSPITAL ASSOCIATION RELATES TO LOBBYING. 451456 451456 36187881 25548909 10638972 93266870 79622537 13644333 9785065 3065604 6719461 31454222 OTHER ASSETS 1307520 RELATED PARTY RECEIVABLES 22488410 23795930 COST REPORT SETTLEMENTS 125679 RELATED PARTY PAYABLE 1729076 1854755 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF JUNE 30, 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND BELIEVES IT IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2009. GOLF OUTING 41461 20001 21460 34618 41461 20001 21460 34618 34618 -13158 1 1 X 1 X 1 X 1 1 1 0 0 3572343 2122164 1450179 0.01340 15754919 9935523 5819396 0.05390 19327262 12057687 7269575 0.06730 6982 238462 238462 0.00220 6982 238462 238462 0.00220 6982 19565724 12057687 7508037 0.06950 0 6076298 303815 36238140 40364832 -4126692 X 1 1 1 1 HOLZER HOSPITAL FOUNDATION

100 JACKSON PIKE GALLIPOLIS OH 45631

X X X HOLZER HOSPITAL FOUNDATION 1 1 1 100.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 1 MEDICAL PLAZA

100 JACKSON PIKE GALLIPOLIS OH 45631

GENERAL, MEDICAL & SURGICAL PART I, LINE 3C: NOT APPLICABLE PART I, LINE 6A: NOT APPLICABLE PART I, LINE 7: EXPENSES WERE CALCULATED USING THE COST-TO-CHARGE RATIO FROM WORKSHEET 2. PART I, LINE 7G: NOT APPLICABLE PART I, L7 COL(F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $6,076,298. PART II: NOT APPLICABLE PART III, LINE 4: BAD DEBT WAS RECORDED AT GROSS CHARGES ONCE AN ACCOUNT HAD BEEN THROUGH MULTIPLE ATTEMPTS FOR PAYMENT. IT WAS THEN SUBMITTED FOR COLLECTIONS, LESS ANY AMOUNTS THAT MAY HAVE BEEN PAID THROUGH INSURANCE OR PRIVATE PAYMENTS. BAD DEBT WAS CALCULATED ON THE AUDITED FINANCIAL STATEMENTS BALANCE. NONE OF THE BAD DEBT IS TREATED AS COMMUNITY BENEFIT. 5% OF THE BAD DEBT IS ESTIMATED AS LIKELY ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR CHARITY CARE. IF IT IS UNCLEAR WHETHER AN ACCOUNT MAY QUALIFY AS CHARITY, IT IS FIRST ASSUMED TO BE CHARITY, NOT BAD DEBT, UNTIL ADDITIONAL INFORMATION SHOWS OTHERWISE.FOOTNOTE FROM FINANCIAL STATEMENTS: AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTABLISHED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF RATE FACTORS APPLIED TO UNPAID ACCOUNTS BASED ON AGING. LOSS RATE FACTORS ARE BASED ON HISTORICAL LOSS EXPERIENCE AND ADJUSTED FOR ECONOMIC CONDITIONS AND OTHER TRENDS AFFECTING THE SYSTEM'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. PART III, LINE 8: MEDICARE COSTS AS REPORTED IN THE MEDICARE COST REPORT WERE CALCULATED USING A COST-TO-CHARGE RATIO METHODOLOGY AS REQUIRED FOR COMPLETING THE MEDICARE COST REPORT. NONE OF THE MEDICARE SHORTFALL IS TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: FOUR PATIENT STATEMENTS ARE SENT TO NON-MEDICARE ACCOUNTS. FIVE PATIENT STATEMENTS ARE SENT TO MEDICARE ACCOUNTS. IF NO PATIENT PAYMENT RESPONSE, ACCOUNTS ARE SELECTED AND PROCESSED TO BAD DEBT. THIS POLICY APPLIES TO PATIENTS WHO QUALIFY UNDER THE CHARITY CARE/FINANCIAL ASSISTANCE POLICY. HOLZER HOSPITAL FOUNDATION PART V, SECTION B, LINE 19D: UNINSURED PATIENTS REGARDLESS OF INCOME LEVEL ARE OFFERED A 30% PROMPT PAY DISCOUNT, THIS DISCOUNT BALANCES OUT THE TOTAL CHARGE TO ANY CONTRACTUAL ADJUSTMENT ADJUDICATED TO ANY INDIVIDUAL COVERED BY INSURANCE. PART VI, LINE 3: NOTICES ARE POSTED THAT SPECIFY THE RIGHTS OF THESE INDIVIDUALS TO RECEIVE WITHOUT CHARGE BASIC, MEDICALLY NECESSARY HOSPITAL-LEVEL SERVICES. THE POSTINGS ARE PRINTED IN ENGLISH AND SPANISH AND ARE LOCATED IN ADMISSIONS AREAS, THE BUSINESS OFFICE, AND THE EMERGENCY DEPARTMENT. PATIENT STATEMENTS CONTAIN FEDERAL POVERTY GUIDELINES, AN EXPLANATION OF WHAT SERVICES MAY QUALIFY FOR FREE CARE, AND INFORMATION ON HOW TO APPLY. THE ORGANIZATION ALSO EMPLOYS FINANCIAL ADVOCATES AND BENEFIT ELIGIBILITY COORDINATORS TO ASSIST IN THE INFORMATION/EDUCATION PROCESS. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR HOLZER HOSPITAL FOUNDATION IS COMPRISED OF THE FOUR-COUNTRY AREA OF GALLIA, JACKSON, AND MEIGS COUNTIES IN OHIO, AND MASON COUNTY IN WEST VIRGINIA. THE SECONDARY SERVICE AREA INCLUDES PARTS OF VINTON, LAWRENCE, ATHENS, AND SCIOTO COUNTIES IN OHIO, AND JACKSON COUNTY IN WEST VIRGINIA. PART VI, LINE 5: HOLZER MEDICAL CENTER BELIEVES THAT EDUCATIONAL AND PREVENTATIVE SERVICES ARE IMPERITIVE TO IMPROVING THE HEALTH OF OUR COMMUNITY. AS SUCH, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT AT HOLZER MEDICAL CENTER ORGANIZES AND PROVIDES HEALTH SCREENINGS THROUGHOUT THE YEAR AT OUR CAMPUS, AT VARIOUS FAIRS AND FESTIVALS IN THE COMMUNITY, AT OUR LOCAL SCHOOLS AND ALSO AT AREA BUSINESSES. NO-COST HEALTH SCREENINGS INCLUDE: BLOOD PRESSURE, GLUCOSE, CHOLESTEROL, BONE DENSITY AND BODY COMPOSITION SCREENINGS. SOME OF OUR LARGER COMMUNITY EVENTS INCLUDE: GALLIA COUNTY FAIR, MEIGS COUNTY FAIR, MASON COUNTY FAIR, BUCKEYE RURAL ELECTRIC EMPLOYEE HEALTH FAIR, BUCKEYE RURAL ELECTRIC ANNUAL MEETING AND HOLZER CENTER FOR CANCER FAIR. HOLZER MEDICAL CENTER ALSO HOSTS A MONTHLY DIABETES EDUCATION MEETING, MS SUPPORT GROUP, CANCER SUPPORT GROUP AND PROVIDES HEALTH SCREENING TO SENIOR CITIZENS IN OUR SERVICE AREA AND SPEAKERS THROUGHOUT THE YEAR TO DISCUSS VARIOUS MEDICAL TOPICS TO COMMUNITY GROUPS. ALONG WITH THESE NO-COST SCREENINGS, THE COMMUNITY HEALTH AND WELLNESS DEPARTMENT PROVIDES EDUCATIONAL INFORMATION TO LOCAL ORGANIZATIONS TO PROMOTE HEALTH AND WELLNESS FOR THEIR EMPLOYEES. PART VI, LINE 6: HOLZER MEDICAL CENTER AND HOLZER MEDICAL CENTER-JACKSON COMPRISE THE TWO HOSPITALS IN THE SYSTEM, WITH HOLZER MEDICAL CENTER ACCOUNTING FOR 83% OF HOSPITAL ADMISSIONS. HOLZER MEDICAL CENTER IS LOCATED IN GALLIA COUNTY AND HOLZER MEDICAL CENTER-JACKSON IS LOCATED IN JACKSON COUNTY. ALL HEALTH SCREENINGS AND PATIENT EDUCATION IS PROVIDED BY STAFF IN AREAS WITHIN OUR PRIMARY SERVICE AREA WHICH INCLUDES GALLIA, JACKSON AND MEIGS COUNTIES IN OHIO AND MASON COUNTY, WEST VIRGINIA AS WELL AS SOME SERVICES PROVIDED IN OUR SECONDARY SERVICE AREA. 1 HOLZER FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 310927482 501(C)(3) 56600 GENERAL SUPPORT 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION MAY PROVIDE FUNDS TO RELATED, EXEMPT ORGANIZATIONS. X X X 1 1 0 0 0 0 0 0 0 BRENT SAUNDERS 306199 0 0 0 0 0 3531 0 0 0 309730 0 0 0 WAYNE MUNRO MD 576417 0 0 0 0 0 36729 0 0 0 613146 0 0 0 JAMES R PHILLIPPE 283473 0 0 0 8359 0 11361 0 0 0 303193 0 0 0 M SUZANNE MIZE MD 0 208423 0 0 0 0 0 32080 0 0 0 240503 0 0 BASHAR ATAI MD 0 225888 0 0 0 35021 0 0 0 0 0 260909 0 0 THOMAS TOPE 0 0 0 0 0 188527 0 0 0 0 0 188527 0 0 KENNETH PAYNE 206813 0 53550 0 0 0 0 0 0 0 260363 0 0 0 JOHN V VIALL MD 156642 0 0 0 0 0 0 0 0 0 156642 0 0 0 LEE SALTZGABER MD 225470 0 0 0 0 0 0 0 0 0 225470 0 0 0 JOHN ALLEN 157520 0 0 0 0 0 0 0 0 0 157520 0 0 0 GERALDE VALLEE 106115 0 72974 0 0 0 0 0 0 0 179089 0 0 0 PART I, LINES 4A-B SCHEDULE J, PART I, LINE 4A: DURING THE CALENDAR YEAR, THOMAS TOPE RECEIVED SEVERANCE PAY IN THE AMOUNT OF $188,527. UNDER THE TERMS OF THE SEVERANCE AGREEMENT MR. TOPE WILL RECEIVE 100% OF BASE SALARY AND OTHER BENEFITS AS OF THE TERMINATION DATE, 7/1/09, THROUGH 1/1/11. HE WILL ALSO BE ENTITLED TO AN ANNUAL AUTO ALLOWANCE, PARTICIPATION IN THE HOSPITAL'S GROUP LIFE INSURANCE PLAN, QUARTERLY PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE IN AN AMOUNT EQUAL TO THE 457(F) CONTRIBUTION, AND OTHER PENSION PLAN PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE BASED ON THE MAXIMUM DEFFERAL ALLOWED. FOLLOWING THIS 18 MONTH PERIOD, MR. TOPE WILL ALSO RECEIVE AN AMOUNT EQUAL TO 22 WEEKS OF BASE SALARY, PLUS 4 WEEKS OF BASE SALARY AS ADDITIONAL RETIREMENT CONSIDERATION (BASED ON THE SALARY IN EFFECT AT THE TERMINATION DATE). SCHEDULE J, PART I, LINE 4B: BRENT SAUNDERS PARTICIPATED IN A 457(F) PLAN AND HAD CONTRIBUTIONS OF $134,623. THESE CONTRIBUTIONS WERE RECEIVED IN 2012 (MARCH AND JUNE). FORM 990, PART VI, SECTION A, LINE 6 HOLZER HEALTH SYSTEM IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B HOLZER HOSPITAL FOUNDATION DECISIONS THAT ARE MADE BY THEIR BOARD OF DIRECTORS CAN BE OVERRULED BY HOLZER HEALTH SYSTEM'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND THE CFO OF HOLZER HEALTH SYSTEM REVIEW FORM 990. A COPY WILL BE PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY BY ALL BOARD MEMBERS, OFFICERS, AND EMPLOYEES, AND ARE REVIEWED BY THE CONFLICT OF INTEREST REVIEW COMMITTEE. MEMBERS OF THE BOARD ARE AWARE THAT THEY SHOULD DISCLOSE CONFLICTS WHEN THEY ARISE, AND MEMBERS ABSTAIN FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS WHERE A CONFLICT IS PRESENT. FORM 990, PART VI, SECTION B, LINE 15 THE HOLZER HEALTH SYSTEM BOARD APPROVES COMPENSATION OF THE CEO AND OTHER OFFICERS. THE BOARD UTILIZES WAGE RECOMMENDATIONS FROM AN UNRELATED CONSULTANT TO DETERMINE THE COMPENSATION. THE CEO MAY BE INVOLVED IN DETERMINING OTHER OFFICERS' COMPENSATION, HOWEVER THE ULTIMATE DECISION RESTS WITH THE BOARD. THE COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE BOARD MINUTES. THE PROCESS WAS LAST UNDERTAKEN DURING DECEMBER 2012. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023, 990, AND 990-T ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 7, PART VII: THE FOLLOWING TRUSTEES AND OFFICERS DEVOTED TIME TO RELATED ORGANIZATIONS: ALAN STOCKMEISTER 1-2 HOURS BASHAR ATAI 1-2 HOURS BRAD MUNN 1-2 HOURS BRENT SAUNDERS 40-50 HOURS DANNY HOLSCHUH 1-2 HOURS GARY ROACH 1-2 HOURS JAMES PHILLIPPEE 40-50 HOURS JUDGE ROBERT GRILLO 1-2 HOURS KENNETH PAYNE 40-50 HOURS LARRY KIDD 1-2 HOURS NIRMAL DUTTA 1-2 HOURS PAUL REED 1-2 HOURS RYAN SMITH 1-2 HOURS STEVEN CHAPMAN 1-2 HOURS SUZANNE MIZE 1-2 HOURS THOMAS TOPE 1-2 HOURS WAYNE MUNRO 40-50 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 72,391. INTERCOMPANY TRANS (RENT, SVCS, FEES) PART IX NOT RECORDED ON FINANCIALS 3,187,438. INTERCOMPANY RENTAL INCOME FROM HOLZER HOME CARE -29,428. INTERCOMPANY GRANTS NOT RECORDED ON FINANCIALS 56,600. TOTAL TO FORM 990, PART XI, LINE 5: 3,287,001. FORM 990, PART XI, LINE 2C: THE AUDIT OVERSIGHT PROCESS AND THE PROCESS OF SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, PART C: DOING BUSINESS AS: HOLZER MEDICAL CENTER HOLZER MEDICAL CENTER - GALLIPOLIS HOLZER CENTER FOR CANCER CARE 90 JACKSON PIKE GALLIPOLIS OH 45631 201780893 MEDICAL PRACTICE OH 0 0 HOLZER HOSPITAL FOUNDATION HOLZER SLEEP CENTER OF JACKSON LLC 90 JACKSON PIKE GALLIPOLIS OH 45631 205809450 MEDICAL PRACTICE OH 0 0 HOLZER HOSPITAL FOUNDATION HOLZER CARDIOVASCULAR INSTITUTE 90 JACKSON PIKE GALLIPOLIS OH 45631 311780671 MEDICAL PRACTICE OH 0 0 HOLZER HOSPITAL FOUNDATION HOLZER MEDICAL CENTER - JACKSON 100 JACKSON PIKE GALLIPOLIS OH 45631 311724085 HEALTH CARE OH 501(C)(3) LINE 3 HOLZER HEALTH SYSTEM 1 HOLZER FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 310927482 CONTINUING ADVANCEMENT OF HEALTH AND MEDICAL CARE OH 501(C)(3) LINE 7 HOLZER HEALTH SYSTEM 1 HOLZER HEALTH SYSTEM 100 JACKSON PIKE GALLIPOLIS OH 45631 311156690 MANAGEMENT SERVICES OH 501(C)(3) LINE 11A, I N/A 0 HOLZER SENIOR CARE CENTER 380 COLONIAL DRIVE BIDWELL OH 45614 311534051 SKILLED NURSING FACILITY OH 501(C)(3) LINE 9 HOLZER HEALTH SYSTEM 1 HOLZER CARDIOVASCULAR LLC 90 JACKSON PIKE GALLIPOLIS OH 45631 311780671 MEDICAL OH N/A HOLZER VANGUARD 100 JACKSON PIKE GALLIPOLIS OH 45631 311192567 STOCK HOLDING COMPANY OH N/A C 0 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 1 1 HOLZER HEALTH SYSTEM J 363636 PER LEASE CONTRACT HOLZER HEALTH SYSTEM L 4697738 PER MANAGEMENT AGREEMENTT HOLZER HEALTH SYSTEM K 500000 PER MANAGEMENT AGREEMENTT HOLZER HEALTH SYSTEM Q 3968885 ACCRUAL TRANSACTION HOLZER HEALTH SYSTEM R 3170651 ACCRUAL TRANSACTION HOLZER FOUNDATION C 106796 ACCRUAL TRANSACTION HOLZER FOUNDATION B 56600 ACCRUAL TRANSACTION HOLZER HEALTH SYSTEM I 108176 PER LEASE CONTRACT