2013-08-15T10:13:19-05:00 2012-09-30 390758449 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2011-10-01 391397028 FORT MEMORIAL HOSPITAL FOUNDATION FORT 9205685157 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 JAMES NELSON 9205685157 2013-08-15 1 JAY ADKISSON CPA P01360892 4144319300 2013-08-14 2011 2016-02-25 16:41:14Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 5798093 0 X N/A X 1981 WI THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. 11 8 0 0 0 0 76016 218455 0 0 394460 210261 56589 -31239 527065 397477 68127 157621 0 0 0 0 0 0 0 138279 146470 206406 304091 320659 93386 5487041 6195034 147013 230231 5340028 5964803 X THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. 0 0 151671 151671 THE FOUNDATION WAS CREATED FOR THE BENEFIT OF FORT HEALTHCARE, INC 5950 5950 SCHOLARSHIPS 157621 1 1 0 0 0 0 0 0 0 1 0 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 7 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 11 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE FORT ATKINSON WI 53538 X CAROL KNOX 1.00 X X 0 0 0 DEAN JOHNSON 1.00 X X 0 0 0 MICHAEL RUMPF 1.00 X X 0 0 0 MARY J BEHLING 1.00 X X 0 0 0 DAN REYNOLDS 1.00 X 0 0 0 MARY ELLEN VINZ 1.00 X 0 0 0 JONATHAN MCLAUGHLIN MD 1.00 X 0 452439 31238 MICHAEL WALLACE 1.00 X 0 342993 33297 DONALD WILLIAMS MD 1.00 X 0 245619 31688 RICHARD TELFER 1.00 X 0 0 0 JACKQUELYN WITT 1.00 X 0 0 0 0 1041051 96223 0 0 1 0 0 81705 136750 218455 85746 85746 5490421 5365906 124515 124515 124515 3471 81705 34710 -31239 -31239 397477 0 0 179022 157621 157621 126318 126318 6417 6417 128 128 11820 11820 DUES AND MEMBERSHIPS 1177 1177 610 610 304091 157621 146470 0 162643 132585 6483 6483 8594 10129 4181056 5155353 1128265 890484 5487041 6195034 64934 149198 82079 81033 147013 230231 X 5111570 5722049 228458 242754 5340028 5964803 5487041 6195034 X 93386 531389 X 0 1 1 X 0 X X X 0 0 0 FORT HEALTHCARE 390286215 3 1 151671 1 151671 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 228458 17745 3450 242753 150474 79684 1700 228458 151916 1108 2550 150474 185269 -9773 23580 151916 1.00000 0 0 0 CERTIFICATES OF DEPOSIT 605980 F MONEY MARKET FUNDS 284504 F 890484 GIFT ANNUITY DONOR RESERVES 73558 RELATED PARTY PAYABLE 7475 81033 397477 304091 93386 531389 531389 624775 963576 531389 34710 566099 397477 0 397477 338801 34710 34710 304091 0 304091 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION INTENDS TO USE THE ENDOWMENT FUNDS FOR CAPITAL EXPENDITURES AND SCHOLARSHIPS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE SYSTEM DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION ON THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE SYSTEM RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2012 AND 2011. TAX RETURNS FOR TAX YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT EXPENSEES FOR SPECIAL EVENTS 34,710. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT EXPENSES FOR SPECIAL EVENTS 34,710. WINTER GALA 81705 81705 3124 81705 81705 3124 3124 -3124 0 FORT HEALTHCARE INC 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 390286215 501 (C) 3 151671 HOSPITAL EQUIPMENT 1 0 SCHOLARSHIPS 9 5950 0 0 0 0 0 0 0 0 0 JONATHAN MCLAUGHLIN MD 0 413478 0 38961 0 0 0 21438 0 9800 0 483677 0 0 MICHAEL WALLACE 0 342993 0 0 0 0 0 23497 0 9800 0 376290 0 0 DONALD WILLIAMS MD 0 241993 0 3626 0 0 0 21951 0 9737 0 277307 0 0 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 IS SENT TO EACH OF THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER OF THE ENTITY AND RELATED ENTITIES ANNUALLY COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE DISCLOSING THEIR CONFLICTS OF INTEREST. A SUMMARY OF CONFLICTS ARE DISTRIBUTED TO THE CHAIRMAN OF THE BOARD AND TO ADMINISTRATIVE SUPPORT PERSONNEL. BOARD MEMBERS ARE COACHED ON HOW TO MANAGE THEIR CONFLICTS. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. COMPENSATION FROM A RELATED ORGANIZATION: FORM 990, PART VII, SECTION A, LINE 1A THE FOLLOWING INDIVIDUALS EARNED WAGES FROM A RELATED ORGANIZATION: JAMES NELSON, SR. VICE PRESIDENT AND CFO OF FORT HEALTHCARE, EARNED $213,291 IN W-2 WAGES AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. MICHAEL WALLACE, PRESIDENT AND CEO OF FORT HEALTHCARE, EARNED $342,993 IN W-2 WAGES AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. JONATHAN MCLAUGHLIN EARNED $452,439 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. DONALD WILLIAMS EARNED $245,619 IN W-2 WAGES AS A PHYSICIAN FOR FORT MEDICAL GROUP AND WORKED ON AVERAGE 40 HOURS PER WEEK RELATED TO THIS POSITION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 531,389. FORT HEALTHCARE INC 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 390286215 HEALTH CARE WI 501(C)(3) LINE 3 N/A 0 FORT MEDICAL GROUP INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391736513 PROVIDE PHYSICIAN SERVICES WI N/A C 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0