2013-11-12T14:27:56-06:00 2012-12-31 351178661 BLUE & CO LLC 8800 LYRA DRIVE SUITE 450 COLUMBUS OH 43240 990 2012-01-01 237374256 MCCULLOUGH-HYDE MEMORIAL HOSPITAL ENDOWMENT FUND MCCU 5135245310 110 NORTH POPLAR OXFORD OH 45056 JOHN CLEMENTS 5135245310 2013-11-12 1 NANCY KIRCHNER P00386751 6148852583 2013-11-12 2012 2016-03-07 17:11:31Z JOHN CLEMENTS 110 NORTH POPLAR STREET OXFORD OH 45056 622302 0 X WWW.MHMH.ORG X 1942 OH TO SUPPORT HEALTH, EDUCATIONAL, AND BUILDING PROGRAMS OF MCCULLOUGH-HYDE MEMORIAL HOSPITAL 10 10 0 0 0 0 296717 185162 0 0 380590 351847 70895 10662 748202 547671 15575 310728 0 0 0 0 0 0 0 547170 104878 562745 415606 185457 132065 10167153 11256494 1701503 1936390 8465650 9320104 SUPPORT THE HOSPITAL WITH HEALTH PROGRAMS, EDUCATION ASSISTANCE, BUILDING AND EQUIPMENT NEEDS 0 0 129605 129605 DEVELOPMENT OFFICE SUPPORT:THE TRUST PROVIDES SUPPORT FOR THE HOSPITAL DEVELOPMENT DEPARTMENTTHAT ACTS AS A LIASON BETWEEN THE HOSPITAL AND THE DONOR COMMUNITY.EFFORTS OF THIS OFFICE OVER THE YEARS HAS PRODUCED AN ENDOWMENT OF APPROX $8 MILLION IN UNRESTRICTED CONTRIBUTIONS AND $2 MILLION IN DESIGNATED GIFTS. 122242 122242 CAPITAL EQUIPMENT SUPPORT:FUNDED ALL OR PART OF 9 EQUIPMENT PURCHASES FOR DEPARTMENTS INCLUDINGONCOLOGY CLINIC, OBSTETRICS, CRITICAL CARE, MEDICAL-SURGICIAL NURSING,LAB, NUTRITION SERVICES, RESPIRATORY THERAPY, VOLUNTEER SERVICES AND INFORMATION TECHNOLOGY (SYSTEM-WIDE ELECTRONIC PHYSICIAN ORDER ENTRY SYSTEM) 58881 58881 EDUCATION SUPPORT:FUNDED ALL OR PART OF 27 EDUCATIONAL ACTIVITIES INCLUDING THREE FOR HEALTHCAREER ADVANCEMENT, 13 RELATED TO CLINICIAL SKILLS DEVELOPMENT AND 11RELATED TO ADMINISTRATIVE AND SUPPORT DEPARTMENT PROFESSIONAL DEVELOPMENT. 310728 1 1 0 0 0 1 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 3 0 1 0 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 OH X JAMES MILLER CONTROLLER 5135245310 110 NORTH POPLAR STREET OXFORD OH 45056 JOHN HARLAND MD 1.00 X 0 0 0 SUSAN CROSS LIPNICKEY 1.00 X 0 0 0 JACK MANN 1.00 X 0 0 0 RICHARD M NORMAN 1.00 X 0 0 0 ALAN OAK 1.00 X 0 0 0 STEPHEN FLEE 1.00 X 0 0 0 WILLIAM DOUGLAS ROSS DO 1.00 X 0 0 0 THOMAS W SPEH 1.00 X 0 0 0 RALPH GUTOWSKI 1.00 X 0 0 0 PAIGE WOOD 1.00 X 0 0 0 BRYAN HEHEMANN 40.00 X 0 206743 21438 JOHN CLEMENTS 40.00 X 0 142936 11197 PAMELA COLLINS 40.00 X 0 127845 9934 TAMMY LANGDON 40.00 X 0 120232 20954 KENNETH KELLER 40.00 X 0 246835 1389 MATTHEW BIRKLE 40.00 X 0 195226 1099 MARK CRISTELL 40.00 X 0 135452 21039 MATTHEW DAGGY 40.00 X 0 237090 1335 MARY BROWN 40.00 X 0 113753 20430 0 1526112 108815 0 0 1 0 0 185162 185162 195508 195508 85293 74631 10662 10662 10662 156339 0 156339 156339 156339 547671 0 0 362509 310728 310728 200 200 50410 50410 2744 2744 27618 27618 9102 9102 13703 13703 1101 1101 415606 310728 104878 0 787997 539743 19275 10553 43207 51091 1083092 473338 301917 609754 9014757 10045353 10167153 11256494 21759 23820 1679744 1912570 1701503 1936390 X 6488323 7243785 176893 188048 1800434 1888271 8465650 9320104 10167153 11256494 132065 722389 0 X 0 1 X 1 0 X X 0 0 0 MCCULLOUGH-HYDE MEMORIAL HOSPITAL INC 310650283 509(A)(3)(A) 0 1 1 295578 1 295578 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 10 32316 98184 88105 1 1 9014757 97325 1099844 166574 10045352 9551600 296717 -706525 127035 9014757 8626691 137514 970829 183434 9551600 7180113 372373 1080059 5854 8626691 8858166 1086641 -2429378 335316 7180113 0.98040 0.01960 1 0 149670 149670 902441 457491 444950 30981 15847 15134 609754 DUE TO RELATED MCCULLOUGH-HYDE MEMORIAL HOSPITAL 1912570 1912570 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: HEALTH EDUCATION, HOSPITAL EQUIPMENT, COMMUNITY HEALTH ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE TRUST AND THE HOSPITAL AND RECOGNIZE A TAX LIABILITY IF THEY HAVE TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2012 AND 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE TRUST AND THE HOSPITAL ARE SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. 0 OXFORD FREE CLINIC PO BOX 18818 FAIRFIELD OH 45018 204253386 501(C)(3) 15150 HEALTH CLINIC MCCULLOUGH-HYDE MEMORIAL HOSPITAL 110 NORTH POPLAR STREET OXFORD OH 45056 310650283 501(C)(3) 295578 PROGRAM DEVELOPMENT, HEALTH PROGRAM FUNDING, EDUCATION PROGRAMS, BUILDING AND FACILITY SUPPORT 1 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION HAS REPRESENTATION ON THE BOARD THAT OVERSEES OPERATIONS. 0 1 0 0 0 0 0 0 0 BRYAN HEHEMANN 0 206743 0 0 0 0 0 938 0 20500 0 228181 0 0 JOHN CLEMENTS 0 142936 0 0 0 0 0 938 0 10259 0 154133 0 0 KENNETH KELLER 0 246835 0 0 0 0 0 0 0 1389 0 248224 0 0 MATTHEW BIRKLE 0 195226 0 0 0 0 0 0 0 1099 0 196325 0 0 MARK CRISTELL 0 126789 0 8663 0 0 0 938 0 20101 0 156491 0 0 MATTHEW DAGGY 0 237090 0 0 0 0 0 0 0 1335 0 238425 0 0 PART I, LINE 4B BRYAN HEHEMANN - LIFE INSURANCE POLICY - PAID UP POLICY AT 65. FACE AMOUNT IS 100K WITH CASH SURRENDER VALUE. THERE IS AN ANNUAL PREMIUM OF $8,874 WITH THE VALUE AT 12/31/12 AT $45,503. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE CFO AND FINANCE COMMITTEE OF THE BOARD PRIOR TO SUBMISSION. ALL BOARD MEMBERS ARE INVITED ATTEND. THE FINANCE COMMITTEE REVIEWS WITH THE FULL BOARD AT THE NEXT SCHEDULED MEETING. FORM 990, PART VI, SECTION B, LINE 12C ALL MEMBERS OF ADMINISTRATION, DEPARTMENT DIRECTORS, MANAGERS, SUPERVISORS AND OTHER INDIVIDUALS WHO ARE, OR MAY BE, RESPONSIBLE FOR THE DIRECT PURCHASE OF GOODS AND/OR SERVICES ON BEHALF OF THE HOSPITAL SHALL BE REQUIRED TO REVIEW THIS POLICY AND COMPLETE A CONFLICT OF INTEREST FORM FOR SUBMISSION TO THE CORPORATE COMPLIANCE OFFICER ANNUALLY. WHEN A CONFLICT OF INTEREST ARISES OR A POTENTIAL CONFLICT OF INTEREST DEVELOPS, THE PERSON WHO IS OR MAY BE IN A CONFLICT OF INTEREST SITUATION IS REQUIRED TO MAKE A FULL WRITTEN DISCLOSURE OF THE SITUATION OR POTENTIAL SITUATION BY COMPLETING AND SIGNING A CONFLICT OF INTEREST QUESTIONNAIRE AND RETURNING IT TO HIS/HER DEPARTMENT DIRECTOR AND/OR APPROPRIATE ADMINISTRATOR, WHO WILL FORWARD THE CONFLICT OF INTEREST FORM TO THE CORPORATE COMPLIANCE OFFICER FOR REVIEW AND APPROPRIATE ACTION. THE CORPORATE COMPLIANCE COMMITTEE SHALL CONDUCT A FULL REVIEW AND ASSESSMENT OF THE POTENTIAL CONFLICT AND WILL PROVIDE ONE OF THE FOLLOWING WRITTEN RECOMMENDATIONS/CONCLUSIONS: 1. THE CIRCUMSTANCES REPORTED DO NOT PRESENT A PROBLEM. 2. ALTERNATE ARRANGEMENTS MADE BY/WITH THE EMPLOYEE ARE ACCEPTABLE AND PRESENT NO PROBLEM. 3. ALTERNATE ARRANGEMENTS ARE NOT ACCEPTABLE AND THE CONFLICT WILL BE DEALT WITH ON AN INDIVIDUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. MCCULLOUGH-HYDE MEMORIAL HOSPITAL INC 110 N POPLAR STREET OXFORD OH 45056 310650283 HOSPITAL OH 501(C)(3) LINE 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 MCCULLOUGH-HYDE MEMORIAL HOSPITAL B 113933 MCCULLOUGH-HYDE MEMORIAL HOSPITAL P 203971