FORT MEMORIAL HOSPITAL FOUNDATION INC: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- FORT MEMORIAL HOSPITAL FOUNDATION INC (EIN 39-1397028)
- Tax period
- 2010-10-01 to 2011-09-30
- Filed
- 2012-08-15
- IRS object ID
- 201242289349302589
- Schema version
- 2010v3.4
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule G
- Schedule I
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-08-15T13:04:15-05:00 | Timestamp |
| Tax Period End Date | 2011-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
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 | 10000 INNOVATION DRIVE SUITE 250 | AddressLine1 |
| City | MILWAUKEE | City |
| State | WI | State |
| ZIP Code | 532264837 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391397028 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | FORT | NameControl |
| Phone | 9205685157 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 535381998 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JAMES NELSON | Name |
| Title | VP OF FISCAL SERVICES | Title |
| Phone | 9205685157 | Phone |
| Date Signed | 2012-08-15 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JAY ADKISSON CPA | Name |
| Phone | 4144319300 | Phone |
| Date Prepared | 2012-08-15 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | JAMES NELSON | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 535381998 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 562376 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | N/A | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1981 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | 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. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 11 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 7 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 73209 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 76016 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 0 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 546958 | InvestmentIncomePriorYear |
| Investment Income Current Year | 394460 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 35762 | OtherRevenuePriorYear |
| Other Revenue Current Year | 56589 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 655929 | TotalRevenuePriorYear |
| Total Revenue Current Year | 527065 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 140190 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 68127 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 0 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 98731 | OtherExpensePriorYear |
| Other Expenses Current Year | 138279 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 238921 | TotalExpensesPriorYear |
| Total Expenses Current Year | 206406 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 417008 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 320659 | RevenuesLessExpensesCY |
| Total Assets BOY | 5520692 | TotalAssetsBOY |
| Total Assets EOY | 5487041 | TotalAssetsEOY |
| Total Liabilities BOY | 137776 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 147013 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 5382916 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 5340028 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | 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. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 57717 | Expense |
| Description | THE FOUNDATION WAS CREATED FOR THE BENEFIT OF FORT HEALTHCARE, INC | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 10410 | Expense |
| Description | SCHOLARSHIPS | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 68127 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 0 | ReportLandBldgEquip |
| Report Invest Oth Securities | 1 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 1 | GrantsToOrganizations |
| Grants To Individuals | 1 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 1 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 8 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 1 | QuidProQuoContributions |
| Quid Pro Quo Disclosure | 1 | QuidProQuoDisclosure |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 11 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 7 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | WI | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JAMES NELSON | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9205685490 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 53538 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (11 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| JAMES K CALDWELL | ||||||
| PRESIDENT | 1.00 | X | X | 0 | 0 | 0 |
| CAROL KNOX | ||||||
| VICE PRESIDENT | 1.00 | X | X | 0 | 0 | 0 |
| THOMAS O WAKEMAN | ||||||
| SECRETARY | 1.00 | X | X | 0 | 0 | 0 |
| MARY J BEHLING | ||||||
| TREASURER | 1.00 | X | X | 0 | 0 | 0 |
| THOMAS GOBEL DDS | ||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | |
| JONATHAN MCLAUGHLIN MD | ||||||
| DIRECTOR | 1.00 | X | 0 | 470082 | 26615 | |
| MICHAEL WALLACE | ||||||
| DIRECTOR | 1.00 | X | 0 | 386279 | 11844 | |
| DONALD WILLIAMS MD | ||||||
| DIRECTOR | 1.00 | X | 0 | 222751 | 0 | |
| RICHARD TELFER | ||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | |
| JAMES NELSON | ||||||
| DIRECTOR | 3.00 | X | 0 | 229608 | 8338 | |
| DEAN JOHNSON | ||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1308720 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 46797 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| All Other Contributions | 76016 | AllOtherContributions |
| Total Contributions | 76016 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 175593 | TotalRevenueColumn |
| Exclusion | $175,593 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 218867 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 218867 | Securities |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 218867 | TotalRevenueColumn |
| Exclusion | $218,867 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 91900 | GrossIncomeFundraisingEvents |
| Fundraising Direct Expenses | 35311 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 56589 | TotalRevenueColumn |
| Exclusion | $56,589 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 527065 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $451,049 | ExclusionAmount |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 68127 | Total |
| Program Services | 68127 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4695 | Total |
| Management And General | 4695 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 41 | Total |
| Management And General | 41 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7620 | Total |
| Management And General | 7620 | ManagementAndGeneral |
Other Expenses OtherExpenses (3 entries)
| DescriptionDescription | TotalTotal | Management And GeneralManagementAndGeneral |
|---|---|---|
| PURCHASED SERVICES | 121976 | 121976 |
| OTHER | 2782 | 2782 |
| DUES AND MEMBERSHIPS | 1165 | 1165 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 206406 | Total |
| Program Services | 68127 | ProgramServices |
| Management And General | 138279 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 230490 | BOY |
| EOY | 162643 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7483 | BOY |
| EOY | 6483 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 8594 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4358572 | BOY |
| EOY | 4181056 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 924147 | BOY |
| EOY | 1128265 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5520692 | BOY |
| EOY | 5487041 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 93560 | BOY |
| EOY | 73455 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 44216 | BOY |
| EOY | 73558 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 137776 | BOY |
| EOY | 147013 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5232442 | BOY |
| EOY | 5111570 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 150474 | BOY |
| EOY | 228458 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5382916 | BOY |
| EOY | 5340028 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5520692 | BOY |
| EOY | 5487041 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 320659 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | -363547 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | X | SupportingOrganization509a3 |
| Supporting Org509a3 Type1 | X | SupportingOrg509a3Type1 |
| 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 | FORT HEALTHCARE | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390286215 | EIN |
| Type Of Organization | 3 | TypeOfOrganization |
| Listed In Governing Doc | 1 | ListedInGoverningDoc |
| Supported Organization Notified | 1 | SupportedOrganizationNotified |
| Organized In US | 1 | OrganizedInUS |
| Amount | $57,717 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Number Of Supported Orgs | 1 | TotalNumberOfSupportedOrgs |
| Sum Of Amounts | 57717 | SumOfAmounts |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities (2 entries)
| DescriptionDescription | Book ValueBookValue | Method Of ValuationMethodOfValuation |
|---|---|---|
| CERTIFICATES OF DEPOSIT | 821433 | F |
| MONEY MARKET FUNDS | 306832 | F |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 1128265 | TotalOfBookValueSecurities |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | GIFT ANNUITY DONOR RESERVES | Description |
| Amount | $73,558 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 73558 | TotalOfAmounts |
| Total Revenue | 527065 | TotalRevenue |
| Total Expenses | 206406 | TotalExpenses |
| Excess Or Deficit For Year | 320659 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | -361847 | NetUnrealizedGLOnInvestments |
| Other | -$1,700 | OtherAmount |
| Total Adjustments | -363547 | TotalAdjustments |
| Excess Or Deficit Per FS | -42888 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 200529 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | -361847 | NetUnrealizedGainsInvestments |
| Other Revenues | 35311 | OtherRevenues |
| Revenue Not Rptd F990 | -326536 | RevenueNotRptdF990 |
| Revenue Subtotal | 527065 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 527065 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 243417 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 37011 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 37011 | ExpensesNotRptdF990 |
| Expenses Subtotal | 206406 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 206406 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| 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 2011 AND 2010. TAX RETURNS FOR TAX YEARS 2007 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE APPLICABLE TAXING AUTHORITIES. |
| PART XI, LINE 8 - OTHER ADJUSTMENTS: | NET ASSETS REALEASED FROM RESTRICTIONS -1,700. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | DIRECT EXPENSEES FOR SPECIAL EVENTS 35,311. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | DIRECT EXPENSES FOR SPECIAL EVENTS 35,311. NET ASSETS RELEASED FROM RESTRICTIONS 1,700. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | WINTER GALA | NameOfEvent1 |
| Gross Receipts Event1 | 91900 | GrossReceiptsEvent1 |
| Gross Revenue Event1 | 91900 | GrossRevenueEvent1 |
| Other Direct Expenses Event1 | 35311 | OtherDirectExpensesEvent1 |
| Gross Receipts Total | 91900 | GrossReceiptsTotal |
| Gross Revenue Total Events | 91900 | GrossRevenueTotalEvents |
| Other Direct Expenses Total Events | 35311 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 35311 | DirectExpenseSummaryEvents |
| Net Income Summary | 56589 | NetIncomeSummary |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 0 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 E SHERMAN AVENUE | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 53538 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 390286215 | EINOfRecipient |
| IRC Section | 501 (C)) 3 | IRCSection |
| Amount Of Cash Grant | 57717 | AmountOfCashGrant |
| Purpose Of Grant | HOSPITAL EQUIPMENT | PurposeOfGrant |
Form990 Schedule I Part III Form990ScheduleIPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Type Of Grant | SCHOLARSHIPS | TypeOfGrant |
| Number Of Recipients | 15 | NumberOfRecipients |
| Amount Of Cash Grant | 10410 | AmountOfCashGrant |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (4 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JONATHAN MCLAUGHLIN MD | |||||||||||||
| 0 | 406173 | 0 | 63909 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 470082 | 0 | 0 |
| MICHAEL WALLACE | |||||||||||||
| 0 | 324279 | 0 | 62000 | 0 | 0 | 0 | 9800 | 0 | 2044 | 0 | 398123 | 0 | 0 |
| DONALD WILLIAMS MD | |||||||||||||
| 0 | 222751 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 222751 | 0 | 0 |
| JAMES NELSON | |||||||||||||
| 0 | 198578 | 0 | 31030 | 0 | 0 | 0 | 8338 | 0 | 0 | 0 | 237946 | 0 | 0 |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (2 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| BADGER BANK | |||
| EMPLOYER OF FORMER BOARD MEMBER DAVID KELEHER | 100000 | FILING ORGANIZATION HAS CERTIFICATES OF DEPOSITS WITH THE BANK | 0 |
| FIRST CITIZENS BANK | |||
| EMPLOYER OF BOARD MEMBER JAMES CALDWELL | 100000 | FILING ORGANIZATION HAS CERTIFICATES OF DEPOSITS WITH THE BANK. | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (4 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| 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. | |
| 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 B, LINE 12C | |
| ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. | FORM 990, PART VI, SECTION C, LINE 19 | |
| CHANGES IN NET ASSETS OR FUND BALANCES: | NET UNREALIZED LOSSES ON INVESTMENTS: -361,847. NET ASSETS REALEASED FROM RESTRICTIONS -1,700. TOTAL TO FORM 990, PART XI, LINE 5: -363,547. | FORM 990, PART XI, LINE 5: |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT HEALTHCARE INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 E SHERMAN AVENUE | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 53538 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390286215 | EIN |
| Primary Activities | HEALTH CARE | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | LINE 3 | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Controlled Org | 0 | ControlledOrg |
Form990 Schedule R Part IV Form990ScheduleRPartIV
Name Of Related Org NameOfRelatedOrg
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FORT MEDICAL GROUP INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 611 SHERMAN AVENUE EAST | AddressLine1 |
| City | FORT ATKINSON | City |
| State | WI | State |
| ZIP Code | 53538 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391736513 | EIN |
| Primary Activity | PROVIDE PHYSICIAN SERVICES | PrimaryActivity |
| Legal Domicile State | WI | LegalDomicileState |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Type Of Entity | C | TypeOfEntity |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 1 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |