2012-08-15T13:04:15-05:00 2011-09-30 WIPFLI LLP 10000 INNOVATION DRIVE SUITE 250 MILWAUKEE WI 532264837 990 2010-10-01 391397028 FORT MEMORIAL HOSPITAL FOUNDATION FORT 9205685157 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 JAMES NELSON 9205685157 2012-08-15 1 JAY ADKISSON CPA 4144319300 2012-08-15 2010 2016-02-24 21:20:13Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 562376 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 7 0 0 0 0 73209 76016 0 0 546958 394460 35762 56589 655929 527065 140190 68127 0 0 0 0 0 0 0 98731 138279 238921 206406 417008 320659 5520692 5487041 137776 147013 5382916 5340028 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 57717 THE FOUNDATION WAS CREATED FOR THE BENEFIT OF FORT HEALTHCARE, INC 10410 SCHOLARSHIPS 68127 1 1 0 0 0 0 0 0 0 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 1 0 0 0 0 0 0 0 1 0 0 0 0 1 8 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 11 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X JAMES NELSON 9205685490 611 SHERMAN AVENUE FORT ATKINSON WI 53538 JAMES K CALDWELL 1.00 X X 0 0 0 CAROL KNOX 1.00 X X 0 0 0 THOMAS O WAKEMAN 1.00 X X 0 0 0 MARY J BEHLING 1.00 X X 0 0 0 THOMAS GOBEL DDS 1.00 X 0 0 0 JONATHAN MCLAUGHLIN MD 1.00 X 0 470082 26615 MICHAEL WALLACE 1.00 X 0 386279 11844 DONALD WILLIAMS MD 1.00 X 0 222751 0 RICHARD TELFER 1.00 X 0 0 0 JAMES NELSON 3.00 X 0 229608 8338 DEAN JOHNSON 1.00 X 0 0 0 0 1308720 46797 0 0 1 0 0 76016 76016 175593 175593 218867 218867 218867 218867 91900 35311 56589 56589 527065 0 0 451049 68127 68127 4695 4695 41 41 7620 7620 PURCHASED SERVICES 121976 121976 OTHER 2782 2782 DUES AND MEMBERSHIPS 1165 1165 206406 68127 138279 0 230490 162643 7483 6483 8594 4358572 4181056 924147 1128265 5520692 5487041 93560 73455 44216 73558 137776 147013 X 5232442 5111570 150474 228458 5382916 5340028 5520692 5487041 X 320659 -363547 X 0 1 1 X 0 X X 0 0 0 FORT HEALTHCARE 390286215 3 1 1 1 57717 1 57717 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 CERTIFICATES OF DEPOSIT 821433 F MONEY MARKET FUNDS 306832 F 1128265 GIFT ANNUITY DONOR RESERVES 73558 73558 527065 206406 320659 -361847 -1700 -363547 -42888 200529 -361847 35311 -326536 527065 0 527065 243417 37011 37011 206406 0 206406 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. WINTER GALA 91900 91900 35311 91900 91900 35311 35311 56589 0 FORT HEALTHCARE INC 611 E SHERMAN AVENUE FORT ATKINSON WI 53538 390286215 501 (C)) 3 57717 HOSPITAL EQUIPMENT SCHOLARSHIPS 15 10410 0 0 0 0 0 0 0 0 0 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 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 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -361,847. NET ASSETS REALEASED FROM RESTRICTIONS -1,700. TOTAL TO FORM 990, PART XI, LINE 5: -363,547. 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