ROANOKE VALLEY HEALTH SERVICES INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- ROANOKE VALLEY HEALTH SERVICES INC (EIN 56-1925492)
- Tax period
- 2009-10-01 to 2010-09-30
- Filed
- 2011-06-01
- IRS object ID
- 201101529349300005
- Schema version
- 2009v1.7
- 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 ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-06-01T08:35:58-05:00 | Timestamp |
| Tax Period End Date | 2010-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DIXON HUGHES GOODMAN LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 500 Ridgefield Court | AddressLine1 |
| City | Asheville | City |
| State | NC | State |
| ZIP Code | 28806 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 561925492 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ROANOKE VALLEY HEALTH SERVICES INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | ROAN | NameControl |
| Phone | 2525358130 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 250 SMITH CHURCH ROAD | AddressLine1 |
| City | ROANOKE RAPIDS | City |
| State | NC | State |
| ZIP Code | 27870 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | SHERRY JENSEN | Name |
| Title | CFO | Title |
| Phone | 2525358130 | Phone |
| Date Signed | 2011-05-31 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Michael Rauchwarg | Name |
| Phone | 8282542254 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | SHERRY JENSEN | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 250 SMITH CHURCH ROAD | AddressLine1 |
| City | ROANOKE RAPIDS | City |
| State | NC | State |
| ZIP Code | 27870 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 3744951 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | WWW.HALIFAXMEDICALCENTER.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1994 | YearFormation |
| State Legal Domicile | NC | StateLegalDomicile |
| Activity Or Mission Description | OPERATION OF PRIMARY CARE MEDICAL OFFICES | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 26 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 22 | NbrIndependentVotingMembers |
| Total Nbr Employees | 54 | TotalNbrEmployees |
| Total Nbr Volunteers | 34 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 68180 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 57804 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 4979193 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 3163247 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 41 | InvestmentIncomePriorYear |
| Investment Income Current Year | 310 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 51627 | OtherRevenuePriorYear |
| Other Revenue Current Year | 523590 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 5099041 | TotalRevenuePriorYear |
| Total Revenue Current Year | 3744951 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 4095585 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 4401890 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 4707142 | OtherExpensePriorYear |
| Other Expenses Current Year | 932283 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 8802727 | TotalExpensesPriorYear |
| Total Expenses Current Year | 5334173 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -3703686 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -1589222 | RevenuesLessExpensesCY |
| Total Assets BOY | 2991370 | TotalAssetsBOY |
| Total Assets EOY | 1760796 | TotalAssetsEOY |
| Total Liabilities BOY | 11930333 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 12288981 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | -8938963 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | -10528185 | NetAssetsOrFundBalancesEOY |
| Mission Description | ROANOKE VALLEY HEALTH SERVICES EXISTS TO MEET THE HEALTHCARE NEEDS OF OUR COMMUNITY BY PROVIDING EXCELLENT AND COMPASSIONATE SERVICES AND ALWAYS PLACING PATIENTS FIRST. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 4522504 | Expense |
| Revenue | 3628846 | Revenue |
| Description | ROANOKE VALLEY HEALTH SERVICES, INC. OPERATES NON-PROFIT PRIMARY CARE MEDICAL OFFICES. THE ORGANIZATION WORKS IN CLOSE TIES WITH HALIFAX REGIONAL MEDICAL CENTER, AND SHARES IN ITS GOALS AND ACHIEVEMENTS THROUGH A CONSTANT PARTNERSHIP OF FULFILLING THE HOSPITAL'S EXEMPT PURPOSE--PROVIDING EXCELLENT HEALTHCARE SERVICE TO THE COMMUNITY. | Description |
| Total Program Service Expense | 4522504 | 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 |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| 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 | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | 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 | 0 | 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 |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 54 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| 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 | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 26 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 22 | 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 | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | NC | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SHERRY JENSEN | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 2525358005 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 250 SMITH CHURCH ROAD | AddressLine1 |
| City | ROANOKE RAPIDS | City |
| State | NC | State |
| ZIP Code | 27870 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| No Listed Persons Compensated | X | NoListedPersonsCompensated |
Form990 Part VII Section A Form990PartVIISectionA (34 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| JOHNNY DRAPER | |||||||
| CHAIRMAN | 1.00 | X | X | 0 | 1100 | 0 | |
| VERNON BRYANT | |||||||
| VICE CHAIRMAN | 1.00 | X | X | 0 | 1100 | 0 | |
| TOM LYNCH | |||||||
| TREASURER | 1.00 | X | X | 0 | 1000 | 0 | |
| BOB PATTERSON | |||||||
| SECRETARY | 1.00 | X | X | 0 | 950 | 0 | |
| J HUGH BAZEMORE | |||||||
| MEMBER-AT-LARGE | 1.00 | X | 0 | 1000 | 0 | ||
| DRGERARDO MARADIAGA | |||||||
| CHIEF OF STAFF | 1.00 | X | 0 | 0 | 0 | ||
| DR SHIVA RAO | |||||||
| PAST CHIEF OF STAFF | 1.00 | X | 0 | 0 | 0 | ||
| ERNEST BARNER | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 650 | 0 | ||
| DREWERY BEALE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 750 | 0 | ||
| WILLIAM HODGE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 1100 | 0 | ||
| REV JOHN W SMITH | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 150 | 0 | ||
| EVELYN DAWSON | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 500 | 0 | ||
| FANNIE GREENE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 150 | 0 | ||
| NEAL PHILLIPS | |||||||
| BOARD MEMBER (UNTIL 8/2009) | 1.00 | X | 0 | 200 | 0 | ||
| JAMES PIERCE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| WILL MAHONE | |||||||
| PRESIDENT/CEO | 1.00 | X | X | 0 | 295786 | 56578 | |
| SHERRY JENSEN | |||||||
| VP OF FINANCE | 1.00 | X | X | 0 | 208597 | 29218 | |
| CARL FEREBEE | |||||||
| CHAIRMAN | 1.00 | X | X | 0 | 91416 | 12289 | |
| MICHAEL E GILSTRAP | |||||||
| VICE CHAIRMAN | 1.00 | X | X | 0 | 0 | 0 | |
| KAREN DANIELS | |||||||
| VP OF NURSING | 1.00 | X | X | 0 | 173505 | 32170 | |
| MICHAEL ADCOCK | |||||||
| VP | 1.00 | X | X | 0 | 61606 | 6953 | |
| CONNIE HILL | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| ROSE FLEMING | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| RUBY PALMER | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| GORDON ROGERS | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| REV MARJORIE HOLM | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| BETTY COOK | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 34488 | 1199 | ||
| DR KENNETH ROBERT | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 194099 | 16465 | ||
| GEOFFREY HARDEE | |||||||
| BOARD MEMBER | 1.00 | X | 0 | 0 | 0 | ||
| MOHAMAD SHAKIR | |||||||
| DOCTOR | 40.00 | 273128 | 0 | 18197 | X | ||
| SYED AHMED | |||||||
| DOCTOR | 40.00 | 237648 | 0 | 17893 | X | ||
| ASRA JAFFAR | |||||||
| DOCTOR | 40.00 | 205435 | 0 | 7279 | X | ||
| BIRHANE KALEAB | |||||||
| DOCTOR | 40.00 | 197126 | 0 | 14031 | X | ||
| CHINEDU ONUORAH | |||||||
| DOCTOR | 40.00 | 196659 | 0 | 2995 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1109996 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1068147 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 215267 | TotalOtherCompensation |
| Number Individuals GT100 K | 5 | 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 | 57804 | AllOtherContributions |
| Total Contributions | 57804 | TotalContributions |
Program Service Revenue ProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | NET PATIENT SERVICE RE | Description |
| Business Code | 621610 | BusinessCode |
| Total Revenue Column | 3163247 | TotalRevenueColumn |
| Related Or Exempt Function Income | 3163247 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 3163247 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 310 | TotalRevenueColumn |
| Exclusion | $310 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | ExclusionExclusionAmount |
|---|---|---|---|---|
| BAD DEBT RECOVERY | 900099 | 465599 | 465599 | |
| Other Revenue | 900099 | 57991 | $57,991 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 523590 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 3744951 | TotalRevenueColumn |
| Related Or Exempt Function Income | 3628846 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $58,301 | ExclusionAmount |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3666943 | Total |
| Program Services | 3094902 | ProgramServices |
| Management And General | 572041 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 551645 | Total |
| Program Services | 465589 | ProgramServices |
| Management And General | 86056 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 183302 | Total |
| Program Services | 154707 | ProgramServices |
| Management And General | 28595 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 377085 | Total |
| Program Services | 377085 | ProgramServices |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3549 | Total |
| Program Services | 3549 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 230300 | Total |
| Program Services | 199476 | ProgramServices |
| Management And General | 30824 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 21598 | Total |
| Program Services | 21598 | ProgramServices |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 33672 | Total |
| Program Services | 33672 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 45835 | Total |
| Program Services | 45835 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 97338 | Total |
| Program Services | 97338 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 26215 | Total |
| Program Services | 26215 | ProgramServices |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | Management And GeneralManagementAndGeneral | Program ServicesProgramServices |
|---|---|---|---|
| RECRUITMENT AND RELOCAT | 94153 | 94153 | |
| OTHER EXPENSES | 2538 | 2538 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5334173 | Total |
| Program Services | 4522504 | ProgramServices |
| Management And General | 811669 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 206347 | BOY |
| EOY | 272144 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1339130 | BOY |
| EOY | 402195 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 65593 | BOY |
| EOY | 1884 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 1713624 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 648655 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1109329 | BOY |
| EOY | 1064969 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 270971 | BOY |
| EOY | 19604 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2991370 | BOY |
| EOY | 1760796 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 81131 | BOY |
| EOY | 142616 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11849202 | BOY |
| EOY | 12146365 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11930333 | BOY |
| EOY | 12288981 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -8996851 | BOY |
| EOY | -10573070 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 57888 | BOY |
| EOY | 44885 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -8938963 | BOY |
| EOY | -10528185 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2991370 | BOY |
| EOY | 1760796 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
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
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1165929 | OtherCostOrOtherBasis |
| Depreciation | 478979 | Depreciation |
| Book Value | 686950 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 131202 | OtherCostOrOtherBasis |
| Depreciation | 53900 | Depreciation |
| Book Value | 77302 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 281822 | OtherCostOrOtherBasis |
| Depreciation | 115776 | Depreciation |
| Book Value | 166046 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 134671 | OtherCostOrOtherBasis |
| Book Value | 134671 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 1064969 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (2 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| OTHER RECEIVABLES | 18339 |
| ESTIMATED THIRD PARTY SETTLEMENTS | 1265 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 19604 | TotalBookValueOtherAssets |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | DUE TO HALIFAX REGIONAL MEDICAL CENTER | Description |
| Amount | $12,146,365 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 12146365 | TotalOfAmounts |
| Total Revenue | 3744951 | TotalRevenue |
| Total Expenses | 5334173 | TotalExpenses |
| Excess Or Deficit For Year | -1589222 | ExcessOrDeficitForYear |
| Total Adjustments | 0 | TotalAdjustments |
| Excess Or Deficit Per FS | -1589222 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 3279352 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 3279352 | RevenueSubtotal |
| Other Revenues Not Included | 465599 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 465599 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 3744951 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 4868574 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | -465599 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | -465599 | ExpensesNotRptdF990 |
| Expenses Subtotal | 5334173 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 5334173 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (2 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Part XII, Line 4b - Other Adjustments: | RECOVERY OF BAD DEBTS: 465599. |
| Part XIII, Line 2d - Other Adjustments: | RECOVERY OF BAD DEBTS: -465599. |
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 | 1 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (9 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| WILL MAHONE | |||||||||||||
| 0 | 251000 | 0 | 36783 | 0 | 8003 | 0 | 38562 | 0 | 18016 | 0 | 352364 | 0 | 0 |
| SHERRY JENSEN | |||||||||||||
| 0 | 183285 | 0 | 22754 | 0 | 2558 | 0 | 14905 | 0 | 14313 | 0 | 237815 | 0 | 0 |
| KAREN DANIELS | |||||||||||||
| 0 | 152654 | 0 | 18808 | 0 | 2043 | 0 | 22000 | 0 | 10170 | 0 | 205675 | 0 | 0 |
| DR KENNETH ROBERT | |||||||||||||
| 0 | 184169 | 0 | 9544 | 0 | 386 | 0 | 0 | 0 | 16465 | 0 | 210564 | 0 | 0 |
| MOHAMAD SHAKIR | |||||||||||||
| 246238 | 0 | 26327 | 0 | 563 | 0 | 0 | 0 | 18197 | 0 | 291325 | 0 | 0 | 0 |
| SYED AHMED | |||||||||||||
| 224644 | 0 | 12692 | 0 | 312 | 0 | 0 | 0 | 17893 | 0 | 255541 | 0 | 0 | 0 |
| ASRA JAFFAR | |||||||||||||
| 205108 | 0 | 15 | 0 | 312 | 0 | 0 | 0 | 7279 | 0 | 212714 | 0 | 0 | 0 |
| BIRHANE KALEAB | |||||||||||||
| 176598 | 0 | 20010 | 0 | 518 | 0 | 0 | 0 | 14031 | 0 | 211157 | 0 | 0 | 0 |
| CHINEDU ONUORAH | |||||||||||||
| 171356 | 0 | 25010 | 0 | 293 | 0 | 0 | 0 | 2995 | 0 | 199654 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| Part I, Line 7 | THE OFFICERS LISTED BELOW ARE RECIPIENTS OF NON-FIXED PAYMENTS FROM A RELATED ORGANIZATION (HALIFAX REGIONAL MEDICAL CENTER, INC.). THE CEO AND VICE PRESIDENT RECEIVE AT-RISK SALARY PAYMENTS FROM THIS RELATED ORGANIZATION BASED ON REACHING BALANCED SCORECARD OBJECTIVES. THE AMOUNT AVAILABLE IS THE AT-RISK SALARY AVAILABLE FOR THE INDIVIDUAL POSITIONS. FOR 2009, THE FOLLOWING OFFICERS RECEIVED PAYMENTS UNDER THIS PLAN: WILL MAHONE $ 36,783 SHERRY JENSEN 22,754 KAREN DANIELS 18,808 | |
| Part III | PART I, LINE 3: INDEPENDENT REVIEW OF COMPENSATION: THE ORGANIZATION DOES NOT DIRECTLY COMPENSATE ANY OFFICER OR KEY EMPLOYEE. SOME OFFICERS AND BOARD MEMBERS OF THE ORGANIZATION ARE EMPLOYEES OF HALIFAX REGIONAL MEDICAL CENTER, INC., A RELATED ORGANIZATION. THE BOARD OF DIRECTORS OF THAT ORGANIZATION USES THE FOLLOWING METHODS TO ESTABLISH COMPENSATION AMOUNTS FOR ITS CEO AND OTHER KEY PERSONNEL: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANTS - WRITTEN EMPLOYEMENT CONTRACTS - COMPENSATION STUDY OR SURVEY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE | Supplemental Information |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (5 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section B, line 11 | THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND INFORMATION PROVIDED BY MANAGEMENT. THE ORGANIZATION PROVIDED EVERY VOTING BOARD MEMBER A COPY OF THE DRAFT 990 PRIOR TO A SCHEDULED MEETING. DETAILS OF THE RETURN WERE DISCUSSED WITH MANAGEMENT AND THE FINANCE COMMITTEE OF THE BOARD, WHO THEN DELIVERED A REPORT TO THE FULL BOARD PRIOR TO FILING THE RETURN WITH THE IRS. |
| Form 990, Part VI, Section B, line 12c | THE ORGANIZATION FOLLOWS THE SAME CONFLICT OF INTEREST POLICY AS ITS AFFILIATE, HALIFAX REGIONAL MEDICAL CENTER. THE POLICY IS REVIEWED ANNUALLY, AND BOARD MEMBERS AND MANAGEMENT ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EVERY YEAR. |
| Form 990, Part VI, Section B, line 15a | THE ORGANIZATION ENGAGES AN OUTSIDE INDEPENDENT PARTY FOR REVIEW OF COMPENSATION PACKAGES. THE CONSULTANT USES COMPARABLE POSITIONS AND BENCHMARKS TO EVALUATE THE SALARIES FOR THE CEO AND VICE PRESIDENTS. THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS THE CONSULTANT'S RECOMMENDATIONS, AND THE FULL BOARD APPROVES THE COMPENSATION PACKAGE SELECTED FOR THE CEO. THE CONSULTATION PROCESS FOR OTHER OFFICERS INVOLVES THE INDEPENDENT CONSULTANTS; HOWEVER, THE CEO HAS FINAL APPROVAL OVER COMPENSATION PACKAGES FOR VICE PRESIDENTS AND BELOW. |
| Form 990, Part VI, Section C, line 18 | RECENT FILINGS OF THE FORM 990 ARE AVAILABLE UPON WRITTEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. IN ADDITION, RECENT FILINGS OF THE FORM 990 ARE AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG. |
| Form 990, Part VI, Section C, line 19 | PHOTOCOPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON WRITEN REQUEST AT THE ORGANIZATION'S ADMINISTRATIVE OFFICE. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 |
|---|---|---|---|---|---|---|---|---|---|
| HALIFAX REGIONAL MEDICAL CENTER | |||||||||
| 250 SMITH CHURCH ROAD | ROANOKE RAPIDS | NC | 27870 | 560989789 | HEALTHCARE | NC | 501(C)(3) | 3 | |
| HALIFAX REGIONAL MEDICAL CENTER FOUNDATION | |||||||||
| 250 SMITH CHURCH ROAD | ROANOKE RAPIDS | NC | 27870 | 561698825 | FUNDRAISING/OPERATIONAL SUPPORT | NC | 501(C)(3) | 7 | HALIFAX REGIONAL MEDICAL CENTER |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 1 | 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 | 1 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |