THEDACARE MEDICAL CENTER-BERLIN INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- THEDACARE MEDICAL CENTER-BERLIN INC (EIN 39-0806359)
- Tax period
- 2009-10-01 to 2010-09-30
- Filed
- 2011-08-15
- IRS object ID
- 201102279349303470
- 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
- Form 990
- Schedule A
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-08-15T14:39:01-05:00 | 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 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | 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 | 390806359 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HEALTH NETWORK INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | COMM | NameControl |
| Phone | 9203611313 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DR | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | tom KRYSTOWIAK | Name |
| Title | CFO | Title |
| Phone | 9203611313 | Phone |
| Date Signed | 2011-08-12 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Terri Rexrode CPA MST | Name |
| Phone | 9206620016 | Phone |
| Date Prepared | 2011-08-12 | DatePrepared |
| 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 | TOM KRYSTOWIAK | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DRIVE | AddressLine1 |
| City | Berlin | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 75721009 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.chnwi.org | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1910 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | COMMUNITY HEALTH NETWORK PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES, HOME CARE SERVICES AND SKILLED NURSING SERVICES TO GREEN LAKE COUNTY AND SURROUNDING COUNTIES WITH TOTAL NET PATIENT SERVICE REVENUES OF $70,020,000(TOTAL GROSS REVENUE OF $139,326,000). | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 12 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 10 | NbrIndependentVotingMembers |
| Total Nbr Employees | 807 | TotalNbrEmployees |
| Total Nbr Volunteers | 150 | TotalNbrVolunteers |
| Total Gross UBI | 1945961 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Current Year | 0 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 66534644 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 74885484 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 141485 | InvestmentIncomePriorYear |
| Investment Income Current Year | 512408 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -197259 | OtherRevenuePriorYear |
| Other Revenue Current Year | -276931 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 66478870 | TotalRevenuePriorYear |
| Total Revenue Current Year | 75120961 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 36907250 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 42679208 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 29016179 | OtherExpensePriorYear |
| Other Expenses Current Year | 31863993 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 65923429 | TotalExpensesPriorYear |
| Total Expenses Current Year | 74543201 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 555441 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 577760 | RevenuesLessExpensesCY |
| Total Assets BOY | 47773650 | TotalAssetsBOY |
| Total Assets EOY | 54650324 | TotalAssetsEOY |
| Total Liabilities BOY | 22801737 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 28017060 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 24971913 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 26633264 | NetAssetsOrFundBalancesEOY |
| Mission Description | To provide superior services to improve the health of those we serve. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 65092498 | Expense |
| Revenue | 72836012 | Revenue |
| Description | Community Health Network operates a 25-bed acute care facility, 75 bed extended care facility, physician clinics located in 8 communities, a home health agency, rehabilitation services and retail pharmacy services.In pursuit of our primary exempt purpose of providing health care services, Community Health Network provides medical care and health information aimed at improving the health status of the communities we serve. We believe that we have a special duty to meet the needs of the poor, indigent, and medically underserved in our communities and surrounding areas. We have provided care to all patients without regard for the ability to pay. Community Health Network operates an emergency room that is open to all persons regardless of ability to pay. It has an open medical staff with privileges available to all qualified physicians in the area. The majority of the board of directors is comprised of independent individuals who are representative of the community. Community Health Network engages in training and education of health care professionals through internship programs. It operates a woman's health and resource clinic that provides services to uninsured and underinsured women through a State of Wisconsin grant program. Community Health Network's vision includes a healthier community. To achieve this vision, it continually assesses the communities for opportunities for health care improvement. Diabetes management has been identified as a community need. Diabetes management and education continues to be a community program offered to the community at no cost. Community Health Network participates in government-sponsored health care programs such as Medicaid, Medicare, CHAMPUS, and Tricare. In fiscal year 2010 over 1,500 accounts received charity care with a total cost of over $945,000. The cost of services provided to Medicaid patients that were not reimbursed totaled more than $3.4 million. Community Health Network's loss for providing long term care services to the communities was $540,000 in 2010. Financial and in-kind contributions to the community totaled approximately $75,000. In addition, Community Health Network actively provided or participated in the following community-based activities and programs of which approximately 11,000 persons in the communities that we serve participated at a total cost to Community Health Network of approximately $140,000. - General health education services such as health fairs; cancer education; heart disease education; diabetes education; family, parent, and sibling education; family planning; and women's health education- Provided health information on the Corporation's web site and through health related publications distributed at no charge- Support groups such as diabetes, cancer, and bereavement- Hosted self-help and wellness programs such as nutrition, weight management and fitness,- Blood pressure screenings, cholesterol testing and school-based testing- Guidance, referral and enrollment assistance for public medical programs and other family support assistance- Discounted or free medical supplies and equipment to those unable to pay- Delivered hot in-home meals- Promoted participation in blood drives by employees- Contributed to the education of student nurses and other health care professionals- Provided first aid for community sporting events- Participated in work site health education programs - Made cash contributions to support community services and events- Provided meeting rooms to community groups at no charge | Description |
| Total Program Service Expense | 65092498 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 0 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | 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 | 1 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| 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 | 1 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 1 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 47 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 807 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| 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 | 12 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 10 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 1 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | 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 | 0 | 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 | THOMAS KRYSTOWIAK | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 9203611313 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DRIVE | AddressLine1 |
| City | Berlin | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (18 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 |
|---|---|---|---|---|---|---|---|
| HenRY DERLETH | |||||||
| SECRETARY | 0.50 | X | X | 4300 | 0 | 0 | |
| James CLARK | |||||||
| VICE CHAIRMAN | 0.50 | X | X | 5900 | 0 | 0 | |
| Jodi timler Olmen | |||||||
| TREASURER | 0.50 | X | X | 5800 | 0 | 0 | |
| Kristin Galatowitsch | |||||||
| BOARD MEMBER | 0.50 | X | 3700 | 0 | 0 | ||
| Pat McConnell | |||||||
| BOARD MEMBER | 0.50 | X | 4100 | 0 | 0 | ||
| P MICHAEL SHATTUCK MD | |||||||
| BOARD MEMBER | 0.50 | X | 231543 | 0 | 20406 | ||
| Russell Kuehn | |||||||
| BOARD MEMBER | 0.50 | X | 3900 | 0 | 0 | ||
| STEVE SORENSON | |||||||
| CHAIRMAN | 0.50 | X | X | 7587 | 0 | 0 | |
| Thomas Willett DO | |||||||
| BOARD MEMBER | 0.50 | X | 3000 | 0 | 0 | ||
| Douglas Guy | |||||||
| PRESIDENT/CEO | 32.00 | X | X | 215867 | 0 | 5741 | |
| LARRY WISE | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| Paul Kajawa | |||||||
| boARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| THOMAS KRYSTOWIAK | |||||||
| CFO | 39.00 | X | 151975 | 3897 | 27835 | ||
| DAVID JONES | |||||||
| PHYSICIAN | 40.00 | 365799 | 0 | 14303 | X | ||
| David Budde | |||||||
| phYSICIAN | 40.00 | 358944 | 0 | 31174 | X | ||
| DAVID W KURTZ | |||||||
| PHYSICIAN | 40.00 | 527076 | 0 | 29623 | X | ||
| JOSEPH LEE | |||||||
| PHYSICIAN | 40.00 | 372164 | 0 | 11110 | X | ||
| URI VAISMAN | |||||||
| PHYSICIAN | 40.00 | 761004 | 0 | 27073 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 3022659 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 3897 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 167265 | TotalOtherCompensation |
| Number Individuals GT100 K | 46 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| ZR Enterprises SC | |||||
| 6809 MAGNOLIA CT | Greendale | WI | 53129 | ER Physician Service | 1294547 |
| Hall Render Killian HEALTH & LYMAN PC | |||||
| 39778 TREASURY CTR | CHICAGO | IL | 60694 | CONSULTING/LEGAL SERVICES | 408672 |
| STAFF CARE INC | |||||
| PO Box 281923 | ATLANTA | GA | 30384 | PHYsician Staffing | 370450 |
| CENTRAL WI ANESTHESIA ASSOC SC | |||||
| PO BOX 249 | BERLIN | WI | 54923 | ANESTHESIA SERVICES | 310504 |
| DAVID RESEN MD PATHOLOGY SERVICES | |||||
| PO BOX 43 | GREEN LAKE | WI | 54941 | PATHOLOGY SERVICES | 239750 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 9 | NumberOfContractorsGT100K |
Program Service Revenue ProgramServiceRevenue (5 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue | ExclusionExclusionAmount |
|---|---|---|---|---|---|
| PATIENT SERVICE REVENU | 624100 | 68176146 | 68176146 | ||
| OTHER OPERATING REVENU | 900099 | 5267409 | 5267409 | ||
| PHARMACY REVENUE | 446110 | 1945961 | 1945961 | ||
| Cafeteria | 900099 | 103511 | $103,511 | ||
| Interest on CMC Invest | 624100 | -607543 | -607543 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 74885484 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 464161 | TotalRevenueColumn |
| Exclusion | $464,161 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 320610 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 597541 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -276931 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -276931 | TotalRevenueColumn |
| Exclusion | -$276,931 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 50404 | Securities |
| Other | 350 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 2507 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 50404 | Securities |
| Other | -2157 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 48247 | TotalRevenueColumn |
| Exclusion | $48,247 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 75120961 | TotalRevenueColumn |
| Related Or Exempt Function Income | 72836012 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 1945961 | UnrelatedBusinessRevenue |
| Exclusion | $338,988 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 371739 | Total |
| Management And General | 371739 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 33361988 | Total |
| Program Services | 29412384 | ProgramServices |
| Management And General | 3949604 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 741788 | Total |
| Program Services | 603780 | ProgramServices |
| Management And General | 138008 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 6299060 | Total |
| Program Services | 5388582 | ProgramServices |
| Management And General | 910478 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1904633 | Total |
| Program Services | 1606491 | ProgramServices |
| Management And General | 298142 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 324949 | Total |
| Management And General | 324949 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 6516043 | Total |
| Program Services | 5608910 | ProgramServices |
| Management And General | 907133 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 183233 | Total |
| Program Services | 8688 | ProgramServices |
| Management And General | 174545 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15703378 | Total |
| Program Services | 14602167 | ProgramServices |
| Management And General | 1101211 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 490482 | Total |
| Program Services | 65229 | ProgramServices |
| Management And General | 425253 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 895448 | Total |
| Program Services | 860385 | ProgramServices |
| Management And General | 35063 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 325555 | Total |
| Program Services | 282371 | ProgramServices |
| Management And General | 43184 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 73119 | Total |
| Program Services | 3428 | ProgramServices |
| Management And General | 69691 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 882494 | Total |
| Program Services | 877100 | ProgramServices |
| Management And General | 5394 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2293466 | Total |
| Program Services | 2263708 | ProgramServices |
| Management And General | 29758 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 550650 | Total |
| Program Services | 295367 | ProgramServices |
| Management And General | 255283 | ManagementAndGeneral |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| PROVISION FOR BAD DEBTS | 2754093 | 2754093 | |
| RECRUITING | 276671 | 254686 | 21985 |
| Medicaid Assessment | 242987 | 242987 | |
| LICENSES, DUES, AND CER | 160408 | 96605 | 63803 |
| MISCELLANEOUS | 141265 | 71486 | 69779 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 49752 | Total |
| Program Services | 37038 | ProgramServices |
| Management And General | 12714 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 74543201 | Total |
| Program Services | 65092498 | ProgramServices |
| Management And General | 9450703 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3875 | BOY |
| EOY | 4025 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8924534 | BOY |
| EOY | 11487208 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8516830 | BOY |
| EOY | 9529706 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 642516 | BOY |
| EOY | 670022 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 759521 | BOY |
| EOY | 1404226 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 49145476 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 30871103 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 17239125 | BOY |
| EOY | 18274373 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7923755 | BOY |
| EOY | 9601754 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3763494 | BOY |
| EOY | 3679010 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 47773650 | BOY |
| EOY | 54650324 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4986999 | BOY |
| EOY | 5643904 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 82799 | BOY |
| EOY | 184047 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12305000 | BOY |
| EOY | 13445000 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1207985 | BOY |
| EOY | 3026493 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4218954 | BOY |
| EOY | 5717616 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 22801737 | BOY |
| EOY | 28017060 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24971913 | BOY |
| EOY | 26633264 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24971913 | BOY |
| EOY | 26633264 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 47773650 | BOY |
| EOY | 54650324 | 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 C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $3,543 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 3543 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Part II-B, Line 1i: | Identifier |
| Return Reference | Explanation of Other Lobbying Activities: | ReturnReference |
| Explanation | WHA Dues | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 919246 | OtherCostOrOtherBasis |
| Book Value | 919246 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 28228297 | OtherCostOrOtherBasis |
| Depreciation | 16037647 | Depreciation |
| Book Value | 12190650 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1222984 | OtherCostOrOtherBasis |
| Depreciation | 887135 | Depreciation |
| Book Value | 335849 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 18301998 | OtherCostOrOtherBasis |
| Depreciation | 13946321 | Depreciation |
| Book Value | 4355677 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 472951 | OtherCostOrOtherBasis |
| Book Value | 472951 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 18274373 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities (12 entries)
| DescriptionDescription | Book ValueBookValue | Method Of ValuationMethodOfValuation |
|---|---|---|
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - CASH AND SHORT-TERM INVESTMENTS | 94810 | F |
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - Common Stocks | 1580894 | F |
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - Corporate Bonds | 474468 | F |
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - Hedge Funds | 178454 | F |
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - Mutual Funds | 1597260 | F |
| BOARD DESIGNATED FOR CAPITAL ACQUISITION - U.S. Treasury Obligations | 311135 | F |
| HELD BY TRUSTEE UNDER BOND INDENTURE AGREEMENTS - Cash and Cash equivalents | 881338 | F |
| HelD BY TRUSTEE UNDER BOND INDENTURE AGREEMENTS - Mutual Funds | 3042792 | F |
| UNEMPLOYMENT COMP. FUNDING-HELD BY STATE OF WI -CASH & SHORT-TERM INVESTMENT | 441549 | F |
| Certificates of Deposit | 704356 | F |
| Mutual Funds | 149698 | F |
| HELD BY VENDOR UNDER DEPOSIT - CASH AND CASH EQUIVALENTS | 145000 | F |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 9601754 | TotalOfBookValueSecurities |
Other Assets OtherAssets (6 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| RECEIVABLE FROM PHYSICIANS | 274819 |
| UNAMORTIZED BOND ISSUE COSTS | 327819 |
| Interest Receivable | 33753 |
| Other Assets | 257543 |
| CMC CLINIC | 273954 |
| ACCOUNTS RECEIVABLE - WILD ROSE | 2511122 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 3679010 | TotalBookValueOtherAssets |
Other Liabilities OtherLiabilities (5 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| DEFERRED COMPENSATION | $3,406,357 |
| Accrued Interest | $96,759 |
| Self Funded Health Insurance | $1,003,635 |
| Net amounts payable from Third-party reimbursement Programs | $861,164 |
| MISCELLANEOUS | $349,701 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 5717616 | TotalOfAmounts |
| Total Revenue | 75120961 | TotalRevenue |
| Total Expenses | 74543201 | TotalExpenses |
| Excess Or Deficit For Year | 577760 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 115530 | NetUnrealizedGLOnInvestments |
| Other | $968,061 | OtherAmount |
| Total Adjustments | 1083591 | TotalAdjustments |
| Excess Or Deficit Per FS | 1661351 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 75718502 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 75718502 | RevenueSubtotal |
| Other Revenues Not Included | -597541 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | -597541 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 75120961 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 75140742 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 597541 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 597541 | ExpensesNotRptdF990 |
| Expenses Subtotal | 74543201 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 74543201 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | In order to account for any uncertain tax positions, ASC Topic 740-10, Accounting for Uncertainty in Income Taxes, requires an organization to assess whether it is more likely than not that a tax position will be sustained upon examination of 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 consolidated financial statements. The Organization recorded no assets or liabilities related to uncertain tax positions or unrecognized tax benefits. Tax returns for the years ended September 30, 2007, 2008, and 2009, remain subject to examination by the applicable taxing authorities. The tax return for the year ended September 30, 2010, is not yet due and has not yet been filed. |
| Part XI, Line 8 - Other Adjustments: | NET ASSET TRANSFERS FROM AFFILIATES: 968061. | |
| Part XII, Line 4b - Other Adjustments: | RENTAL EXPENSES: -597541. | |
| Part XIII, Line 2d - Other Adjustments: | RENTAL EXPENSES: 597541. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent150 | X | Pcent150 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 0 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 1562 | PersonsServed |
| Total Community Benefit Expense | 1005178 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 1005178 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01400 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 9906527 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 6407311 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3499217 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04870 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 1562 | PersonsServed |
| Total Community Benefit Expense | 10911705 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 6407311 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 4504395 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.06270 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 7388 | PersonsServed |
| Total Community Benefit Expense | 38065 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 25 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 38040 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00050 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 159 | PersonsServed |
| Total Community Benefit Expense | 21792 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 21792 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00030 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 77876 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 77876 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00110 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 7547 | PersonsServed |
| Total Community Benefit Expense | 137733 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 25 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 137708 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00190 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 9109 | PersonsServed |
| Total Community Benefit Expense | 11049438 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 6407336 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 4642103 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.06460 | PercentOfTotalExpense |
Community Support CommunitySupport
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 5000 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 5000 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Total
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 5000 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 5000 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $1,321,333 | BadDebtExpenseAmount |
| Amount Reimbursed By Medicare | 12110240 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 11992439 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 117801 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
Form990 Schedule H Part V Form990ScheduleHPartV (15 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Licensed HospitalLicensedHospital | General Medical And SurgicalGeneralMedicalAndSurgical | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours | OtherOther |
|---|---|---|---|---|---|---|---|---|
| Berlin Memorial Hospital | ||||||||
| 225 Memorial Drive | Berlin | WI | 54923 | X | X | X | X | Outpatient Physician Clinic |
| CHN Medical Office Building | ||||||||
| 225 Memorial Drive | Berlin | WI | 54923 | Outpatient Physician Clinic | ||||
| CHN MEDICAL CENTER - Wautoma | ||||||||
| N Highway 22 | Wautoma | WI | 54982 | Outpatient Physician Clinic | ||||
| CHN MEdical Center - Markesan | ||||||||
| 340 ENTERPRISE DRIVE | Markesan | WI | 53946 | Outpatient Physician Clinic | ||||
| CHN Medical Center - Princeton | ||||||||
| 502 W Water Street | Princeton | WI | 54968 | Outpatient Physician Clinic | ||||
| CHN Medical Center - Montello | ||||||||
| 315 Church Street | Montello | WI | 53949 | Outpatient Physician Clinic | ||||
| CHN Medical Center - Ripon | ||||||||
| 1080 Fond Du Lac Street | Ripon | WI | 54971 | Outpatient Physician Clinic | ||||
| CHN Medical Center - Redgranite | ||||||||
| 402 Preston Lane | Redgranite | WI | 54970 | outpatient Physician Clinic | ||||
| CHN Medical Center - Eastridge | ||||||||
| W832 Highway 91 | Berlin | WI | 54923 | outpatient Physician Clinic | ||||
| CHN Medical Center - Womens Health | ||||||||
| 270 Marquette Street | Berlin | WI | 54923 | outpatient Physician Clinic | ||||
| CHN Orthopedics & Sports Medicine | ||||||||
| 191 Memorial Drive | Berlin | WI | 54923 | outpatient Physician Clinic | ||||
| Juliette Manor | ||||||||
| 169 East Huron Street | Berlin | WI | 54923 | Skilled Nursing Facility | ||||
| CHN Home Care | ||||||||
| 270 Marquette Street | Berlin | WI | 54923 | Home Health Care | ||||
| Community Medical Center - Green Lake | ||||||||
| 670 Cty Highway A | Green Lake | WI | 54941 | outpatient Physician Clinic | ||||
| CHN MEDICAL CENTER - GREEN LAKE | ||||||||
| N6205 BUSSE DR | GREEN LAKE | WI | 54941 | Outpatient Physician Clinic | ||||
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Costing Method Used | Part I, Line 7: The numbers in the table for charity care and unreimbursed Medicaid were derived from use of the Worksheet 2 cost-to-charge ratio. The cost of the community health improvements were calculated based on labor costs, supply costs and room costs. Health professional education costs were based on the amount of scholarships awarded and the room & labor costs for providing community education for health professionals in our communities. Cash is the amount of contributions to the community and in-kind donations are based on the cost of the in-kind donation. | CostingMethodUsed |
| Bad Debt Footnote | Part III, Line 4: USED COST TO CHARGE RATIO BASED ON COST BEING THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSE AND NON-PATIENT CARE OPERATIONS AND CHARGES BEING PATIENT CHARGES NET OF COMMUNITY BENEFIT CHARGES.MANY PATIENTS WHOSE ACCOUNTS/OUT-OF-POCKET LIABILITY ARE WRITTEN OFF TO BAD DEBT ARE UNABle TO PAY BUT DID NOT COMPLETE THE PROCESS FOR CHARITY CARE/FINANCIAL ASSISTANCE. BECAUSE THESE PATIENTS WOULD HAVE QUALIFIED FOR CHARITY CARE, BUT DIDN'T COMPLETE THE PROCESS, THESE BAD DEBT WRITE-OFFS SHOULD BE CONSIDERED COMMUNITY BENEFIT AS CHARITY CARE. IN ADDITION, COMMUNITY HEALTH NETWORK CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANGE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT-SERVING PATIENTS EVEN THOUGH WE MAY NOT RECEIVE PAYMENT. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE COMMUNITY HEALTH NETWORK CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. COMMUNITY HEALTH NETWORK HAS A SURPLUS BECUASE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER THE MEDICARE COST REPORT | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: PATIENTS WHO HAVE AN APPLICATION OUTSTANDING ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTIONS PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSISTANCE/PARTIAL CHARITY CARE) ARE CONSIDERED SELF PAY AND PAYMENT ARRANGEMENTS MUST BE MADE. SHOULD THE PATIENT FAIL TO MAKE PAYMENT ARRANGEMENTS OR MAINTAIN THE PAYMENTS AGREED UPON, THEY WILL BE NOTIFIED IN WRITING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE AMOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. | DebtCollectionPolicy |
| General Explanation | Part VI, line 8 - Wisconsin | GeneralExplanation |
| Needs Assessment | Part VI, Line 2: COMMUNITY HEALTH NETWORK WORKS IN COLLABORATION WITH GREEN LAKE AND WAUSHARA COUNTY PUBLIC HEALTH TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A PLAN OF CARE BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. COMMUNITY HEALTH NETWORK ALSO PARTICIPATES WITH THE GREEN LAKE COUNTY AND WAUSHARA COUNTY WELLNESS COALITION. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGANIZATIONS IN THE AREA. COMMUNITY HEALTH NETWORK ALSO ASSESSES COMMUNITY NEED BY USING UNIVERSITY OF WISCONSIN HEALTH RANKINGS WHICH PROVIDES COUNTY BY COUNTY BREAKDOWNS OF HEALTH OUTCOMES, HEALTH FACTORS, AND HEALTH ISSUES TO ASSIST IN DETERMINING COMMUNITY NEED. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: SELF PAY PATIENTS ARE CONTACTED BY A MEMBER OF THE PATIENT ACCOUNTING STAFF TO INFORM THEM OF AVAILABLE GOVERNMENT PROGRAMS AND CHARITY CARE. IF APPROPRIATE, THE PATIENT ACCOUNTING STAFF WILL OFFER ASSISTANCE WITH THE COMPLETION OF THE COMMUNITY CARE (CHARITY CARE) APPLICATION. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: COMMUNITY HEALTH NETWORK PRIMARILY SERVES RESIDENTS FROM GREEN LAKE, MARQUETTE, AND WAUSHARA COUNTIES. THE SERVICE AREA HAD AN ESTIMATED POPULATION OF 63,000 IN 2010 AND IS MOSTLY RURAL. THE POPULATION CONSISTS OF 19.8% UNDER THE AGE OF 18, 30.0% FROM 18 TO 44, 29.99% FROM 45 TO 64, AND 20.3% WHO ARE 65 AND OLDER. PORTIONS OF THE COMMUNITY HEALTH NETWORK SERVICE AREA ARE FEDERALLY QUALIFIED HPSA AREAS. COMMUNITY HEALTH NETWORK OPERATES THE ONLY HOSPITAL IN GREEN LAKE COUNTY. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: COMMUNITY HEALTH NETWORK ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE ALSO PROVIDE MEETING ROOMS AND SUPPORT TO OTHER NOT-FOR-PROFIT ORGANIZATIONS THAT IMPROVE THE HEALTH OF THE COMMUNITY. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTH ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: THE MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF.COMMUNITY HEALTH NETWORK CONDUCTS HEALTH FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS.COMMUNITY HEALTH NETWORK ALSO CONDUCTS CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, AND EDUCATION OPPORTUNITIES FOR PHYSICIANS AND MEDICAL STUDENTS. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: COMMUNITY HEALTH NETWORK IS AFFILIATED WITH WILD ROSE HOSPITAL THROUGH PARTNERS HEALTH SYSTEM (PHS). THE BENEFIT IS A COORDINATED EFFORT TO PROVIDE COMPREHENSIVE HEALTH CARE TO AN EXTENDED MULTI-COUNTY RURAL AREA. AN ADDITIONAL BENEFIT IS INCREASED EFFICIENCIES THROUGH SHARED RESOURCES, THEREFORE PROVIDING A WIDER RANGE OF HEALTH SERVICES THROUGHOUT THE ENTIRE COMBINED SERVICE AREA. | AffiliatedHealthCareSystem |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| 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 (8 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| P MICHAEL SHATTUCK MD | |||||||||||||
| 196387 | 0 | 35156 | 0 | 0 | 0 | 0 | 0 | 20406 | 0 | 251949 | 0 | 0 | 0 |
| Douglas Guy | |||||||||||||
| 215867 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 5741 | 0 | 221608 | 0 | 0 | 0 |
| THOMAS KRYSTOWIAK | |||||||||||||
| 137919 | 3536 | 0 | 0 | 14056 | 361 | 0 | 0 | 27139 | 696 | 179114 | 4593 | 0 | 0 |
| DAVID JONES | |||||||||||||
| 365799 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 14303 | 0 | 380102 | 0 | 0 | 0 |
| David Budde | |||||||||||||
| 127716 | 0 | 211228 | 0 | 20000 | 0 | 0 | 0 | 31174 | 0 | 390118 | 0 | 0 | 0 |
| DAVID W KURTZ | |||||||||||||
| 437138 | 0 | 89938 | 0 | 0 | 0 | 0 | 0 | 29623 | 0 | 556699 | 0 | 0 | 0 |
| JOSEPH LEE | |||||||||||||
| 305960 | 0 | 66204 | 0 | 0 | 0 | 0 | 0 | 11110 | 0 | 383274 | 0 | 0 | 0 |
| URI VAISMAN | |||||||||||||
| 643637 | 0 | 117367 | 0 | 0 | 0 | 0 | 0 | 27073 | 0 | 788077 | 0 | 0 | 0 |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI (2 entries)
| Issuer EINIssuerEIN | CUSIP NumberCUSIPNumber | Date IssuedDateIssued | Issue PriceIssuePrice | Description Of PurposeDescriptionOfPurpose | DefeasedDefeased | On Behalf Of IssuerOnBehalfOfIssuer |
|---|---|---|---|---|---|---|
| Wisconsin Health and Educational Facilities Authority | ||||||
| 391337855 | 97710VUX4 | 2004-08-01 | 10060000 | See Schedule O for description | 0 | 0 |
| Wisconsin Health and Educational Facilities Authority | ||||||
| 391337855 | 97710VVF2 | 2004-08-01 | 5000000 | See Schedule O for description | 0 | 0 |
Form990 Schedule K Part II Form990ScheduleKPartII (2 entries)
| Total ProceedsTotalProceeds | Amount In Reserve FundAmountInReserveFund | Amount DefeasedAmountDefeased | Issuance Costs From ProceedsIssuanceCostsFromProceeds | Capital ExpendituresCapitalExpenditures | Year Of Subst CompletionYearOfSubstCompletion | Current RefundingCurrentRefunding | Advance RefundingAdvanceRefunding | Final Allocation MadeFinalAllocationMade | Adequate Books And Recds MaintaindAdequateBooksAndRecdsMaintaind | Working Capital ExpendituresWorkingCapitalExpenditures |
|---|---|---|---|---|---|---|---|---|---|---|
| 10060000 | 756255 | 3745240 | 201200 | 5357305 | 2005 | 1 | 0 | 1 | 1 | |
| 5000000 | 2712071 | 100000 | 2102286 | 2005 | 1 | 0 | 1 | 1 | 85643 |
Form990 Schedule K Part III Form990ScheduleKPartIII (2 entries)
| Owning Bond Financed PropertyOwningBondFinancedProperty | Any Lease ArrangementsAnyLeaseArrangements | Mngment Cntrct Bond Financd PrprtyMngmentCntrctBondFinancdPrprty | Any Research AgreementsAnyResearchAgreements | Bond Counsel Routinely EngagedBondCounselRoutinelyEngaged | Prcntge Prvt Business Use By OthersPrcntgePrvtBusinessUseByOthers | Percentage Of Prvt Business Re UBIPercentageOfPrvtBusinessReUBI | Total Private Business UseTotalPrivateBusinessUse | Post Issuance Compliance ProcdrsPostIssuanceComplianceProcdrs |
|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 0 | 0 | 0 | 0.00600 | 0.00000 | 0.00600 | 1 |
| 0 | 1 | 0 | 0 | 0 | 0.00600 | 0.00000 | 0.00600 | 1 |
Form990 Schedule K Part IV Form990ScheduleKPartIV (2 entries)
| Form8038 T FiledForm8038TFiled | Variable Rate IssueVariableRateIssue | Hedge Identified In Books And RecdsHedgeIdentifiedInBooksAndRecds | Gross Proceeds Invested In GICGrossProceedsInvestedInGIC | Gross Proceeds InvestedGrossProceedsInvested | Exception To RebateExceptionToRebate |
|---|---|---|---|---|---|
| 0 | 0 | 0 | 0 | 0 | 0 |
| 0 | 1 | 0 | 0 | 0 | 0 |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (3 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| Thomas Willett DO | |||
| CHN Board Member | 108060 | CHN rents space from Dr. Willett for Medical Group offices. | 0 |
| Thomas Willett DO | |||
| chN Board Member | 99000 | CHN CONTRACTS PHYSICIAN SERVICES FROM DR WILLETT | 0 |
| P MICHAEL SHATTUCK MD | |||
| CHN Board Member | 138636 | CHN RENTS SPACE FROM DR. SHATTUCK FOR MEDICAL GROUP OFFICES | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| Form 990, Part VI, Section A, line 2 | HENRY DERLETH, RUSSELL KUEHN AND THOMAS WILLETT, BOARD MEMBERS, HAVE A BUSINESS RELATIONSHIP. | |
| Form 990, Part VI, Section A, line 6 | Membership may be obtained by anyone eighteen or more years of age and either: (A) Reside or work in the corporation's Service Area, which is defined as the following ZIP codes: 53919, 53923, 53926, 53930, 53931, 53935, 53939, 53946, 53947, 53949, 53952, 53953, 53956, 53964, 54909, 54921, 54923, 54930, 54934, 54940, 54941, 54943, 54960, 54963, 54964, 54965, 54966, 54967, 54968, 54970, 54971, 54976, 54980, 54982, 54984, and 54986. An individual is deemed to work within the Corporation's Service Area if his or her primary source of income stems from work performed in the Service Area; or (B) an employee of the Corporation or member of his or her family. May become a Member of the Corporation upon submission of a signed application delivered to the Principal Office of the Corporation. The Corporation's Board of Directors or its designee(s) has the authority to, from time to time, make good faith determinations regarding whether an applicant or an existing Member meets the qualifications for Membership of the Corporation. Any person who does not meet the criteria as determined by the Board of Directors or its designee(s) will not be a Member. An individual's membership shall be terminated upon death, resignation or the failure to meet the qualification. Individuals granted Honorary Membership in the Corporation shall be entitled to lifelong voting membership in the Corporation. | |
| Form 990, Part VI, Section A, line 7a | There are twelve Directors on the Board of Directors that are elected annually by the members at the Annual Meeting or at a special meeting held for such purpose. The Chief Executive Officer is an ex-officio voting member of the Board of Directors | |
| Form 990, Part VI, Section B, line 11 | The Board of Directors (BOD) has delegated the detail review of the Form 990 to the management of the Corporation. | |
| Form 990, Part VI, Section B, line 12c | It is the Director, officer and/or committee member's responsibility to disclose to the Board of Directors or committee considering a transaction, any potential financial interest. The Chairperson of the Board or Committee may then question the interested person further. The board or committee makes the decision whether a conflict of interest exists. In addition to the above, directors, officers and committee members execute and deliver to CHN a "Certificate Regarding Conflicts of Interest" on an annual basis. Per the policy, the Board is to conduct periodic reviews of its transactions and arrangements. Review shall include - Whether compensation arrangements and benefits are reasonable and are the result of arm's-length bargaining - Whether acquisitions of physician practices and other provider services result in private inurement or impermissible private benefit - Whether partnerships, joint ventures, and other types of arrangements further CHN's charitable purpose and do not result in private inurement or impermissible private benefit | |
| The compensation determination for the CEO of Community Health Network is as follows: The CEO is under an employment contract. His salary is reviewed per his contract by the Executive Committee of the Board of Directors (those without conflict). The Executive Committee reviews compensation benchmark data, compares the data with the CEO's current salary and makes a salary determination which is then voted on by the Executive Committee. The compensation determination for the CFO and Executive Vice President of Community Health Network is as follows. The same process applies to both the CFO & Executive Vice President of Community Health Network: Once a year, CHN's CEO reviews compensation benchmark data and compares the data with the CFO & Executive Vice President's current salary and the proposed increase. Based on the data, the CEO, a person without conflict, determines the CFO & Executive Vice President's salary for the coming year. The salary is discussed and agreed upon by CHN's CEO and the individual. The questions were marked "no" as the process for 2010 was not documented. | ||
| Form 990, Part VI, Section C, line 19 | The organization believes its governing documents, conflict of interest policy, and financial statements are the property of the organization and does not make them available to the public. | |
| FORM 990, PART VII, SECTION A: | THOMAS KRYSTOWIAK WORKS 1 HOUR/WEEK FOR A RELATED ORGANIZATION. | AVERAGE HOURS |
| Form 990, Part XI, line 2c | Management provides oversight of the audit. The audit is presented to the Finance Committee of the Board of Directors. | Responsible for the audit |
| Part XI, line 2c | The process has not changed from the prior year. | oversight of audit |
| Schedule K, Part I, Line A Additional CUSIP Numbers Wisconsin Health and Educational Facilities Bond has the additional CUSIP numbers: 97710VUZ9 97710VUY2 97710VVA3 97710VVB1 97710VVC9 97710VVD7 97710VVE5 |
Schedule R IRS990ScheduleR
Form990 Schedule R Part I Form990ScheduleRPartI
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEDICAL CENTER OF GREEN LAKE LLC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | N6205 BUSSE DR | AddressLine1 |
| City | GREEN LAKE | City |
| State | WI | State |
| ZIP Code | 54941 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 261424367 | EIN |
| Legal Domicile State | WI | LegalDomicileState |
| Total Income | 216523 | TotalIncome |
| EOY Assets | 2127548 | EOYAssets |
Form990 Schedule R Part II Form990ScheduleRPartII (3 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|
| Community Health Network Foundation Inc | |||||||||
| 225 Memorial Drive | Berlin | WI | 54923 | 731639346 | Supporting Organization | WI | 501(c)(3) | 11B-II | N/A |
| WILD ROSE COMMUNITY MEMORIAL HOSPITALINC | |||||||||
| PO BOX 243 | WILD ROSE | WI | 54984 | 396089134 | HOSPITAL | WI | 501(c)(3) | 3 | N/A |
| PARTNERS HEALTH SYSTEM INC | |||||||||
| 225 MEMOrial Drive | BERlin | WI | 54923 | 271119447 | SUPPORTING ORGANIZATION | WI | 501(c)(3) | 11A-II | N/A |
Form990 Schedule R Part IV Form990ScheduleRPartIV
Name Of Related Org NameOfRelatedOrg
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heartland Ventures Inc | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 Memorial Drive | AddressLine1 |
| City | Berlin | City |
| State | WI | State |
| ZIP Code | 54923 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391567067 | EIN |
| Primary Activity | Management Services | PrimaryActivity |
| Legal Domicile State | WI | LegalDomicileState |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Type Of Entity | C | TypeOfEntity |
| Percentage Ownership | 1.00000 | PercentageOwnership |
| 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 | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 1 | 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 | 1 | 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 | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | No Reportable transactions | BusinessNameLine1 |