2011-02-03T09:20:33-06:00 2010-09-30 WIPFLI LLP 10000 INNOVATION DR SUITE 250 MILWAUKEE WI 532264837 990 2009-10-01 391397028 Fort Memorial Hospital Foundation FORT 9205685157 611 Sherman Avenue East Fort Atkinson WI 535381998 James Nelson 9205685157 2011-02-01 1 JAY ADKISSON 4144319300 2011-01-26 2009 2016-02-24 21:20:13Z James Nelson 611 Sherman Avenue East Fort Atkinson WI 535381998 6317548 0 X n/a X 1981 WI The Foundation is organized and shall be operated solely for charitable purposes exclusively for the benefit of Fort Atkinson Memorial Hospital, the hospital operated by Fort HealthCare, Inc., an integrated health care delivery system, including the carrying on of such programs as the Board of Directors of this corporation from time to time deems to be suitable and appropriate. 11 8 0 0 0 0 46463 73209 0 49163 546958 36604 35762 132230 655929 158098 140190 0 0 0 972 19655 98731 177753 238921 -45523 417008 4911309 5520692 76135 137776 4835174 5382916 The Foundation is organized and shall be operated solely for charitable purposes exclusively for the benefit of Fort Atkinson Memorial Hospital, the hospital operated by Fort HealthCare, Inc., an integrated health care delivery system, including the carrying on of such programs as the Board of Directors of this corporation from time to time deems to be suitable and appropriate. 0 0 129890 The Foundation was created for the benefit of Fort HealthCare, Inc 10300 Scholarships 140190 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 1 7 0 0 0 0 0 0 0 1 1 0 0 0 11 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X James Nelson 9205685490 611 Sherman Avenue Fort Atkinson WI 53538 X James K Caldwell 1.00 X X 0 0 0 Carol Knox 1.00 X X 0 0 0 Mary J Behling 1.00 X X 0 0 0 Thomas O Wakeman 1.00 X X 0 0 0 Thomas Gobel DDS 1.00 X 0 0 0 Dean Johnson 1.00 X 0 0 0 Richard Martin 1.00 X 0 0 0 Jonathan McLaughlin MD 1.00 X 0 502427 29403 Richard Telfer 1.00 X 0 0 0 Michael Wallace 1.00 X 0 295716 32438 Donald Williams MD 1.00 X 0 219774 19446 James Nelson 3.00 X 0 189723 30305 0 1207640 111592 0 0 1 0 0 73209 73209 90953 90953 6095611 5639606 456005 456005 456005 57775 22013 35762 35762 655929 0 0 582720 140190 140190 3278 3278 62 62 7260 7260 Purchased Services 86475 85503 972 Dues and Memberships 1174 1174 Other 482 482 238921 140190 97759 972 216170 230490 9925 7483 3592038 4358572 1093176 924147 4911309 5520692 29773 93560 46362 44216 76135 137776 X 4683258 5232442 151916 150474 4835174 5382916 4911309 5520692 X 0 1 1 X 0 X X 0 0 0 Fort HealthCare Inc 390286215 Type 1 1 1 1 129890 1 129890 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 Certificates of Deposit 875934 F Money Market Funds 48213 F 924147 Gift Annuity Donor Reserves 44216 44216 655929 238921 417008 130734 130734 547742 808676 130734 130734 677942 -22013 -22013 655929 260934 22013 22013 238921 0 238921 Part X: Description of Uncertain Tax Positions Under FIN 48: The organization recorded no assets or liabilities related to uncertain tax positions in 2010 and 2009. Tax returns for the years ended September 30, 2009, 2008, and 2007 remain subject to examination by the applicable taxing authorities. Part XII, Line 4b - Other Adjustments: Direct expenses for Special Events: -22013. Part XIII, Line 2d - Other Adjustments: Direct expenses for special events: 22013. Winter Gala 53475 53475 18708 53475 53475 18708 18708 34767 0 Fort HealthCare Inc 611 E Sherman Avenue Fort Atkinson WI 53538 390286215 501(c)3 129890 Hospital Equipment Scholarships 14 10300 0 0 0 0 0 0 0 0 0 Jonathan McLaughlin MD 0 485314 0 17113 0 0 0 9800 0 19603 0 531830 0 0 Michael Wallace 0 295716 0 0 0 0 0 9800 0 22638 0 328154 0 0 Donald Williams MD 0 219774 0 0 0 0 0 334 0 19112 0 239220 0 0 James Nelson 0 189723 0 0 0 0 0 7667 0 22638 0 220028 0 0 Cambridge State Bank Employer of Board Member David Keleher 250000 Filing organization has certificates of deposits with the bank. 0 First Citizens Bank Employer of Board Member James Caldwell 100000 Filing organization has certificates of deposits with the bank. 0 Form 990, Part VI, Section B, line 11 A copy of the 990 is sent to each of the board of directors prior to filing. Form 990, Part VI, Section B, line 12c Each board member of the entity and related entities annually complete a conflict of interest questionnaire disclosing their conflicts of interest. A summary of conflicts are distributed to the chairman of the board and to administrative support personnel. Board members are coached on how to manage their conflicts. Form 990, Part VI, Section C, line 19 All documents are available to the public upon request. Fort HealthCare Inc 611 E Sherman Avenue Fort Atkinson WI 53538 390286215 Health Care WI 501(c)(3) Line 3 N/A Fort Medical Group Inc 611 Sherman Avenue East Fort Atkinson WI 53538 391736513 Provide physician services WI N/A C 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0