2024-08-07T14:15:12-05:00 2023-09-30 390758449 WIPFLI LLP 170 N RADNOR-CHESTER RD SUITE 200 RADNOR PA 19087 990 2022-10-01 391397028 FORT MEMORIAL HOSPITAL FOUNDATION INC FORT 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 JAMES NELSON ASSISTANT TREASURER 9205685000 2024-07-29 1 0 SOLOMON MARDAKHAEV P01806552 6105653930 2024-07-16 2022 2024-08-08 14:25:15Z JAMES NELSON 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 542667 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. 10 6 0 11 0 0 153621 97185 0 0 176692 236821 0 0 330313 334006 112191 83575 0 0 0 0 0 0 53327 46367 53327 158558 136902 171755 197104 7976529 8979321 125637 141747 7850892 8837574 X THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED SOLELY FOR CHARITABLE PURPOSES EXCLUSIVELY FOR THE BENEFIT OF FORT ATKINSON MEMORIAL HOSPITAL, THE HOSPITAL OPERATED BY FORT HEALTHCARE, INC., AN INTEGRATED HEALTH CARE DELIVERY SYSTEM, INCLUDING THE CARRYING ON OF SUCH PROGRAMS AS THE BOARD OF DIRECTORS OF THIS CORPORATION FROM TIME TO TIME DEEMS TO BE SUITABLE AND APPROPRIATE. 0 0 54075 54075 0 FORT MEMORIAL HOSPITAL FOUNDATION WAS CREATED FOR THE SOLE BENEFIT OF FORT HEALTHCARE. FOUR AREAS OF STRATEGIC FOCUS GUIDE OUR FUNDRAISING AND GRANTING PROCESS. BENEVOLENT CARE INCLUDES PROGRAM FUNDING TO ASSIST PATIENTS WHO CANNOT AFFORD CARE. PROVIDING EXCEPTIONAL CARE INCLUDES FUNDING FOR EQUIPMENT, TECHNOLOGY AND SERVICES THAT ENHANCE THE QUALITY OF CARE AND PATIENT SATISFACTION. LIVING HEALTHIER INCLUDES SERVICES FOCUSED ON COMMUNITY WELLNESS INITIATIVES. 29500 29500 0 ADVANCING CAREERS IN HEALTHCARE INCLUDES SCHOLARSHIPS AND TRAINING FOR EMPLOYEES. 83575 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 5 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 10 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X JAMES NELSON 9205685000 611 SHERMAN AVENUE EAST FORT ATKINSON WI 535381998 MICHAEL ANDERSON MD BOARD MEMBER 1.00 40.00 X 0 1595636 44201 MICHAEL WALLACE SENIOR ADVISOR 1.00 40.00 X 0 637198 45607 MARY BECK METZGER SECRETARY 1.00 40.00 X X 0 65927 15750 DONALD WILLIAMS MD BOARD MEMBER 1.00 X 0 29479 1406 CAROL BURROWS PRESIDENT 1.00 X X 0 0 0 ROY BUDLONG BOARD MEMBER 1.00 3.00 X 0 0 0 ANDY DIDION BOARD MEMBER 1.00 3.00 X 0 0 0 JAMES FITZPATRICK PHD BOARD MEMBER 1.00 3.00 X 0 0 0 CHRISTI OTT BOARD MEMBER 1.00 3.00 X 0 0 0 THOMAS VINZ BOARD MEMBER 1.00 3.00 X 0 0 0 JAMES NELSON ASSISTANT TREASURER 1.00 40.00 X 0 363506 45461 0 2691746 152425 0 0 1 0 0 97185 97185 154752 154752 290730 208661 82069 82069 82069 334006 0 0 236821 X 54075 54075 29500 29500 41235 41235 1147 1147 10945 10945 136902 83575 0 53327 367754 362431 7608775 8616890 7976529 8979321 52079 68189 73558 73558 125637 141747 X 7532471 8504644 318421 332930 7850892 8837574 7976529 8979321 197104 789578 0 X 0 1 X 1 0 X X 1 FORT HEALTHCARE INC 390286215 3 1 54075 0 1 54075 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 GIFT ANNUITY DONOR RESERVES 73558 73558 X 1123584 789578 789578 334006 0 334006 136902 0 136902 0 136902 PART X, LINE 2: FORT MEDICAL GROUP PROVIDES FOR INCOME TAXES ON A LIABILITY METHOD WHEREBY DEFERRED TAX ASSETS ARE RECOGNIZED FOR DEDUCTIBLE TEMPORARY DIFFERENCES, OPERATING LOSSES, AND TAX CREDIT CARRYFORWARDS AND DEFERRED TAX LIABILITIES ARE RECOGNIZED FOR TAXABLE TEMPORARY DIFFERENCES. BOTH ARE CALCULATED USING ENACTED TAX RATES WHEN THE DIFFERENCES ARE REALIZED OR SETTLED. TEMPORARY DIFFERENCES ARE THE DIFFERENCES BETWEEN THE REPORTED AMOUNTS OF ASSETS AND LIABILITIES AND THEIR TAX BASES. DEFERRED TAX ASSETS ARE REDUCED BY A VALUATION ALLOWANCE WHEN, IN THE OPINION OF MANAGEMENT, IT IS MORE LIKELY THAN NOT THAT SOME PORTION OR ALL OF THE DEFERRED TAX ASSETS WILL NOT BE REALIZED. THE FINAL TAX RETURN FOR FMG WAS FILED AS OF JANUARY 1, 2022 SINCE FMG WAS MERGED INTO THE HOSPITAL AS OF THIS DATE. ALL NET OPERATING LOSS CARRYFORWARDS FROM FMG HAVE BEEN RELINQUISHED AS OF THE DATE OF THE MERGER. 1 FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 390286215 501 (C)(3) 54075 0 HOSPITAL SUPPORT 1 0 SCHOLARSHIPS 22 29500 PART I, LINE 2: THE FORT MEMORIAL HOSPITAL FOUNDATION (FMHF) PROVIDES PHILANTHROPIC FUNDING TO FORT HEALTHCARE (FHC) TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY. FMHF GRANTS ARE ALIGNED WITH FHC'S STRATEGIC GOALS, SUPPORT OPERATIONAL EXCELLENCE AND HELP FHC ADOPT INNOVATIVE TECHNOLOGY AND PATIENT CARE PRACTICES. THE FOUNDATION HAS CHOSEN FOUR PRIORITIES FOR FUNDING. PROPOSALS FOR FUNDING MUST FIT WITHIN ONE OF THESE FOCUS AREAS; BENEVOLENT CARE, KEEPING YOUR FAMILY HEALTHY, PROVIDE THE BEST HEALTH CARE POSSIBLE, EDUCATE PEOPLE FOR CAREERS IN HEALTHCARE. DEPARTMENTS RECEIVING GRANTS ARE RESPONSIBLE TO REPORT THE USE OF FUNDS, OUTCOMES AND ANECDOTAL STORIES THAT ILLUSTRATE THE IMPACT OF THE GRANT. REPORTING REQUIREMENTS WILL BE DETERMINED COLLABORATIVELY PRIOR TO A FINAL FUNDING DECISION. THE SCHOLARSHIP CRITERIA ARE DETERMINED BY AGREEMENT WITH THE DONOR AT THE TIME OF THEIR CONTRIBUTION. THE FOUNDATION HAS TWO CATEGORIES OF DOCUMENTATION FOR THE SCHOLARSHIPS: 1) SCHOLARSHIPS ESTABLISHED THROUGH A TRUST OR ESTATE DOCUMENT; 2) SCHOLARSHIPS ESTABLISHED BY LIVING DONORS FOR WHICH THERE IS WRITTEN GUIDANCE. 0 0 0 0 0 0 0 0 0 MICHAEL ANDERSON MD BOARD MEMBER 0 627061 0 408271 0 560304 0 12839 0 31362 0 1639837 0 0 MICHAEL WALLACE SENIOR ADVISOR 0 463044 0 167455 0 6699 0 12200 0 33407 0 682805 0 0 JAMES NELSON ASSISTANT TREASURER 0 273841 0 84208 0 5457 0 12200 0 33261 0 408967 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S ACCOUNTING MANAGER AND CFO. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. 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. BOARD MEMBERS WITH A CONFLICT OF INTEREST ABSTAIN FROM VOTING ON THE MATTERS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 41,235. TOTAL EXPENSES 41,235. PAIN CENTERS OF WISCONSIN - FORT ATKINSON LLC 1604 MADISON AVENUE FORT ATKINSON WI 53538 900777376 HEALTH CARE SERVICES WI 445366 938957 FORT HEALTHCARE INC FORT HEALTHCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 390286215 HEALTH CARE WI 501(C)(3) LINE 3 N/A 0 FORTCARE INC 611 SHERMAN AVENUE EAST FORT ATKINSON WI 53538 391725831 PREFERRED PROVIDER ORGANIZATION WI N/A C 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0