TY 2010 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) JERRY KITOWSKI MD CHIEF OF STAFF/DIRECTOR	1.00	X			0	0	0
(2) BETH SMETANA DIRECTOR	1.00	X			0	0	0
(3) HATTIE WALKER RN DIRECTOR	1.00	X			0	0	0
(4) KAY FINCH TREASURER	1.00	X			0	0	0
(5) MICHAEL DOUGHERTY DIRECTOR	1.00	X			0	0	0
(6) GENE RANSOM CHAIRMAN	1.00	X			0	0	0
(7) JAY SEVERANCE DIRECTOR	1.00	X			0	0	0
(8) BARBARA BROWER VICE CHAIR	1.00	X			0	0	0
(9) DENNIS EBERHARDT DIRECTOR	1.00	X			0	0	0
(10) STAN GAYNOR CEO & SECRETARY	41.00		X		206,326	0	42,542
(11) ROBERT DALEY VP, FISCAL & INFORMATION S	41.00		X		148,510	0	8,144
(12) CAROL MARTIN MD ER PHYSICIAN	35.00			X	233,136	0	34,349
(13) KAARE TINGELSTAD MD ER PHYSICIAN	35.00			X	235,004	0	35,618
(14) HOLLY WINN HUMAN RESOURCES	40.00			X	136,102	0	19,776
(15) KIMBERLY STRAUB MD ER PHYSICIAN	35.00			X	172,399	0	6,467
(16) MARY BETH WHITE-JACOBS VP PATIENT CARE SERVICES	40.00			X	138,133	0	19,695

(A) Name and business address	(B) Description of services	(C) Compensation
BLACK RIVER FALLS ANESTHESIA INC 1212 HARRISON STREET BLACK RIVER FALLS,WI54615	CRNA/ANESTHESIA PROFESSIONAL SERVICES	783,162
GUNDERSEN CLINIC PO BOX 4020 LA CROSSE,WI54615	RADIOLOGY PROFESSIONAL SERVICES	738,222
REMEDY MEDICAL SERVICES 3587 GATEWAY DRIVE EAU CLAIRE,WI54701	ER PHYSICIAN SERVICES	424,862
DWS ANESTHESIA W5327 SOUTHVIEW DRIVE NECEDAH,WI54646	CRNA/ANESTHESIA PROFESSIONAL SERVICES	267,664

2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 4

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	5,500	5,500
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	405,522		405,522
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	12,962,937	11,111,963	1,850,974
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	610,606	523,418	87,188
9	Other employee benefits .......	2,914,506	2,498,345	416,161
10	Payroll taxes ...........	981,814	819,197	162,617
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	30,379		30,379
c	Accounting ...........	116,200		116,200
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	3,783,111	3,545,740	237,371
12	Advertising and promotion ....	378,126		373,653	4,473
13	Office expenses .......	4,040,316	3,791,971	248,345
14	Information technology ......	187,080		187,080
15	Royalties ..
16	Occupancy ...........	1,195,769	1,195,769
17	Travel ............	156,881	132,447	24,434
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	53,549	53,549
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	1,923,295	1,923,295
23	Insurance ..............	137,575		137,575
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	BAD DEBT EXPENSE	2,279,226	2,279,226
b	MINOR EQUIPMENT	287,732	248,515	39,217
c	DUES AND SUBSCRIPTIONS/	283,155	141,460	141,695
d	MISCELLANEOUS	247,911	138,100	109,811
e	REPAIRS AND MAINTENANCE	179,502	179,386	116
f	All other expenses	-172,986	-172,986
25	Total functional expenses. Add lines 1 through 24f	32,987,706	28,414,895	4,568,338	4,473
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	3,535	1	4,406
2	Savings and temporary cash investments .......	4,996,799	2	8,650,397
3	Pledges and grants receivable, net .........	281,918	3	168,114
4	Accounts receivable, net .........	4,026,494	4	3,986,762
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	253,364	8	266,089
9	Prepaid expenses and deferred charges ............	88,591	9	114,486
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	36,145,338
b	Less: accumulated depreciation. .....	10b	14,289,354	23,070,981	10c	21,855,984
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..	2,881,453	13	3,009,259
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	921,368	15	974,701
16	Total assets. Add lines 1 through 15 (must equal line 34)...	36,524,503	16	39,030,198
	17	Accounts payable and accrued expenses .	2,361,634	17	3,398,004
18	Grants payable ..........		18
19	Deferred revenue ..........	3,309	19	9,935
20	Tax-exempt bond liabilities ..........	14,190,138	20	13,786,638
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	1,115,182	23	977,931
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	548,368	25	706,539
26	Total liabilities. Add lines 17 through 25.....	18,218,631	26	18,879,047
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	17,938,790	27	19,919,919
28	Temporarily restricted net assets .....	367,082	28	231,232
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	18,305,872	33	20,151,151
34	Total liabilities and net assets/fund balances .....	36,524,503	34	39,030,198

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of support?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2010. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2009. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2010. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2010

Name of organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ, that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, aggregate contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... Arrow Bullet

Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization BLACK RIVER MEMORIAL HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part I
Part I	Contributors (see Instructions)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization BLACK RIVER MEMORIAL HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part II
Part II	Noncash Property (see Instructions)
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Page 1 of 1 of Part III

Name of organization
BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities .................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated Group Totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots non-taxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? If "Yes," describe in Part IV ..........................

Yes

2,281

Total. lines 1c through 1i ...................................

2,281

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
EXPLANATION OF OTHER LOBBYING ACTIVITIES:	PART II-B, LINE 1I:	BLACK RIVER MEMORIAL HOSPITAL, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. WHA HAS NOTIFIED BLACK RIVER MEMORIAL HOSPITAL THAT APPROXIMATELY $1,027 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. BLACK RIVER MEMORIAL HOSPITAL, INC. IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, BLACK RIVER MEMORIAL HOSPITAL PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT APPROXIMATELY $1,254 OF THE FEES PAID BY BLACK RIVER MEMORIAL HOSPITAL IN 2010 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or pleasure) Preservation of an historically importantly land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06 ........	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back	(d)Three Years Back	(e)Four Years Back
1a	Beginning of year balance ....
b	Contributions ........
c	Investment earnings or losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance held as:

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

Term endowment: SchDMd Bullet

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

InvestmentsLand, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	31,500		31,500
b	Buildings ................	23,967,653	5,933,529	18,034,124
c	Leasehold improvements ............
d	Equipment ................	12,146,185	8,355,825	3,790,360
e	Other .................
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				21,855,984

Schedule D (Form 990) 2010

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) FUNDED DEPRECIATION INVESTMENTS FOR CAPITAL IMPROVEMENTS	2,946,141	F
(2) DONOR RESTRICTED FOR SCHOLARSHIP PROGRAMS AND EQUIPMENT PURCHASES	63,118	F







Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)	3,009,259

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Amount
Federal Income Taxes
DEFERRED COMPENSATION LIABILITY		706,539








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		706,539
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1	34,753,460
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	32,987,706
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	1,765,754
4	Net unrealized gains (losses) on investments ..........................	4	79,525
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV) .................................	8
9	Total adjustments (net). Add lines 4 - 8 .............................	9	79,525
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	1,845,279

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	34,984,176
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV): ............	2d	246,961
e	Add lines 2a through 2d .....................			2e	246,961
3	Subtract line 2e from line 1.....................			3	34,737,215
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV): ...........	4b	16,245
c	Add lines 4a and 4b.......................			4c	16,245
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......			5	34,753,460

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	33,218,422
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV): ............	2d	246,961
e	Add lines 2a through 2d......................			2e	246,961
3	Subtract line 2e from line 1.....................			3	32,971,461
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV): ............	4b	16,245
c	Add lines 4a and 4b.......................			4c	16,245
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......			5	32,987,706

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:	PART X:	THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASIS OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2010 AND 2009, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE FINANCIAL STATEMENTS. IN ADDITION, THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2010 AND 2009. FEDERAL TAX RETURNS FOR TAX YEARS 2007 AND THEREAFTER REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE.
PART XII, LINE 2D - OTHER ADJUSTMENTS:		RENTAL EXPENSES INCLUDED WITH EXPENSES ON F/S 246,961.
PART XII, LINE 4B - OTHER ADJUSTMENTS:		PARTNERS OF BRMH REVENUES NET AGAINST EXPENSES ON F/S 15,400. PARTNERS OF BRMH CONTRIBUTIONS NET AGAINST EXPENSES ON F/S 170. EXPENSES NET AGAINST REVENUES ON F/S -10,546. DIETARY INSTRUCTION REVENUE NET AGAINST EXPENSES ON F/S 11,221.
PART XIII, LINE 2D - OTHER ADJUSTMENTS:		RENTAL EXPENSES INCLUDED WITH EXPENSES ON F/S 246,961.
PART XIII, LINE 4B - OTHER ADJUSTMENTS:		PARTNERS OF BRMH REVENUES NET AGAINST EXPENSES ON F/S 15,400. PARTNERS OF BRMH CONTRIBUTIONS NET AGAINST EXPENSES ON F/S 170. EXPENSES NET AGAINST REVENUES ON F/S -10,546. DIETARY INSTRUCTION REVENUE NET AGAINST EXPENSES ON F/S 11,221.

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization
BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and e-mail solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.

(i) Name and address of individual or entity (fundraiser)	(ii) Activity	(iii) Did fundraiser have custody or control of contributions?		(iv) Gross receipts from activity	(v) Amount paid to (or retained by) fundraiser listed in col. (i)	(vi) Amount paid to (or retained by) organization
	(ii) Activity	Yes	No	(iv) Gross receipts from activity		(vi) Amount paid to (or retained by) organization
Total .................

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2010

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.

		(a) Event #1 EASTER BUNNY BRUNCH (event type)	(b) Event #2 HATS OFF FOR HOSPICE (event type)	(c) Other Events 3 (total number)	(d) Total Events (Add col. (a) through col. (c))
1	Gross receipts . . .	7,079	11,769	8,322	27,170
2	Less: Charitable contributions . . .
3	Gross income (line 1 minus line 2) . . .	7,079	11,769	8,322	27,170
4	Cash prizes . . .
5	Non-cash prizes . .
6	Rent/facility costs . .		1,076		1,076
7	Food and beverages . .	4,338	329	937	5,604
8	Entertainment . . .		385		385
9	Other direct expenses .		2,770	711	3,481
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........				10,546
11	Net income summary. Combine lines 3 and 10 in column (d)............				16,624

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (Add col. (a) through col. (c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," Explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," Explain:

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ...........................

YesNo

Schedule G (Form 990 or 990-EZ) 2010

Page 3

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Provide the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)

Identifier	ReturnReference	Explanation

Schedule G (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Does the organization have a charity care policy? If "No," skip to question 6a...........

Yes

If "Yes," is it a written policy? .......................

Yes

If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.

Applied uniformly to all hospitals Applied uniformly to most hospitals Generally tailored to individual hospitals

Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.

Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low

income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If

"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....

Yes

200% 250% 300% 350% 400% Other

If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Does the organization's policy provide free or discounted care to the "medically indigent"? ......

Yes

Does the organization budget amounts for free or discounted care provided under its charity care policy? ...

Yes

If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............

Does the organization prepare an annual community benefit report?.............

Yes

If "Yes," does the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Charity Care and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..	150,706	0	150,706	0.490 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	4,822,275	3,068,598	1,753,677	5.710 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....	146,453	83,218	63,235	0.210 %
dTotal Charity Care and Means-Tested Government Programs .....	5,119,434	3,151,816	1,967,618	6.410 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	139,159	7,489	131,670	0.430 %
f Health professions education (from Worksheet 5) ..	226,550	0	226,550	0.740 %
g Subsidized health services (from Worksheet 6) ..	7,722,712	4,548,486	3,174,226	10.340 %
h Research (from Worksheet 7)	0	0
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	106,333	0	106,333	0.350 %
jTotal Other Benefits ...	8,194,754	4,555,975	3,638,779	11.860 %
kTotal. Add lines 7d and 7j. ..	13,314,188	7,707,791	5,606,397	18.270 %

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010

Schedule H (Form 990) 2010

Page 2

Part II

Community Building Activities Complete this table if the organization conducted any community building activities.

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other	10,126	10,126	0.030 %
10	Total	10,126	10,126	0.030 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense (at cost).....

1,367,310

Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..

683,655

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

7,694,251

Enter Medicare allowable costs of care relating to payments on line 5.....

8,442,829

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-748,578

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Does the organization have a written debt collection policy? ...............

If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	BLACK RIVER MEMORIAL HOSPITAL INC 711 WEST ADAMS STREET BLACK RIVER FALLS,WI54615	X	X	X	X

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

Name of Hospital Facility:NOT REQUIRED

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet those needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Development of a community benefit plan for the facility
	d	Participation in community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the CHNA
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs.		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8		No
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?..		9		No
	If “Yes,” indicate the FPG family income limit for eligibility for free care: %

Schedule H (Form 990) 2010

Page 5

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care to low income individuals?.........		10		No
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: %
11	Explained the basis for calculating amounts charged to patients?.................		11		No
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12		No
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13		No
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted at all times on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........		14		No
15	Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments or arrests
	e	Other (describe in Part VI)
16	Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?...................................		16		No
	If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other (describe in Part VI)
17	Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
	e	Other (describe in Part VI)

Schedule H (Form 990) 2010

Page 6

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18		No
	If “No,” indicate the reasons why (check all that apply):
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility did not have a policy relating to emergency medical care
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Charges for Medical Care
19	Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
	a	The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
	b	The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
	c	The hospital facility used the Medicare rate for those services
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?...................................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2010

Page 7

Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, measured by total revenue per facility, from largest to smallest) How many non-hospital facilities did the organization operate during the tax year?
Name and address		Type of Facility (Describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2010

Page 8

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2	Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
		PART I, LINE 6A: BLACK RIVER MEMORIAL HOSPITAL, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON WHA'S DATABASE AND WEBSITE.
		PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICES REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990.
		PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT BLACK RIVER MEMORIAL HOSPITAL, INC. INCLUDE THE OPERATION OF THE HOSPITAL'S INPATIENT MEDICAL/SURGICAL NURSING UNIT AS WELL AS THE COMMUNITY BASED HOSPICE AND HOMECARE PROGRAMS. THE HOSPITAL INPATIENT UNIT DEPARTMENT OPERATES 24 HOURS PER DAY SEVEN DAYS PER WEEK AND IS STAFFED BY A GROUP OF HIGHLY TRAINED NURSING STAFF INCLUDING REGISTERED NURSES, LICENSED PRACTICED NURSES, AND OTHER SUPPORT STAFF. MANY OF THE ADMISSIONS TO THE HOSPITAL INPATIENT NURSING UNIT COME FROM THE HOSPITAL'S EMERGENCY DEPARTMENT WHICH IS OPERATED TO PROVIDE EMERGENCY CARE TO PATIENTS OF THE COMMUNITY AND SURROUNDING AREAS. THE HOSPICE AND HOMECARE PROGRAMS ARE PROVIDED AS COMMUNITY SUPPORT SERVICES TO THE AREA OF JACKSON COUNTY, WISCONSIN. JACKSON COUNTY IS A LARGE COUNTY IN WISCONSIN AND OFTEN SIGNIFICANT TRAVEL AND EFFORTS ARE NEEDED TO PROVIDE THESE SERVICES TO PATIENTS IN THE MOST COMFORTABLE SETTING WHICH IS THEIR HOMES. ALL OF THESE SUBSIDIZED HEALTH SERVICES WORK IN SUPPORT AND COOPERATION WITH THE COMBINED EFFORTS OF BLACK RIVER MEMORIAL HOSPITAL AND SHARE MANY SUPPORT FUNCTIONS OF THE HOSPITAL IN AN EFFORT TO PROVIDE EXCELLENT LOW COST CARE TO PATIENTS IN THEIR LOCAL COMMUNITY AND AREA. A SIGNIFICANT PAYOR FOR THESE PROGRAMS IS THE MEDICARE PROGRAM WHICH DOES NOT REIMBURSE THE HOSPITAL FOR THESE SERVICES IN CALL CASES BASED ON COST SO A SIGNIFICANT LOSS IS ABSORBED BY THE HOSPITAL TO PROVIDE THESE SERVICES TO MEMBERS OF THE COMMUNITY. IT IS THE GOAL OF BLACK RIVER MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY.THE COSTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES IS BASED ON THE COSTING METHODS USED ON THE HOSPITAL'S MEDICARE COST REPORT. THIS METHODOLOGY PROVIDES FOR A DIRECT ALLOCATION OF EXPENSES AS WELL AS PROVIDING THE SAME DATA TO THE MEDICARE PROGRAM AS WELL AS TO THE IRS FOR FORM 990 PURPOSES.
		PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2279226.
		PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT," THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. BLACK RIVER MEMORIAL HOSPITAL, INC. PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. BLACK RIVER MEMORIAL HOSPITAL, INC., LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, HOME CARE, HOSPICE, INFUSION SERVICES, SWING BED SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH PATHOLOGY, SURGICAL SERVICES, WOMENS' SERVICES, AND DURABLE MEDICAL EQUIPMENT, TO NAME SOME OF THE MAJOR SERVICES PROVIDED.
		PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY REPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE ORGANIZATION PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL.
		PART III, LINE 8: BLACK RIVER MEMORIAL HOSPITAL, INC. IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS MEDICARE REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN BASED ON THE IRS 990 INSTRUCTIONS INCLUDES GROSS MEDICARE REVENUE BUT DOES NOT CONSIDER CONTRACTUAL ADJUSTMENTS FOR THE REIMBURSEMENT THAT IS ACTUALLY RECEIVED FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE ALSO DOES NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS RADIOLOGIST, RESPIRATORY THERAPY, OR ANESTHESIA PROFESSIONAL SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT BLACK RIVER MEMORIAL HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF JACKSON COUNTY, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY.
		FORM 990, SCHEDULE H, PART III, SECTION C, LINE 9A:WRITTEN COLLECTION POLICY EXPLANATION:THE HOSPITAL CURRENTLY DOES NOT HAVE A WRITTEN COLLECTION POLICY, HOWEVER THE HOSPITAL HAS OTHER POLICIES AND PROCEDURES IN PLACE WHICH HELP THE PATIENT ACCOUNTING DEPARTMENT AND THE HOSPITAL TO PROVIDE A FAIR AND EQUITABLE COLLECTION EFFORT TO PATIENT ACCOUNTS. THE HOSPITAL ALSO EMPLOYS TWO PATIENT ADVOCATES WHO ASSIST PATIENTS IN FINDING MEANS OF PAYING FOR ACCOUNTS OR BETWEEN THE EFFORTS OF THE PATIENT ADVOCATES AND THE HOSPITALS PATIENT ACCOUNTING DEPARTMENT, CHARITY AND COMMUNITY CARE INFORMATION IS PROVIDED TO PATIENTS. ALL PATIENTS ARE GIVEN A MINIMUM NUMBER OF SELF-PAY STATEMENTS ON A MONTHLY BASIS BEFORE FURTHER ACTION IS TAKEN THROUGH COLLECTION AGENCIES AS WELL TO ENSURE THAT PATIENTS ARE GIVEN A CHANCE TO MAKE PAYMENT OR FIND PAYMENT ARRANGEMENTS FOR OUTSTANDING BALANCES. THE HOSPITAL BELIEVES THAT THIS IS ALSO A PART OF ITS COMMUNITY SERVICE MISSION TO PROVIDE PATIENTS WITH THE TOOLS AND EDUCATION ON OTHER FUNDING SOURCES OR CHARITY CARE PROGRAMS AS WELL AS PAYMENT ARRANGEMENT OPPORTUNITIES OVER A LONG OR SHORT-TERM PERIOD OF TIME.
		PART VI, LINE 2: ON AN ANNUAL BASIS, BLACK RIVER MEMORIAL HOSPITAL, INC. (BRMH) DOES A STRATEGIC HEALTH ASSESSMENT OF THE COMMUNITY WITH INPUT FROM PHYSICIANS, VOLUNTEERS, EMPLOYEES, GOVERNMENTAL HEALTH AGENCIES, BUSINESS OWNERS, AND COMMUNITY MEMBERS. IN ADDITION, BRMH PERIODICALLY CONTRACTS WITH OUTSIDE AGENCIES TO CONDUCT PHONE INTERVIEWS WITH COMMUNITY MEMBERS. DURING THE SAME TIME FRAME AS THE TELEPHONE INTERVIEWS, FOCUS GROUPS ARE CONDUCTED TO HELP IDENTIFY NEEDS OF THE COMMUNITY.
		PART VI, LINE 3: UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH ONE OF THE HOSPITAL'S PATIENT FINANCIAL COUNSELORS EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE PATIENT FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAL ASSISTANCE OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE.
		PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR BLACK RIVER MEMORIAL HOSPITAL, INC. ENCOMPASSES ALL PERSONS LIVING WITHIN A 30 MILE RADIUS OF THE HOSPITAL. THIS AREA INCLUDES JACKSON COUNTY AND PARTS OF EAU CLAIRE, MONROE, LACROSSE, TREMPEALEAU, WOOD, ADAMS AND CLARK COUNTIES. SOME OF THE COMMUNITIES INCLUDED IN THIS AREA ARE ALMA CENTER, BLAIR, HIXTON, HUMBIRD, MELROSE, MERRILLAN, SPARTA, OSSEO, TOMAH, NEILLSVILLE, AND WHITEHALL. BLACK RIVER MEMORIAL HOSPITAL, INC. IS THE ONLY HOSPITAL LOCATED IN JACKSON COUNTY, WISCONSIN. THE HOSPITAL PROVIDES A SIGNIFICANT PORTION OF ITS PATIENT CARE SERVICES TO BENEFICIARIES OF THE MEDICARE AND MEDICAID PROGRAMS AS WELL AS THE HO-CHUNK NATION (A LOCAL TRIBAL NATION WITH A LARGE PORTION OF ITS POPULATION RESIDING IN JACKSON COUNTY, WISCONSIN). THE HO-CHUNK NATION ALSO IS ABLE TO ACCESS CARE AT THE HOSPITAL AT REDUCED RATES THROUGH A REGULATION KNOWN AS THE "MEDICARE-LIKE PAYMENTS RULE." THE HOSPITAL ALSO IS THE MAIN SUPPLIER OF HEALTHCARE SERVICES TO FIVE STATE OPERATED INSTITUTIONS WHICH ARE OPERATED BY THE WISCONSIN DEPARTMENT OF CORRECTIONS. THE STATE OF WISCONSIN ALSO REIMBURSES THE HOSPITAL AT RATES BELOW THE GENERAL PUBLIC IN AN EFFORT TO REDUCE COSTS PASSED ON TO TAXPAYERS IN THE STATE. IN 2010, THESE FOUR MAJOR PROGRAM POPULATIONS ACCOUNTED FOR OVER 60 PERCENT OF THE PATIENT SERVICES PROVIDED BY THE HOSPITAL DURING THE YEAR.
		PART VI, LINE 6: AS A COMMUNITY-OWNED HOSPITAL, BLACK RIVER MEMORIAL HOSPITAL, INC. CONTINUES TO BE PROACTIVELY INVOLVED WITH AREA COMMUNITY MEMBERS THROUGH A VARIETY OF EDUCATIONAL FORUMS, SUPPORT GROUPS, WELLNESS AND SAFETY FAIRS, DIABETES FAIR, HO-CHUNK HEALTH FAIR, KIDS' SAFETY CAMP, COMMUNITY CPR AND 1ST AID TRAINING, PRE-NATAL AND BREASTFEEDING CLASSES, BABYSITTING CLINICS, SPORTS INJURY CLINIC, COACHING CLINICS, AND PROVIDING ONGOING COVERAGE AT SPORTING EVENTS. SUPPORT GROUPS INCLUDE DIABETES, ALZHEIMERS, AND BEREAVEMENT. THERE ARE A NUMBER OF LOCAL ORGANIZATIONS THAT ARE REPRESENTED OR FACILITATED BY HOSPITAL STAFF INCLUDING: JACKSON COUNTY'S WORKFORCE ALLIANCE, GREATER BLACK RIVER AREA SAFETY COUNCIL, JACKSON COUNTY HEALTHCARE ALLIANCE, JACKSON COUNTY TOBACCO COALITION, TOGETHER FOR JACKSON COUNTY KIDS, JACKSON COUNTY EMERGENCY MANAGEMENT PLANNING WORKFORCE, AND MANY OTHERS. THE HOSPITAL PROVIDES FREE BLOOD PRESSURE AND OTHER SCREENINGS AT LOCAL BUSINESSES AND COMMUNITY EVENTS SUCH AS THE JACKSON COUNTY FAIR. THE HOSPITAL WELCOMES MEDICAL STUDENTS FOR INTERNSHIPS AND CLINICALS. THE HOSPITAL ALSO PARTICIPATES IN THE MEALS ON WHEELS PROGRAM BY DELIVERING MEALS TO LOCAL SENIORS WHO ARE HOME BOUND. THE HOSPITAL PROVIDES SUPPORT AND SPONSORSHIP TO THE RED CROSS BLOODMOBILE FIVE TIMES A YEAR.
REPORTS FILED WITH STATES	PART VI, LINE 7	WI

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number
39-1027536

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image

Enter total number of other organizations ................................ . Bullet Image

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2010

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant
(1) SCHOLARSHIPS FOR HEALTHCARE EDUCATION	4	5,500

Part IV

Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.

Identifier	Return Reference	Explanation
OTHER INFORMATION:	PART IV:	THE PARTNERS OF BLACK RIVER MEMORIAL HOSPITAL HAVE SCHOLARSHIP FUNDS THAT ARE AVAILABLE TO LOCAL STUDENTS. THE HOSPITAL MAINTAINS THE FUNDS THAT ARE AVAILABLE FOR SCHOLARSHIP DISBURSEMENTS FOR THE PARTNERS IN AN AUXILIARY ACCOUNT THAT IS CONSOLIDATED ONTO THE HOSPITAL'S GENERAL LEDGER. THE PARTNERS AWARD UP TO FOUR SCHOLARSHIPS EACH YEAR FOR STUDENTS SEEKING EDUCATION IN A HEALTH SERVICE AREA OF STUDY. THE PARTNERS ORGANIZATION DETERMINES THE ELIGIBILITY OF CANDIDATES AND SELECTS THE SCHOLARSHIP RECIPIENTS. THE HOSPITAL MAINTAINS THE FUNDS AND DISBURSES THE SCHOLARSHIP UPON REQUEST OF THE PARTNERS ORGANIZATION.

Schedule I (Form 990) 2010

Additional Data

Software ID:
Software Version:

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Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) STAN GAYNOR	(i) (ii)	164,602 0	0 0	41,724 0	28,816 0	13,726 0	248,868 0	0 0
(2) ROBERT DALEY	(i) (ii)	131,122 0	0 0	17,388 0	7,040 0	1,104 0	156,654 0	0 0
(3) CAROL MARTIN MD	(i) (ii)	232,962 0	0 0	174 0	22,706 0	11,643 0	267,485 0	0 0
(4) KAARE TINGELSTAD MD	(i) (ii)	234,708 0	0 0	296 0	23,441 0	12,177 0	270,622 0	0 0
(5) HOLLY WINN	(i) (ii)	128,516 0	0 0	7,586 0	6,426 0	13,350 0	155,878 0	0 0
(6) KIMBERLY STRAUB MD	(i) (ii)	172,225 0	0 0	174 0	0 0	6,467 0	178,866 0	0 0
(7) MARY BETH WHITE-JACOBS	(i) (ii)	112,539 0	0 0	25,594 0	6,301 0	13,394 0	157,828 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
	PART I, LINE 4B	EMPLOYEES NOTED WHO PARTICIPATE IN THE HOSPITAL'S 457B DEFERRED COMPENSATION PLAN: STAN GAYNOR $19,084; CAROL MARTIN $11,353; KAARE TINGELSTAD $11,500

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number
39-1027536

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	CITY OF BLACK RIVER FALLS	39-6005399		10-31-2005	8,430,000	HOSPITAL ADDITIONS AND RENOVATIONS		X		X		X
B	JACKSON COUNTY	39-6005703		12-21-2005	6,570,000	HOSPITAL ADDITIONS AND RENOVATIONS		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .
2 Amount of bonds defeased . . . .	682,266		531,096
3 Total proceeds of issue . . . .	8,430,000		6,570,000
4 Gross proceeds in reserve funds . .
5 Capitalized interest from proceeds.
6 Proceeds in refunding escrow. . . . .
7 Issuance costs from proceeds . . .	176,925		134,831
8 Credit enhancement from proceeds.
9 Working capital expenditures from proceeds . .
10 Capital expenditures from proceeds . .	8,253,075		6,435,169
11 Other spent proceeds . .
12 Other unspent proceeds. . .
13 Year of substantial completion . . .	2007		2007
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue?		X		X
15 Were the bonds issued as part of an advance refunding issue?		X		X
16 Has the final allocation of proceeds been made? . .	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .	X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .	X		X

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2010

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use?		X		X
b Are there any research agreements that may result in private business use of bond-financed property? . .		X		X
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .	X		X
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . .
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .	0.010 %		0.010 %
6 Total of lines 4 and 5 . . .. . . . . .	0.010 %		0.010 %
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?	X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .		X		X
2 Is the bond issue a variable rate issue?		X		X
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?		X		X
b Name of provider .
c Term of hedge . .
d Was the hedge superintegrated? .
e Was a hedge terminated? .
4a Were gross proceeds invested in a GIC? .		X		X
b Name of provider .
c Term of GIC . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .
5 Were any gross proceeds invested beyond an available temporary period? .		X		X
6 Did the bond issue qualify for an exception to rebate? . . .		X		X

Schedule K (Form 990) 2010

Page 3

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

BLACK RIVER MEMORIAL HOSPITAL INC

Employer identification number

39-1027536

Identifier	Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 6		MEMBERSHIP OF BLACK RIVER MEMORIAL HOSPITAL, INC. CONSIST OF TWO CLASSES, INDIVIDUAL AND GROUP AS FOLLOWS: INDIVIDUAL MEMBERSHIP-ANY ADULT RESIDING WITHIN THE GEOGRAPHICAL AREA OF JACKSON COUNTY AND ADJOINING COUNTIES WHO CONTRIBUTED THE SUM OF TWENTY DOLLARS OR MORE TO THE 1965 CAMPAIGN FOR CONSTRUCTION OF THE HOSPITAL BUILDING SHALL BE ENTITLED TO LIFE MEMBERSHIP AS LONG AS HE OR SHE RESIDES WITHIN THE GEOGRAPHICAL AREA OF JACKSON COUNTY AND ADJOINING COUNTIES. A FAMILY CONTRIBUTION, OR ONE BY EITHER SPOUSE INDIVIDUALLY, ENTITLES BOTH HUSBAND AND WIFE TO INDIVIDUAL MEMBERSHIP IN THE CORPORATION. GROUP MEMBERSHIP-ANY COMMUNITY GROUP AS A CHURCH, RELIGIOUS ASSOCIATION, FRATERNAL ORGANIZATION, CHARITABLE ORGANIZATION, VETERANS ORGANIZATION, CIVIC CLUB, BUSINESS ORGANIZATION, OR CORPORATION WITHIN THE GEOGRAPHICAL AREA OF JACKSON COUNTY AND ADJOINING COUNTIES WHICH HAS CONTRIBUTED THE SUM OF TWENTY DOLLARS OR MORE TO THE 1965 CAMPAIGN FOR THE CONSTRUCTION OF THE HOSPITAL BUILDING SHALL BE ENTITLED TO LIFE MEMBERSHIP AS LONG AS THE ORGANIZATION IS IN EXISTENCE. SUCH ORGANZATIONS SHALL DESIGNATE ANNUALLY, IN WRITING, ONE PERSON TO ACT ON ITS BEHALF AT MEETINGS OF MEMBERS. MEMBERSHIP SHALL TERMINATE IF THE MEMBER RELINQUISHES MEMBERSHIP OR IF THE MEMBER CEASES TO EXIST. ANY ADULT RESIDING OR ORGANIZATION EXISTING WITHIN THE GEOGRAPHICAL AREA OF JACKSON COUNTY AND ADJOINING COUNTIES WHO DID NOT CONTRIBUTE TO THE 1965 CAMPAIGN FOR THE HOSPITAL BUILDING MAY BECOME A LIFE MEMBER AS PROVIDED ABOVE BY CONTRIBUTING TWENTY DOLLARS OR MORE TO THE CORPORATION. EXCEPT AS OF JUNE 1, 2001, A FAMILY CONTRIBUTION, OR ONE BY EITHER SPOUSE INDIVIDUALLY, NO LONGER ENTITLES BOTH HUSBAND AND WIFE TO INDIVIDUAL MEMBERSHIPS IN BLACK RIVER MEMORIAL HOSPITAL, INC.
FORM 990, PART VI, SECTION A, LINE 7A		THE MEMBERS SHALL ELECT MEMBERS OF THE BOARD OF DIRECTORS. EACH MEMBER IS ENTITLED TO ONE VOTE, AND EACH GROUP MEMBER SHALL, BEFORE THE START OF THE MEETING, DESIGNATE IN WRITING TO THE SECRETARY OF THE CORPORATION THE PERSON ENTITLED TO VOTE FOR THE GROUP MEMBER.
FORM 990, PART VI, SECTION A, LINE 7B		THE MEMBERS OF BLACK RIVER MEMORIAL HOSPITAL, INC. HAVE THE AUTHORITY TO VOTE ON ALL MATTERS PRESENTED BY THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11		THE BOARD OF DIRECTORS OF BLACK RIVER MEMORIAL HOSPITAL, INC. RECEIVED A COPY OF THE 990 FOR REVIEW PRIOR TO THE FILING OF THEIR RETURN AT THEIR MEETING ON OCTOBER 25, 2011. MEMBERS OF THE BOARD WERE ALSO ALLOWED TO HAVE A COMMENT PERIOD TO COMMUNICATE ANY REQUESTED CHANGES TO THE VICE PRESIDENT OF FINANCE OF THE HOSPITAL, AND IF ANY CHANGES ARE MADE THE BOARD REVIEWS AN UPDATED FINAL COPY PRIOR TO FILING THE RETURN WITH THE IRS. THE HOSPITAL'S VICE PRESIDENT OF FINANCE ALSO REVIEWED THE RETURN IN DETAIL PRIOR TO ITS SUBMISSION TO THE INTERNAL REVENUE SERVICE.
	FORM 990, PART VI, SECTION B, LINE 12C	CONFLICTS OF INTEREST ARE REVIEWED YEARLY AT THE ANNUAL MEMBER MEETING. ANY ISSUES WHICH MAY ARISE ARE DISCUSSED AND HANDLED APPROPRIATELY. ANY MEMBER OF THE BOARD OF DIRECTORS WITH NOTED CONFLICTS ARE ASKED TO OBSTAIN FROM VOTING ON ANY POTENTIAL CONFLICTED ISSUES. A SIMILAR PROCESS IS USED BY THE BOARD OF DIRECTORS FOR THE REVIEW OF CONFLICTS OF INTEREST WITH THE CHIEF EXECUTIVE OFFICER AND VICE PRESIDENTS OF THE HOSPITAL.
	FORM 990, PART VI, SECTION B, LINE 15	THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER IS REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY CONSIDERING COMPENSATION LEVELS AT SIMILIAR SITUATED ORGANIZATIONS (TYPICALLY NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS IN THE SAME REVENUE CATEGORY). THE ORGANIZATION ALSO UTILIZES A WRITTEN EMPLOYMENT CONTRACT FOR THE CHIEF EXECUTIVE OFFICER WHICH ALSO MAY REFERENCE MANY STANDARD HOSPITAL EMPLOYEE BENEFITS WHICH THE CHIEF EXECUTIVE OFFICER FOLLOWS AS WELL SUCH AS EMPLOYEE HEALTH INSURANCE. THE COMPENSATION OF ADMINISTRATIVE LEVEL EMPLOYEES IS APPROVED BY THE CEO AND REVIEWED BY THE BOARD OF DIRECTORS.
	FORM 990, PART VI, SECTION C, LINE 19	BLACK RIVER MEMORIAL HOSPITAL, INC.'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATMENTS ARE REVIEWED AT THE HOSPITAL'S ANNUAL MEETING WHICH IS OPEN TO THE GENERAL PUBLIC. SUMMARIZED FINANCIAL STATEMENT DATA IS ALSO AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION'S WEBSITE.
CHANGES IN NET ASSETS OR FUND BALANCES:	FORM 990, PART XI, LINE 5:	NET UNREALIZED GAINS ON INVESTMENTS: 79,525.
SELECTION OF INDEPENDENT ACCOUNTANT	PART XII, LINE 2C	THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILTY FOR THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE BOARD OF DIRECTORS TAKES TIME TO MEET WITH INDEPENDENT ACCOUNTANTS FOLLOWING THE AUDIT EACH YEAR TO REVIEW THE FINANCIAL STATEMENTS AND ITEMS NOTED DURING THE AUDIT WITHOUT MANAGEMENT PRESENT TO ALLOW EVEN MORE OVERSIGHT BY THE BOARD INTO THE ANNUAL AUDIT PROCESS. MEMBERS OF THE BOARD OF DIRECTORS ALSO HAVE THE CONTACT INFORMATION OF THE INDEPENDENT ACCOUNTANT AND ARE ENCOURAGED TO CONTACT THE ACCOUNTANTS DURING THE YEAR WHEN QUESTIONS ARISE. THERE HAS BEEN NO CHANGE TO THESE PROCEDURES DURING THE PAST YEAR.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2010

Additional Data

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1	Briefly describe the organization’s mission or most significant activities: IN THE SPIRIT OF "EXCELLENCE ALWAYS," BLACK RIVER MEMORIAL HOSPITAL'S MISSION IS TO: PROVIDE HIGH QUALITY, ACCESSIBLE, PROGRESSIVE HEALTH CARE; CONNECT PATIENTS WITH VALUED HEALTH CARE PROVIDERS AND SERVICES; ENHANCE THE HEALTH AND WELL BEING OF ALL PEOPLE WE SERVE; REMAIN FISCALLY VIABLE TO REINVEST IN THE COMMUNITY'S FUTURE HEALTH CARE NEEDS.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	9
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	309
6	Total number of volunteers (estimate if necessary) ....	6	216
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	240,385
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	-89,431

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	212,713	106,673
9	Program service revenue (Part VIII, line 2g) .........	31,036,621	34,560,238
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	74,017	183,335
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	-81,822	-96,786
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	31,241,529	34,753,460
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	5,000	5,500
14	Benefits paid to or for members (Part IX, column (A), line 4) ....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	16,446,855	17,875,385
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 4,473
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	13,716,804	15,106,821
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	30,168,659	32,987,706
19	Revenue less expenses. Subtract line 18 from line 12......	1,072,870	1,765,754
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	36,524,503	39,030,198
21	Total liabilities (Part X, line 26)............	18,218,631	18,879,047
22	Net assets or fund balances. Subtract line 21 from line 20 .....	18,305,872	20,151,151

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4a	(Code: ) (Expenses $ 26,383,450 including grants of $ 5,500 ) (Revenue $ 32,432,844 )
	BLACK RIVER MEMORIAL HOSPITAL, INC. PROVIDES HIGH QUALITY, COST EFFECTIVE, PRIMARY HEALTH CARE TO ALL PEOPLE IN NEED OF CARE. AMONG THE INPATIENT AND OUTPATIENT SERVICES PROVIDED ARE DIAGNOSTIC IMAGING, REHABILITATION SERVICES, RESPIRATORY CARE, SURGICAL SERVICES, CARDIAC MONITORED CARE, LAB SERVICES, PHARMACY SERVICES, 24 HOUR EMERGENCY ROOM, POISON CONTROL, AND MANY OTHERS. DURING 2010, THE HOSPITAL PROVIDED OVER 2,600 INPATIENT DAYS OF CARE TO ADULTS, PEDIATRICS, SWING BED, AND NURSERY INPATIENTS AS WELL AS OVER 9,127 EMERGENCY ROOM AND 16,901 OUTPATIENT SERVICES TO THOSE IN NEED OF CARE. THE HOSPITAL ALSO SERVES AS A VITAL LINK TO THE COMMUNITY BY PROVIDING OUTREACH PROGRAMS AND SERVICES THAT MEET IDENTIFIED NEEDS IN AN EFFORT TO ENHANCE THE HEALTH AND WELFARE OF THE PEOPLE IN ITS AREA. IN ITS EFFORT TO ATTAIN THIS MISSION AND GOAL THE HOSPITAL PROVIDES:-FREE AND REDUCED COST CARE TO THOSE WITH A DEMONSTRATED NEED-CARE TO THOSE COVERED UNDER GOVERNMENT ENTITLEMENT PROGRAMS WHICH MAY NOT COVER THE CHARGES OR COST OF SERVICES PROVIDED-HEALTH EDUCATION AND OUTREACH PROGRAMS TO ALL MEMBERS OF THE COMMUNITY AT LITTLE OR NO COST TO THE PARTICIPANTSCHARITY CARE GIVEN TO PERSONS UTILIZING OUR HOSPITAL AMOUNTED TO A TOTAL OF $249,576 IN TOTAL CHARGES. IN ADDITION, WE FURNISH CARE TO PERSONS COVERED UNDER GOVERNMENT ENTITLEMENT PROGRAMS WHICH PAY AT RATES LESS THAN CHARGES. DISCOUNTS TO THESE PROGRAMS FOR HOSPITAL SERVICES AMOUNTED TO $12,187,448.BLACK RIVER MEMORIAL HOSPITAL ALSO CONDUCTED NUMEROUS EDUCATIONAL AND SUPPORTIVE ACTIVITIES TO ENCOURAGE THE GOOD HEALTH AND WELFARE OF THE MEMBERS OF THE COMMUNITY WE SERVE. THESE ACTIVITIES INCLUDE:-CPR INSTRUCTION AND TRAINING TO VARIOUS MEMBERS OF THE COMMUNITY AND ORGANIZATIONS INCLUDING ALL FIRST RESPONDER AND AMBULANCE RESCUE UNITS WITHIN JACKSON COUNTY-TRAINING TO YOUNG PERSONS WITHIN THE COMMUNITY TO EQUIP THESE INDIVIDUALS FOR BABYSITTING RESPONSIBILITIES-FACILITIES FOR MEETINGS AND SUPPORT PERSONNEL, INCLUDING LEADERSHIP FOR GRIEF GROUPS, ALZHEIMER SUPPORT GROUPS, MULTIPLE SCLEROSIS SUPPORT GROUPS, ALCOHOLICS ANONYMOUS, GAMBLERS ANONYMOUS, WEIGHT REDUCTION CLASSES, INTERFAITH CARE GIVERS (A NON-DENOMINATIONAL GROUP OF CARE GIVERS WITHIN JACKSON COUNTY), IN TOUCH, LIFELINE (A PERSONAL EMERGENCY RESPONSE SYSTEM AVAILABLE AT NOMINAL COSTS TO AREA RESIDENTS)-PROVIDING ASSISTANCE TO HEALTH EDUCATORS BY SPONSORING INTERNSHIPS FOR STUDENT NURSES, RADIOLOGICAL, REHABILITATION, AND LABORATORY TECHNICIAN STUDENTS.-PROVIDING CHILD BIRTH EDUCATIONAL CLASSES-PROVIDING LEADERSHIP TO STATE AND REGION WIDE HEALTH ORGANIZATIONS INCLUDING THE WISCONSIN HOSPITAL ASSOCIATION, HEALTH CARE FINANCIAL MANAGEMENT ASSOCIATION, NURSE EXECUTIVES, HEALTH EDUCATORS, AND PERINATAL CARE ASSOCIATION TO FURTHER HEALTHCARE GOALS OUTSIDE OF OUR DIRECT SERVICE AREA.

4b	(Code: ) (Expenses $ 1,151,607 including grants of $ ) (Revenue $ 1,100,357 )
	BLACK RIVER MEMORIAL'S HOSPICE PROGRAM GIVES THOSE PATIENTS WITH LIFE-LIMITING OR TERMINAL ILLNESSES THE OPPORTUNITY TO LIVE PAIN-FREE AND WITH DIGNITY DURING THE LAST STAGE OF THEIR LIFE. TOTAL HOSPICE DAYS OF SERVICE PROVIDED TO PATIENTS IN 2010 WERE 7,985.

4c	(Code: ) (Expenses $ 879,838 including grants of $ ) (Revenue $ 796,898 )
	BLACK RIVER MEMORIAL HOSPITAL'S HOMECARE PROGRAM PROVIDES COMPREHENSIVE HEALTHCARE SERVICES IN THE MOST COMFORTABLE SETTING-THE PATIENT'S HOME. IN 2010, THERE WERE 1,755 TOTAL HOMECARE VISITS PROVIDED TO PATIENTS CONSISTING OF SKILLED NURSING, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, HOME HEALTH AIDE, AND MEDICAL SOCIAL SERVICE HEALTHCARE SERVICES PROVIDED TO PATIENTS IN THEIR HOMES.

4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 28,414,895

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,269,610	0	166,591

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		33,863

f	All other contributions, gifts, grants, and similar amounts not included above1f		72,810
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			106,673
			Business Code
2a	HOSPITAL PATIENT SERVI		621,400	32,047,358	32,039,182	8,176
b	HOSPICE PATIENT REVENU		621,400	1,100,357	1,100,357
c	HOMECARE PATIENT REVEN		621,400	796,898	796,898
d	OTHER HOSPITAL SERVICE		621,400	615,625	393,662	221,963
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			34,560,238
3	Investment income (including dividends, interest
	and other similar amounts).....			167,702			167,702
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross Rents	130,216
b	Less: rental expenses	246,961
c	Rental income or (loss)	-116,745
d	Net rental income or (loss).......			-116,745		10,246	-126,991
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	2,716,226	500
b	Less: cost or other basis and sales expenses	2,701,093
c	Gain or (loss)	15,133	500
d	Net gain or (loss)..........			15,633			15,633
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a		27,170
b	Less: direct expenses ...b		10,546
c	Net income or (loss) from fundraising events..			16,624			16,624
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a		6,454
b	Less: cost of goods sold ..b		3,119
c	Net income or (loss) from sales of inventory..			3,335			3,335
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......
12	Total revenue. See Instructions....			34,753,460	34,330,099	240,385	76,303


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			3,535	1	4,406
2	Savings and temporary cash investments .......			4,996,799	2	8,650,397
3	Pledges and grants receivable, net .........			281,918	3	168,114
4	Accounts receivable, net .........			4,026,494	4	3,986,762
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			253,364	8	266,089
9	Prepaid expenses and deferred charges ............			88,591	9	114,486
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	36,145,338
b	Less: accumulated depreciation. .....	10b	14,289,354	23,070,981	10c	21,855,984
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..			2,881,453	13	3,009,259
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			921,368	15	974,701
16	Total assets. Add lines 1 through 15 (must equal line 34)...			36,524,503	16	39,030,198
17	Accounts payable and accrued expenses .			2,361,634	17	3,398,004
18	Grants payable ..........				18
19	Deferred revenue ..........			3,309	19	9,935
20	Tax-exempt bond liabilities ..........			14,190,138	20	13,786,638
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			1,115,182	23	977,931
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			548,368	25	706,539
26	Total liabilities. Add lines 17 through 25.....			18,218,631	26	18,879,047
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			17,938,790	27	19,919,919
28	Temporarily restricted net assets .....			367,082	28	231,232
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			18,305,872	33	20,151,151
34	Total liabilities and net assets/fund balances .....			36,524,503	34	39,030,198