Form990-EZ
Click to see list of attachments
Department of the Treasury
Internal Revenue Service
Short Form
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code
(except black lung benefit trust or private foundation)
bullet Sponsoring organizations of donor advised funds, organizations that operate one or more hospital facilities, and certain controlling organizations as defined in section 512(b)(13) must file Form 990 (see instructions).
All other organizations with gross receipts less than $200,000 and total assets less than $500,000 at the end of the year may use this form.
bulletThe organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-1150
2010
Open to Public
Inspection
A
For the 2010 calendar year, or tax year beginning 01-01-2010, and ending 12-31-2010
B
Check if applicable:
C Name of organization
RIVER FALLS AREA HOSPITAL FOUNDATION INC
 
Number and street (or P. O. box, if mail is not delivered to street address)1629 E DIVISION STREET
  Room/suite
City or town, state or country, and ZIP + 4 RIVER FALLS, WI54022
D Employer identification number

39-1290725
E Telephone number

(715) 307-6001
F Group Exemption
Number. . bullet  
G Accounting method: Other (specify) bullet   H Check bulletI Website:bulletWWW.RIVERFALLSAREAHOSPITAL.COMJ Tax-Exempt status(check only one)—Click to see attachment(   ) bullet(insert no.) or
K Check bullet A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postcard) may be required (see instructions). But if the organization chooses to file a return, be sure to file a complete return.
L Add lines 5b, 6c, and 7b, to line 9 to determine gross receipts; If gross receipts are $200,000 or more, or if total assets (Part II, line 25, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ.. . bullet $ 140,923
Part IRevenue, Expenses, and Changes in Net Assets or Fund Balances (See the instructions for Part I.) Check if the organization used Schedule O to respond to any question in this Part I . . . . . . . .
VerticalRevenue 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . 1 78,011
2 Program service revenue including government fees and contracts . . . . . . . 2  
3 Membership dues and assessments . . . . . . . . . . . . . . 3  
4 Investment income . . . . . . . . . . . . . . . . . . 4 964
5a Gross amount from sale of assets other than inventory . . . . 5a  
b Less: cost or other basis and sales expenses . . 5b  
c Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) . . 5c  
6 Gaming and fundraising events
a Gross income from gaming (attach Schedule G if greater than $15,000) 6a  
b Gross income from fundraising events (not including $ 61,948 of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceed $15,000) . . . . . . . Click to see attachment
c Less: direct expenses from gaming and fundraising events . . . 6c 14,242
d Net income or (loss) from gaming and fundraising events (Add lines 6a and 6b and subtract line 6c) 6d 47,706
7a Gross sales of inventory, less returns and allowances . . . . 7a  
b Less: cost of goods sold . . . . . . . . . . 7b  
c Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) . . . . . . 7c  
8 Other revenue (describe in Schedule O) . . . . . . . . . 8  
9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 . . . . . . . . . 9 126,681
VerticalExpenses 10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . 10 86,713
11 Benefits paid to or for members . . . . . . . . . . . . . . . 11  
12 Salaries, other compensation, and employee benefits . . . . . . . . . . . 12  
13 Professional fees and other payments to independent contractors . . . . . . . . 13 3,150
14 Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . . 14  
15 Printing, publications, postage, and shipping . . . . . . . . . . . . 15 11,023
16 Other expenses (describe in Schedule O) . . . . . . . . . . 16 4,064
17 Total expenses. Add lines 10 through 16 . . . . . . . . . . . . 17 104,950
VerticalNetAssets 18 Excess or (deficit) for the year (Subtract line 17 from line 9) . . . . . . . . . 18 21,731
19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
end-of-year figure reported on prior year’s return) . . . . . . . . . . . 19 219,153
20 Other changes in net assets or fund balances (explain in Schedule O) . . . . . . . 20 -240,884
21 Net assets or fund balances at end of year. Combine lines 18 through 20 . . . . . Bullet 21 0
Part IIBalance Sheets Check if the organization used Schedule O to respond to any question in this Part II. . . . . . . . .

(See the instructions for Part II.)(A) Beginning of year(B) End of year
22Cash, savings, and investments . . . . . . . . . .
179,964
22
0
23Land and buildings . . . . . . . . . . . . .
 
23
 
24Other assets (describe in Schedule O) . . . . . .
45,994
24
0
25Total assets . . . . . . . . . . . . . .
225,958
25
0
26
Total liabilities (describe in Schedule O) . . . . .
6,805
26
0
27Net assets or fund balances (line 27 of column (B) must agree with line 21) .
219,153
27
0
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 10642I Form 990-EZ (2010)
Form 990-EZ (2010)
Page 2
Part IIIStatement of Program Service Accomplishments Check if the organization used Schedule O to respond to any question in this Part III . Expenses
(Required for section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts; optional for others.)
What is the organization's primary exempt purpose? THE FOUNDATION IS DEDICATED EXCLUSIVELY FOR CHARITABLE AND EDUCATIONAL PURPOSES. THE FOUNDATION RAISES FUNDS TO SUPPORT THE RIVER FALLS AREA HOSPITAL AND OTHER COMMUNITY HEALTH INITIATIVES.
Describe what was achieved in carrying out the organization's exempt purposes. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 THE FOUNDATION PROVIDES FUNDS TO SUPPORT THE RIVER FALLS AREA HOSPITAL AND OTHER COMMUNITY HEALTH INITIATIVES. FUNDS HAVE BEEN DISTRIBUTED TO PURCHASE MEDICAL EQUIPMENT SUCH AS AEDS, IV PUMPS, AUDIOMETERS, AND FITNESS MACHINES. OTHER ASSISTANCE PROVIDES FUNDS FOR TRAINING MEDICAL PERSONNEL.
(Grants $ 81,713) If this amount includes foreign grants, check here ...MediumBullet		 28a 82,467
29 THE FOUNDATION PROVIDES SCHOLARSHIPS TO STUDENTS TAKING CLASSES TO OBTAIN A DEGREE IN A HEALTH RELATED FIELD.
(Grants $ 5,000) If this amount includes foreign grants, check here ...MediumBullet		 29a 5,000
30
(Grants $   ) If this amount includes foreign grants, check here ...MediumBullet 		30a
31 Other program services (describe in Schedule O) . . . . . . . . . . . .
(Grants $   ) If this amount includes foreign grants, check here...MediumBullet		 31a
32 Total program service expenses (add lines 28a through 31a) . . . . . . . . . bullet 32 87,467
Part IVList of Officers, Directors, Trustees, and Key Employees. List each one even if not compensated. (See the instructions for Part IV.) Check if the organization used Schedule O to respond to any question in this Part IV . . . . . . . .
(a) Name and address (b) Title and average
hours per week
devoted to position		 (c) Compensation
(If not paid,
enter -0-.) 		(d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
LORI PETERSON
1629 E DIVISION ST
RIVER FALLS,WI54022
 CHAIR2.00 0 0 0
JENNIFER O'NEILL
1629 E DIVISION ST
RIVER FALLS,WI54022
 VICE-CHAIR1.00 0 0 0
MARY JOHNSON
1629 E DIVISION ST
RIVER FALLS,WI54022
 SECRETARY1.00 0 0 0
STEVE KELM
1629 E DIVISION ST
RIVER FALLS,WI54022
 ELECTED DIRECTOR1.00 0 0 0
GREG PETERS
1629 E DIVISION ST
RIVER FALLS,WI54022
 TREASURER1.00 0 0 0
PAT SURA
1629 E DIVISION ST
RIVER FALLS,WI54022
 ELECTED DIRECTOR1.00 0 0 0
DONNA MILLER
1629 E DIVISION ST
RIVER FALLS,WI54022
 DIRECTOR1.00 0 0 0
HEATHER LOGELIN
1629 E DIVISION ST
RIVER FALLS,WI54022
 EXECUTIVE DIRECTOR20.00 0 0 0
DAVID MILLER
1629 E DIVISION ST
RIVER FALLS,WI54022
 APPOINTED MEMBER1.00 0 0 0
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 3
Part VOther Information(Note the statement requirements in the instructions for Part V.)YesNo Check if the organization used Schedule O to respond to any question in this Part V . . . .
33
Did the organization engage in any activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ..............
33
 
No
34
Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the change on Schedule O (see instructions). ...................
34
 
No
35
If the organization had income from business activities, such as those reported on lines 2, 6a, and 7a (among others), but not reported on Form 990-T, explain in Schedule O why the organization did not report the income on Form 990-T. ........................
a
Did the organization have unrelated business gross income of $1,000 or more or was it a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements?
35a
 
No
b
If "Yes," has it filed a tax return on Form 990-T for this year? (see instructions) ........
35b
 
 
36
Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes,” complete applicable parts of Schedule N Click to see attachment.............
36
Yes
 
37a
Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet
37a
0
b
Did the organization file Form 1120-POL for this year? ...............
37b
 
 
38a
Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were
any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?
38a
 
No
b
If “Yes,” complete Schedule L, Part II and enter the total amount involved .
38b
 
39
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on line 9 ......
39a
 
b
Gross receipts, included on line 9, for public use of club facilities ....
39b
 
40a
Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:
section 4911 bullet0 ; section 4912 bullet0 ; section 4955 bullet0
b
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I. ....
40b
 
No
c
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 ..bullet0
d
Section 501(c)(3) and 501(c)(4) organizations. Enter amount of tax on line 40c reimbursed by the organization ...................bullet0
e
All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T. .................
40e
 
No
41List the states with which a copy of this return is filed. bulletWI, MN
42aThe organization's books are in care of bulletGREG PETERS Telephone no. bullet (715) 426-4503
Located at bullet1629 E DIVISION STREET
RIVER FALLS,WI ZIP + 4bullet54022
b
At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)?
Yes
No
42b
 
No
If “Yes,” enter the name of the foreign country: bullet  
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
c
At any time during the calendar year, did the organization maintain an office outside of the U.S.?
42c
 
No
If “Yes,” enter the name of the foreign country: bullet  
43.......bullet
and enter the amount of tax-exempt interest received or accrued during the tax year . . . bullet43
 
44a
Did the organization maintain any donor advised funds? If "Yes", Form 990 must be completed instead of
Yes
No
Form 990-EZ.. . . . . . . . . . . . . . . . . . . .
44a
 
No
b
Did the organization operate one or more hospital facilities during the year? If ‘Yes,’ Form 990 must be completed instead of Form990-EZ. . . . . . . . .
44b
 
No
c
Did the organization receive any payments for indoor tanning services during the year? . . . . . . .
44c
 
No
d
If 'Yes' to line 44c, has the organization filed a Form 720 to report these payments? If ‘No,’ provide an explanation in Schedule O. . . . . . . . .
44d
 
 
45
Is any related organization a controlled entity of the organization within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. . . . . . . . .
45
 
No
45a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If ‘Yes,’ Form 990 and Schedule R must be completed instead of Form990-EZ. .
45a
 
No
46
Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I. . . . . . . . . .
46
 
No
Form 990-EZ (2010)
Form 990-EZ (2010)
Page 4
Part VI
Section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts only. All section 501(c)(3) organizations and section 4947(a)(1) nonexempt charitable trusts must answer questions 47-49b and 52. Check if the organization used Schedule O to respond to any question in this Part VI . . . . . . . .
Yes
No
47
Did the organization engage in lobbying activities? If "Yes," complete Schedule C, Part II . . . .
47
 
No
48
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E . . .
48
 
No
49a
Did the organization make any transfers to an exempt non-charitable related organization? . . . .
49a
 
No
b
If "Yes," was the related organization a section 527 organization? . . . . . . . . .
49b
 
 
50
Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each employee paid more than $100,000 (b) Title and average
hours per week
devoted to position		 (c) Compensation
 (d) Contributions to
employee benefit plans &
deferred compensation		 (e) Expense
account and
other allowances
NONE
50(f)
Total number of other employees paid over $100,000 . . . . . . . . . . . . . bullet  

51
Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."
(a) Name and address of each independent contractor paid more than $100,000 (b) Type of service (c) Compensation
NONE
51(d)
Total number of other independent contractors each receiving over $100,000 . . . . . . . bullet  
52
Did the organization complete Schedule A? NOTE: All Section 501(c)(3) organizations and 4947(a)(1) nonexempt charitable trusts must attach a completed Schedule A ....................
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(See instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
Form 990-EZ (2010)

Additional Data


Software ID:  
Software Version:  

Form 990-EZ, Special Condition Description:
Special Condition Description
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.
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
RIVER FALLS AREA HOSPITAL FOUNDATION INC
 
Employer identification number

39-1290725
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.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
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.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
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)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(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?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
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.") .... 145,375 112,772 166,476 131,498 125,717 681,838
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.. 145,375 112,772 166,476 131,498 125,717 681,838
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.           681,838
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.. 145,375 112,772 166,476 131,498 125,717 681,838
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 2,104 3,883 3,188 1,988 964 12,127
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..   1,644 195     1,839
11 Total support (Add lines 7 through 10).           695,804
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
97.990 %
15
15
97.340 %
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
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.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
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:  
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
RIVER FALLS AREA HOSPITAL FOUNDATION INC
 
Employer identification number

39-1290725
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
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?
b
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
Yes No
 
RUFFALOCODY
65 KIRKWOOD NORTH RD SW
 
CEDAR RAPIDS, IA52404 		TELEFUNDRAISING   No 14,335 4,318 10,017
Total .................right arrow 14,335 4,318 10,017
3
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
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

HARVEST MOON BARN DANCE
(event type) 		(b) Event #2

 
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 61,948     61,948
2 Less: Charitable
contributions . . . 		       
3 Gross income (line 1
minus line 2) . . . 		61,948     61,948
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . . 1,000     1,000
7 Food and beverages . . 2,964     2,964
8 Entertainment . . . 3,000     3,000
9 Other direct expenses . 7,278     7,278
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 14,242
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 47,706
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.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
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? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
HEATHER LOGELIN
Address right arrow
1629 EAST DIVISION ST
RIVER FALLS,WI54022
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
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 $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
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:  
SCHEDULE N
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Liquidation, Termination, Dissolution or Significant Disposition of Assets
bullet Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32 or Form 990-EZ, line 36.
bullet Attach certified copies of any articles of dissolution, resolutions or plans.
bullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
RIVER FALLS AREA HOSPITAL FOUNDATION INC
 
Employer identification number
39-1290725
Part I
Liquidation, Termination or Dissolution. Complete if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line
36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity
CASH 12-31-2010 202,225 CASH BALANCE 27-4116873 ALLINA AFFILIATED FOUNDATION
 
MR 10103 2925 CHICAGO AVE
MINNEAPOLIS,MN55407 		501(C)(3)
PLEDGES RECEIVABLE OF $60732 LESS GRANTS PAYABLE OF $22072. 12-31-2010 38,659 CASH BASIS 27-4116873 ALLINA AFFILIATED FOUNDATION
 
MR 10103 2925 CHICAGO AVE
MINNEAPOLIS,MN55407 		501(C)(3)






















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
Yes
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution? . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III. bullet
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
Cat. No. 50087Z
Schedule N (Form 990 or 990-EZ) 2010

Schedule N (Form 990 or 990-EZ) 2010
Page 2
Part I
Liquidation, Termination or Dissolution (continued)
Note. If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B) should equal -0-.
Yes
No
3
Did the organization distribute its assets in accordance with its governing instrument(s)? If “No,” describe in Part III . . . . . . . . . . .
3
Yes
 
4a
Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate? . . . . . .
4a
Yes
 
b
If “Yes,” did the organization provide such notice? . . . . . . . . . . . . . . . . . . . . . . . . . .
4b
Yes
 
5
Did the organization discharge or pay all liabilities in accordance with state laws? . . . . . . . . . . . . . . . . . . .
5
Yes
 
6a
Did the organization have any tax-exempt bonds outstanding during the year? . . . . . . . . . . . . . . . . . . . .
6a
 
No
b
Did the organization discharge or defease tax-exempt bond liabilities in accordance with the Internal Revenue Code and state laws? . . . . . . . .
6b
 
No
c
If “Yes,” describe in Part III how the organization defeased or otherwise settled these liabilities. If “No,” explain in Part III.

Part II
Sale, Exchange, Disposition or Other Transfer of More Than 25% of the Organization's Assets. Complete if the organization answered "Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Use Part III if additional space is needed.
1(a)Description of asset(s)
distributed or transaction
expenses paid		 (b)Date of
distribution		 (c)Fair market value of
asset(s) distributed or
amount of transaction
expenses		 (d)Method of
determining FMV for
asset(s) distributed or
transaction expenses		 (e)EIN of recipient (f)Name and address of recipient (g)IRC section
of recipient(s) (if
tax-exempt) or type
of entity


















Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2a
Yes
 
b
Become an employee of, or independent contractor for, a successor or transferee organization? . . . . . . . . . . . . . . . .
2b
Yes
 
c
Become a direct or indirect owner of a successor or transferee organization? . . . . . . . . . . . . . . . . . . . . .
2c
 
No
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets? . . . . . . .
2d
 
No
e
If the organization answered "Yes" to any of the questions in this line, provide the name of the person involved and explain in Part III.
Schedule N(Form 990 or 990-EZ) 2010

Schedule N (Form 990 or 990-EZ) 2010
Page 3
Part III
Supplemental Information. Complete to provide the information required by Parts I and II,
and any additional information.
Identifier Return Reference Explanation
    PART I, LINE 2E: HEATHER LOGELIN, EXECUTIVE DIRECTOR
    PART I, LINE 2E: HEATHER HAS BEEN AND WILL CONTINUE TO BE THE EMPLOYED EXECUTIVE DIRECTOR FOR THE NEWLY FORMED ALLINA AFFILIATED FOUNDATION.TWO BOARD MEMBERS WILL ALSO BE RETAINED AS EX-OFFICIO DIRECTORS FOR THE NEWLY FORMED ALLINA AFFILIATED FOUNDATION.
Schedule N (Form 990 or 990-EZ) 2010


Additional Data


Software ID:  
Software Version:  


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
RIVER FALLS AREA HOSPITAL FOUNDATION INC
 
Employer identification number

39-1290725
Identifier Return Reference Explanation
OTHER INVESTMENT INCOME FORM 990-EZ, PART I, LINE 4 INTEREST INCOME 964..
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: FREE CLINIC OF PIERCE & ST CROIX COUNTIES. GRANTEE ADDRESS: 1629 E DIVISION ST RIVER FALLS, WI 54022. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 07/31/10. AMOUNT GIVEN: 15,282.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: RIVER FALLS AREA HOSPITAL. GRANTEE ADDRESS: 1629 E DIVISION ST RIVER FALLS, WI 54022. GRANTEE RELATIONSHIP: THE HOSPITAL DIRECTOR IS A MEMBER OF THE FOUNDATION BOARD. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 10/20/10. AMOUNT GIVEN: 35,339.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: PIERCE COUNTY PUBLIC HEALTH DEPT. GRANTEE ADDRESS: 412 W KINNE STREET ELLSWORTH, WI 54011. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 9,700.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: TANYA BEYER. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: KARISSA DOUGHERTY. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: KIRSTEN IMRIE. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: LAURA KOESTER. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: KELLY OTTEM. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: JAMES PLUMMER. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: JODI BAZILLE. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: JOCELYN GORHAM. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: NANCI HANNA-HAMMOND. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: SCHOLARSHIPS. GRANTEE NAME: JENNIER SMITH. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: NAMI ST CROIX VALLEY. GRANTEE ADDRESS: 1629 E DIVISION ST RIVER FALLS, WI 54022. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 1,500.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: SCHOOL DISTRICT OF RF. GRANTEE ADDRESS: 211 N FREEMONT ST RM 208 RIVER FALLS, WI 54022. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 10/20/10. AMOUNT GIVEN: 12,000.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: SPRING VALLEY AREA AMBULANCE SERVICES. GRANTEE ADDRESS: 407 SOUTH NEWMAN SVE SPRING VALLEY, WI 54767. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 4,392.
GRANTS AND SIMILAR AMOUNTS PAID FORM 990-EZ, PART I, LINE 10 ACTIVITY CLASSIFICATION: GRANTS. GRANTEE NAME: TURNINGPOINT. GRANTEE ADDRESS: PO BOX 304 RIVER FALLS, WI 54022. GRANTEE RELATIONSHIP: NONE. PROPERTY DESCRIPTION: CASH. DATE OF GIFT: 06/07/10. AMOUNT GIVEN: 3,500. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 86,713.
OTHER EXPENSES FORM 990-EZ, PART I, LINE 16 DESCRIPTION: BANK FEES. AMOUNT: 1,006. DESCRIPTION: COMMUNITY OUTREACH. AMOUNT: 415. DESCRIPTION: FILING FEES. AMOUNT: 158. DESCRIPTION: INSURANCE. AMOUNT: 402. DESCRIPTION: MISCELLANEOUS. AMOUNT: 538. DESCRIPTION: SUPPLIES. AMOUNT: 1,116. DESCRIPTION: TRAVEL. AMOUNT: 429. TOTAL TO FORM 990-EZ, LINE 16: 4,064.
OTHER CHANGES IN NET ASSETS FORM 990-EZ, PART I, LINE 20 DESCRIPTION: TRANSFER OF ASSETS TO ALLINA AFFILIATED FNDTN VIA ALLINA HOSPITALS & CLINICS. AMOUNT: -240,884.
OTHER ASSETS FORM 990-EZ, PART II, LINE 24 DESCRIPTION: PLEDGES RECEIVABLE. BEG. OF YEAR AMOUNT: 45,994. END OF YEAR AMOUNT: 0.
OTHER LIABILITIES FORM 990-EZ, PART II, LINE 26 DESCRIPTION: GRANTS PAYABLE. BEG. OF YEAR AMOUNT: 6,805. END OF YEAR AMOUNT: 0.
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


Software ID:  
Software Version:  

TY 2010 TransferPrsnlBnftContractsDecl
Name:
RIVER FALLS AREA HOSPITAL FOUNDATION INC
EIN: 39-1290725
Declaration:
THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT.