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)	(F) Estimated amount of other compensation from the organization and related organizations
(1) William Piervincenzi Trustee	1.00	X				0	0	0
(2) William LeDoux Trustee(Ex-Off)	1.00	X				0	0	0
(3) Thomas O'Brien Trustee	1.00	X				0	0	0
(4) Susan Fiore MD Physician	39.00				X	131,562	0	5,385
(5) Sue Adams Trustee	1.00	X				0	0	0
(6) Steven Haas VP of Finance	0.00			X		0	203,954	20,526
(7) Sanda Horan Interim ExecDir	6.50	X	X			0	163,036	9,241
(8) Robert Seidman Chief Admin Off	.50		X			0	270,109	29,299
(9) Robert Kinloch Trustee	1.00	X				0	0	0
(10) Randall Moore Dir. of Pharmacy	40.00				X	100,957	0	15,755
(11) Peter Stickeler Trustee	1.00	X				0	0	0
(12) Peter Molnar Trustee	1.00	X				0	0	0
(13) Nancy Slauson Trustee	1.00	X				0	0	0
(14) Margo McGilvrey Chief Nursing Officer	0.00			X		0	216,269	15,166
(15) Liz Davis Treasurer	1.00	X	X			0	0	0
(16) Joshua Ratner Chief Strategy Officer	0.00			X		0	236,613	16,967
(17) Joseph Piasek Vice Chair	1.00	X	X			0	0	0

(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)	(F) Estimated amount of other compensation from the organization and related organizations
(18) John Finch Chief Info & Community Officer	0.00			X	0	228,086	26,786
(19) Jillienne LaFever-Craver Trustee	1.00	X			0	0	0
(20) Jenny Morrill-Liddle Trustee	1.00	X			0	0	0
(21) Howard Berliner Trustee	1.00	X			0	0	0
(22) Fred Margulies Secretary	1.00	X	X		0	0	0
(23) Frank Ehrlich Chief Medic Off	1.00		X		0	316,984	10,665
(24) Eugene Heslin MD Trustee(ex-off)	1.00	X			0	0	0
(25) Edmond Morache CEO to oct 2010	37.50	X	X		134,767	0	10,456
(26) David Scarpino CFO	.50		X		0	317,789	20,248
(27) David Riordan Trustee	1.00	X			0	0	0
(28) David Lundquist CEO	.50	X	X		0	609,887	22,590
(29) Charles Flinn Chief Operating Officer	0.00			X	0	286,673	8,552
(30) Carey Wagner Chairperson	1.00	X	X		0	0	0
(31) Arthur Martello Trustee	1.00	X			0	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
Seco Physical & Occupational Therapy PO Box 1046 Norwich,NY13815	Consulting	209,009
Protrac Construction 2870 Route 9/ Suite 1 Valatie,NY12184	Construction	359,645
MSI Systems Corp PO Box 535213 Atlanta,GA303535213	Physician Staffing	515,643
Mark S Hall dba MS Hall & Assoc PO Box 564 Syracuse,NY13205	Consulting	101,241
Laboratory Corp of America 1225 Jay Lane Graham,NC27253	Laboratory Services	111,240
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 5

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	0
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	282,170		282,170
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	4,308,915	3,472,626	836,289
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	20,626	12,376	8,250
9	Other employee benefits .......	624,614	384,273	240,341
10	Payroll taxes ...........	376,855	226,113	150,742
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	34,100		34,100
c	Accounting ...........	76,504		76,504
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	0
12	Advertising and promotion ....	0
13	Office expenses .......	1,264,974	746,183	518,791
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	214,431	24,818	189,613
17	Travel ............	31,869	17,547	14,322
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	28,955	27,318	1,637
20	Interest ...........	53,314		53,314
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	585,574	585,574
23	Insurance ..............	109,227	109,227
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	Shared Services	624,565	192,231	432,334
b	Purchased Services	1,677,245	1,224,857	452,388
c	Health Alliance Assessment	14,005		14,005
d	Dues & Subscriptions	30,955	2,830	28,125
e	Bad Debt	323,574	323,574
f	All other expenses	5,932	5,932
25	Total functional expenses. Add lines 1 through 24f	10,688,404	7,355,479	3,332,925	0
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 ..........	896,736	1	748,273
2	Savings and temporary cash investments .......	187,632	2	0
3	Pledges and grants receivable, net .........	70,374	3	26,918
4	Accounts receivable, net .........	633,171	4	1,102,642
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5	0
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	0
7	Notes and loans receivable, net .............		7	0
8	Inventories for sale or use ..............	209,717	8	224,341
9	Prepaid expenses and deferred charges ............	68,291	9	45,934
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	14,514,878
b	Less: accumulated depreciation. .....	10b	10,430,928	1,927,385	10c	4,083,950
11	Investments—publicly traded securities ..........		11	0
12	Investments—other securities. See Part IV, line 11 ......		12	0
13	Investments—program-related. See Part IV, line 11 ..		13	0
14	Intangible assets .........		14	0
15	Other assets. See Part IV, line 11 ...........	4,426,435	15	4,445,370
16	Total assets. Add lines 1 through 15 (must equal line 34)...	8,419,741	16	10,677,428
	17	Accounts payable and accrued expenses .	1,490,917	17	1,392,068
18	Grants payable ..........		18
19	Deferred revenue ..........	70,725	19	1,171
20	Tax-exempt bond liabilities ..........		20
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 ..	1,439,838	23	1,577,385
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	3,901,581	25	4,654,217
26	Total liabilities. Add lines 17 through 25.....	6,903,061	26	7,624,841
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	1,230,088	27	3,048,089
28	Temporarily restricted net assets .....	509,092	28	226,998
29	Permanently restricted net assets .....	-222,500	29	-222,500
	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 .....	1,516,680	33	3,052,587
34	Total liabilities and net assets/fund balances .....	8,419,741	34	10,677,428

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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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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:	10000105
Software Version:	2010v3.2

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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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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 Margaretville Memorial Hospital
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 Margaretville Memorial Hospital
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
Margaretville Memorial Hospital

Employer identification number

15-0552726

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:	10000105
Software Version:	2010v3.2

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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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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

3,829

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

3,829

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
Part II-B, Line 1i	Part II-B, Line 1i - Other Activities Description	Margaretville Memorial Hospital pays dues to The Healthcare Association of New York State (HANYS) and the American Hospital Association (AHA). In accordance with section 6033 (e) of the Internal Revenue Code, and as reported by HANYS and AHA, a portion of these dues are attributable to lobbying activities. The lobbying activities applicable to 2010 HANYS and AHA annual dues were $3,164 and $665, respectively.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:	10000105
Software Version:	2010v3.2

- 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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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 .................	23,128		23,128
b	Buildings ................	4,277,289	3,237,297	1,039,992
c	Leasehold improvements ............	232,416	181,313	51,103
d	Equipment ................	8,713,261	7,012,318	1,700,943
e	Other .................	1,268,784		1,268,784
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				4,083,950

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









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

Part IX

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

(a) Description				(b) Book value
(1) Other receivable				86,133
(2) Other Assets				7,003
(3) Interest in Net Assets of KRH Foundation				274,948
(4) Due from Affiliates				1,131,120
(5) Assets Limited As to Use				2,946,166




Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........				4,445,370

Part X

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

1.(a) Description of Liability		(b) Amount
Federal Income Taxes
Other Non-Current Liabilities		495,486
Due to Third Party Payors		2,569,893
Due to Related Parties		1,588,838






Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		4,654,217
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
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3
4	Net unrealized gains (losses) on investments ..........................	4
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
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10

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
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
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
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
c	Add lines 4a and 4b.......................		4c
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......		5

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............		1
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
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
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
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......		5

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
Part XI, Line 8	Part XI, Line 8: Other Changes in Net Assets or Fund Balances	Net assets released from restrictions for capital purposes $362936 Change in interest in NA of Margaretville Hosp Fdn $ -282094

Schedule D (Form 990) 2010

Additional Data

Software ID:	10000105
Software Version:	2010v3.2

- 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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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) ..	189,585	79,930	109,655	1.030 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	749,154	222,740	526,414	4.930 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	938,739	302,670	636,069	5.960 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..	3,219,450	2,349,312	870,138	8.140 %
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..
jTotal Other Benefits ...	3,219,450	2,349,312	870,138	8.140 %
kTotal. Add lines 7d and 7j. ..	4,158,189	2,651,982	1,506,207	14.100 %

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.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(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	Total

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? ..........................

Yes

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

182,431

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

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).....

3,015,196

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

2,404,924

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

610,272

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? ...............

Yes

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......

Yes

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)
0	Margaretville Memorial Hospita 42084 State Route 28 Margaretville,NY12455	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:Margaretville Memorial Hospita

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		No
	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	Yes
	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 VI - Additional Information	Part VI - Needs Assessment (continued)Strategic Plan Executive Summary:Margaretville Hospital embraces and continues to implement our 2010-2011 strategic initiatives, outlined below.I.Vision StatementMH will become the highest quality provider of rural health care, the health care provider of choice in the markets we serve.We will achieve this by providing:a.A safe, compassionate and personal clinical environmentb.State of the art diagnosticsc. Restructured network of primary cared.Surgical servicese.An expanded continuum of long term care servicesf.An expanded network of doctors and medical professionalsg.Round the clock emergency careh.Accessibility through transportation and community outreachi.Preventive and educational wellness programsjSensitivity to all within our culturally diverse communityII.GoalsIn order to deploy this vision, MH has developed the following goals for 2009 - 2010 which are listed in priority order:1.To expand and renovate emergency, diagnostic imaging and health center facilities.2.To provide state-of-the-art equipment in diagnostic imaging and "scoping" technologies.3.To utilize telemedicine and other technologies to link MMH to radiology and other specialties.4.To recruit private practice physicians to work at MMH in medical and surgical specialties.5.To analyze facilities' location and management in order to implement the appropriate array and structure of family health centers.6.To recruit Internal Medicine or Family Practice physicians to the community.7.To develop, implement, measure and monitor safety and clinical standards and outcomes.8.To organize the inpatient spaces so that every room is a private room.9.To continually improve clinical excellence in the E.R. through development of pathways, protocols, policies and resources.10.Retain an Emergency Department Medical Director.11.To investigate the needs and preferences of the Hispanic, Hasidic and other communities and develop strategies to meet them.12.To network with other rural health providers regionally and nationally to develop academic and medical professional relationships.13.To conduct a community needs assessment.14.To develop an annual calendar of community outreach programs and medical screenings.15.To offer medical support services to adult housing with services.16.To expand Lifeline.17.To study the feasibility of a health club connected to physical therapy and cardiac rehab services.Three Year Implementation Report:Margaretville Hospital has continued our financial and clinical recovery in 2010. Our year-end financial statements indicate an excess of revenue over expenses and a major improvement in cash management. With a "healthy" financial bottom line and better than industry benchmarks for number of days of cash on hand, we were able to continue, expand or promote our mission and our core programs and services. Provision of a maintenance program to those community members that have completed a course of physical therapy treatments to maintain their highest level of physical functioning.Further upgrades in diagnostic equipment have been made in our lab, radiology and surgical services. Implemented PAC's system in radiology to allow physicians real time computer based access to patient imaging.Upgraded information technology in our lab and radiology departments.Continue services in family health centers to allow for greater access by working families and the underserved. Recruited a board certified internist and a family practice physician.Private rooms are provided based on patient need.Maintained a high level of transcription services to improve legibility of medical records.Emergency Department protocols, policies and procedures continue to be under review and revision for ongoing improvement of clinical excellence.*Immunizations are provided to adult housing facilities and the local community.Continued on Schedule O.
	Part V - Explanation of Number of Facility Type	N/A
	Part VI - Needs Assessment	Critical Access Hospital Status:The 1997 Balanced Budget Act (BBA) significantly reduced Medicare payments to rural hospitals, thereby severely affecting many rural hospitals' long term financial viability. To remedy the situation, the U.S. Congress created the Rural Hospital Flexibility Program to allow certain rural hospitals to convert to Critical Access Hospital status and receive retrospective, cost based Medicare reimbursements. Since 2001, Margaretville Hospital ("MH") has maintained this status.Mission Statement:Margaretville Hospital is a rural community health care provider within the HealthAlliance of the Hudson Valley system. MH provides a continuum of care to persons in Delaware, Greene, Ulster and Schoharie Counties. We provide excellence in personalized family health services through our primary care centers, acute care hospital, emergency care, wellness programs and long term care services. For over 78 years, MH has been, and will continue to be, an organization that contributes to the economic, social and educational wellbeing of the region.Performance in Meeting Community Health Needs:During the past year, we have worked hard to ensure that all of our service area continues to receive primary, specialty and emergency medical care as needed. We continue to analyze patient demographic data and health care migration patterns to ensure that we are current in our understanding of the communities' needs.Utilizing monthly patient survey/opinion scorecards, we monitor our performance based on exit interviews with both our inpatients and outpatients. This review instrument has provided our clinical leadership group with useful information in areas such as dietary, nursing care, medical staff, laboratory and radiology.Margaretville Hospital continues to receive recognition for quality medical care as evidenced by IPRO indicators, JCAHO/Department of Health and outpatient medical record compliance audit. Through community forums, speaking engagements by senior management and medical staff and Board of Trustees community outreach, we are confident that our performance is meeting the communities' health needs. Performance in Providing Charity Care:As reviewed by our Finance Committee and our Board of Trustees annually, our charity care policy stipulates that no patient shall be denied care or treatment as a result of his/her inability to pay for such care. In those cases where non-insured patients who do not qualify for Medicaid or other federal programs, but do quality for charity care, these individuals shall have access to and do receive the appropriate level of care consistent with the Mission of the hospital and our adopted Charity Care policies.Performance in Improving Access to Health Services for the Underserved:We continue to meet the identified needs and challenges of providing rural health services. Our initiatives have been specific to identified areas of need and complement our previous efforts.Continued increased utilization of family health centers with expanded hours to meet the needs of working families and single parent households including immunization programs with extended clinic hours.Expanded social services with increased utilization of the swing bed program. Access to a computer work station located in the patient recreation room which provides access to web sites to obtain information regarding medical concerns.Continued operation of the hospital's ambulance service.Continue to develop and expand the community Wellness program to provide educational opportunities in medical specialty areas.Continue to provide 2 Health Fairs annually to the community.Corporate Structure:HealthAlliance, Inc, an integrated delivery system including Benedictine Hospital and The Kingston Hospital, is the active parent of Margaretville Hospital. Continued at "Additional Information" section.
	Part III, Line 9b - Provisions On Collection Practices For Qualified Patients	The Credit and Collection Policy for Self Pay Balances provides that, in some cases, non insured patients that do not qualify for Medicaid qualify for charity care. In those instances the Credit and Collection Department will follow the guidelines as set forth in the Charity Care policy. The Charity Care Policy provides that the Financial Counselor evaluates the information provided in patients Charity Care application in conjunction with Federal Income Poverty Guidelines to determine the write-off percentage. If the patient/guarantor qualifies for Charity Care based on the sliding scale, the patient will be required to pay the outstanding amount. A payment plan is established not to exceed 10% of the guarantors gross monthly income.
	Part III, Line 8 - Explanation Of Shortfall As Community Benefit	Since Margaretville Hospital is a Critical Access Hospital, the hospital receives 101% of its cost for most of its services, therefore, Margaretville should always have a profit from Medicare. The amount reported on Line 6 was derived by using the Medicare allowable costs as reported on the Hospital's New York State Institutional Cost Report and the applicable adjustments from Worksheet B.
	Part III, Line 4 - Bad Debt Expense	A/F/S Footnote - Receivables for Patient Care and Allowances for Doubtful AccountsPatient accounts receivable are recorded when health services are provided by Margaretville. Additions to the allowance for doubtful accounts are recorded to the provision for bad debts. Accounts written-off as uncollectible are deducted from the allowance for doubtful accounts. The amount of the allowance for doubtful accounts is based upon managements assessments of historical and expected net collections, business and economic conditions, trends in Medicare and Medicaid health care coverage and other collection indicators.Bad debt expense at cost is $182,431. Bad debt expense per the audited financial statement is $323,574.The cost-to-charge ratio derived from The New York State Institutional Cost Report was applied to the bad debt expense per the audited financial statements to determine the amount reported in Part III, line 2.
	Part I, Line 7g - Costs Associated With Physicans Clinics	The costs on line 7g include $693,054 of costs attributable to physician clinics.
	Part I, Line 7 - Explanation of Costing Methodology	Margaretville Memorial Hospital's costing methodology was based upon the 2010 New York State Institutional Cost Report and the 2010 Medicare (Form 2552) Cost Report. These cost reports are filed with the New York State Department of Health and the applicable CMS intermediary, respectively. The cost-to-charge ratio derived from The New York State Institutional Cost Report was used for the various sub-line items of line #7.

Schedule H (Form 990) 2010

Additional Data

Software ID:	10000105
Software Version:	2010v3.2

- TIN:

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

Margaretville Memorial Hospital

Employer identification number

15-0552726

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? ........

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)
(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) Steven Haas	(i) (ii)	192,954	11,000		5,079	15,447	224,480
(2) Sanda Horan	(i) (ii)	152,036	11,000		3,866	5,375	172,277
(3) Robert Seidman	(i) (ii)	259,574		10,535	13,841	15,458	299,408
(4) Margo McGilvrey	(i) (ii)	197,769	14,000	4,500	5,000	10,166	231,435
(5) Joshua Ratner	(i) (ii)	207,001	14,000	15,612	3,928	13,039	253,580
(6) John Finch	(i) (ii)	219,687		8,399	11,659	15,127	254,872
(7) Frank Ehrlich	(i) (ii)	294,704		22,280		10,665	327,649
(8) David Scarpino	(i) (ii)	271,789	41,500	4,500	6,875	13,373	338,037
(9) David Lundquist	(i) (ii)	513,073	81,250	15,564	13,027	9,563	632,477
(10) Charles Flinn	(i) (ii)	268,173	14,000	4,500	3,438	5,114	295,225

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

Schedule J (Form 990) 2010

Additional Data

Software ID:	10000105
Software Version:	2010v3.2

- 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

Margaretville Memorial Hospital

Employer identification number

15-0552726

Identifier	Return Reference	Explanation
	Schedule H, Part VI, Needs Assessment	Three Year Implementation Report (continued)Exercise equipment is provided to staff on the campus.Alcohol and drug counseling services continue to be available weekly.Cultural diversities and preferences are met on an individual basis including dietary, privacy needs, religious practices and language interpreters.Medical screenings and outreach programs have been expanded to include health fairs and community events such as the annual Flea Market.Views and input from the community are solicited by participation at community group meetings and round table discussions as well as enhancing patient survey information.Continue to network with other rural health care providers to promote professional growth and resources.Serving the community in 2010 and Beyond:MH will continue to participate in a wide variety of Health Fairs, Health Screenings, community education events, public forums, etc. designed to raise awareness and improve health status.Solicitation of feedback from patients in the community at large will continue through a variety of mechanisms.Commitment to quality improvement will be sustained through the development of treatment protocols and the use of benchmarking to identify opportunities and measure success. Leadership will continue to reach out to the public and strengthen the ties between the hospital and those we serve.Continue to aggressively market our quality based and community centered health care philosophy to effectively meet the health care needs of those we serve.Telemedicine Initiative (web-based) for MH Emergency Department to TKH Emergency Department for assisting in patient assessment and care under development.*Received a Certificate of Need approval and did expand the square footage in our Emergency Department.
	Schedule H, Part V, Section B	PURSUANT TO IRS ANNOUNCEMENT 2011-37 DATED JUNE 9, 2011, SCHEDULE H PART V SECTION B WAS MADE OPTIONAL FOR 2010. ACCORDINGLY MARGARETVILLE MEMORIAL HOSPITAL HAS ELECTED NOT TO COMPLETE THIS SECTION. HOWEVER, DUE TO LACERTE SOFTWARE DESIGN LIMITATIONS THE PROGRAM ERRONEOUSLY COMPLETED SECTION B AND COULD NOT BE OVERRIDDEN. ACCORDINGLY SECTION B SHOULD BE DISREGARDED AS MARGARETVILLE MEMORIAL HOSPITAL HAS ELECTED NOT TO COMPLETE THIS SECTION.
Form 990, Part VI, Line 19	Form 990, Part VI, Line 19: Other Organization Documents Publicly Available	Upon request, the organization will make available only those documents required to be disclosed under the public inspection laws.
Form 990, Part VI, Line 15b	Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees	Reviewed through internal Compensation Committee, along with verification of all external fair market value analysis and data.
Form 990, Part VI, Line 12c	Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts	Annual compliance questionnaires are required to be signed by all officers, directors, trustees and key employees. All questionnaires are returned to the Corporate Compliance officer for review and filing. If a conflict is noted, the Officer reports said conflict to the CEO and Board of Directors for discussion and resolution. Once a resolution is met, the Officer instructs the individual who completed the questionnaire of a final outcome and action plan if applicable.
Form 990, Part VI, Line 11	Form 990, Part VI, Line 11: Form 990 Review Process	The finance director and CFO undertake a detailed review of the 990. In addition, select board members undertake a review of the organization's Form 990 and then review with the CFO any commentary, observations, and recommendations, as appropriate.
Form 990, Part VI, Line 7a	Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body	Health Alliance, Inc., the sole corporate member of Margaretville Memorial Hospital, has the power to elect one or more members of the local governing body of the Hospital.
Form 990, Part VI, Line 6	Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder	Health Alliance, Inc., which is a tax-exempt organization, is the sole corporate member of Margaretville Memorial Hospital.

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:	10000105
Software Version:	2010v3.2

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Margaretville Memorial Hospital

Employer identification number

15-0552726

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) Benedictine Medical PC 105 Marys Avenue Kingston,NY12401 14-1764537	Inactive Medical PC	NY	501(C)(3)	11A	Benedictine Hospital		No
(2) Benedictine Hospital 105 Marys Avenue Kingston,NY12401 14-1338470	Operate a Tax-Exempt Hospital	NY	501(C)(3)	3	Health Alliance INC		No
(3) Kingston Regional Senior Living Corp 396 Broadway Kingston,NY12401 30-0164277	Operate a Continuing Care Retirement Community	NY	501(C)(3)	9	Kingston Community Services Corp		No
(4) Kingston Community Services Corp 396 Broadway Kingston,NY12401 14-1684383	Private Non-Operating Foundation	NY	501(C)(3)	PF	Health Alliance INC		No
(5) FASC Foundation 741 Grant Avenue Lake Katrine,NY12449 26-4201295	Supporting Foundation	NY	501(C)(3)	7	The Kingston Hospital		No
(6) Health Alliance INC 741 Grant Avenue Lake Katrine,NY12449 26-1850453	Support	NY	501(C)(3)	11A	NA		No
(7) The Kingston Hospital 396 Broadway Kingston,NY12401 14-1349558	Operate a Tax-Exempt Hospital	NY	501(C)(3)	3	Health Alliance INC		No
(8) Margaretville Nursing Home INC 42158 State Highway 28 Margaretville,NY12455 22-3143565	Operate a Skilled Nursing Facility	NY	501(C)(3)	9	Margaretville Memorial Hospital	Yes
(9) Margaretville Health Foundation 42084 State Highway 28 Margaretville,NY124552820 26-1998454	Supporting Foundation	NY	501(C)(3)	11A	Margaretville Memorial Hospital	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Multi Provider Support Services LLC 105 Marys Avenue Kingston,NY12401 14-1811898	Office Supp	NY	N/A	Related				No			No
(2) Comprehensive Support Services LLC 45 Pine Grove Avenue Kingston,NY12401 14-1805027	Diag Imag	NY	N/A	Related				No			No
(3) Ulster Radiation & Oncology Center 117 Marys Avenue Kingston,NY12401	Rad Oncol	NY	N/A	Related				No			No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)
(1) Mid Hudson Physicians PC 396 Broadway Kingston,NY12401 20-3564769	Medical Services	NY	Kingston Hospital	C Corp
(2) Kingston Regional Health Care Enterprise 396 Broadway Kingston,NY12401 16-1514994	Real Estate Investment	NY	Kingston Hospital	C Corp

Schedule R (Form 990) 2010

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .

Yes

m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1) Margaretville Nursing Home INC	o	91,771	cost
(2) Margaretville Nursing Home INC	n	119,530	cost
(3) Margaretville Health Foundation	c	362,936	cost
(4)
(5)
(6)

Schedule R (Form 990) 2010

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Are all partners section 501(c)(3) organizations?		(e) Share of end-of-year assets	(f) Disproprtionate allocations?		(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(h) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(e) Share of end-of-year assets	Yes	No	(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:	10000105
Software Version:	2010v3.2

1	Briefly describe the organization’s mission or most significant activities: Margaretville Memorial Hospital ("MMH") is a rural Critical Access Hospital whose mission is to provide immediate access to high quality medical care and diagnostic testing services to medically underserved areas in the Catskill Mountains.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	20
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	17
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	160
6	Total number of volunteers (estimate if necessary) ....	6	3
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	359,791	516,196
9	Program service revenue (Part VIII, line 2g) .........	9,937,785	11,022,641
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	30,851	45,606
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	423,170	521,594
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	10,751,597	12,106,037
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4) ....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	5,800,095	5,613,180
16a	Professional fundraising fees (Part IX, column (A), line 11e)....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	4,472,924	5,075,224
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	10,273,019	10,688,404
19	Revenue less expenses. Subtract line 18 from line 12......	478,578	1,417,633
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	8,419,741	10,677,428
21	Total liabilities (Part X, line 26)............	6,903,061	7,624,841
22	Net assets or fund balances. Subtract line 21 from line 20 .....	1,516,680	3,052,587

Sign Here

	Signature of officer	Date

	Type or print name and title.

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (see instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.


4a	(Code: ) (Expenses $ 7,355,479 including grants of $ ) (Revenue $ 11,307,039 )
	Margaretville Hospital is a voluntary, not for profit corporation providing acute health care services to residents and visitors to the Catskill region. Margaretville Memorial Hospital recorded 2,232 patient days, 3,961 Emergency Room visits, 117 outpatient surgeries, 7,386 clinic visits (MFHC closed 10/1/10 & RFHC closed 11/12/10), 372 discharges and 189 infusion therapies.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 7,355,479

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	367,286	2,849,400	211,636

				(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		70,000
e	Government grants (contributions)1e		360,963

f	All other contributions, gifts, grants, and similar amounts not included above1f		85,233
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			516,196
			Business Code
2a	Net Patient Serv. Rev		621,300	11,022,641	11,022,641
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			11,022,641
3	Investment income (including dividends, interest
	and other similar amounts).....			38,822			38,822
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents	22,847
b	Less: rental expenses
c	Rental income or (loss)	22,847
d	Net rental income or (loss).......			22,847			22,847
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	15,007	4,500
b	Less: cost or other basis and sales expenses	12,418	305
c	Gain or (loss)	2,589	4,195
d	Net gain or (loss)..........			6,784			6,784
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
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...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	Shared Services		561,000	284,398	284,398
b	Miscellaneous Income		900,099	139,424			139,424
c	Ambulance Income		621,910	74,925			74,925
d	All other revenue ....
e	Total. Add lines 11a–11d ......			498,747
12	Total revenue. See Instructions....			12,106,037	11,307,039		282,802


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			896,736	1	748,273
2	Savings and temporary cash investments .......			187,632	2	0
3	Pledges and grants receivable, net .........			70,374	3	26,918
4	Accounts receivable, net .........			633,171	4	1,102,642
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5	0
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	0
7	Notes and loans receivable, net .............				7	0
8	Inventories for sale or use ..............			209,717	8	224,341
9	Prepaid expenses and deferred charges ............			68,291	9	45,934
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	14,514,878
b	Less: accumulated depreciation. .....	10b	10,430,928	1,927,385	10c	4,083,950
11	Investments—publicly traded securities ..........				11	0
12	Investments—other securities. See Part IV, line 11 ......				12	0
13	Investments—program-related. See Part IV, line 11 ..				13	0
14	Intangible assets .........				14	0
15	Other assets. See Part IV, line 11 ...........			4,426,435	15	4,445,370
16	Total assets. Add lines 1 through 15 (must equal line 34)...			8,419,741	16	10,677,428
17	Accounts payable and accrued expenses .			1,490,917	17	1,392,068
18	Grants payable ..........				18
19	Deferred revenue ..........			70,725	19	1,171
20	Tax-exempt bond liabilities ..........				20
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 ..			1,439,838	23	1,577,385
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			3,901,581	25	4,654,217
26	Total liabilities. Add lines 17 through 25.....			6,903,061	26	7,624,841
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			1,230,088	27	3,048,089
28	Temporarily restricted net assets .....			509,092	28	226,998
29	Permanently restricted net assets .....			-222,500	29	-222,500
	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 .....			1,516,680	33	3,052,587
34	Total liabilities and net assets/fund balances .....			8,419,741	34	10,677,428