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) HOWARD BLACK MD SECRETARY	1	X				0	0
(2) MATTHEW BOIRE VICE CHAIR	1	X				0	0
(3) HERB CARPENTER BOARD MEMBER	1	X				0	0
(4) HAROLD CHASKEY MD BOARD MEMBER	1	X				0	0
(5) JAMES DELUCAS MD BOARD MEMBER	1	X				0	0
(6) ALEX EDWARDS BOARD MEMBER	1	X				0	0
(7) JOHN ETTLING PHD BOARD MEMBER	1	X				0	0
(8) GINNY HAY BOARD MEMBER	1	X				0	0
(9) ADORE FLYNN-KURTZ BOARD MEMBER	1	X				0	0
(10) LINDA LUCK PHD BOARD MEMBER	1	X				0	0
(11) JOHN MASELLA CHAIR	1	X				0	0
(12) ALICE RECORE TREASURER	1	X				0	0
(13) CURT SNYDER MD BOARD MEMBER	1	X				0	0
(14) DREW SABELLA BOARD MEMBER	1	X				0	0
(15) JOHN ZURLO BOARD MEMBER	1	X				0	0
(16) STEPHENS MUNDY PRESIDENT	45		X	X	X	702,147	47,416
(17) WOUTER RIETSEMA MD MEDICAL DIRECTOR	45		X	X	X	367,260	47,155

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) JOYCE RAFFERTY VP OF FINANCE	45	X	X	X		341,654	0	51,124
(19) CYNTHIA GARDNER VP PATIENT SERVICES	45	X	X	X		266,993	0	23,085
(20) NOREEN BRADY VP HUMAN RESOURCES	45		X	X	X	194,982	0	23,095
(21) DEBRA DONAHUE VP PLANNING & PROFESSIONAL SERVICES	45		X	X		219,071	0	40,222
(22) CHARLES VOLK ORTHOPEDIC SURGEON	45		X	X		574,929	0	35,968
(23) JOHN GRIFFIN MEDICAL ONCOLOGIST	45		X	X		549,763	0	40,352
(24) JOSEPH ARGUELLES NEUROSURGEON	45		X	X		453,130	0	37,392
(25) SAMER SIOUFFI PHYSICIAN	45		X	X		452,057	0	23,166
(26) STEPHAN CURRY ANESTHESIOLOGIST	45		X	X		400,942	0	35,284
(27) SHAUN SMITH VP/CHIEF HUMAN RESOURCES	45		X	X		36,054	0	6,608

(A) Name and business address	(B) Description of services	(C) Compensation
MEDICUS ANESTHESIA SERVICES LLC 7 INDUSTRIAL WAY SALEM,NH03079	ANESTHESIOLOGIST SERVICES	445,244
MEDICAL SEARCH LLC PO BOX 535213 ATLANTA,GA30353	LOCUM PHYSICIANS	422,792
MUHAMMOND AHMAD 117 EAGLE CITY CV HUNTERTOWN,IN46748	ANESTHESIOLOGIST	353,122
NIXON PEABODY LLP 1100 CLINTON SQUARE ROCHESTER,NY14604	LEGAL	254,159
MARGARET BALASSONE MD PO BOX 227 SARANAC LAKE,NY12983	ANESTHESIOLOGIST	225,713
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 16

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	4,558,982		4,558,982
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	115,415,402	102,842,405	12,572,997
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	5,336,040	4,574,069	761,971
9	Other employee benefits .......	20,534,968	17,602,638	2,932,330
10	Payroll taxes ...........	8,269,552	7,088,703	1,180,849
11	Fees for services (non-employees):
a	Management ......	10,715,798	8,125,899	2,589,899
b	Legal .........	455,886		455,886
c	Accounting ...........	144,080		144,080
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	11,968,648	9,075,948	2,892,700
12	Advertising and promotion ....	916,281	694,825	221,456
13	Office expenses .......	547,165	414,921	132,244
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	1,093,779	606,339	487,440
17	Travel ............	473,215	331,906	141,309
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	4,043,863	4,043,863	0
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	15,707,556	13,531,963	2,175,593
23	Insurance ..............	1,363,575	1,034,013	329,562
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	SUPPLIES	47,929,200	45,875,416	2,053,784
b	BAD DEBTS	8,726,129	6,617,113	2,109,016
c	LEASE/RENTALS	4,645,114	1,499,147	3,145,967
d	MAINTENANCE & REPAIRS	3,580,253	2,714,942	865,311
e	OTHER EXPENSES (LAUNDRY, POSTAGE, PRINTING, PHONE, RECRUITING, CONSULTING)	3,110,564	2,330,755	779,809
f	All other expenses
25	Total functional expenses. Add lines 1 through 24f	269,536,050	229,004,865	40,531,185	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 ..........		1
2	Savings and temporary cash investments .......	18,940,975	2	21,070,225
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	33,360,079	4	38,526,267
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	3,890,141	8	3,792,107
9	Prepaid expenses and deferred charges ............	5,699,593	9	4,861,649
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	281,487,492
b	Less: accumulated depreciation. .....	10b	170,721,439	104,515,751	10c	110,766,053
11	Investments—publicly traded securities ..........	29,291,424	11	31,575,389
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	7,210,518	15	7,056,788
16	Total assets. Add lines 1 through 15 (must equal line 34)...	202,908,481	16	217,648,478
	17	Accounts payable and accrued expenses .	19,737,836	17	20,416,818
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........	38,280,000	20	35,640,000
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 ..	38,833,476	23	42,583,366
24	Unsecured notes and loans payable to unrelated third parties ....	5,000,000	24	4,928,459
25	Other liabilities. Complete Part X of Schedule D.....	50,034,301	25	52,303,083
26	Total liabilities. Add lines 17 through 25.....	151,885,613	26	155,871,726
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	48,546,678	27	59,180,840
28	Temporarily restricted net assets .....	1,132,247	28	1,251,969
29	Permanently restricted net assets .....	1,343,943	29	1,343,943
	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 .....	51,022,868	33	61,776,752
34	Total liabilities and net assets/fund balances .....	202,908,481	34	217,648,478

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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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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:	10000077
Software Version:	v1.00

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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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
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 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER
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
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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:	10000077
Software Version:	v1.00

- 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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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
1a	Beginning of year balance ....	28,439,452	30,574,187	51,619,138
b	Contributions ........	0	0	846,429
c	Investment earnings or losses ...	2,733,512	4,650,730	-4,318,606
d	Grants or scholarships .....	0	0	0
e	Other expenditures for facilities and programs ........	1,054,609	5,414,154	17,088,730
f	Administrative expenses ....	788,752	1,371,311	484,044
g	End of year balance ......	29,329,603	28,439,452	30,574,187

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

Board designated or quasi-endowment: SchDMd Bullet

91.1 %

Permanent endowment: SchDMd Bullet

4.3 %

Term endowment: SchDMd Bullet

4.6 %

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)

Yes

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

Yes

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		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	0	1,207,815		1,207,815
b	Buildings ................	0	155,754,980	79,111,106	76,643,874
c	Leasehold improvements ............	0	3,154,531	0	3,154,531
d	Equipment ................	0	121,326,000	91,610,333	29,715,667
e	Other .................	0	44,166	0	44,166
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........					110,766,053

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









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

Part X

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

1.(a) Description of Liability		(b) Amount
Federal Income Taxes
DEFERRED COMPENSATION PLAN		3,167,135
ACCRUED PENSION COSTS		22,479,157
PROFESSIONAL LIABILITY		5,850,000
ASSET RETIREMENT OBLIGATION		297,138
THIRD PARTY SETTLEMENTS		3,508,000
DUE TO COMMUNITY PROVIDERS, INC.		3,950,841
SWAP AGREEMENT LIABILITY		6,935,110
L-T COMPENSATION RELATED		3,514,214
THIRD PARTY		2,568,000
DEFERRED REVENUE		33,488
Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		52,303,083
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	279,068,067
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	269,536,050
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	9,532,017
4	Net unrealized gains (losses) on investments ..........................	4	2,075,372
5	Donated services and use of facilities .............................	5	0
6	Investment expenses ...................................	6	0
7	Prior period adjustments ..................................	7	0
8	Other (Describe in Part XIV) .................................	8	-853,505
9	Total adjustments (net). Add lines 4 - 8 .............................	9	1,221,867
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	10,753,884

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	277,470,087
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	0
b	Donated services and use of facilities .........	2b	0
c	Recoveries of prior year grants ...........	2c	0
d	Other (Describe in Part XIV): ............	2d	0
e	Add lines 2a through 2d .....................			2e	0
3	Subtract line 2e from line 1.....................			3	277,470,087
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	0
b	Other (Describe in Part XIV): ...........	4b	1,597,980
c	Add lines 4a and 4b.......................			4c	1,597,980
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......			5	279,068,067

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	271,066,010
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a	0
b	Prior year adjustments ..............	2b	0
c	Other losses ................	2c	0
d	Other (Describe in Part XIV): ............	2d	1,529,960
e	Add lines 2a through 2d......................			2e	1,529,960
3	Subtract line 2e from line 1.....................			3	269,536,050
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	0
b	Other (Describe in Part XIV): ............	4b	0
c	Add lines 4a and 4b.......................			4c	0
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......			5	269,536,050

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
SchD_P05_S00_L04	Schedule D, Part V, Line 4	CERTAIN BOARD-DESIGNATED OR QUASI-ENDOWMENT FUNDS HAVE BEEN ESTABLISHED TO MEET SPECIFIC CURRENT AND FUTURE NEEDS OF THE HOSPITAL OR TO ADEQUATELY DISCHARGE FUTURE LIABILITIES. THESE FUNDS INCLUDE THE PLANT AND CAPITAL IMPROVEMENT FUNDS, WHICH ARE DESIGNATED FOR SPECIFIC PROJECTS SUCH AS THE SURGICAL CENTER CONSTRUCTION, AND DESIGNATED FUNDS FOR BOTH SELF-INSURANCE AND FOR CVPH'S VARIOUS EMPLOYEE BENEFIT PLANS. TEMPORARILY RESTRICTED NET ASSETS ARE INTENDED FOR THE PURCHASE OF PROPERTY AND EQUIPMENT. PERMANENTLY RESTRICTED NET ASSETS ARE TO BE HELD IN PERPETUITY, THE INCOME FROM WHICH IS EXPENDABLE TO SUPPORT HEALTH CARE SERVICES, INCLUDING MEDICAL SERVICES PROVIDED TO CHILDREN, AND PROVIDING FOR CHARITY CARE.
SchD_P10_S00_L02	Schedule D, Part X, Line 2	THE MEDICAL CENTER IS A NOT-FOR-PROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. EFFECTIVE JANUARY 1, 2007, THE MEDICAL CENTER ADOPTED PROVISIONS OF FIN 48. FIN 48 ADDRESSES THE ACCOUNTING UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTERPRISE'S FINANCIAL STATEMENTS AND PRESCRIBES A THRESHOLD OF MORE-LIKELY-THAN-NOT FOR RECOGNITION AND DERECOGNITION OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. FIN 48 ALSO PROVIDES RELATED GUIDANCE ON MEASUREMENT, CLASSIFICATION, INTEREST AND PENALTIES, AND DISCLOSURE. THE ADOPTION OF PROVISIONS OF FIN 48 DID NOT HAVE A MATERIAL EFFECT ON THE MEDICAL CENTER'S FINANCIAL STATEMENTS.
SchD_P11_S00_L08	Schedule D, Part XI, Line 8	BOOK INCOME OVER SCHEDULE K-1 INCOME -JT VENTURE: $252,575, CHANGE IN FAIR VALUE OF INTEREST RATE SWAP: ($1,529,961), OTHER: $6,079, PENSION PLAN RELATED AS A RESULT OF SFAS 158: $298,080, CHANGE IN INTEREST IN CVPH FOUNDATION: $119,722 TOTAL OTHER CHANGES IN FUND BALANCE: ($853,505)
SchD_P12_S00_L04b	Schedule D, Part XII, Line 4b	BOOK INCOME OVER SCHEDULE K-1 INCOME ($252,575) GOVERNMENT GRANTS $1,382,475 DISTRIBUTION OF RESTRICTED FUNDS FROM THE FOUNDATION OF CVPH MEDICAL CENTER $468,080 TOTAL = $1,597,980
SchD_P13_S00_L02d	Schedule D, Part XIII, Line 2d	CHANGE IN FAIR VALUE OF INTEREST RATE SWAP $1,529,960

Schedule D (Form 990) 2010

Additional Data

Software ID:	10000077
Software Version:	v1.00

- 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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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

	(a) Number of activities or programs (optional)	(b) Persons served (optional)	(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) ..			685,125	0	685,125	0.26 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .			31,368,718	19,601,078	11,767,640	4.51 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	0	0	32,053,843	19,601,078	12,452,765	4.77 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....			1,841,757	1,703,521	138,236	0.05 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..
jTotal Other Benefits ...	0	0	1,841,757	1,703,521	138,236	0.05 %
kTotal. Add lines 7d and 7j. ..	0	0	33,895,600	21,304,599	12,591,001	4.82 %

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).....

3,747,000

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

1,498,800

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).....

98,696,167

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

114,972,134

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

-16,275,967

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 %
1VALCOUR IMAGING LLC	IMAGING SERVICES	75 %	0 %	25 %
2PET SCAN LLC	IMAGING SERVICES	49 %	0 %	51 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CETNER 75 BEEKMAN ST PLATTSBURGH,NY12901	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:CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CETNER

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

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet those needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Development of a community benefit plan for the facility
	d	Participation in community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the CHNA
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs.		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?..		9	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for free care: 150%

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	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 400%
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	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	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	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	Yes
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	Yes
	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?10
Name and address		Type of Facility (Describe)
1	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
2	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
3	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
4	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
5	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
6	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
7	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
8	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
9	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY
10	CVPH AMBULATORY SURGERY CENTER 77 PLAZA BLVD PLATTSBURGH,NY12901	AMBULATORY SURGERY

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
SchH_P01_S00_L03c	Schedule H, Part I, Line 3c
SchH_P01_S00_L06a	Schedule H, Part I, Line 6a
SchH_P01_S00_L07	Schedule H, Part I, Line 7	IN ACCORDANCE WITH THE IRS INSTRUCTIONS, CVPH USED THE RATIO OF COST TO CHARGES TO CALCULATE COSTS. SPECIFICALLY, THE FACILITY'S TOTAL EXPENSES FROM PART IX LINE 25 OF $269,536,050 LESS BAD DEBT EXPENSES OF $8,726,129 PER PART IX LINE 24E LESS COMMUNITY BENEFIT EXPENSES PER SCH. H PART 1 LINE 7(E)(C) OF $1,841,757 WAS USED TO DETERMINE THE 2010 RCC PERCENTAGE. THE GROSS CHARITY CARE WRITE OFFS WAS OBTAINED FROM OUR REVENUE REPORTS AND TO WHICH THE CALCULATED RCC APPLIED. LINE 7 (E): Clinton County NY is designated as a Healthcare Professional Shortage Area (HPSA) for Primary Care. To help alleviate the lack of access primary care in the county and surrounding area, CVPH has been operating a Health Center Clinic to provide medical treatment for this at risk population. During 2010 this clinic had in excess of 20,000 patient encounters with a payer mix of 59.09% Medicaid and Medicare, 38.24% Commercial and 2.67% self pay.
SchH_P01_S00_L072f	Schedule H, Part I, Line 7, Column f	AMOUNT OF BAD DEBT EXPENSE INCLUDED IN FORM 990 PART IX LINE 25 COLUMN (A), BUT REMOVED FROM THIS FIGURE FOR PURPOSES OF CALCULATING THE RCC PERCENTAGE WAS $8,726,129 AS REFLECTED ON PART IX LINE 24(E).
SchH_P01_S00_L07g	Schedule H, Part I, Line 7g
SchH_P03_S0A_L04	Schedule H, Part III, Section A, Line 4	IN ACCORDANCE WITH IRS 990 INSTRUCTIONS CVPH APPLIED THE CALCULATED RATIO OF COST TO CHARGES TO THE FACILITY'S 2010 BAD DEBT EXPENSE OF $8,726,129 IN ORDER TO CALCULATE THE BAD DEBT EXPENSE (AT COST) AS REPORTED ON PART III LINE 2.
SchH_P03_S0B_L08	Schedule H, Part III, Section B, Line 8	USED MEDICARE ONLY TOTAL CHARGES FROM INSTITUTIONAL COST REPORT FOR 2010 AND APPLIED THE RATIO OF COST TO CHARGES FROM THE 2010 COST REPORT DATA. APPROXIMATELY 48% OF OUR REVENUE IS DERIVED FROM MEDICARE PATIENTS. WE FEEL THE SHORTFALL FROM THIS PROGRAM IS DIRECTLY A COMMUNITY BENEFIT IN THAT WE ARE SOLE COMMUNITY HOSPITAL.
SchH_P03_S0C_L09b	Schedule H, Part III, Section C, Line 9b	CVPH HAS A FORMAL CREDIT AND COLLECTION POLICY. ALL PATIENT ACCOUNTS WILL BE BILLED AND FOLLOWED UP ON IN A TIMELY FASHION. ALL DISCOUNTS WILL BE APPLIED AND OFFERED PER POLICY, UNIFORMLY AND WITHOUT PREJUDICE OR DISCRIMINATION. THE POLICY CONSISTS OF DOCUMENTED PROCEDURES FOR INSURANCE, CREDIT BALANCES, SELF PAY OUTPATIENT, AND SELF PAY INPATIENT (NO INSURANCE & AFTER INSURANCE). THERE ARE SPECIFIED PAYMENT ARRANGEMENTS THAT ARE OFFERED AND THE TIME FRAME ALLOTTED FOR REPAYMENT IS GRADUATED BASED ON THE AMOUNT OWED, RANGING FROM 30 DAYS TO 36 MONTHS. CUSTOMER SERVICE REPRESENTATIVES PLACE PHONE CALLS TO PATIENTS TO RESOLVE ACCOUNTS OR ESTABLISH PAYMENT ARRANGEMENTS. AFTER ACCOUNTS HAVE BEEN AT THE PRIMARY BAD DEBT AGENCY FOR A PERIOD OF 6 MONTHS WITHOUT PAYMENTS, THE ACCOUNTS ARE FORWARDED TO A SECOND PLACEMENT AGENCY FOR ATTEMPTED RECOVERY.
SchH_P06_S00_L02	Schedule H, Part VI, Line 2	CVPH WORKS BOTH COLLABORATIVELY AND INDEPENDENTLY TO ASSESS THE HEALTH-CARE NEEDS OF THE COMMUNITIES IT SERVES. IN COLLABORATION WITH OTHER HOSPITALS, HEALTH DEPARTMENTS AND AGENCIES FROM THE COUNTIES OF CLINTON, ESSEX AND FRANKLIN IN NEW YORK CVPH PARTICIPATES IN THE MAPPING OUR WAY TO A HEALTHIER COMMUNITY PROCESS THAT IS COORDINATED BY THE NEW YORK STATE DEPARTMENT OF HEALTH. GOAL IS TO ANALYZE DATA AND SEEK OPINIONS FROM THE PUBLIC TO DETERMINE THE MAJOR CHALLENGES, NEEDS AND BARRIERS TO PROVIDING SERVICES. BY BRINGING THE VARIOUS PROVIDERS TOGETHER FROM A THREE-COUNTY AREA IT IS BELIEVED THAT THIS PROVIDES A BROADER, MORE REPRESENTATIVE DETERMINATION OF THE NEEDS THAT EXIST. A FOUR-STEP PROCESS IS USED TO ESTABLISH PRIORITIES AS PART OF THE FORMALIZED COMMUNITY HEALTH ASSESSMENT. DATA IS COMPILED AND ANALYZED, PRIORITIES ARE DETERMINED, FOCUS GROUPS SEEK CONSENSUS AND REPORT OUT, DATA IS FURTHER WEIGHTED AND A FINAL SELECTION OF PRIORITIES FOCUSING ON ACCESS TO CARE AND THE NEED TO DIRECT RESOURCES TO TREATMENT OF CHRONIC DISEASE WERE ADOPTED AS KEY NEEDS. TO THAT END CVPH HAS DIRECTED RESOURCES TO SUPPORT OF THE ADIRONDACK REGION MEDICAL HOME, PHYSICIAN RECRUITMENT, ITS DIABETES EDUCATION CENTER AND COMMUNITY EFFORT RELATED TO THE IMPORTANCE OF PROPER NUTRITION AND EXERCISE. WORKING INDEPENDENTLY, CVPH ASSESSES NEEDS BY ENCOURAGING AN OPEN DIALOGUE WITH ITS VARIOUS COMMUNITY CONSTITUENCIES. THE MEDICAL CENTER HOSTS MEETINGS, VISITS CLUBS AND ORGANIZATIONS, SURVEYS ITS PATIENTS, ENCOURAGES FEEDBACK THROUGH ITS WEB SITE AND INVITES FORMER PATIENTS FOR LUNCH AND TO SHARE OBSERVATIONS ABOUT UNMET NEEDS AND WAYS TO IMPROVE SERVICES WITH EMPHASIS ON FILLING EXISTING GAPS IN SERVICE. AS PART OF ITS STRATEGIC PLANNING PROCESS A COORDINATED AND FORMALIZED APPROACH IS TAKEN TO ASSESS PERCEIVED NEEDS FROM THE COMMUNITY, MEDICAL STAFF, EMPLOYEES AND BOARD MEMBERS UTILIZING FULL AND HALF-DAY MEETING SESSIONS.
SchH_P06_S00_L03	Schedule H, Part VI, Line 3	THE FOLLOWING INFORMATION IS LISTED ON EVERY PATIENT STATEMENT: "FINANCIAL AID MAY BE AVAILABLE TO QUALIFIED PATIENTS. PLEASE CALL OUR OFFICE AT 562-7074 TO SEE IF YOU QUALIFY." WE ALSO HAVE INFORMATIONAL FLYERS AT THE CASHIERS DESK AND SEVERAL OTHER AREAS IN THE HOSPITAL. AT TIME OF REGISTRATION FOR EVERY SELF PAY PATIENT, WE ASK PERMISSION TO HAVE THE PATIENT CONTACTED TO SEE IF THEY QUALIFY FOR MEDICAID. ALSO, WHEN MAKING A CALL TO COLLECT ON PATIENT ACCOUNTS, THE PATIENT IS OFFERED TO TAKE PART IN CVPH'S CARES PROGRAM WHERE APPROPRIATE TO DO SO.
SchH_P06_S00_L04	Schedule H, Part VI, Line 4	THE PRIMARY SERVICE AREA FOR CVPH IS DEFINED AS CLINTON COUNTY AND THE NORTHEAST CORNER OF ESSEX COUNTY. THE REMAINDER OF ESSEX COUNTY, FRANKLIN COUNTY AND THE EASTERN HALF OF ST. LAWRENCE COUNTY REPRESENT THE SECONDARY SERVICE AREA FOR CVPH MEDICAL CENTER. OUR PAYER MIX IS 33.4% COMMERCIAL, 11.76% MEDICAID, 47.91% MEDICARE, 3.90% OTHER AND 3.03% SELF PAY. CVPH IS THE ONLY HOSPITAL IN CLINTON COUNTY, WHICH HAS A POPULATION OF APPROXIMATELY 83,000 AND IS THE LARGEST EMPLOYER IN THE TRI-COUNTY AREA. CENSUS FIGURES FOR THE SERVICE AREA ARE MONITORED; HOWEVER CHANGES IN THE CENSUS FIGURES HAVE NOT BEEN HIGHLY SIGNIFICANT IN THE PAST DECADE. AS IN MUCH OF THE NATION, MOST NOTABLE IS THE AGING POPULATION, A TREND THAT IS BEING MONITORED BECAUSE OF THE CORRELATION BETWEEN AGE AND INCREASED UTILIZATION OF HEALTH SERVICES AND BECAUSE OF THE ANTICIPATED INCREASED NEED FOR HOME HALTH AND SKILLED NURSING FACILITIES THAT IF NOT PRESENT CREATE A BACKLOG FOR THE MEDICAL CENTER. A SNAPSHOT OF THE CENSUS IN CLINTON COUNTY AND THE SURROUNDING COUNTIES REFLECTS: A LOW POPULATION DENSITY WEHN COMPARED WITH THE REST OF NEW YORK STATE AND THE NATION, A PREDOMINANTLY WHITE/CAUCASIAN POPULATION WITH LITTLE DIVERSITY. IN CLINTON COUNTY A POPULATION SKEWING OLDER AS ONLY 24% OF THE POPULATION IS 19 OR YOUNGER WHILE 23% OF THE POPULATION IS AGE 55 OR OLDER, MEDIAN HOUSEHOLD AND FAMILY INCOMES SUBSTANTIALLY LOWER THAN THE REST OF NEW YORK STATE, LOWER EDUCATION LEVELS THAN THE AVERAGE FOR NEW YORK STATE. PART 6 LINE 5: COALITION BUILDING: COLUMN (A) CVPH AS THE LARGEST HEALTH RESOURCE IN THE NORTH COUNTRY COLLABORATES WITH NUMEROUS AGENCIES AND ORGANIZATIONS FOR MULTIPLE PURPOSES. CVPH IS A DRIVING FORCE IN CREATING THE ADIRONDACK REGION MEDICAL HOME PILOT, AN INITIATIVE MEANT TO IMPROVE CARE, CONSERVE RESOURCES, AND INCREASE ACCESS. IN 2010, CVPH PARTICIPATED WITH THE CLINTON, ESSEX, AND FRANKLIN COUNTY HEALTH DEPARTMENTS AND OTHER PROVIDERS INCLUDING ADIRONDACK MEDICAL CENTER, ALICE HYDE MEDICAL CENTER, AND ELIZABETHTOWN COMMUNITY HOSPITAL IN THE THREE-COUNTY REGION WITH FACT FINDING AND PUBLIC PARTICIPATION IN MEETING THE OBLIGATIONS OF THE COMMUNITY HEALTH ASSESSMENT AND MOBILIZING FOR ACTION THROUGH PLANNING AND PARTNERSHIPS PROCESS. CVPH IS A LEADER IN THE EXPLORE EDUCATIONAL CONSORTIUM ALONG WITH THE CLINTON COUNTY HEALTH DEPARTMENT, PLATTSBURGH STATE UNIVERSITY, CLINTON COMMUNITY COLLEGE, ETC., TO BRING FOUR ALL-DAY SEMINARS TO THE COMMUNITY FOR THE BENEFIT OF PROVIDERS. THE MEDICAL CENTER FACILITATES MEETINGS WITH AREA SKILLED NURSING FACILITIES TO ACHIEVE MAXIMUM ACCESS FOR RESIDENTS THROUGHOUT THE COUNTY. CVPH HOSTS A SPECIAL PROGRAM IN CONJUNCTION WITH STOP DOMESTIC VIOLENCE TO HEIGHTEN AWARENESS. THE MEDICAL CENTER, FITZPATRICK CANCER CENTER AND CVPH WOMEN'S IMAGING CENTER ARE ACTIVELY INVOLVED WITH THE CLINTON COUNTY HEALTH PARTNERSHIP TO PROMOTE CANCER SCREENING AND PROVIDE ACCESS FOR CARE. CVPH STAFF WORK WITH THE MEDICAL CENTER'S FOUNDATION TO DEVELOP CRITERIA AND MAKE SELECTIONS FOR SCHOLARSHIP RECIPIENTS. THESE SCHOLARSHIPS ARE FOR HIGH-SCHOOL SENIORS WHO WISH TO PURSUE HEALTH CAREERS AND EXISTING EMPLOYEES WHO WISH TO EXPAND THEIR EDUCATION AND ADVANCE THEIR SKILLS AS HEALTH PRACTITIONERS. PART VI, LINE 6: FROM A CANCER SURVIVORSHIP PROGRAM ON THE FRONT LAWN AND FREE COMMUNITY LECTURES TO SUPPORT GROUPS AND SCREENINGS. CVPH MEDICAL CENTER PLAYS AN IMPORTANT ROLE IN PROMOTING HEALTH IN ITS COMMUNITY. A FREE MONTHLY COMMUNITY LECTURE SERIES COVERS A WIDE RANGE OF TOPICS FROM DIABETERS AND CANCER TO BULLYING AND BACK CARE. CVPH SPONSORS A NUMBER OF FREE SUPPORT GROUPS INCLUDING PROGRAMS ON DIABETES, MULTIPLE CANCER GROUPS, AND BEREAVEMENT. AN ARRAY OF FOCUSED CLASSES IS HELD FOR EXPECTANT MOTHERS AS PART OF AN OVERALL CHILDBIRTH EDUCATION INITIATIVE. REGULAR CAR-SEAT SAFETY CHECKS ARE HELD TO ENSURE THAT INFANTS AND TODDLERS ARE APPROPRIATELY SECURED IN THEIR VEHICLES. CVPH WORKS IN CONJUNCTION WITH THE ADIRONDACK SAFE KIDS NETWORK FOR AN ANNUAL BIKE AND SKATEBOARD SAFETY FAIR THAT DISTRIBUTES HUNDREDS OF FREE SAFETY HELMETS. OF COURSE CVPH IS A REGULAR PARTICIPANT AT VARIOUS HEALTH FAIRS IN THE REGION DISPENSING EDUCATIONAL INFORMATION AND PROVIDING FREE HEALTH SCREENINGS. THE HEART CENTER COLLABORATES WITH THE LOCAL MALL TO PROMOTE EXERCISE BY WALKING THE INNER PERIMETER OF THE FACILITY. CVPH ALSO WORKS WITH OTHER AGENCIES TO FACILITATE INSURANCE COVERAGE FOR ELIGIBLE INDIVIDUALS AND FAMILIES. THE MEDICAL CENTER, FITZPATRICK CANCER CENTER AND CVPH WOMEN'S IMAGING CENTER ARE ACTIVELY INVOLVED WITH THE CLINTON COUNTY HEALTH PARTNERSHIP TO PROMOTE CANCER SCREENING AND PROVIDE ACCESS FOR CARE. CVPH ALSO PARTICIPATES WITH THE ACTION FOR HEALTH WORK GROUP CREATED AS PART OF THE MAPP/CHA PROCESS IN NEW YORK STATE. ACCOMPLISHMENTS OF THE ACTION FOR HEALTH INITIATIVE INCLUDE: -HOSTING NEW VISIONS PROGRAM FOR SELECTED COLLEGE BOUND HIGH-SCHOOL SENIORS PLANNING TO MAJOR IN A HEALTH-RELATED FIELD OF STUDY -CHRONIC DISEASE STRATEGIC PLANNING -DEVELOPMENT OF THE SARANAC RIVER TRAIL IN THE CITY OF PLATTSBURGH -MOVING TOBACCO PRODUCTS OUT OF SIGHT IN MANY RETAIL ESTABLISHMENTS -DEVELOPMENT OF THE CADYVILLE DISK GOLF COURSE -NUTRITIONAL IMPROVEMENTS IN SCHOOLS.
SchH_P06_S00_L06	Schedule H, Part VI, Line 6	FROM A CANCER SURVIVORSHIP PROGRAM ON THE FRONT LAWN AND FREE COMMUNITY LECTURES TO SUPPORT GROUPS AND SCREENINGS, CVPH MEDICAL CENTER PLAYS AN IMPORTANT ROLE IN PROMOTING HEALTH IN ITS COMMUNITY. A FREE MONTHLY COMMUNITY LECTURE SERIES COVERS A WIDE RANGE OF TOPICS FROM DIABETES AND CANCER TO BULLYING AND BACK CARE. CVPH SPONSORS A NUMBER OF FREE SUPPORT GROUPS INCLUDING PROGRAMS ON DIABETES, MULTIPLE CANCER GROUPS, AND BEREAVEMENT. AN ARRAY OF FOCUSED CLASSES IS HELD FOR EXPECTANT MOTHERES AS PART OF AN OVERALL CHILDBIRTH EDUCATION INITIATIVE. REGULAR CAR-SEAT SAFETY CHECKS ARE HELD TO INSURE THAT INFANTS AND TODDLERS ARE APPROPRIATELY SECURED IN THEIR VEHICLES. CVPH WORKS IN CONJUNCTION WITH THE ADIRONDACK SAFE KIDS NETWORK FOR AN ANNUAL BIKE AND SKATEBOARD SAFETY FAIR THAT DISTRIBUTES HUNDREDS OF FREE SAFETY HELMETS. OF COURSE CVPH IS A REGULAR PARTICIPANT AT VARIOUS HEALTH FAIRS IN THE REGION DISPENSING EDUCATIONAL INFORMATION AND PROVIDING FREE HEALTH SCREENINGS. THE HEART CENTER COLLABORATES WITH THE LOCAL MALL TO PROMOTE EXERCISE BY WALKING THE INNER PERIMETER OF THE FACILITY. CVPH ALSO WORKS WITH OTHER AGENCIES TO FACILITATE INSURANCE COVERAGE FOR ELIGIBLE INDIVIDUALS AND FAMILIES. THE MEDICAL CENTER , FITZPATRICK CANCER CENTER AND CVPH WOMEN'S IMAGING CENTER ARE ACTIVELY INVOLVED WITH THE CLINTON COUNTY HEALTH PARTNERSHIP TO PROMOTE CANCER SCREENING AND PROVIDE ACCESS FOR CARE. CVPH ALSO PARTICIPATES WITH THE ACTION FOR HEALTH WORK GROUP CREATED AS PART OF THE MAPP/CHA PROCESS IN NEW YORK STATE. ACCOMPLISHMENTS OF THE ACTION FOR HEALTH INITIATIVE INCLUDE: HOSTING NEW VISIONS PROGRAM FOR SELECTED COLLEGE BOUND HIGH-SCHOOL SENIORS PLANNING TO MAJOR IN A HEALTH-RELATED FIELD OF STUDY. CHRONIC DISEASE STRATEGIC PLANNING DEVELOPMENT OF THE SARANAC RIVER TRAIL IN THE CITY OF PLATTSBURGH, MOVING TOBACCO PRODUCTS OUT OF SIGHT IN MANY RETAIL ESTABLISHMENTS , DEVELOPMENT OF THE CADYVILLE DISK GOLF COURSE, AND NUTRITIONAL IMPROVEMENTS IN SCHOOLS.
SchH_P06_S00_L07	Schedule H, Part VI, Line 7	CVPH MEDICAL CENTER IS A SUBSIDIARY CORPORATION OF COMMUNITY PROVIDERS, INC. (CPI). CPI IS A SECTION 501(C)(3) ORGANIZATION AND A 509(a)(1) HOLDING COMPANY LOCATED IN PLATTSBURGH, NEW YORK. CPI IS A MULTI-CORPORATE PROVIDER OF HEALTH SERVICES. ALONG WITH CVPH MEDICAL CENTER, OTHER SUBSIDIARY CORPORATIONS OF CPI ARE AS FOLLOWS: ELIZABETHTOWN COMMUNITY HOSPITAL. IN 1993, CPI BECAME THE "SOLE MEMBER" OF THE ELIZABETHTOWN COMMUNITY HOSPITAL CORPORATION (ECH). EDH, ESTABLISHED IN 1926, IS A NOT-FOR-PROFIT, 25-BED HOSPITAL LOCATED APPROXIMATELY 40 MILES SOUTH OF PLATTTSBURGH IN ELIZABETHTOWN, NEW YORK. FOUNDATION OF CVPH MEDICAL CENTER, INC. THE FOUNDATION OF CVPH MEDICAL CENTER, INC. IS A TAX-EXEMPT CORPORATION ESTABLISHED BY CPI IN 1989 TO GENERATE PRIVATE CHARITABLE CONTRIBUTIONS TO MEET THE GENERAL HEALTH CARE NEEDS OF THE GEOGRAPHIC REGION THAT CPI AND THE MEDICAL CENTER SERVE. CHAMPLAIN VALLEY HEALTH NETWORK, INC., IS A FOR-PROFIT CORPORATION CREATED IN 1996 TO HANDLE RISK ARRANGEMENTS WITH HEALTH INSURERS. IT CURRENTLY PROVIDES PHYSICIAN-BILLING SERVICES AND EMPLOYS MEDICAL OFFICE PERSONNEL TO SUPPORT THE PRACTICES OF PHYSICIANS EMPLOYED BY CVPH. MEDIQUEST CORPORATION IS A FOR-PROFIT CORPORATION ORGANIZED IN 1985 FOR THE PURPOSE OF DEVELOPING OTHER LINES OF BUSINESS THAT ARE AVAILABLE TO OTHER ENTITIES AS WELL AS TO THE MEDICAL CENTER. MEDIQUEST IS PRIMARILY A REAL ESTATE HOLDING COMPANY THAT OWNS SEVERAL SUITES IN ADJACENT MEDICAL OFFICE BUILDINGS AND ALSO IS THE PARENT COMPANY OF EMT OF CVPH, A FREESTANDING, NOT-FOR-PROFIT AMBULANCE COMPANY. PART VI, LINE 8: CVPH MEDICAL CENTER FILES A COMMUNITY SERVICES PLAN REPORT WITHT THE NEW YORK STATE DEPARTMENT OF HEALTH.

Schedule H (Form 990) 2010

Additional Data

Software ID:	10000077
Software Version:	v1.00

- 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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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? ....

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

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

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

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

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

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

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

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

Yes

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) STEPHENS MUNDY	(i) (ii)	471,915 0	113,653 0	116,579 0	0 0	47,416 0	749,563 0	0 0
(2) WOUTER RIETSEMA MD	(i) (ii)	295,396 0	56,472 0	15,392 0	0 0	47,155 0	414,415 0	0 0
(3) JOYCE RAFFERTY	(i) (ii)	275,060 0	52,023 0	14,571 0	0 0	51,124 0	392,778 0	0 0
(4) CYNTHIA GARDNER	(i) (ii)	214,514 0	41,189 0	11,290 0	0 0	23,085 0	290,078 0	0 0
(5) DEBRA DONAHUE	(i) (ii)	175,325 0	34,241 0	9,505 0	0 0	40,222 0	259,293 0	0 0
(6) SHAUN SMITH	(i) (ii)	26,054 0	10,000 0	0 0	0 0	6,608 0	42,662 0	0 0
(7) NOREEN BRADY	(i) (ii)	161,114 0	33,868 0	0 0	0 0	23,095 0	218,077 0	0 0
(8) CHARLES VOLK	(i) (ii)	524,181 0	50,749 0	0 0	0 0	35,968 0	610,898 0	0 0
(9) STEPHAN CURRY	(i) (ii)	364,942 0	0 0	36,000 0	0 0	35,284 0	436,226 0	0 0
(10) SAMER SIOUFFI	(i) (ii)	452,057 0	0 0	0 0	0 0	23,166 0	475,223 0	0 0
(11) JOHN GRIFFIN	(i) (ii)	549,763 0	0 0	0 0	0 0	40,352 0	590,115 0	0 0
(12) JOSEPH ARGUELLES	(i) (ii)	453,130 0	0 0	0 0	0 0	37,392 0	490,522 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
SchJ_P01_S00_L01a	Schedule J, Part I, Line 1a	TRAVEL FOR COMPANIONS: TOTAL TRAVEL COSTS FOR COMPANION OF STEPHENS MUNDY, CEO, OF LESS THAN $1,000 WERE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVED THIS BENEFIT.
SchJ_P01_S00_L01b	Schedule J, Part I, Line 1b	TOTAL TRAVEL COSTS FOR COMPANION OF STEPHENS MUNDY, CEO, OF LESS THAN $1,000 WERE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVED THIS BENEFIT.
SchJ_P01_S00_L04	Schedule J, Part I, Line 4	A DISTRIBUTION TO STEPHENS MUNDY, CEO, IN THE AMOUNT OF $116,579 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MR. MUNDY'S TAXABLE COMPENSATION. MR. MUNDY'S DISTRIBUTION OCCURRED AS A RESULT OF MEETING PRIOR YEAR VESTING AND FULL VESTING IN THE 2010 CONTRIBUTION OF $113,047. EACH OF THE FOLLOWING EMPLOYEES ALSO FULLY VESTED IN SERP CONTRIBUTIONS MADE BY THE ORGANIZATION DURING 2010 AND IN PRIOR YEARS. FULLY VESTED AMOUNTS WERE INCLUDED IN EACH EMPLOYEE'S TAXABLE WAGES, AND ARE REPORTED ON SCH. J, PART II, COLUMN B (III). SERP CONTRIBUTIONS DURING 2010 WERE: WOUTER RIETSEMA $15,392 JOYCE RAFFERTY $14,571 CYNTHIA GARDNER $11,290 DEBRA DONAHUE $9,505
SchJ_P01_S00_L06	Schedule J, Part I, Line 6	DURING 2010, CVPH CONTINUED A COMPENSATION INCENTIVE PLAN FOR MANAGEMENT OF THE ORGANIZATION. THE PLAN SETS FORTH NUMEROUS OBJECTIVES AND GOALS TO BE MET IN ORDER TO EARN AN INCENTIVE AWARD. EACH OF THE GOALS ARE AIMED AT IMPROVING THE EXPANSE OF CVPH'S SERVICE OFFERINGS, QUALITY OF SERVICE AND OPERATION, AND MEETING COMMUNITY NEEDS. UNDER THE PLAN, THESE GOALS AND OBJECTIVES ARE ASSIGNED POINT VALUES, TOWARD A TOTAL 100 POSSIBLE POINTS. SPECIFIC MEASURES ARE SET TO DETERMINE WHETHER THE STATED OBJECTIVE HAS BEEN MET. ONE OF THE OBJECTIVES INCLUDED IN THE 2010 PLAN IS KEYED TO NET MARGIN OF THE ORGANIZATION. THIS OBJECTIVE MEASURE, HOWEVER, HAS NO MORE THAN 10 POTENTIAL POINTS THAT MAY BE ACHIEVED IF THE ORGANIZATION MAINTAINS THE STATED BUDGETED MARGIN, AND IS INTENDED TO MEET THE OVERALL GOAL OF MAINTAINING THE FINANCIAL HEALTH OF THE ORGANIZATION. OTHER GOALS IN THE PLAN ARE TO IMROVE QUALITY OF SERVICES, EXPANSE OF SERVICE OFFERINGS, ORGANIZATIONAL DEVELOMENT, AND REACH COMMUNITY NEEDS.

Schedule J (Form 990) 2010

Additional Data

Software ID:	10000077
Software Version:	v1.00

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number
14-1338471

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AD8	06-07-2007	19,565,000	CONSTRUCTION OF SURGICAL SVC WING		X		X		X
B	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AB2	12-19-2006	12,650,000	REFINANCE SERIES 1997 BONDS		X		X		X
C	COUNTY OF CLINTON INDUSTRIAL DEVELOPMENT AGENCY	14-6035154	187476AE6	06-25-2007	12,505,000	RENOVATION OF SURGICAL AREA		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .	0		0		0
2 Amount of bonds defeased . . . .	0		0		0
3 Total proceeds of issue . . . .	19,565,000		12,650,000		12,505,000
4 Gross proceeds in reserve funds . .	1,172,250		0		727,569
5 Capitalized interest from proceeds.	0		0		0
6 Proceeds in refunding escrow. . . . .	0		12,511,605		0
7 Issuance costs from proceeds . . .	1,340,812		138,395		811,805
8 Credit enhancement from proceeds.	0		0		0
9 Working capital expenditures from proceeds . .	0		0		0
10 Capital expenditures from proceeds . .	17,051,938		0		10,965,626
11 Other spent proceeds . .	0		0		0
12 Other unspent proceeds. . .	0		0		0
13 Year of substantial completion . . .	2009		1998		2009
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue?		X		X	X
15 Were the bonds issued as part of an advance refunding issue?		X	X			X
16 Has the final allocation of proceeds been made? . .	X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .	X		X		X

Part III

Private Business Use

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

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

Cat. No. 50193E

Schedule K (Form 990) 2010

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use?		X		X		X
b Are there any research agreements that may result in private business use of bond-financed property? . .		X		X		X
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .	X		X		X
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . .	0 %		0 %		0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .	0 %		0 %		0 %
6 Total of lines 4 and 5 . . .. . . . . .	0 %		0 %		0 %
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?	X		X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .		X		X		X
2 Is the bond issue a variable rate issue?	X		X		X
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?	X		X		X
b Name of provider .	KEY BANK		KEY BANK		KEY BANK
c Term of hedge . .	35		11		35
d Was the hedge superintegrated? .		X		X		X
e Was a hedge terminated? .		X		X		X
4a Were gross proceeds invested in a GIC? .		X		X		X
b Name of provider .
c Term of GIC . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .
5 Were any gross proceeds invested beyond an available temporary period? .		X		X		X
6 Did the bond issue qualify for an exception to rebate? . . .	X		X		X

Schedule K (Form 990) 2010

Page 3

Part V

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2010

Additional Data

Software ID:	10000077
Software Version:	v1.00

- 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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

Identifier	Return Reference	Explanation
F990_P06_S0A_L06	Form 990, Part VI, Section A, Line 6	COMMUNITY PROVIDERS INCORPORATED (CPI) IS THE SOLE VOTING MEMBER OF THE ORGANIZATION.
F990_P06_S0A_L07a	Form 990, Part VI, Section A, Line 7a	COMMUNITY PROVIDERS INCORPORATED SHALL ELECT THE DIRECTORS TO HOLD OFFICE ANNUALLY. EACH DIRECTOR SHALL HOLD OFFICE UNTIL THE EXPIRATION OF THE TERM AND UNTIL A SUCCESSOR HAS BEEN ELECTED AND SHALL HAVE QUALIFIED, OR UNTIL THE DIRECTOR'S PRIOR RESIGNATION OR REMOVAL.
F990_P06_S0B_L11a	Form 990, Part VI, Section B, Line 11a	CVPH PROVIDES AN ELECTRONIC COPY OF FORM 990 TO EACH BOARD MEMBER PRIOR TO THE FORM BEING FILED.
F990_P06_S0B_L12c	Form 990, Part VI, Section B, Line 12c	CVPH HAS A WRITTEN CONFLICT OF INTEREST POLICY AS A PART OF ITS GOVERNING DOCUMENTS. THE POLICY IS APPLICABLE TO MEMBERS OF THE GOVERNING BODY, OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION REQUIRES THAT MEMBERS HAVING A CONFLICT OF INTEREST IN A TRANSACTION RECUSE THEMSELVES OF VOTING ON THE MATTER. PROPOSED AND ONGOING TRANSACTIONS ARE REVIEWED BY APPROPRIATE GROUPS OF INDIVIDUALS (COMMITTEES AND/OR LEVELS OF REVIEW) TO ENSURE THE BEST INTEREST OF THE HOSPITAL. THE ORGANIZATION SOLICITS FROM EACH MEMBER OF THE GOVERNING BODY, OFFICERS, AND KEY EMPLOYEES AN ANNUAL SIGNED STATEMENT CERTIFYING COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND SELF-DISCLOSURE OF CERTAIN INTERESTS FOR EACH ANNUAL PERIOD.
F990_P06_S0B_L15	Form 990, Part VI, Section B, Line 15	PART A: CVPH HAS A FORMAL PROCESS THAT IS USED TO DETERMINE THE COMPENSATION OF THE CEO ON AN ANNUAL BASIS. THIS PROCESS INCLUDES A COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, ENGAGING AN INDEPENDENT CONSULTANT, PERFORMANCE OF A COMPENSATION SURVEY OR STUDY, REVIEW OF OTHER ORGANIZATION'S 990 FORMS, AND APPROVAL BY THE BOARD OF COMPENSATION COMMITTEE. A WRITTEN EMPLOYMENT AGREEMENT IS ESTABLISHED SETTING FORTH THE COMPENSATION AND BENEFITS OF THE CEO. CVPH PAYS NON-FIXED EARNINGS BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA THAT ARE PROSPECTIVELY AGREED UPON AS GOALS FOR THE CEO. PART B: THE SAME FORMAL PROCESS NOTED IN QUESTION 15(A) ABOVE IS USED TO DETERMINE THE BASE COMPENSATION OF THE OTHER OFFICERS. NON-FIXED EARNINGS OF OTHER OFFICERS ARE BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA AND COMPARATIVE MARKET DATA.
F990_P06_S0C_L19	Form 990, Part VI, Section C, Line 19	CVPH MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PARTIES DESIRING COPIES OF SUCH DOCUMENTS MUST PRESENT THEMSELVES AT THE ADMINISTRATIVE OFFICES OF CVPH OR BY SENDING A REQUEST IN WRITING TO CVPH ADMINISTRATIVE OFFICES. THE ORGANIZATION HAS INSTRUCTIONS POSTED ON ITS WEBSITE FOR THOSE SEEKING COPIES OF DOCUMENTS.
F990_P11_S00_L05	Form 990, Part XI, Line 5	NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS: $2,075,372, BOOK INCOME OVER SCHEDULE K-1 INCOME -JT VENTURE: $252,575, CHANGE IN FAIR VALUE OF INTEREST RATE SWAP: ($1,529,961), OTHER: $6,079, PENSION PLAN RELATED AS A RESULT OF SFAS 158: $298,080, CHANGE IN INTEREST IN CVPH FOUNDATION: $119,722 TOTAL OTHER CHANGES IN FUND BALANCE: $1,221,867

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:	10000077
Software Version:	v1.00

- 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

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

Employer identification number

14-1338471

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) COMMUNITY PROVIDERS INC (CPI) 75 BEEKMAN ST PLATTSBURGH,NY12901 22-2544844	HLTH SVC COOR	NY	501(C)(3)	11(B)	PARENT		No
(2) CVPH MEDICAL CENTER FOUNDATION 75 BEEKMAN ST PLATTSBURGH,NY12901 14-1727048	HLTH SVC SUPP	NY	501(C)(3)	11(B)	CPI		No
(3) ELIZABETHTOWN COMMUNITY HOSPITAL PARK STREET ELIZABETHTOWN,NY12932 14-1364513	HOSPITAL	NY	501(C)(3)	3	CPI		No
(4) EMT OF CVPH 75 BEEKMAN ST PLATTSBURGH,NY12901 06-1718419	AMBULANCE SVC	NY	501(C)(3)	11(B)	CPI		No

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?		(k) Percentage ownership
(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) VALCOUR IMAGING 16 DEGRANDPRE WAY PLATTSBURGH,NY12901 77-0607949	DIAGNOSTIC IMAGING	NY	CVPH MED CTR	Related	1,491,776	493,371		No		Yes		75 %

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)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership
(1) CHAMPLAIN VALLEY HEALTH NETWORK 75 BEEKMAN STREET PLATTSBURGH,NY12901 16-1586102	ADMINISTR SVCS	NY	CPI	C	0	0	0 %
(2) MEDIQUEST INC 75 BEEKMAN ST PLATTSBURGH,NY12901 14-1663061	MED OFFICE LEASE	NY	CPI	C	0	0	0 %

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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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

Yes

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

Yes

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

Yes

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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

Yes

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

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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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) CVPH MEDICAL CENTER FOUNDATION	c	468,080	ACTUAL COST
(2) ELIZABETHTOWN COMMUNITY HOSPITAL	d	299,203	ACTUAL COST
(3) EMT OF CVPH	d	337,543	ACTUAL COST
(4) MEDIQUEST INC	d	982,129	ACTUAL COST
(5) COMMUNITY PROVIDERS INC (CPI)	e	3,950,841	ACTUAL COST
(6) MEDIQUEST INC	j	403,723	ACTUAL COST
(7) EMT OF CVPH	p	1,904,419	ACTUAL COST
(8) CVPH MEDICAL CENTER FOUNDATION	l	72,994	ACTUAL COST
(9) CVPH MEDICAL CENTER FOUNDATION	n	181,676	ACTUAL COST

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:	10000077
Software Version:	v1.00

- TIN:

TY 2010 ReasonableCauseExplanation

Name:

CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER

EIN: 14-1338471

Software ID:10000077

Software Version:v1.00

Explanation:

ADDITIONAL TIME IS REQUESTED TO GATHER ALL OF THE INFORMATION NECESSARY TO FILE A COMPLETE AND ACCURATE REPORT.

1	Briefly describe the organization’s mission or most significant activities: CVPH MEDICAL CENTER'S MISSION IS TO PROVIDE QUALITY HEALTH CARE FOR THE NORTH COUNTRY REGION IN UPSTATE NEW YORK.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	15
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	15
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	2,551
6	Total number of volunteers (estimate if necessary) ....	6	138
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	74,588
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	74,099

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,582,979	1,850,555
9	Program service revenue (Part VIII, line 2g) .........	253,177,514	276,562,077
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,214,865	865,839
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	-300,019	-210,404
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	255,675,339	279,068,067
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4) ....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	140,167,923	154,114,944
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	109,249,393	115,421,106
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	249,417,316	269,536,050
19	Revenue less expenses. Subtract line 18 from line 12......	6,258,023	9,532,017
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	202,908,481	217,648,478
21	Total liabilities (Part X, line 26)............	151,885,613	155,871,726
22	Net assets or fund balances. Subtract line 21 from line 20 .....	51,022,868	61,776,752

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	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 $ 229,004,865 including grants of $ ) (Revenue $ 274,092,857 )
	CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER (CVPH) IS A 341-BED ACUTE CARE HOSPITAL AND 54-BED SKILLED NURSING FACILITY. CVPH PROVIDES COMPREHENSIVE MEDICAL AND SURGICAL SERVICES TO THE NORTHERN NEW YORK STATE REGION, REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE OR ABILITY TO PAY. DURING 2010, CVPH PROVIDED 100,516 PATIENT DAYS OF CARE TO ITS 12,511 ADMISSIONS, AND 50,651 EMERGENCY CARE CENTER VISITS. DURING THE YEAR, 17,206 SURGICAL PROCEDURES WERE PERFORMED. 973 BIRTHS OCCURRED IN CVPH FACILITIES. CVPH EMPLOYS MORE THAN 2,000 INDIVIDUALS. IN ADDITION, THE HOSPITAL HAS 162 MEMBERS OF ITS MEDICAL STAFF, 90% OF WHICH ARE BOARD CERTIFIED. THE HOSPITAL IS JOINT COMMISSION ACCREDITED AND LICENSED BY THE NEW YORK STATE DEPARTMENT OF HEALTH. IN ADDITION TO ITS MAIN CAMPUS, CVPH OPERATES SEVERAL OUTPATIENT FACILITIES WHERE SERVICES ARE PROVIDED TO ITS PATIENTS INCLUDING: AMBULATORY SURGERY, PHYSICAL AND OCCUPATIONAL THERAPY, REHABILITATION, RENAL DIALYSIS, AND DIAGNOSTIC IMAGING. CVPH ALSO OPERATES HEALTH CLINICS LOCATED IN OUTLYING GEOGRAPHIC AREAS, TO BETTER SERVE THE HEALTH NEEDS OF CVPH'S RURAL COMMUNITY SERVICE AREA. THROUGH ITS VARIOUS LOCATIONS, OUTREACH ACTIVITIES, AND SUPPORT GROUPS, CVPH IS ACTIVE IN THE COMMUNITY IN PROMOTING HEALTH AND WELLNESS OF THE BODY, MIND, AND SPIRIT. CVPH PROVIDES ONGOING MEDICAL EDUCATION TO ITS MEDICAL STAFF, IN ADDITION TO OFFERING AN X-RAY TECHNOLOGY PROGRAM FOR ENROLLED STUDENTS. THEY ALSO MAINTAIN A COMPREHENSIVE MEDICAL LIBRARY AND HAVE MADE AVAILABLE WEB-BASED LINKS FOR THE COMMUNITY TO EASILY ACCESS HEALTH AND WELLNESS INFORMATION AND EDUCATIONAL MATERIALS. CVPH ACCEPTS NUMEROUS INSURANCE PLANS, AND IS MEDICARE AND MEDICAID APPROVED. ADDITIONALLY, CVPH HAS A CHARITY CARE POLICY TO ACCOMMODATE PATIENTS WHOSE FINANCIAL MEANS ARE WITHIN SPECIFIED GUIDELINES.

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












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












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ 0 including grants of $ 0 ) (Revenue $ 0 )
4e	Total program service expenses$ 229,004,865

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	4,558,982	0	410,867

				(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		0
b	Membership dues....1b		0
c	Fundraising events....1c		0
d	Related organizations...1d		468,080
e	Government grants (contributions)1e		1,382,475

f	All other contributions, gifts, grants, and similar amounts not included above1f		0
g	Noncash contributions included in lines 1a-1f:$ 0
h	Total. Add lines 1a-1f.......			1,850,555
			Business Code
2a	NET PATIENT SERVICE REVENUE			270,638,162	270,638,162	0	0
b	REVENUE FROM DIAGNOSTIC IMAGING FACILITY		621,500	1,600,488	1,525,900	74,588	0
c	BLOOD BANK			892,421	892,421	0	0
d	LABORATORY DIAGNOSTIC & CLINICAL SERVICES			14,272	14,272	0	0
e	PROFESSIONAL MEDICAL EDUCATION			32,681	32,681	0	0
f	All other program service revenue .			3,384,053	989,421	0	2,394,632
g	Total. Add lines 2a–2f........			276,562,077
3	Investment income (including dividends, interest
	and other similar amounts).....			865,839	0	0	865,839
4	Income from investment of tax-exempt bond proceeds..			0	0	0	0
5	Royalties............			0	0	0	0
		(i) Real	(ii) Personal
6a	Gross Rents	100,681	0
b	Less: rental expenses	311,085	0
c	Rental income or (loss)	-210,404	0
d	Net rental income or (loss).......			-210,404	0	0	-210,404
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	0	0
d	Net gain or (loss)..........
8a	Gross income from fundraising events (not including $ 0 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..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See Instructions....			279,068,067	274,092,857	74,588	3,050,067


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........				1
2	Savings and temporary cash investments .......			18,940,975	2	21,070,225
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			33,360,079	4	38,526,267
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			3,890,141	8	3,792,107
9	Prepaid expenses and deferred charges ............			5,699,593	9	4,861,649
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	281,487,492
b	Less: accumulated depreciation. .....	10b	170,721,439	104,515,751	10c	110,766,053
11	Investments—publicly traded securities ..........			29,291,424	11	31,575,389
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			7,210,518	15	7,056,788
16	Total assets. Add lines 1 through 15 (must equal line 34)...			202,908,481	16	217,648,478
17	Accounts payable and accrued expenses .			19,737,836	17	20,416,818
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........			38,280,000	20	35,640,000
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 ..			38,833,476	23	42,583,366
24	Unsecured notes and loans payable to unrelated third parties ....			5,000,000	24	4,928,459
25	Other liabilities. Complete Part X of Schedule D.....			50,034,301	25	52,303,083
26	Total liabilities. Add lines 17 through 25.....			151,885,613	26	155,871,726
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			48,546,678	27	59,180,840
28	Temporarily restricted net assets .....			1,132,247	28	1,251,969
29	Permanently restricted net assets .....			1,343,943	29	1,343,943
	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 .....			51,022,868	33	61,776,752
34	Total liabilities and net assets/fund balances .....			202,908,481	34	217,648,478