Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2010
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2010 and ending 06-30-2011
BCheck if applicable:
CName of organization
THE HOPEDALE MEDICAL FOUNDATION
 
Doing Business As
HOPEDALE MEDICAL COMPLEX
 
Number and street (or P.O. box if mail is not delivered to street address)
PO BOX 267
 
Room/suite
City or town, state or country, and ZIP + 4
HOPEDALE, IL61747
D Employer identification number

37-0808925
E Telephone number

G Gross receipts $ 25,287,748
F Name and address of principal officer:
ALFRED ROSSI
PO BOX 267
HOPEDALE,IL61747
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.HOPEDALEMEDICALCOMPLEX.COM
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1961
M State of legal domicile: IL
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: MAINTAIN A MEDICAL COMPLEX THAT INCLUDES AN ACUTE CARE HOSPITAL AND HEALTH CARE FACILITY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) .... 3 9
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 6
5 Total number of individuals employed in calendar year 2010 (Part V, line 2a) ... 5 423
6 Total number of volunteers (estimate if necessary) .... 6 35
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 108,868
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b -43,278
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 588,756 755,989
9 Program service revenue (Part VIII, line 2g) ......... 21,735,669 19,423,183
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 115,927 99,277
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 380,764 3,079,291
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 22,821,116 23,357,740
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 43,974 30,721
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) 12,205,423 11,701,562
16a Professional fundraising fees (Part IX, column (A), line 11e).... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet25,123    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 10,014,683 9,764,168
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 22,264,080 21,496,451
19 Revenue less expenses. Subtract line 18 from line 12...... 557,036 1,861,289
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............ 20,276,587 22,894,079
21 Total liabilities (Part X, line 26)............ 8,522,457 9,224,768
22 Net assets or fund balances. Subtract line 21 from line 20 ..... 11,754,130 13,669,311
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid Preparer's Use Only Preparer's
signatureBig Right Arrow 		Date
right pointing bullet image Preparer’s taxpayer identification number
(see instructions)
Firm’s name (or yours
if self-employed),
address, and ZIP + 4Big Right Arrow




 		EIN right pointing bullet image
Phone no. right pointing bullet image
May the IRS discuss this return with the preparer shown above? (see instructions) .........
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2010)
Form 990 (2010)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III . . . . . . . . . .
1
Briefly describe the organization’s mission: THE HOPEDALE MEDICAL FOUNDATION IS A NON-PORFIT, CHARITABLE CORPORATION COMMITTED TO EXCELLENCE IN PROMOTING GOOD HEALTH AND WELLNESS TO ALL, AND SERVING THE HEALTHCARE NEEDS OF THE SICK AND ELDERLY, 24 HOURS A DAY, 7 DAYS A WEEK, WITHOUT DISCRIMINATION AND REGARDLESS OF ONE'S ABILITY TO PAY.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the exempt purpose achievements for each of the organization’s three largest program services by expenses.
Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 14,882,128 including grants of $ 30,721 ) (Revenue $ 17,197,344 )
THE HOPEDALE MEDICAL COMPLEX IS OWNED AND OPERATED BY THE NOT-FOR-PROFIT CHARITABLE CORPORATION KNOWN AS THE HOPEDALE MEDICAL FOUNDATION. THE HOPEDALE MEDICAL COMPLEX STARTED AS A 20-BED HOSPITAL IN 1955 IN HOPEDALE, ILLINOIS AND HAS EXPANDED OVER THE YEARS TO OFFER A CONTINUUM OF CARE SERVICES, INCLUDING A 25-BED ACUTE CARE HOSPITAL, NURSING HOME, INDEPENDENT AND ASSISTED LIVING FACILITY AS WELL AS A WELLNESS CENTER.THE HOPEDALE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND OFFERS VIRTUALLY THE SAME SERVICES AS A LARGER, URBAN HOSPITAL, INCLUDING 24 HOUR EMERGENCY ROOM, ICU, GENERAL AND ADVANCED VASCULAR SURGERY, ORTHOPEDIC SURGERY, PLASTIC/RECONSTRUCTIVE SURGERY, OPEN MRI AND CT SCANNER. THE HOPEDALE MEDICAL COMPLEX ALSO OFFERS PHYSICIAN SERVICES THROUGH FOUR SATELLITE OFFICES IN ATLANTA, MANITO, MACINAW AND DELAVAN.HOPEDALE WELLNESS CENTER HAS AN INDOOR GYM, WALKING TRACK, THREE THERAPY POOLS, DAY CARE, PHYSICAL THERAPY DEPARTMENT AND CONFERENCE ROOM FOR THEIR MEMBERS TO USE. THE WELLNESS CENTER ALSO OFFERS CLUB MEMBERSHIPS TO THE RESIDENTS OF HOPEDALE AND SURROUNDING AREAS. PRESENTLY, THE WELLNESS CENTER HAS APPROXIMATELY 1,000 MEMBERS WHO ENROLLED IN VARIOUS PROGRAMS AND ACTIVITIES. A SPORTS MEDICINE PROGRAM HAS ALSO BEEN DEVELOPED FOR LOCAL SCHOOL DISTRICTS AND SPORTS TEAMS THAT THE COMPLEX SERVES TO IMPROVE CONDITIONING OF ATHLETES AND TO REDUCE SPORTS INJURIES. THE COST TO OPERATE THE WELLNESS CENTER IS MORE THAN THE REVENUE THAT IS DERIVED FROM THE HEALTH MEMBERSHIPS WITH THE DIFFERENCE REPRESENTING A BENEFIT TO THE RESIDENTS AND THE COMMUNITY.SERVICE AREATHE HOPEDALE MEDICAL COMPLEX SERVES THE MEDICAL NEEDS OF THE LOCAL CITIZENS WITHIN A 50 MILE RADIUS OF HOPEDALE, ILLINOIS. THE HOPEDALE MEDICAL COMPLEX OPERATES FOUR SATELLITE PHYSICIAN OFFICES IN ADDITION TO A PHYSICIAN'S OFFICE LOCATED ON THE MAIN CAMPUS FOR THE CONVENIENCE OF OUR PATIENTS WITHIN OUR SERVICES AREA.HOSPITAL STAFFTHE HOPEDALE MEDICAL COMPLEX HAS A DEDICATED STAFF OF TRAINED HEALTH PROFESSIONALS THAT HAVE JOINED TOGEATHER AS A TEAM TO PROVIDE THE BEST POSSIBLE HEALTH CARE FOR THE PATIENTS AND RESIDENTS OF OUR COMMUNITY.FINANCIAL ASSISTANCE PROGRAMSTHE HOPEDALE MEDICAL COMPLEX HAS POLICIES IN PLACE TO ENSURE THAT NECESSARY HEALTH SERVICES ARE NOT DENIED BASED ON ABILITY TO PAY AND THAT ALL PATIENTS ARE TREATED FAIRLY AND EQUITABLY, AND WITH RESPECT AND COMPASSION. HOPEDALE MEDICAL COMPLEX ASSISTS PERSONS WITHOUT INSURANCE COVERAGE BY WAIVING ALL OR PART OF THE CHARGES FOR SERVICES IT PROVIDES. SIGNS ARE POSTED IN THE ADMITTING AREAS SO THAT HOSPITAL POLICIES ARE CLEARLY COMMUNICATED TO PATIENTS AND PROSPECTIVE PATIENTS.EMERGENCY SERVICESTEH HOPEDALE MEDICAL COMPLEX OPERATES AN EMERGENCY ROOM THAT IS OPEN 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY ROOM PROVIDES SERVICE TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY AND DENIES SERVICE TO NO ONE.COMMUNITY LEADERSHOPEDALE MEDICAL FOUNDATION'S BOARD OF DIRECTORS IS COMPOSED OF VARIOUS LEADERS FROM THE COMMUNITY. THE DIRECTOR'S REPRESENT DIVERSE BACKGROUNDS AND INDUSTRIES WITHIN THE COMMUNITY.MEDICAL STAFFTHE MEDICAL STAFF AT HOPEDALE MEDICAL CENTER IS OPEN AND OFFERS PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA.UNCOMPENSATED CARETHE HOPEDALE MEDICAL COMPLEX PARTICIPATES IN MEDICARE, MEDICAID, CHAMPUS, TRICARE AND OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. THE CONTRACTED AMOUNT FOR THE ABOVE SERVICES EXCEPT MEDICARE IS OFTEN LESS THAN THE ACTUAL COST OF THE SERVICES, WITH THE DIFFERENCE REPRESENTING A BENEFIT TO THE PATIENT AND THE COMMUNITY.
4b (Code:   ) (Expenses $ 2,343,334 including grants of $   ) (Revenue $ 2,673,379 )
HOPEDALE NURSING HOME IS A 74-BED LICENSED FACILITY OFFERING 24-HOUR NURSING CARE. IT IS PHYSICALLY LOCATED ON CAMPUS AND CONNECTED TO THE HOSPITAL FOR THE CONVENIENCE OF OUR RESIDENTS AND THEIR FAMILIES.
4c (Code:   ) (Expenses $ 1,603,031 including grants of $   ) (Revenue $ 1,608,042 )
HOPEDALE COMMONS IS A 67-BED INDEPENDENT AND ASSISTED LIVING FACILITY. IT IS ALSO LOCATED ON CAMPUS AND IS LOCATED NEAR THE HOSPITAL, NURSING HOME, AND PHYSICIAN OFFICE FOR THE CONVENIENCE OF OUR RESIDENTS AND THEIR FAMILIES.
(Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
RENEWED HOPE - SENIOR PROGRAM TO HELP SENIORS COPE WITH DEPRESSION, UNRESOLVED GRIEF, ANXIETY, NERVOUSNESS, WORRY, ISOLATION, LONELINESS, COPING WITH HEALTH/PHYSICAL CHANGES, DIFFICULTY CONCENTRATING, SLEEP OR APPETITE CHANGES, FEELINGS OF HOPELESSNESS/HELPLESSNESS, ANGER, LOW SELF-ESTEEM AND PERSONALITY CHANGES.
(Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
OTHER COMMUNITY ACTIVITIES -HEALTH FAIR AT WELLNESS CENTERTHE HMC WELLNESS FAIR (FIT FAIR) ACCOMPLISHES THE GOAL OF EDUCATING THE COMMUNITY ABOUT HEALTH. AREA CITIZENS ARE EXPOSED TO THE MOST CURRENT HEALTH INSURANCE AS WELL AS EDUCATION ON IMPORTANT LIFESTYLE CHOICES. THE EVENT REACHES BETWEEN 200 AND 500 INDIVIDUALS EACH YEAR. EVENT INCLUDES SPEAKERS, BOOTHS, SCREENINGS, RAFFLES, CHILDREN'S INFLATABLES, LIFE FLIGHT HELICOPTER DISPLAY, AND THE CHILDREN'S TRIATHALON. SCHOLARSHIP AWARD WINNERS ARE ANNOUNCED.GO RED FOR WOMENGO RED FOR WOMEN ACCOMPLISHES THE GOAL OF EDUCATING THE COMMUNITY ABOUT WOMEN'S HEALTH. THE INFORMATION FOCUSES ON HEART HEALTH WITH THE ADDITION OF OTHER CURRENT WOMEN'S HEALTH TOPICS. ANNUALLY, BETWEEN 100 AND 200 WOMEN ATTEND. THE EVENT INCLUDES SPEAKERS, DEMONSTRATIONS, FOOD AND RAFFLES.ANNUAL 5K RUN/WALKEACH JULY 4TH, THE HOPEDALE WELLNESS CENTER SPONSORS A 5K RUN/WALK OPEN TO ALL RESIDENTS OF THE COMMUNITY. AWARDS ARE GIVEN TO DIFFERENT WINNERS OF VARIOUS AGE GROUPS OF RUNNERS AND WALKERS.DIETICIAN HEALTHY EATING SEMINARSTHE HOPEDALE MEDICAL FOUNDATION DIETICIAN HOLDS VARIOUS SEMINARS ANNUALLY TO HELP RESIDENTS OF THE COMMUNITY AND EMPLOYEES TO EAT A HEALTHIER DIET. VARIOUS RECIPES ARE GIVEN TO PARTICIPANTS WHICH ENCOURAGE HEALTHIER DIETS.
4d Other program services. (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 18,828,493
Form 990 (2010)
Form 990 (2010)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? Click to see attachment........
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete
Schedule D, Part IClick to see attachment.......................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IVClick to see attachment...................
9
Yes
 
10
Did the organization, directly or through a related organization, hold assets in term, permanent,or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.Click to see attachment
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.Click to see attachment
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.Click to see attachment
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.Click to see attachment
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.Click to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.Click to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If “Yes,” complete Schedule D, Parts XI, XII, and XIII Click to see attachment
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the United States? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
Form 990 (2010)
Form 990 (2010)
Page 4
Part IV
Checklist of Required Schedules (continued)
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H..... Click to see attachment
20a
Yes
 
b
Did the organization attach its audited financial statement to this return? Note: All Form 990 filers that operate one or more hospitals must attach audited financial statements. ..... Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants and other assistance to governments and organizations in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.. Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III..... Click to see attachment
22
Yes
 
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I...... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................ Click to see attachment
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II........................... Click to see attachment
26
Yes
 
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor, or a grant selection committee member, or to a person related to such an individual? If “Yes,” complete Schedule L, Part III............... Click to see attachment
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ......................... Click to see attachment
28a
Yes
 
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV................... Click to see attachment
28b
Yes
 
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV.. Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule MClick to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............ Click to see attachment
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I........................... Click to see attachment
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35
Is any related organization a controlled entity within the meaning of section 512(b)(13)? .....
35
Yes
 
a
Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2010)
Form 990 (2010)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V . . . . . . . . . .
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
74
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
423
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2010)
Form 990 (2010)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI . . . . . . . . . .
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year ..............
1a
9
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
6
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? ..
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Does the organization have members or stockholders? ................
6
Yes
 
7a
Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? .........................
7a
Yes
 
b
Are any decisions of the governing body subject to approval by members, stockholders, or other persons? ..
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Does the organization have local chapters, branches, or affiliates? ............
10a
Yes
 
b
If “Yes,” does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? ....
10b
Yes
 
11a
Has the organization provided a copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Does the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ...........................
12b
Yes
 
c
Does the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this is done ....................
12c
Yes
 
13
Does the organization have a written whistleblower policy? ...............
13
Yes
 
14
Does the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line a or b, describe the process in Schedule O. (See instructions.)
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” has the organization adopted a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
IL
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization makes its governing documents, conflict of interest policy, and financial statements available to the public.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
LARRY KLOC
107 TREMONT STREET
HOPEDALE,IL61747
(309) 449-4375
Form 990 (2010)
Form 990 (2010)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII . . . . . . . . . .
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) ALFRED N ROSSI MD
CHAIRMAN; PHYSICIAN
 2.00 X   X       65,947 0 0
(2) MATTHEW B ROSSI MD
SECRETARY/TREASURER; PHYSICIAN
 2.00 X   X       92,290 0 7,677
(3) MICHAEL J MCLAUGHLIN
DIRECTOR
 2.00 X           0 0 0
(4) ROLAND RICH
DIRECTOR
 2.00 X           0 0 0
(5) TOM HIESER
DIRECTOR
 2.00 X           0 0 0
(6) RAY SLACK
DIRECTOR
 2.00 X           0 0 0
(7) JARIE SLACK
DIRECTOR
 2.00 X           0 0 0
(8) DONALD OSWALD
DIRECTOR; EMPLOYEE
 2.00 X           14,244 0 0
(9) HENRY ALLEN
DIRECTOR
 2.00 X           0 0 0
(10) MARK F ROSSI
COO
 40.00     X       117,814 46,296 7,652
(11) LARRY KLOC
CFO
 40.00     X       92,432 0 16,872
(12) JOHN ZANON
RETAIL PHARMACY DIRECTOR
 40.00         X   114,736 0 12,447
(13) WENDY MOBERLY
HOSPITAL PHARMACY DIRECTOR
 40.00         X   108,982 0 5,446








Form 990 (2010)
Form 990 (2010)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (check all that apply) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 606,445 46,296 50,094
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 in reportable compensation from the organizationMediumBullet3
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
EMERGENCY PHYSICIAN STAFFING SOLUTIONS
12528 SR 78
HAVANA,IL62644 		STAFFING AGENCY 1,006,905
CTSI
17314 SHERWOOD FOREST RD
HAVANA,IL62644 		TRANSCRIPTION SERVICES 133,667
TRI COUNTY ANESTHESIA SC
PO BOX 267
HOPEDALE,IL61747 		ANESTHESIA SERVICES 122,100
EIDE BAILLY
3999 PENNSYLVANIA AVE
DUBUQUE,IA52002 		ACCOUNTING 113,570
HELPING HANDS HOME HEALTHCARE
627 S MAIN ST
CREVE COEUR,IL61610 		STAFFING AGENCY 109,626
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization MediumBullet6
Form 990 (2010)
Form 990 (2010)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, gifts, grants and other similar amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c 12,100
d Related organizations...1d  
e Government grants (contributions)1e 55,039
f All other contributions, gifts, grants, and
similar amounts not included above1f 		688,850
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 755,989
Program Service Revenue Business Code
2a PATIENT SERVICE REVENU 621,110 14,722,679 14,722,679    
b NURSING HOME 623,000 2,673,379 2,673,379    
c ASSISTED/INDEPENDENT 623,000 1,608,042 1,608,042    
d WELLNESS CENTER 713,940 341,317 341,317    
e MASSAGE THERAPY 621,300 77,766   77,766  
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 19,423,183
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 125,598     125,598
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties............MediumBullet        
(i) Real (ii) Personal
6a Gross Rents 649,232  
b Less: rental expenses    
c Rental income or (loss) 649,232  
d Net rental income or (loss).......MediumBullet 649,232     649,232
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 75,168  
b Less: cost or other basis and sales expenses 77,342 24,147
c Gain or (loss) -2,174 -24,147
d Net gain or (loss)..........MediumBullet -26,321     -26,321
8a Gross income from fundraising events (not including
$ 12,100
of contributions reported on line 1c). See Part IV, line 18 ...
a 11,932
b Less: direct expenses ...b 10,733
c Net income or (loss) from fundraising events..MediumBullet 1,199   1,199
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...MediumBullet        
10a Gross sales of inventory, less
returns and allowances .
a 3,948,047
b Less: cost of goods sold ..b 1,817,786
c Net income or (loss) from sales of inventory..MediumBullet 2,130,261 2,099,159 31,102  
Miscellaneous Revenue Business Code
11a CHILD CARE 624,410 180,957     180,957
b CAFETERIA INCOME 722,210 83,453     83,453
c SPORTS CLINIC 621,300 26,430 26,430    
d All other revenue .... 7,759 7,759    
e Total. Add lines 11a–11d ......MediumBullet 298,599
12 Total revenue. See Instructions....MediumBullet 23,357,740 21,478,765 108,868 1,014,118
Form 990 (2010)
Form 990 (2010)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
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 11,408 11,408
2 Grants and other assistance to individuals in the U.S. See Part IV, line 22 19,313 19,313
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 .... 408,473 182,504 225,969  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 439,979 373,139 66,840  
7 Other salaries and wages 9,164,816 8,593,929 570,887  
8 Pension plan contributions (include section 401(k) and section 403(b) employer contributions) .... 110,041 89,532 20,509  
9 Other employee benefits ....... 977,642 894,490 83,020 132
10 Payroll taxes ........... 600,611 545,116 55,495  
11 Fees for services (non-employees):        
a Management ...... 125,219   125,219  
b Legal ......... 43,810   43,810  
c Accounting ........... 124,427   124,427  
d Lobbying ...........        
e Professional fundraising. See Part IV, line 17..    
f Investment management fees ......        
g Other .......... 1,037,129 874,308 147,821 15,000
12 Advertising and promotion .... 184,590 115,473 66,341 2,776
13 Office expenses ....... 2,573,379 2,368,489 201,372 3,518
14 Information technology ......        
15 Royalties ..        
16 Occupancy ........... 911,310 812,532 98,778  
17 Travel ............ 42,224 25,753 12,774 3,697
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ........... 136,103 113,362 22,741  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 1,097,904 1,027,980 69,924  
23 Insurance .............. 210,137 106,783 103,354  
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 SERVICES 1,328,654 1,103,280 225,374  
b BAD DEBT EXPENSE 1,253,682 1,253,682    
c REPAIRS & MAINTENANCE 301,897 276,905 24,992  
d MEDICAID TAXES 268,168 40,515 227,653  
e COLLECTIONS 125,535   125,535  
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 21,496,451 18,828,493 2,642,835 25,123
26 Joint costs. Check here MediumBullet 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 		       
Form 990 (2010)
Form 990 (2010)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ..........   1 2,555
2 Savings and temporary cash investments ....... 2,567,410 2 5,807,895
3 Pledges and grants receivable, net ......... 356,123 3 453,831
4 Accounts receivable, net ......... 2,916,276 4 2,806,496
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 34,811 5 54,589
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 .......... 111,677 6 76,139
7 Notes and loans receivable, net .............   7 49,311
8 Inventories for sale or use .............. 778,367 8 813,119
9 Prepaid expenses and deferred charges ............ 190,191 9 273,715
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 31,900,938
b Less: accumulated depreciation. ..... 10b 21,206,368 11,097,450 10c 10,694,570
11 Investments—publicly traded securities .......... 1,541,118 11 905,979
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 ........... 683,164 15 955,880
16 Total assets. Add lines 1 through 15 (must equal line 34)... 20,276,587 16 22,894,079
Liabilities 17 Accounts payable and accrued expenses . 2,125,875 17 2,023,039
18 Grants payable ..........   18  
19 Deferred revenue .......... 364,053 19 370,998
20 Tax-exempt bond liabilities .......... 4,700,000 20 4,275,000
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 .. 308,881 23 479,040
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities. Complete Part X of Schedule D..... 1,023,648 25 2,076,691
26 Total liabilities. Add lines 17 through 25..... 8,522,457 26 9,224,768
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 11,244,630 27 12,459,726
28 Temporarily restricted net assets ..... 509,500 28 1,209,585
29 Permanently restricted net assets .....   29  
Organizations that do not follow SFAS 117, check here MediumBullet 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 ..... 11,754,130 33 13,669,311
34 Total liabilities and net assets/fund balances ..... 20,276,587 34 22,894,079
Form 990 (2010)
Form 990 (2010)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI . . . . . . . . . .
1
Total revenue (must equal Part VIII, column (A), line 12) . . .
1
23,357,740
2
Total expenses (must equal Part IX, column (A), line 25) . . . . .
2
21,496,451
3
Revenue less expenses. Subtract line 2 from line 1 . . . .
3
1,861,289
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) . .
4
11,754,130
5
Other changes in net assets or fund balances (explain in Schedule O) . . . .
5
53,892
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) . . . . . .
6
13,669,311
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII . . . . . . . . . .
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?..
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O............................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2010)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
f
g
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization? ................
11g(i)
 
 
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
(i)
Name of supported organization 		(ii)
EIN 		(iii)
Type of organization (described on lines 1- 9 above or IRC section (see instructions)) 		(iv)
Is the organization in col. (i) listed in your governing document? 		(v)
Did you notify the organization in col. (i) of your support? 		(vi)
Is the organization in col. (i) organized in the U.S.? 		(vii)
Amount of support?
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
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).            
12
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public Support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) (a) 2006 (b) 2007 (c) 2008 (d) 2009 (e) 2010 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)            
13 Total support (Add lines 9, 10c, 11 and 12.).            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2010
Name of organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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—
Special Rules
......................... 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)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)
Page 1 of 1 of Part I
Name of organization
THE HOPEDALE MEDICAL FOUNDATION
  		Employer identification number

37-0808925
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




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Aggregate contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  




(Complete Part II if there is
a noncash contribution.)
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 II
Name of organization
THE HOPEDALE MEDICAL FOUNDATION
  		Employer identification number

37-0808925
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
THE HOPEDALE MEDICAL FOUNDATION
  		Employer identification number

37-0808925
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		 (c)
Use 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		 (c)
Use 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		 (c)
Use 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		 (c)
Use of gift		 (d)
Description of how gift is held
 
(e)
Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
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 .......    
5
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? ............
6
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. ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet $  
8
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)? ....................................
9
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.
1a
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.
b
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 $  
2
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:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
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

Schedule D (Form 990) 2010
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
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):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIV and complete the following table:
Amount
c Beginning balance ................................. 1c 1,743
d Additions during the year .............................. 1d 2,250
e Distributions during the year ............................. 1e 1,337
f Ending balance ................................... 1f 2,656
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIV.
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current Year (b)Prior Year (c)Two Years Back (d)Three Years Back (e)Four Years Back
1a Beginning of year balance ....      
b Contributions ........      
c Investment earnings or losses ...      
d Grants or scholarships .....      
e Other expenditures for facilities
and programs ........ 		     
f Administrative expenses ....      
g End of year balance ......      
2
Provide the estimated percentage of the year end balance held as:
a
Board designated or quasi-endowment: SchDMd Bullet  
b
Permanent endowment: SchDMd Bullet  
c
Term endowment: SchDMd Bullet  
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIV the intended uses of the organization's endowment funds.
Part VI
Investments—Land, 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 .................   663,463 663,463
b Buildings ................   15,707,952 7,196,366 8,511,586
c Leasehold improvements ............        
d Equipment ................   14,620,828 13,206,722 1,414,106
e Other .................   908,695 803,280 105,415
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........SchDMdBullet 10,694,570
Schedule D (Form 990) 2010

Schedule D (Form 990) 2010
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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.)Small Bullet  
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.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of Liability (b) Amount
Federal Income Taxes  
ACCRUED PROFESSIONAL LIABILITY 25,000
ACCRETION LIABILITY 255,339
CAPITALIZED LEASE OBLIGATIONS 201,605
ESTIMATED THIRD PARTY PAYOR SETTLEMENT 1,594,747





Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)Small Bullet 2,076,691
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

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 23,357,740
2 Total expenses (Form 990, Part IX, column (A), line 25) ..................... 2 21,496,451
3 Excess or (deficit) for the year. Subtract line 2 from line 1 ............. 3 1,861,289
4 Net unrealized gains (losses) on investments .......................... 4 57,879
5 Donated services and use of facilities ............................. 5  
6 Investment expenses ................................... 6  
7 Prior period adjustments .................................. 7  
8 Other (Describe in Part XIV) ................................. 8 -3,987
9 Total adjustments (net). Add lines 4 - 8 ............................. 9 53,892
10 Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 ......... 10 1,915,181
Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIV): ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ...... 5  
Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ............. 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIV): ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIV): ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ...... 5  
Part XIV
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
  PART IV, LINE 1B: SOME NURSING HOME PATIENTS HOLD SMALL AMOUNTS OF FUNDS ON DEPOSIT WITH THE ORGANIZATION FOR INCIDENTALS AND LOW VALUE SERVICES, SUCH AS HAIR-CUTS. THE ORGANIZATION DOES NOT RECORD THE AMOUNTS AS ASSETS OF THE ORGANIZATION.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOPEDALE MEDICAL FOUNDATION HAS BEEN RECOGNIZED AS TAX EXEMPT PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THE FOUNDATION IS SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. HOPEDALE MEDICAL FOUNDATION FILES A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE TAX POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HOSPITALS INCLUDE SUCH MATTERS AS THE FOLLOWING: THE TAX EXEMPT STATUS OF THE ENTITY AND VARIOUS POSITIONS RELATIVE TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). UBIT IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFIT OF A TAX POSITION IS RECOGNIZED IN THE FINANCIAL STATEMENTS IN THE PERIOD DURING WHICH, BASED ON ALL AVAILABLE EVIDENCE, MANAGEMENT BELIEVES THAT IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING THE RESOLUTION OF APPEALS OR LITIGATION PROCESSES, IF ANY. TAX POSITIONS ARE NOT OFFSET OR AGGREGATED WITH OTHER POSITIONS. TAX POSITIONS THAT MEET THE "MORE LIKELY THAN NOT" RECOGNITION THRESHOLD ARE MEASURED AS THE LARGEST AMOUNT OF TAX BENEFIT THAT IS MORE THAN 50% LIKELY TO BE REALIZED ON SETTLEMENT WITH THE APPLICABLE TAXING AUTHORITY. THE DIFFERENCE BETWEEN THE BENEFIT OF A TAX POSITION RECORDED FOR FINANCIAL STATEMENT PURPOSES AND THE AMOUNT REFLECTED ON A TAX RETURN IS RECORDED AS A LIABILITY FOR UNCERTAIN TAX BENEFITS IN THE ACCOMPANYING BALANCE SHEETS ALONG WITH ANY ASSOCIATED INTEREST AND PENALTIES THAT WOULD BE PAYABLE TO THE TAXING AUTHORITIES UPON EXAMINATION. AS OF JUNE 30, 2011 AND 2010, THERE WERE NO UNCERTAIN TAX BENEFITS RELATED TO UNCERTAIN TAX POSITIONS IDENTIFIED AND RECORDED AS A LIABILITY. FORMS 990 AND 990-T FILED BY THE FOUNDATION ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. GENERALLY, FORMS 990 AND 990-T FILED BY THE FOUNDATION ARE NO LONGER SUBJECT TO EXAMINATION FOR THE YEARS 2007 AND PRIOR.
PART XI, LINE 8 - OTHER ADJUSTMENTS:   PRIOR PERIOD ADJUSTMENT -3,987.
Schedule D (Form 990) 2010

Additional Data


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SCHEDULE G
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.
(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
Total .................right arrow      
3
List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50083H
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.
(a) Event #1

GALA
(event type) 		(b) Event #2

 
(event type) 		(c) Other Events

  
(total number) 		(d) Total Events
(Add col. (a) through col. (c))
VerticalRevenue 1 Gross receipts . . . 24,032     24,032
2 Less: Charitable
contributions . . . 		12,100     12,100
3 Gross income (line 1
minus line 2) . . . 		11,932     11,932
VerticalDirectExpenses 4 Cash prizes . . .        
5 Non-cash prizes . .        
6 Rent/facility costs . .        
7 Food and beverages . . 5,018     5,018
8 Entertainment . . . 852     852
9 Other direct expenses . 4,863     4,863
10 Direct expense summary. Add lines 4 through 9 in column (d) ........... right arrow 10,733
11 Net income summary. Combine lines 3 and 10 in column (d)............ right arrow 1,199
Part III
Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue (a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (Add col. (a) through col. (c))
1 Gross revenue . . . .        
VerticalDirectExpenses 2 Cash prizes . . . .        
3 Non-cash prizes . . .        
4 Rent/facility costs . . .        
5 Other direct expenses . .        
6 Volunteer labor . . .
 
 
 
7 Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow  
8 Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow  
9
Enter the state(s) in which the organization operates gaming activities:
a
Is the organization licensed to operate gaming activities in each of these states? ............
b
If "No," Explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....
b
If "Yes," Explain:
 
11
Does the organization operate gaming activities with nonmembers? .................
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? ...........................
Schedule G (Form 990 or 990-EZ) 2010
Schedule G (Form 990 or 990-EZ) 2010
Page 3
13
Indicate the percentage of gaming activity operated in:
a
The organization's facility ......................
13a
 
b
An outside facility ........................
13b
 
14
Provide the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? ......................................
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address:
Name right arrow
Address right arrow
 
 
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? ............................
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)
Identifier ReturnReference Explanation
Schedule G (Form 990 or 990-EZ) 2010
Additional Data


Software ID:  
Software Version:  
SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet 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
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Charity Care and Certain Other Community Benefits at Cost
Yes
No
1a
Does the organization have a charity care policy? If "No," skip to question 6a...........
1a
Yes
 
b
If "Yes," is it a written policy? .......................
1b
Yes
 
2
If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.
3
Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.
a
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:
3a
Yes
 
b
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: .....
3b
Yes
 
c
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.
4
Does the organization's policy provide free or discounted care to the "medically indigent"? ......
4
Yes
 
5a
Does the organization budget amounts for free or discounted care provided under its charity care policy? ...
5a
Yes
 
b
If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........
5b
Yes
 
c
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?...............
5c
 
No
6a
Does the organization prepare an annual community benefit report?.............
6a
 
No
6b
If "Yes," does the organization make it available to the public? ..............
6b
 
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Charity Care and Certain Other Community Benefits at Cost
Charity Care and
Means-Tested Government Programs		 (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) .. 		    632,968 0 632,968 3.130 %
b Unreimbursed Medicaid (from
Worksheet 3, column a) . 		    847,914 461,485 386,429 1.910 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....     0 0    
dTotal Charity Care and
Means-Tested Government Programs ..... 		    1,480,882 461,485 1,019,397 5.040 %
Other Benefits
e Community health improvement
services and community
benefit operations (from
(Worksheet 4) .... 		    723,705 421,012 302,693 1.500 %
f Health professions education
(from Worksheet 5) .. 		    6,736 0 6,736 0.030 %
g Subsidized health services
(from Worksheet 6) .. 		           
h Research (from Worksheet 7)            
i Cash and in-kind contributions
to community groups
(from Worksheet 8) .. 		    30,721 0 30,721 0.150 %
jTotal Other Benefits ...     761,162 421,012 340,150 1.680 %
kTotal. Add lines 7d and 7j. ..     2,242,044 882,497 1,359,547 6.720 %
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
No
1
Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense (at cost).....
2
611,726
3
Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..
3
0
4
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
5
Enter total revenue received from Medicare (including DSH and IME).....
5
7,005,535
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
6,885,537
7
Subtract line 6 from line 5. This is the surplus or (shortfall)........
7
119,998
8
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:
Section C. Collection Practices
9a
Does the organization have a written debt collection policy? ...............
9a
Yes
 
b
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......
9b
Yes
 
Part IV
Management Companies and Joint Ventures
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership% 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2010
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 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe)
1 HOPEDALE MEDICAL COMPLEX
PO BOX 267
HOPEDALE,IL61747 		X X     X   X    
Schedule H (Form 990) 2010
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:HOPEDALE MEDICAL COMPLEX
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    
9 Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?.. 9    
If “Yes,” indicate the FPG family income limit for eligibility for free care:   %
Schedule H (Form 990) 2010
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    
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
11 Explained the basis for calculating amounts charged to patients?................. 11    
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    
13 Included measures to publicize the policy within the community served by the hospital facility?....... 13    
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    
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    
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
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    
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    
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    
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2010
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?8
Name and address Type of Facility (Describe)
1 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
2 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
3 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
4 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
5 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
6 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
7 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
8 HOPEDALE NURSING HOME
111 TREMONT STREET
HOPEDALE,IL61747 		NURSING HOME
9
10
Schedule H (Form 990) 2010
Schedule H (Form 990) 2010
Page 8
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2 Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Identifier ReturnReference Explanation
    PART I, LINE 7: THE ORGANIZATION CALCULATED THE COST AMOUNTS NOTED IN PART I, LINE 7 BY UTILIZING ITS CURRENT COST ACCOUNTING SYSTEM. THE COST ACCOUNTING SYSTEM ADDRESSES ALL PATIENT SEGMENTS REPORTED ON, INCLUDING, BUT NOT LIMITED TO INPATIENT, OUTPATIENT, MEDICAID, UNINSURED, AND MEDICARE.
    PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1253682.
COMMUNITY BETTERMENT REPORT: PART I, LINE 6A: HOPEDALE MEDICAL FOUNDATION BEGAN TO ACCUMULATE DATA AND INPUT FROM THE COMMUNITY ON SPECIFIC NEEDS DURING THE LATER PART OF CALENDAR YEAR 2011. MEETINGS WITH VARIOUS COMMUNITY GROUPS AND LEADERS HAVE BEEN FRUITFUL WITH IDEAS AND SUGGESTIONS THAT WILL BE INCORPORATED INTO OUR COMMUNITY BENEFIT REPORT. HOPEDALE MEDICAL FOUNDATION HAS CONTRACTED WITH ICAHN (ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK) TO ACCUMULATE ALL THE DATA THAT WILL BE NEEDED TO COMPLETE THE REPORT THAT WILL BE SHARED WITH THE LOCAL COMMUNITY.
    PART III, LINE 4: THE ORGANIZATION USED A COST TO CHARGE RATIO TO DETERMINE THE COST AMOUNT OF THE BAD DEBT EXPENSE. WORKSHEET 2, RATIO OF PATIENT CARE COST TO CHARGES, AS PROVIDED IN THE IRS INSTRUCTIONS WAS USED TO DETERMINE THE APPROPRIATE RATIO.THE ORGANIZATION DOES NOT ISSUE A STANDALONE FINANCIAL STATEMENT; HOWEVER, IT IS INLCUDED AS A PART OF THE HOPEDALE RURAL HEALTH ASSOCIATION, INC. AND SUBSIDIARIES CONSOLIDATED FINANCIAL STATEMENTS. THE BAD DEBT FOOTNOTE DISCLOSURE FROM THE CONSOLIDATED FINANCIAL STATEMENTS IS AS FOLLOWS:PATIENT RECEIVABLES DUE DIRECTLY FROM THE PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING ACCOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACOUNTS AND BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS. THE ORGANIZATION DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT ACCOUNTS RECEIVABLE ARE DUE IN FULL WHEN BILLED. ACCOUNTS ARE CONSIDERED PAST DUE WHEN AN AMOUNT IS PAST DUE ACCORDING TO THE PAYORS' AGREED-UPON TERMS. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSE WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED. AS A SERVICE TO THE PATIENT, THE ORGANIZATION BILLS THIRD-PARTY PAYORS DIRECTLY AND THE PATIENT WHEN THE PATIENT'S LIABILITY IS DETERMINED.THE CHARITY CARE FOONOTE DISCLOSURE FROM THE CONSOLIDATED FINANCIAL STATEMENT IS AS FOLLOWS:HOPEDALE MEDICAL FOUNDATION PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE HOPEDALE MEDICAL FOUNDATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THESE AMOUNTS ARE NOT REPORTED AS NET PATIENT SERVICE REVENUE. HOPEDALE MEDICAL FOUNDATION HAS A CHARITY CARE POLICY AND MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES.
    PART III, LINE 8: THE ORGANIZATION DERIVED ITS COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT BY USING COST REPORT WORKSHEETS. MEDICARE COSTS ARE DETERMINED THROUGH THE MEDICARE COST FINDING PROCESS WHICH ALLOCATES GENERAL SERVICE CENTER COSTS TO REVENUE DEPARTMENTS. ROUTINE AND ICU COSTS ARE DETERMINED BASED ON AN AVERAGE COST PER DAY MULTIPLIED BY THE NUMBER OF MEDICARE ALLOWABLE DAYS. MEDICARE ANCILLARY COSTS ARE DETERMINED BY THE RATIO OF DEPARTMENT COSTS TO DEPARTMENT CHARGES THEN THE RESULTING % IS APPLIED TO MEDICARE ALLOWABLE CHARGES. THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA.
    PART III, LINE 9B: THE ORGANIZATION APPLIES THE FOLLOWING PROCESSES AND PROCEDURES IN ITS COLLECTION PRACTICES FOR THOSE WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE:POLICY:THE DISTINCTION BETWEEN CHARITY CARE AND BAD DEBT IS THE INABILITY TO PAY VERSUS THE UNWILLINGNESS OF THE PERSON TO PAY THEIR ACCOUNT. THOSE WITH LOW INCOMES OR WITH CATASTROPHIC MEDICAL BILLS MAY BE MEDICALLY INDIGENT EVEN THOUGH THEY ARE ABLE TO MEET BASIC LIVING EXPENSES. HOPEDALE MEDICAL COMPLEX WILL NOT DENY SERVICES TO ANY PATIENT DUE TO RACE, COLOR, RELIGION, GENDER, ANCESTRY, SEXUAL ORIENTATION, FINANCIAL CLASS OR NATIONAL ORIGIN.HOPEDALE MEDICAL FOUNDATION IS COMMITTED, TO THE EXTENT RESOURCES ALLOW, TO PROVIDING QUALITY HEALTHCARE TO ITS PATIENTS AND RESIDENTS REGARDLESS OF THEIR ABILITY TO PAY.THE HOPEDALE MEDICAL FOUNDATION FINANCIAL ASSISTANCE PROGRAM ALLOWS FOR FREE OR REDUCED MEDICAL SERVICES TO PATIENTS WHO RECEIVE INPATIENT AND OUTPATIENT CARE; HAVE NO HEALTH COVERAGE OR HAVE COVERAGE THAT PAYS ONLY FOR PART OF THE BILL AND ARE INELIGIBLE FOR ANY PRIVATE OR GOVERNMENTAL SPONSORED COVERAGE (SUCH AS MEDICAID); AND MEET THE INCOME AND ASSETS ELIGIBILITY CRITERIA.FINANCIAL ASSISTANCE IS AVAILABLE FOR NECESSARY HOSPITAL AND PHYSICIAN CHARGES ONLY.ELIGIBILITY DETERMINATION:FINANCIAL ASSISTANCE FORMS AND INSTRUCTIONS SHALL BE FURNISHED TO PATIENTS WHEN FINANCIAL ASSISTANCE IS REQUESTED, WHEN NEED IS INDICATED, OR WHEN FINANCIAL SCREENING INDICATES POTENTIAL NEED, IN THE CASE OF PATIENTS WITHOUT HEALTH INSURANCE. ALL APPLICATIONS SHOULD BE FOLLOWED BY DOCUMENTATION TO VERIFY INCOME AMOUNTS INDICATED ON THE APPLICATION FORM. ALL INFORMATION RECEIVED RELATING TO THE APPLICATION WILL BE KEPT CONFIDENTIAL AND USED TO VERIFY FINANCIAL NEEDS. STEPS USED BY HOPEDALE MEDICAL FOUNDATION TO DETERMINE AND VERIFY FINANCIAL ASSISTANCE:1) HOSPITAL IDENTIFIES ANY UNINSURED, UNDERINSURED, OR SELF-PAY PATIENTS.2) PATIENT COMPLETES APPLICATION/FINANCIAL STATEMENT THAT INCLUDES INCOME, ASSETS, AND LIABILITIES.3) FINANCIAL COUNSELOR INTERVIEWS PATIENT TO ASSESS THE PATIENT'S ABILITY TO PAY IN FULL; ABILITY TO PAY REASONABLE MONTHLY INSTALLMENTS; AND QUALIFICATION FOR FINANCIAL ASSISTANCE.4) HOSPITAL MAKES INITIAL DETREMINATION BASED UPON APPLICATION AND ANY ORAL INFORMATION PROVIDED BY PATIENT. PATIENT SIGNS APPLICATION CONFIRMING ACCURACY OF INFORMATION PROVIDED.5) PATIENT SUPPLIES DOCUMENTATION OF RESOURCES AND OUTSTANDING OBLIGATIONS WITHIN 30 DAYS FROM DATE OF APPLICATION.6) HOSPITAL MAKES FINAL DETERMINATION REGARDING ELIGIBILITY FOR FINANCIAL ASSISTANCE.7) HOSPITAL SENDS NOTIFICATION LETTER TO THE PATIENT AND/OR FAMILY WITH THE DECISION. NOTICE WILL INCLUDE INSTRUCTIONS FOR ESTABLISHING A PAYMENT PLAN, IF NEEDED, AND REASON FOR DENIAL, IF APPLICABLE.
  PART III, SECTION A, LINE 1 THE FILING ORGANIZATION REPORTS BAD DEBT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15 IS FOLLOWED TO THE EXTENT THAT IT ALIGNS WITH THE GUIDELINES SET FORTH BY GAAP.
    PART VI, LINE 2: SERVICES OFFERED BY THE FOUNDATION INCLUDE MEDICAL/SURGICAL, SWING BED, CRITICAL CARE, OUTPATIENT SURGICAL SERVICES AND A SIGNIFICANT NUMBER OF OTHER ANCILLARY SERVICES NECESSARY TO MEET THE HEALTH CARE NEEDS OF THE COMMUNITY. THE HOSPITAL ALSO OFFERS 24-HOUR EMERGENCY ROOM SERVICES, LABORATORY AND DIAGNOSTIC IMAGING, PHYSICAL THERAPY AND OUTPATIENT/AMBULATORY PROCEDURES. ALTHOUGH CARE IS RENDERED TO ALL TO THE EXTENT POSSIBLE, MIDDLE AGED TO GERIATRIC PATIENT CARE COMPOSES BOTH THE PRIMARY AND SECONDARY SERVICE AREAS AND OUR PATIENT DEMOGRAPHICS.
    PART VI, LINE 3: SIGNS AND BROCHURES ARE LOCATED IN THE REGISTRATION AND MOST OTHER ENTRANCE AREAS. STAFF IN THE ADMISSIONS AND PATIENT REGISTRATION AREA ARE TRAINED TO RECOMMEND THAT PATIENTS MEET OUR PATIENT FINANCIAL COUNSELOR FOR AN APPLICATION AND TO DISCUSS BILLING AND COLLECTION PROCEDURES.
    PART VI, LINE 4: SIXTY-FIVE PERCENT OF ADMISSIONS COME FROM 9 CENSUS TRACTS SURROUNDING THE HOSPITAL, THE PRIMARY SERVICE AREA. AN ADDITIONAL EIGHTEEN PERCENT COME FROM 8 CENSUS TRACTS, THE SECONDARY SERVICE AREA, FURTHER, BUT CONTIGUOUS TO THE PRIMARY SERVICE AREA. THE TOTAL SERVICE AREA POPULATION IS 134,000. AGES 45-65 COMPOSE 26.5% AND AGE 65+ COMPOSES 15.5% OF THE AREA POPULATION.
    PART VI, LINE 6: THE FOUNDATION MAINTAINS A WELLNESS CENTER WHICH HAS THERAPY AND EXCERCISE POOLS, WEIGHT ROOM AND GYMNASIUM AREAS, A LAP TRACT, EXCERCISE MACHINES, AND MEETING ROOMS. WEIGHT-LOSS, NUTRITION COUNSELING, CHRONIC CONDITION MANAGEMENT SESSIONS ARE HELD IN THE MEETING ROOMS, AS WELL AS COMMUNITY MEETINGS. BLOOD DRIVES ARE REGULARY SCHEDULED. THE COST TO OPERATE THE WELLNESS CENTER IS MORE THAN THE REVENUE THAT IS DERIVED FROM THE HEALTH MEMBERSHIP. THE DIFFERENCE REPRESENTS A BENEFIT TO THE MEMBERS OF AREA COMMUNITIIES.ANNUAL 5K RUN/WALK - EACH JULY 4TH THE HOPEDALE WELLNESS CENTER SPONSORS A 5K RUN/WALK OPEN TO ALL RESIDENTS OF THE COMMUNITY. AWARDS ARE GIVEN TO DIFFERENT WINNERS OF VARIOUS AGE GROUPS OF RUNNERS AND WALKERS.GO RED FOR WOMEN - GO RED FOR WOMEN ACCOMPLISHES THE GOAL OF EDUCATING THE COMMUNITY ABOUT WOMEN'S HEALTH. THE INFORMATION FOCUSES ON HEART HEALTH WITH THE ADDITION OF OTHER CURRENT WOMEN'S HEALTH TOPICS. ANNUALLY, BETWEEN 100 AND 200 WOMEN ATTEND. EVENT INCLUDES SPEAKERS, DEMONSTRATIONS, FOOD AND RAFFLES.DIETITIAN HEALTHY EATING SEMINARS - THE HOPEDALE MEDICAL COMPLEX DIETITIAN HOLDS VARIOUS SEMINARS ANNUALLY TO HELP RESIDENTS OF THE COMMUNITY AND EMPLOYEES TO EAT A HEALTHIER DIET. VARIOUS RECIPES ARE GIVEN TO PARTICIPANTS WHICH ENCOURAGE HEALTHIER DIETS.EMERGENCY SERVICES - HOPEDALE MEDICAL COMPLEX OPERATES AN EMERGENCY ROOM THAT IS OPEN 24-HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY ROOM PROVIDES SERVICE TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY AND DENIES SERVICE TO NO ONE.COMMUNITY LEADERS - HOPEDALE MEDICAL FOUNDATION'S BOARD OF DIRECTORS IS COMPOSED OF VARIOUS LEADERS FROM THE COMMUNITY. THE DIRECTORS REPRESENT DIVERSE BACKGROUNDS AND INDUSTRIES WITHIN THE COMMUNITY.MEDICAL STAFF - THE MEDICAL STAFF AT HOPEDALE MEDICAL COMPLEX IS OPEN AND OFFERS PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE AREA.EXCESS FUNDS - HOPEDALE MEDICAL FOUNDATION IS COMMITTED TO SERVING THE RESIDENTS OF AREA COMMUNITIES. THE HOSPITAL CONTINUES THESE EFFORTS BY USING EXCESS FUNDS TO EXPAND ITS FACILITIES AND SERVICES TO BETTER SERVE THE COMMUNITY.
    PART VI, LINE 7: THE FOUNDATION IS NOT PART OF AN AFFILIATED GROUP.
REPORTS FILED WITH STATES PART VI, LINE 7 IL
  PART VI, LINE 7: THE FOUNDATION IS LOCATED IN THE MIDDLE OF CENTRAL ILLINOIS; GENERALLY ALL PATIENTS ARE FROM THE SURROUNDING COMMUNITIES. ANNUAL HOSPITAL QUESTIONNAIRES ARE SENT TO THE ILLINOIS DEPARTMENT OF PUBLIC HEALTH WHICH INCLUDE A REVIEW OF COMMUNITY BENEFIT ACTIVITIES.
Schedule H (Form 990) 2010
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2010
Open to Public
Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number
37-0808925
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance






















2
Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image
 
3
Enter total number of other organizations ................................ . Bullet Image
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2010

Schedule I (Form 990) 2010
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance
(1) SCHOLARSHIPS FOR STUDENTS ENTERING FIELDS OF HEALTHCARE & AG 26 19,313      













Part IV
Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: IN KEEPING WITH THE SUPPORT OF EDUCATION OF THE YOUTH IN THE AREA COMMUNITIES, AND ENCOURAGING THEM TO ENTER THE IMPORTANT FIELDS OF HEALTHCARE AND AGRICULTURE, HOPEDALE MEDICAL FOUNDATION AWARDS SCHOLARSHIPS TO HIGH SCHOOL STUDENTS AND COLLEGE FRESHMAN. HOPEDALE MEDICAL FOUNDATION REQUIRES AN APPLICATION FROM STUDENTS FROM QUALIFYING SCHOOLS IN THE LOCAL AREA. SCHOLARSHIPS ARE AWARDED BY AN INDEPENDENT JUDGE BASED ON RECOMMENDATIONS, ACT SCORES, STUDENT NARRATIVE, AND CLASS RANKING. SCHOLARSHIP MONEY IS SENT DIRECTLY TO THE RECIPIENT'S SCHOOL TO ENSURE THE MONEY IS USED TOWARDS TUITION.
Schedule I (Form 990) 2010


Additional Data


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Software Version:  


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
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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....
1b
 
 
2
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? ....
2
 
 
3
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.
4
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:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2010

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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) MARK F ROSSI (i)
(ii)		 117,814
0 		0
0 		0
46,296 		6,968
0 		684
0 		125,466
46,296 		0
0















Schedule J (Form 990) 2010

Schedule J (Form 990) 2010
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Schedule J (Form 990) 2010

Additional Data


Software ID:  
Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet 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
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number
37-0808925
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
Yes No Yes No Yes No
A VILLAGE OF HOPEDALE ILLINOIS VARIABLE RATE DEMAND REVENUE BONDS SERIES 09
  		37-6002155 43950QAA0 09-23-2009 5,500,000 REFINANCE 1998 BONDS AND CONSTRUCTION COSTS   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired. . . . .        
2 Amount of bonds defeased . . . .        
3 Total proceeds of issue . . . . 5,500,000      
4 Gross proceeds in reserve funds . .        
5 Capitalized interest from proceeds.        
6 Proceeds in refunding escrow. . . . .        
7 Issuance costs from proceeds . . . 110,000      
8 Credit enhancement from proceeds. 49,744      
9 Working capital expenditures from proceeds . .        
10 Capital expenditures from proceeds . . 1,178,060      
11 Other spent proceeds . . 4,150,580      
12 Other unspent proceeds. . . 11,616      
13 Year of substantial completion . . . 2011
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? X              
15 Were the bonds issued as part of an advance refunding issue?   X            
16 Has the final allocation of proceeds been made? . .   X            
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . 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            
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .   X            
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2010
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            
b Are there any research agreements that may result in private business use of bond-financed property? . .   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? .                
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 . . . . . . . . . . . . . SchKMediumBullet 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 . SchKMediumBullet 0.600 %      
6 Total of lines 4 and 5 . . .. . . . . . 0.600 %      
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities? 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            
2 Is the bond issue a variable rate issue? X              
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?   X            
b Name of provider .  
  		 
  		 
  		 
 
c Term of hedge . .        
d Was the hedge superintegrated? .                
e Was a hedge terminated? .                
4a Were gross proceeds invested in a GIC? .   X            
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            
6 Did the bond issue qualify for an exception to rebate? . . .   X            
Schedule K (Form 990) 2010

Schedule K (Form 990) 2010
Page 3
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Schedule K (Form 990) 2010

Additional Data


Software ID:  
Software Version:  

Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ. MediumBulletSee separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Description of transaction (c) Corrected?
Yes No





2
Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.
(a) Name of interested person and purpose (b) Loan to or from the organization? (c)Original principal amount (d)Balance due (e) In default? (f) Approved by board or committee? (g)Written agreement?
To From Yes No Yes No Yes No
(1) DR JOSEPH ROSSI
LOAN TO OPEN THE DELAVAN OFFICE 		  X 32,118 32,118   No Yes   Yes  
(2) DR MATT ROSSI
PHYSICIAN RENT RECEIVABLE 		  X 32,812 32,812   No Yes   Yes  
(3) DR LARRY ROSSI
PHYSICIAN RENT RECEIVABLE 		  X 4,764 4,764   No Yes   Yes  
(4) DR ALFRED ROSSI
PHYSICIAN RENT RECEIVABLE 		  X 21,777 21,777   No Yes   Yes  
(5) AARON ROSSI
LOAN TO SUPPORT COMPLETION OF MEDICAL SCHOOL 		  X 16,800 16,800   No Yes   Yes  
(6) DR PHIL ROSSI
PHYSICIAN RENT RECEIVABLE 		  X 22,457 22,457   No Yes   Yes  
Total ...............Small Bullet $ 130,728
Part III
Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b)Relationship between interested person and the organization (c)Amount of grant or type of assistance
For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990 or 990-EZ) 2010
Schedule L (Form 990 or 990-EZ) 2010
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) DR PHILLIP ROSSI FAMILY RELATIONSHIP 172,652 COMPENSATION FOR ER SERVICES   No
(2) LISA MCLAUGHLIN FAMILY RELATIONSHIP 43,684 COMPENSATION FOR EMPLOYMENT AS PHARMACY DIRECTOR   No
(3) CYNTHIA NOREUIL FAMILY RELATIONSHIP 52,321 COMPENSATION FOR EMPLOYMENT AS DIRECTOR OF ASSISTED AND INDEPENDENT LIVING FACILITIES   No
(4) LARRY NOREUIL FAMILY RELATIONSHIP 62,059 COMPENSATION FOR EMPLOYMENT AS ASSOC NURSING HOME ADMINISTRATOR AND ENVIRONMENTAL HEALTH DIRECTOR   No
(5) DR LARRY ROSSI FAMILY RELATIONSHIP 131,700 ANESTESIA SERVICES - LARRY ROSSI IS OWNER OF TRI-COUNTY ANESTHESIA. TRI-COUNTY ANESTHSIA PROVIDES SERVICES TO THE ORGANIZATION.   No
(6) PEGGIE ROSSI FAMILY RELATIONSHIP 35,887 COMPENSATION FOR EMPLOYMENT AS PHYSICIAN BILLING AND RECEIVABLES ACCOUNTANT   No
(7) LORAYNE ROSSI FAMILY RELATIONSHIP 6,000 PAYMENT FOR REAL ESTATE/INSURANCE/MAINTENANCE ON PROPERTY DONATED TO HOSPITAL UPON HER DEATH   No
(8)  
  		        No
(9) PHILLIP NOREUIL FAMILY RELATIONSHIP 29,286 COMPENSATION FOR EMPLOYMENT AS MAINTENANCE SPECIALIST.   No
(10) LAURA MURRAY FAMILY RELATIONSHIP 35,988 COMPENSATION FOR EMPLOYMENT AS NURSE.   No
Part V
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).
Identifier Return Reference Explanation
SCHEDULE L, PAGE 2, PART IV EXPLANATION OF TRANSACTIONS HOPEDALE MEDICAL FOUNDATION PROVIDES A BUILDING AND SERVICES (NURSING, SECRETARIAL AND OTHER SERVICES) FOR PRIVATE PHYSICIANS, SOME OF WHOM ARE DIRECTORS/OFFICERS OF THE FOUNDATION AND THEIR FAMILY MEMBERS. THE FACILITY AND SERVICES ARE PROVIDED IN EXCHANGE FOR ER SERVICES PROVIDED FOR THE FOUNDATION BY THE PHYSICIANS. THE EXCHANGE IS BELIEVED TO BE IN THE ORDINARY COURSE OF HOSPITAL BUSINESS AND IS REPORTED AT ARM'S LENGTH.THE VALUE OF THE ER SERVICES PROVIDED BY DIRECTORS AND OFFICERS AND THEIR FAMILY MEMBERS IN EXCHANGE FOR USE OF BUILDING SPACE AND SERVICES ARE AS FOLLOWS AND ARE INCLUDED IN AMOUNTS REPORTED IN PART IV.DR. PHILLIP ROSSI $159,591DR. MATTHEW ROSSI $82,270DR. ALFRED ROSSI $65,947
SCHEDULE L, PART II LOANS TO INTERESTED PERSONS: HOPEDALE MEDICAL FOUNDATION EXTENDS CREDIT TO DOCTORS, INCLUDING THOSE DOCTORS THAT ARE ON AND RELATED TO THE BOARD OF DIRECTORS. CREDIT IS FOR RENT THAT IS DUE TO THE HOSPITAL, TO SUPPORT A NEW CLINIC IN A NEARBY COMMUNITY AND TO SUPPORT COMPLETION OF MEDICAL SCHOOL. BELIEVED TO BE IN THE ORDINARY CORUSE OF HOSPITAL BUSINESS AND PROVIDED AT ARMS LENGTH.
SCHEDULE L DESCRIPTION OF FAMILY RELATIONSHIPS: LAWRENCE ROSSI WAS THE FOUNDER OF THE HOPEDALE MEDICAL FOUNDATION. HIS WIFE IS LORAYNE ROSSI. ALFRED ROSSI, LARRY ROSSI, MATT ROSSI, PHILLIP ROSSI, MARK ROSSI, CYNTHIA NOREUIL, LISA MCLAUGHLIN, AND LAURA MURRAY ARE CHILDREN OF LAWRENCE AND LORAYNE ROSSI. SPOUSES OF THE ABOVE ARE PEGGIE ROSSI, LARRY NOREUIL AND MICHAEL MCLAUGHLIN. GRANDCHILDREN OF LAWRENCE AND LORAYNE ARE AARON ROSSI AND PHILLIP NOREUIL.
Schedule L (Form 990 or 990-EZ) 2010

Additional Data


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SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
NonCash Contributions
Right pointing arrow large imageComplete if the organization answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of Contributions or items contributed 		(c)
Contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
contribution amounts
1 Art—Works of art ....        
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		     
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded .        
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ... X 1 265,000 INTEREST IN LAND TRUST
18 Collectibles .....        
19 Food inventory ...        
20 Drugs and medical supplies .        
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( )
26 Other Right pointing arrow large image( )
27 Other Right pointing arrow large image( )
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement ...
29
 
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it
must hold for at least three years from the date of the initial contribution, and which is not required to be used
for exempt purposes for the entire holding period? ..................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell non-cash
contributions? ............................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization did not report revenues in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) 2010
Schedule M (Form 990) 2010
Page 2
Part II
Supplemental Information. Complete this part to provide the information required by Part I, lines 30b,
32b, and 33. Also complete this part for any additional information.
Identifier Return Reference Explanation
Schedule M (Form 990) 2010
Additional Data


Software ID:  
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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
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
Identifier Return Reference Explanation
FORM 990, PART VI, SECTION A, LINE 2   ALFRED ROSSI, DIRECTOR, MATTHEW ROSSI, DIRECTOR, MIKE MCLAUGHLIN, DIRECTOR, AND MARK F. ROSSI, COO ALL HAVE A FAMILY RELATIONSHIP. SEE FURTHER DESCRIPTION REGARDING FAMILY RELATIONSHIPS ON SCH L, PART V. RAY SLACK AND JARIE SLACK HAVE A FAMILY RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 6   THE SOLE MEMBER OF HOPEDALE MEDICAL FOUNDATION IS HOPEDALE RURAL HEALTH ASSOCIATION, INC., AN ILLINOIS NOT FOR PORFIT CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7A   DIRECTORS SHALL BE APPOINTED TO THE BOARD BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER FROM AMONG THOSE PERSONS NOMINATED BY THE NOMINATING COMMITTEE OF THE SOLE MEMBER.
FORM 990, PART VI, SECTION A, LINE 7B   THE SOLE MEMBER OF HOPEDALE MEDICAL FOUNDATION, HOPEDALE RURAL HEALTH ASSOCIATION, INC. HAS THE FOLLOWING RIGHTS AND POWERS: A. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD OF DIRECTORS OF THE FOUNDATION; B. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR, VICE CHAIR, PRESIDENT AND OTHER OFFICERS OF THE FOUNDATION; C. TO ELECT OR REMOVE, WITH OR WITHOUT CAUSE, THE AUDITORS OF THE FOUNDATION; D. TO APPROVE ANY CHANGES TO THE GOVERNANCE DOCUMENTS OF THE FOUNDATION; E. TO APPROVE THE MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, CORPORATE REORGANIZATION OR DISSOLUTION OF THE FOUNDATION; F. TO APPROVE THE CREATION OF NEW SUBSIDIARIES OR AFFILIATES BY THE FOUNDATION; G. TO APPROVE THE STRATEGIC AND FINANCIAL PLANS AND THE CAPITAL AND OPERATING BUDGETS OF THE FOUNDATION; H. TO APPROVE DEBT INCURRED BY THE FOUNDATION IN EXCESS OF $500,000; I. TO APPROVE THE PURCHASE, SALE, LEASE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF ASSETS IN EXCESS OF $150,000; J. TO APPROVE ALL NON-BUDGETED DEBT OR TRANSFERS OF ASSETS IN EXCESS OF AN AMOUNT ESTABLISHED FROM TIME TO TIME BY THE SOLE MEMBER; K. TO APPROVE THE MANAGED CARE POLICY OF THE FOUNDATION; AND L. TO APPROVE THE FILING OF THE BANKRUPTCY BY THE FOUNDATION.
FORM 990, PART VI, SECTION B, LINE 11   THE ORGANIZATION'S CFO AND CONTROLLER REVIEW THE FORM 990 WITH EXTERNAL ACCOUNTANTS. THE BOARD IS THEN PROVIDED A FINAL COPY OF THE FORM 990 BEFORE IT IS FILED.
  FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO ALL MEMBERS OF THE BOARD OF DIRECTORS AND ALL CORPORATE OFFICERS, AGENTS AND EMPLOYEES OF THE FOUNDATION, INCLUDING INDEPENDENT CONTRACTORS, PROVIDERS OF SERVICES AND MATERIALS. AN ANNUAL DISCLOSURE STATEMENT IS COMPLETED BY ALL PERSONS TO WHOM THE CONFLICT OF INTEREST POLICY APPLIES TO ASSIST THEM IN CONSIDERING ALL REAL AND APPARENT CONFLICTS OR DUALITIES IN CONNECTION WITH THE FOUNDATION'S ACTIVITIES. DISCLOSURE IS ALSO REQUIRED WHENEVER CONFLICTS ARISE. THE WRITTEN DISCLOSURE NOTICES OF CONFLICTS ARE FILED WITH THE PRESIDENT OF THE FOUNDATION OR ANY OTHER PERSON DESIGNATED BY THE PRESIDENT. ALL DISCLOSURE NOTICES ARE NOTED FOR RECORD IN THE MINUTES OF A MEETING OF THE BOARD OF DIRECTORS. WHEN OFFICERS, DIRECTORS, EMPLOYEES OR AGENTS BELIEVE THEY HAVE A REAL OR APPARENT CONFLICT, THEY ABSTAIN FROM MAKING MOTIONS, VOTING, EXECUTING AGREEMENT OR TAKING ANY OTHER SIMILAR DIRECT ACTION ON BEHALF OF THE FOUNDATION. THEY ARE NOT PRECLUDED FROM DEBATE OR OTHER SIMILAR INVOLVEMENT ON BEHALF OF THE FOUNDATION. ANY VIOLATION OF THE DUTY OF THE DISCLOSURE BY DIRECTORS OR OFFICERS OF THE FOUNDATION IS GROUNDS FOR REMOVAL FROM THE OFFICE.
  FORM 990, PART VI, SECTION B, LINE 15 THE COO'S COMPENSATION IS REVEIWED AND APPROVED BY THE COMPENSATION COMMITTEE. THE MEMBERS OF THE ENTIRE GOVERNING BODY MAKE UP THE COMPENSATION COMMITTEE. THE ORGANIZATION USES AN INDEPENDENT CONSULTANT TO GATHER COMPARABILITY DATA AND PROVIDE ADDITIONAL ANALYSIS. THE COMPENSATION COMMITTEE DOCUMENTS ITS DELIBERATIONS IN THE GOVERNING BOARD MINUTES AND ESTABLISHES A WRITTEN CONTRACT. THIS PROCESS TAKES PLACE ANNUALLY. THE CFO'S COMPENSATION IS REVIEWED AND APPROVED BY THE CHAIRMAN OF THE BOARD, THE COO, AND THE HR DIRECTOR. THE HR DIRECTOR OVERSEES THE SALARY PROGRAM FOR ALL OTHER EMPLOYEES.
  FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
VOLUNTEER BOARD OF DIRECTORS: PART VII THE BOARD OF DIRECTORS ARE NOT COMPENSATED FOR THEIR SERVICES AS THE BOARD OF DIRECTORS. COMPENSATION REPORTED TO BOARD MEMBERS ON PART VII IS RELATED TO COMPENSATION FOR SERVICES AS EMPLOYEES AND ER PHYSICIANS. AVERAGE HOURS PER WEEK REPORTED FOR EACH BOARD MEMBER IS AN ESTIMATE OF TIME SPENT SOLELY ON BOARD OF DIRECTOR DUTIES.
OFFICER HOURS: PART VII HOURS DEVOTED TO POSITION WITH RELATED ORGANIZATION: MARK ROSSI WAS EMPLOYED BY HOPEDALE MEDICAL FOUNDATION BETWEEN JAN - SEPT 2010. MARK ROSSI WAS EMPLOYED BY HOPEDALE REAL ESTATE SERVICES BETWEEN OCT 2010 AND JUNE 2011. DURING ALL OF THE ABOVE EMPLOYMENT PERIOD, HE SPENT APPROXIMATELY 50% OF HIS TIME ON EACH ORGANIZATION.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 57,879. PRIOR PERIOD ADJUSTMENT -3,987. TOTAL TO FORM 990, PART XI, LINE 5: 53,892.
FINANCIAL STATEMENTS AUDIT OVERSIGHT: FORM 990, PART XII, LINE 2C: THERE WERE NO CHANGES IN THE PROCESS DURING THE YEAR.
VOLUNTEERS: FORM 990, PART I, LINE 6: VOLUNTEERS CONTRIBUTE BY WORKING IN THE GIFT SHOP, TRANSPORTING PATIENTS AND RESIDENTS OF THE COMPLEX TO/FROM APPOINTMENTS AND ASSIST WITH RESIDENT ACTIVITIES IN THE NURSING HOME AND ASSISTED LIVING FACILITY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2010

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
THE HOPEDALE MEDICAL FOUNDATION
 
Employer identification number

37-0808925
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







(1) MISS MONA'S LLC
107 TREMONT ST
HOPEDALE,IL61747
 DAY CARE IL 180,958 69,397 HOPEDALE REAL ESTATE SERVICES INC
 










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
Yes No
(1) PRAIRIE HEALTH SERVICES INC

PO BOX 267

HOPEDALE,IL61747
37-1390103 		PROMOTE PUBLIC HEALTH AND WELFARE IL 501(C)(3) PF HOPEDALE RURAL HEALTH ASSOCIATION INC
 
Yes
 
(2) HOPEDALE RURAL HEALTH ASSOCIATION INC

PO BOX 267

HOPEDALE,IL61747
39-1390105 		SUPPORT HEALTHCARE, EDUCATION AND RESEARCH IL 501(C)(3) PF N/A
 
No










For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2010
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 V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












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



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) HOPEDALE REAL ESTATE SERVICES INC
107 TREMONT STREET
HOPEDALE,IL61747
37-1406582 		PROPERTY RENTAL IL PRAIRIE HEALTH SERVICES INC
  		C      












Schedule R (Form 990) 2010
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
No
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 . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
Yes
 
j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
Yes
 
2
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) HOPEDALE REAL ESTATE SERVICES INC

 I 7,014 GAAP
(2) HOPEDALE REAL ESTATE SERVICES INC

 N 125,219 GAAP
(3) HOPEDALE REAL ESTATE SERVICES INC

 Q 101,746 GAAP
(4) HOPEDALE REAL ESTATE SERVICES INC

 R 3,565 GAAP
(5)
(6)
Schedule R (Form 990) 2010
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 V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(h)
General or
managing
partner?
Yes No Yes No Yes No






























Schedule R (Form 990) 2010
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:  
Software Version: