TY 2010 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) LEONARD SANDRIDGE TRUSTEE	2.0	X				0	0
(2) TOM REYNOLDS MD vice chair	5.0	X	X			0	0
(3) CONSTANCE KINCHELOE TRUSTEE	2.0	X				0	0
(4) H LEE KIRK JR PRESIDENT/CEO	34.0	X	X			387,901	18,941
(5) KARL BEIER MD IMMEDIATE PAST CHAIR	5.0	X	X			0	0
(6) R EDWARD HOWELL TRUSTEE	2.0	X				0	0
(7) LARRY FITZGERALD TRUSTEE	5.0	X				0	0
(8) ROBERT GIBSON MD TRUSTEE	2.0	X				0	0
(9) STEVEN DEKOSKY MD TRUSTEE	2.0	X				0	0
(10) MICHAEL ARMM CHAIR	5.0	X	X			0	0
(11) C WAYNE HAWKINS SECRETARY	5.0	X	X			0	0
(12) BILL CANNON JR TREASURER	5.0	X	X			0	0
(13) SAM MORGAN SENIOR VICE PRESIDENT CFO	36.0		X			189,930	5,167
(14) SUSAN EDWARDS VP HUMAN RESOURCES	40.0			X		117,286	21,196
(15) JANICE SUTER VP NURSING	40.0			X		147,046	13,898
(16) TIM FRITTS CONTROLLER	40.0				X	139,743	3,897
(17) PAULETTE BUCHANAN CAT SCAN TECH	40.0				X	133,021	9,503

(A) Name and business address	(B) Description of services	(C) Compensation
ADVANCED SHIELDING 23355 LN TURNPIKE WEST POINT,KY40177	ARCHITECTURE	865,140
SIEMENS PO BOX 7777 PHILADELPHIA,PA19175	MEDICAL EQUIP MAINT	277,392
HANCOCK DANIELS JOHNSON AND NAGEL P PO BOX 72050 RICHMOND,VA232552050	LEGAL	219,188
CRENSHAW CONSTRUCTION COMPANY INC 129 EAST DAVIS ST STE 230 CULPEPER,VA22701	ARCHITECTURE	411,590
DECOSTA CONSTRUCTION SPECIALTIES 14907 DUNSTAN LANE MONKTON,MD21111	ARCHITECTURE	280,846
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 32

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	27,492	27,492
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	3,114	3,114
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	1,012,135	0	1,012,135	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	25,120,603	20,528,939	4,591,664	0
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	643,400	495,418	147,982	0
9	Other employee benefits .......	3,872,528	2,981,835	890,693	0
10	Payroll taxes ...........	1,996,189	1,537,066	459,123	0
11	Fees for services (non-employees):
a	Management ......	286,790	11,920	274,870	0
b	Legal .........	164,907	0	164,907	0
c	Accounting ...........	105,990	0	105,990	0
d	Lobbying ...........	6,485	0	6,485	0
e	Professional fundraising. See Part IV, line 17..	0			0
f	Investment management fees ......	9,740	0	9,740	0
g	Other ..........	0	0	0	0
12	Advertising and promotion ....	168,488	0	168,488	0
13	Office expenses .......	154,196	130,940	23,256	0
14	Information technology ......	595,416	297,708	297,708	0
15	Royalties ..	0	0	0	0
16	Occupancy ...........	1,282,636	987,630	295,006	0
17	Travel ............	0	0	0	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0	0	0	0
19	Conferences, conventions, and meetings ....	57,336	28,668	28,668	0
20	Interest ...........	27,150	27,150	0	0
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	3,760,942	3,760,942	0
23	Insurance ..............	424,530	407,549	16,981
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	BAD DEBT	10,594,369	9,005,214	1,589,155	0
b	MINOR EQUIPMENT	187,505	127,663	59,842	0
c	FOOD	454,108	385,992	68,116	0
d	REPAIRS & MAINTENANCE	95,175	71,381	23,794	0
e	DUES & SUBSCRIPTIONS	99,368	49,684	49,684	0
f	All other expenses	19,566,976	16,458,069	3,108,907	0
25	Total functional expenses. Add lines 1 through 24f	70,717,568	57,324,374	13,393,194	0
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	4,925,980	1	1,540,211
2	Savings and temporary cash investments .......		2
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	8,217,280	4	12,082,591
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............	122,318	7	174,114
8	Inventories for sale or use ..............	1,186,496	8	1,614,802
9	Prepaid expenses and deferred charges ............	374,912	9	732,934
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	70,123,992
b	Less: accumulated depreciation. .....	10b	42,766,990	23,335,051	10c	27,357,002
11	Investments—publicly traded securities ..........	2,542,124	11	2,358,393
12	Investments—other securities. See Part IV, line 11 ......	770,700	12	833,327
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	39,584,347	15	39,321,214
16	Total assets. Add lines 1 through 15 (must equal line 34)...	81,059,208	16	86,014,588
	17	Accounts payable and accrued expenses .	5,205,914	17	7,779,850
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........	5,563,534	20	4,313,353
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 ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	798,653	25	898,513
26	Total liabilities. Add lines 17 through 25.....	11,568,101	26	12,991,716
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	69,491,107	27	73,022,872
28	Temporarily restricted net assets .....		28
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	69,491,107	33	73,022,872
34	Total liabilities and net assets/fund balances .....	81,059,208	34	86,014,588

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2010

Name of organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

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

Special Rules

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

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

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

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

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

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

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

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

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

Page 1 of 1 of Part III

Name of organization
Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part III

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below.
SchCMd Bullet

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

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

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

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

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

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

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

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots non-taxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

Yes

6,485

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

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

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

6,485

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

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

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

Term endowment: SchDMd Bullet

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of investment		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................
b	Buildings ................	16,751,344	10,320,342	6,431,002
c	Leasehold improvements ............	349,097	347,728	1,369
d	Equipment ................	50,439,267	31,354,336	19,084,931
e	Other .................	2,584,284	744,584	1,839,700
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				27,357,002

Schedule D (Form 990) 2010

Page 3

Part VII

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

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








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

Part VIII

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

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









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

Part IX

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

(a) Description				(b) Book value
(1) INVEST IN CULPEPER SURGERY CTR				905,098
(2) OTHER RECEIVABLES				127,905
(3) DUE FROM AFFILIATES				38,235,721
(4) SETTLEMTS DUE FROM THIRD PARTY				52,490





Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........				39,321,214

Part X

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

1.(a) Description of Liability		(b) Amount
Federal Income Taxes		0
INVESTMENT IN CMA		898,513








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		898,513
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

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

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

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

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other

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

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

Yes

200% 250% 300% 350% 400% Other

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

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

Yes

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

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

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

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

Yes

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

Yes

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

Charity Care and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..	1,919,571		1,919,571	3.190 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	5,757,109	4,382,504	1,374,605	2.290 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	7,676,680	4,382,504	3,294,176	5.480 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	318,865		318,865	0.530 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..	674,975		674,975	1.120 %
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	16,640		16,640	0.030 %
jTotal Other Benefits ...	1,010,480		1,010,480	1.680 %
kTotal. Add lines 7d and 7j. ..	8,687,160	4,382,504	4,304,656	7.160 %

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

Schedule H (Form 990) 2010

Page 2

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

3,611,620

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

485,329

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

Section B. Medicare

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

16,450,587

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

23,942,746

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

-7,492,159

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1culpeper med assoc	multi-specialty medical pract	51.000 %	49.000 %
2culpeper surg center	outpatient surgical services	59.340 %	40.660 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	CULPEPER REGIONAL HOSPITAL 501 SUNSET LANE CULPEPER,VA22701	X	X	X

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Name of Hospital Facility:CULPEPER REGIONAL HOSPITAL

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

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

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

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?11
Name and address		Type of Facility (Describe)
1	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
2	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
3	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
4	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
5	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
6	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
7	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
8	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
9	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
10	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE
11	CULPEPER MEDICAL ASSOCIATES LLC 14115 LOVERS LANE STE 100 CULPEPER,VA22701	CMA CORPORATE OFFICE

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 3C		The Hospital provides financial assistance to all individuals that qualify under the Hospital's financial assistance policy. To qualify under the Hospital's financial assistance policy, the individual can demonstrate that his/her family income is below the 200% federal poverty guidelines limit or, if the individual has family income above the 200% federal poverty guidelines, that he/she has incurred catastrophic medical costs. The Hospital does not use an asset test or other threshold (other than the federal poverty guidelines) to determine eligibility for financial assistance under the organization's financial assistance policy. However, the Hospital may review an individual's bank account activity to verify the information provided on the individual's financial assistance application. In addition, each account with a balance greater than $5,000 related to care provided to self-pay patients is screened for financial assistance using a software program that pulls information from various sources to predict whether such patient's family income is less than 200% of the federal poverty guidelines. If the software program determines that a patient likely qualifies for financial assistance, the Hospital will presume eligibility with the Hospital's financial assistance policy and write off the patient's accounts to charity. Once the patient's account is written off to charity, the Hospital ceases all collection efforts with respect to the account.
PART I, LINE 5		Culpeper Regional Hospital does not budget amounts for charity care expense. The Hospital provides emergency and other medically necessary care to all patients, regardless of their ability to pay or the cost to the Organization.
PART I, LINE 6A		Culpeper Regional Hospital, Inc. prepares its own community benefit report.
PART I, LINE 7	SUBSIDIZED HEALTH SERVICES	It is part of the Culpeper Regional Hospital mission to ensure availability of health care services to patients in the community, 24 hours a day, 7 days a week, regardless of the patients' ability to pay. Culpeper Regional Hospital is a small community hospital located in a rural area that has difficulty attracting and retaining physicians. In order to ensure 24/7 coverage of inpatient internal medical services, emergency room services, obstetric services, and multi-specialty services within the community (each of which is an identified community need), Culpeper Regional Hospital provides physician subsidies to attract and keep physicians in the community. If Culpeper Regional Hospital did not provide these subsidized health services, community members would often be forced to leave the community to receive care. These subsidized health services costs have not been included in the shortfalls listed for Medicaid or Medicare, or as another community benefit or community building activity reported in Part I, Line 7 or Part II.
PART I, LINE 7 COLUMN F		THE ORGANIZATION REMOVED THE BAD DEBT EXPENSE FROM THE TOTAL EXPENSE PRIOR TO THE CALCULATIONS.
PART I, LINE 7		The costing methodology used to calculate amounts reported in Line 7 was a cost-to-charge ratio derived from Worksheet 2, ratio of patient care cost-to-charges.
PART III, LINE 4		The costing methodology used to calculate amounts reported in Line 2 was a cost-to-charge ratio derived from Worksheet 2, ratio of patient care cost-to-charges, which was multiplied against the Hospitals' bad debt expense to arrive at the Hospital's bad debt expense at cost. In order to estimate the amount of the Hospital's bad debt expense, at cost, attributable to patients eligible under the organization's charity care policy, the Hospital used the following methodology. First, for each account attributable to a self-pay patient that had a balance in excess of $5,000, the Hospital uses a software program that pulls information from various sources to predict whether the patient that had received the care likely would qualify under the Hospital's financial assistance policy. If the software program identified a patient as likely qualifying for financial assistance, the Hospital presumes the patient's eligibility under the financial assistance policy and writes off the account to charity. Then, the Hospital examines the outstanding self-pay accounts that have a balance of less than $5,000. The Hospital does not use the aforementioned software program to determine whether the patients incurring these accounts are likely to qualify for financial assistance. As a result, these accounts are included in the Hospital's bad debt expense, if they are not paid upon. Finally, the Hospital applies the percentage of self-pay accounts with a balance in excess of $5,000 that are presumed to qualify for financial assistance (approximately 20%) to the bad debt expense attributable to the self-pay accounts under $5,000 to estimate the bad debt expense attributable to patients who likely would qualify for financial assistance under the Hospital's charity care policy if sufficient information had been made available to make a determination of eligibility. This bad debt expense was then multiplied by the cost-to-charge ratio calculated pursuant to Worksheet 2 to determine the bad debt expense at cost attributable to patients likely eligible under the organization's financial assistance policy. The Hospital's bad debt expense, at cost, attributable to patients that likely qualify for financial assistance should be considered a community benefit provided by the Hospital. Although the Hospital has made a strong effort to provide presumptive charity care to self-pay patients, it is not feasible for the Hospital to make a charity care determination with respect to all of the patients that do not complete the financial assistance application process, particularly with respect to small balances. Since these patients would have qualified under the financial assistance policy if they had completed the application, the bad debt expense associated with treating them should still be treated as a community benefit. The lack of completion of the financial assistance policy should not alter the character of the cost.
PART III, LINE 8		THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE SHORTFALL REPORTED ON LINE 7 WAS CALCULATED USING THE COST-TO-CHARGE RATIO FROM THE MEDICARE COST REPORT AND THEREFORE ONLY INCLUDE ALLOWABLE COSTS AS DEFINED BY MEDICARE. THE ORGANIZATION'S MEDICARE SHORTFALL, AS REPORTED IN SCHEDULE H, PART III, SECTION B, 7, SHOULD BE CONSIDERED A COMMUNITY BENEFIT. ALTHOUGH PROVIDING THE BEST POSSIBLE CARE TO OUR MEDICARE PATIENTS CREATES A FINANCIAL LOSS, PART OF THE MISSION OF OUR ORGANIZATION IS TO SERVE ELDERLY PATIENTS WITHIN THE COMMUNITY, AND WE BELIEVE PROVIDING SUCH CARE HAS CONTRIBUTED TO THE IMPROVEMENT OF COMMUNITY HEALTH. FURTHERMORE, BY PROVIDING THE BEST POSSIBLE CARE TO OUR MEDICARE PATIENTS, WE RELIEVE THE GOVERNMENT AND SURROUNDING OTHER HOSPITALS OF THE FINANCIAL BURDEN OF TREATING THESE PATIENTS INSURED BY THE MEDICARE PROGRAM.
PART III, LINE 9B		CULPEPER REGIONAL HOSPITAL MANAGEMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES (INCLUDING ACTIONS THE HOSPITAL MAY TAKE IN THE EVENT OF NON-PAYMENT, INCLUDING COLLECTIONS ACTION AND REPORTING TO CREDIT AGENCIES) THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR CHARITY, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR CHARITY FROM CULPEPER REGIONAL HOSPITAL, AND A PATIENT'S GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH CULPEPER REGIONAL HOSPITAL. FOR PATIENTS WHO QUALIFY FOR CHARITY AND WHO ARE COOPERATING IN GOOD FAITH TO RESOLVE THEIR DISCOUNTED HOSPITAL BILLS, CULPEPER REGIONAL HOSPITAL MAY OFFER EXTENDED PAYMENT PLANS, WILL NOT SEND UNPAID BILLS TO OUTSIDE COLLECTION AGENCIES, AND WILL CEASE ALL COLLECTION EFFORTS. CULPEPER REGIONAL HOSPITAL WILL NOT IMPOSE EXTRAORDINARY COLLECTIONS ACTIONS WITHOUT FIRST MAKING REASONABLE EFFORTS TO DETERMINE WHETHER THAT PATIENT IS ELIGIBLE FOR CHARITY CARE UNDER THIS FINANCIAL ASSISTANCE POLICY. REASONABLE EFFORTS SHALL INCLUDE VALIDATING THAT THE PATIENT OWES THE UNPAID BILLS AND THAT ALL SOURCES OF THIRD-PARTY PAYMENTS HAVE BEEN IDENTIFIED AND BILLED BY THE HOSPITAL, DOCUMENTATION THAT CULPEPER REGIONAL HOSPITAL HAS OR HAS ATTEMPTED TO OFFER THE PATIENT THE OPPORTUNITY TO APPLY FOR CHARITY CARE PURSUANT TO THIS POLICY AND THAT THE PATIENT HAS NOT COMPLIED WITH THE HOSPITAL'S APPLICATION REQUIREMENTS AND DOCUMENTATION THAT THE PATIENT HAS BEEN OFFERED A PAYMENT PLAN BUT HAS NOT HONORED THE TERMS OF THAT PLAN.
PART VI, LINE 2	NEEDS ASSESSMENT	Culpeper Regional Hospital (CRH) collaborated with the Virginia Department of Health and Fauquier Hospital to produce a Community Health Needs Assessment for Virginia's Planning District 9, which includes Culpeper, Madison, Fauquier, Orange and Rappahannock Counties. CRH defines its Total Service Area as Culpeper, Madison, and Orange Counties, plus parts of Southern Fauquier County. Fauquier Hospital considers Fauquier and Rappahannock Counties as its Service Area. As such, Culpeper Regional Hospital has contracted with a company, Community Health Solutions, Inc. to prepare a Community Health Needs Assessment for Culpeper, Madison and Orange Counties, while Fauquier Hospital is using the same company to prepare a Community Health Needs Assessment for Fauquier and Rappahannock Counties. Information from both needs assessments will be combined and supplemented by data from the Virginia Department of Health to produce a comprehensive Community Health Needs Assessment for the total Planning District. The Community Health Needs Assessment was completed in Fall 2011 and is expected to be reported upon in CRH's 2011 Form 990. Culpeper Regional Hospital is now in the process of implementing certain of the community needs that have been identified in the Community Health Needs Assessment produced by Community Health Solutions, Inc.
PART VI, LINE 3	PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	Culpeper Memorial Hospital has several ways it informs and educates patients and persons who may be in need and are eligible for assistance. When staff (cashier, financial counselors and registers) are speaking with a patient that states they are not able to pay, the patient is encouraged to apply for financial assistance. Brochures describing the financial assistance policy are placed in our billing statements, as well as the applicable poverty guidelines for qualifying for financial assistance. In addition, financial assistance applications, as well as FAQs with respect to the financial assistance policy, are handed out to patients upon registration. The Hospital's website posts the Hospital's financial assistance policy and guidelines for applying.
PART VI, LINE 4	COMMUNITY INFORMATION	CULPEPER REGIONAL HOSPITAL DEFINES ITS TOTAL SERVICE AREA AS CULPEPER, MADISON, ORANGE, AND RAPPAHANNOCK COUNTIES, PLUS SELECTED ZIP CODES IN SOUTHERN FAUQUIER COUNTY (20115, 20119, 22712, 22720, 22728, 22734 AND 22742). POPULATION ESTIMATE FOR 2011 FOR THIS AREA IS 131,906, WITH 65,434 MALES AND 66,472 FEMALES. PROJECTED POPULATION FOR 2016 IS 144,737, WHICH IS A 9.7% CHANGE. THE AVERAGE HOUSEHOLD INCOME FOR THIS AREA IS $73,389, WITH THE MEDIAN HOUSEHOLD INCOME BEING $59,427. POPULATION DISTRIBUTION BY AGE IS AS FOLLOWS: 0-17 YEARS 24.5%, 18-34 YEARS 19.7%, 35-54 YEARS 29.2%, 55+ YEARS 26.6%. RACE/ETHNICITY DISTRIBUTION IS AS FOLLOWS: CAUCASIAN 78.4%, AFRICAN AMERICAN 13%, HISPANIC 5.5%, ASIAN 1.1%, ALL OTHERS 2%. EDUCATION LEVE IS AS FOLLOWS: LESS THAN HIGH SCHOOL 6.2%, SOME HIGH SCHOOL 10.2%, HIGH SCHOOL DEGREE 34.2%, SOME COLLEGE/ASSOC. DEGREE, 27.1%, BACHELOR DEGREE OF GREATER 22.3%.
PART VI, LINE 5	PROMOTION OF COMMUNITY HEALTH	Culpeper Regional Hospital promotes the health of its community in several ways. First, the Hospital provides medical staff privileges to qualified physicians for its departments. Additionally, all financial surpluses generated by the Hospital are used exclusively to improve patient care services and to further the charitable purposes of the organization.
PART VI, LINE 6	AFFILIATED HEALTH CARE SYSTEM	Culpeper Regional Hospital is part of an affiliated health care system that provides an array of healthcare services to its community. The Hospital is affiliated with Culpeper Regional Health System, a related tax-exempt organization that holds a 51% interest in the Hospital. Additionally, the University of Virginia (a section 501(c)(3) tax-exempt organization) holds a 49% interest in the Hospital on behalf of its Medical Center. The Hospital is an acute care hospital, which is a sole community provider. The Hospital provides essential healthcare services to the community, including emergency and obstetric services, which would not otherwise be provided due to their unprofitable nature. Otherwise, these healthcare services would need to be provided by another tax-exempt organization or directly by the government. In addition, Culpeper Regional Health System undertakes a number of activities that benefit the community. For instance, Culpeper Regional Health System runs a free 12-week program designed to help members of the community live a healthier lifestyle, named Drop It! The Healthy Living and Weight Loss Challenge. The program includes a health fair with health screenings, interactive fitness demonstrations, nutritional information and other health and wellness booths. The program also includes group exercise classes, held each Monday during the 12 weeks. For each pound a participant loses during the program, a designated amount is donated to benefit allied and nursing health programs in the region.
STATE FILING OF COMMUNITY BENEFIT REPORT	990 SCHEDULE H, PART VI	VA,

Schedule H (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

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

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

Attach to Form 990

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Culpeper Memorial Hospital Inc

Employer identification number
54-0622371

Part I

General Information on Grants and Assistance

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

Yes No

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

Part II

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

(a) Name and address of organization or government	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) culpeper regional health system501 sunset lane culpeper,VA22701	16,640	free clinic

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

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

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

Cat. No. 50055P

Schedule I (Form 990) 2010

Page 2

Part III

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

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance

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
part i, line 2	GRANTS TO US ORGANIZATIONS	CULPEPER REGIONAL HOSPITAL PROVIDES FUNDS TO CULPEPER REGIONAL HEALTH SYSTEM A RELATED 501(C)(3) TAX EXEMPT ORGANIZATION TO PROVIDE FUNDS FOR THE FREE CLINIC OF CULPEPER.

Schedule I (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Yes

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

Yes

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) H LEE KIRK JR	(i) (ii)	372,901 0	0 0	15,000 0	2,990 0	15,951 0	406,842 0
(2) SAM MORGAN	(i) (ii)	177,180 0	12,750 0	0 0	1,831 0	3,336 0	195,097 0
(3) JOHN MAXWELL	(i) (ii)	158,082 0	11,851 0	0 0	0 0	20,041 0	189,974 0
(4) DENNIS SMITH	(i) (ii)	142,348 0	0 0	0 0	1,114 0	19,154 0	162,616 0
(5) JANICE SUTER	(i) (ii)	136,853 0	10,193 0	0 0	1,464 0	12,434 0	160,944 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
Part I, Line 1a		The organization provides health/social club dues as a benefit for the President/CEO. The value of this benefit is included on the CEO's Form W-2 as wage income.

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Culpeper Memorial Hospital Inc

Employer identification number
54-0622371

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	INDUSTRIAL DEVELOP AUTHORITY OF TOWN CULPEPER VA	54-1312068	000000000	12-23-2003	8,262,873	HEALTH FACILITIES REV BOND 03		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .	5,903,476
2 Amount of bonds defeased . . . .
3 Total proceeds of issue . . . .	8,302,651
4 Gross proceeds in reserve funds . .
5 Capitalized interest from proceeds.
6 Proceeds in refunding escrow. . . . .
7 Issuance costs from proceeds . . .	125,000
8 Credit enhancement from proceeds.
9 Working capital expenditures from proceeds . .
10 Capital expenditures from proceeds . .	2,914,778
11 Other spent proceeds . .	5,262,573
12 Other unspent proceeds. . .
13 Year of substantial completion . . .	2004
	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

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? . .
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 . . . . . . . . . . . . .
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 .
6 Total of lines 4 and 5 . . .. . . . . .
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

Page 3

Part V

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Identifier	Return Reference	Explanation
DESCRIPTION OF 990 REVIEW PROCESS	PART VI, LINE 11	The Form 990 is prepared with assistance from an outside accounting firm, and reviewed by the Chief Financial Officer and Controller. The Form 990 is presented to the Culpeper Regional Hospital Finance Committee, with time allotted at the end of the presentation for questions and comments from the Finance Committee Members. In addition, a copy of the Form 990 is made available to each of the Organization's Board members for their review and comment prior to filing.
MONITORING CONFLICTS OF INTEREST	PART VI, LINE 12C	The organization has adopted a conflict of interest policy. Annually, each board member must disclose any conflicts of interest with the organization or any other board members. In addition to the annual disclosure, each meeting of the Board begins with a voluntary verbal self-disclosure of any conflicts with any items on the agenda. As additional issues arise during the course of a meeting, a similar self-disclosure is expected to be made. If self-disclosures are not forth-coming, the board members are encouraged to raise the possibility of potential conflicts with regard to other board members. During the course of doing business, if conflicts are suspected by anyone affiliated with the organizataion with regard to key employees, officers, or board members, they are encouraged to notify the Chief Executive Officer of their suspicions. The CEO will investigate, employing legal counsel as necessary, and will resolve as appropriate. Ultimately it is the responsibility of the Chief Executive Officer and the Chairman of the Board to enforce the policy.
PROCESS FOR DETERMINING COMPENSATION	PART VI, LINE 15	THE ORGANIZATION UTILIZES AN INDEPENDENT COMPENSATION CONSULTANT, A WRITTEN EMPLOYMENT CONTRACT, A COMPENSATION SURVEY OR STUDY, APPROVAL BY THE BOARD/COMPENSATION COMMITTEE, AND A CONTEMPORANEOUS WRITTEN SUBSTANTIAION OF THE DECISION MAKING PROCESS WHEN DETERMINING COMPENSATION for the ceo and other officers and key employees.
DOCUMENT AVAILABLITY	PART VI, LINE 19	THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
joint venture policy	PART VI, SECTION B, LINE 16B	Culpeper Memorial Hospital has entered into two joint ventures, both to undertake medical services with physicians. For both joint ventures, Culpeper Memorial Hospital has taken steps to safeguard the organization's exempt status by, for example, controlling greater than 50% of the vote and value of each joint venture and making distributions from the joint venture solely in accordance with the percentage of ownership held by each partner. In addition, Culpeper Memorial Hospital intends to adopt an explicit, written policy requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law. It is the Hospital's intention to have the policy drafted and approved by the Board as early as possible in the 2011 tax year.
PART XI LINE 5	RECONCILIATION OF NET ASSETS	UNREALIZED LOSS $(204,445) BOOK GAIN ON PARTNERSHIPS 140,178 K-1 CMA 619,909 K-1 CSC (470,597) ---------- TOTAL $ 85,045
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:LEONARD SANDRIDGE TITLE:TRUSTEE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:TOM REYNOLDS MD TITLE:vice chair HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:CONSTANCE KINCHELOE TITLE:TRUSTEE HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:H LEE KIRK JR TITLE:PRESIDENT/CEO HOURS:12
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:KARL BEIER MD TITLE:IMMEDIATE PAST CHAIR HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:R EDWARD HOWELL TITLE:TRUSTEE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:LARRY FITZGERALD TITLE:TRUSTEE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:ROBERT GIBSON MD TITLE:TRUSTEE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:STEVEN DEKOSKY MD TITLE:TRUSTEE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:MICHAEL ARMM TITLE:CHAIR HOURS:5
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:C WAYNE HAWKINS TITLE:SECRETARY HOURS:2
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:BILL CANNON JR TITLE:TREASURER HOURS:4
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:SAM MORGAN TITLE:SENIOR VICE PRESIDENT CFO HOURS:8
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:SUSAN EDWARDS TITLE:VP HUMAN RESOURCES HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:JANICE SUTER TITLE:VP NURSING HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:TIM FRITTS TITLE:CONTROLLER HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:PAULETTE BUCHANAN TITLE:CAT SCAN TECH HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:DENNIS SMITH TITLE:DIRECTOR OF PHARMACY HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:TEMPLE COATES TITLE:DIRECTOR REHAB SERVICES HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:TRACEY SHIFFLETT TITLE:DIRECTOR OF BUSINESS OFFICE HOURS:
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:JOHN MAXWELL TITLE:SENIOR VICE PRESIDENT COO HOURS:8

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:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Culpeper Memorial Hospital Inc

Employer identification number

54-0622371

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) CULPEPER REGIONAL HEALTH SYSTEMS 501 SUNSET LANE CULPEPER,VA22701 54-1366700	MGMT	VA	501(C)(3)	509(a)(3)			No

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

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) CULPEPER SURGERY CENTER LLC 541 SUNSET LANE CULPEPER,VA22701 54-1975624	HEALTHCARE	VA	CULPEPER HOSP	related	2,208,521	1,340,154		No	0			59.340 %
(2) CULPEPER MEDICAL ASSOCIATES 100 SAUNDERS ST CULPEPER,VA22701 54-1822695	MEDICAL SERVI	VA	CULPEPER HOSP	related	7,958,701	2,997,304		No	0			51.000 %

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) CULPEPER PHYSICIAN HOSPITAL ORGANIZATION PO BOX 592 CULPEPER,VA22701 54-1703526	MEMBERSHIP OR	VA	CMH	C CORP	395,979	212,072	70.000 %

Schedule R (Form 990) 2010

Page 3

Part V

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

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

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

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

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

Yes

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

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

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

Yes

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

Yes

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

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

Yes

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

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

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

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved
(1) culpeper physician hospital organization	n	316,230
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2010

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: To help people achieve and maintain optimal health by providing the best possible health care services.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	12
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	11
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	822
6	Total number of volunteers (estimate if necessary) ....	6	300
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	12,555
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	-7,177

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	0	353,471
9	Program service revenue (Part VIII, line 2g) .........	69,687,206	71,182,975
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	2,618,669	2,373,035
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	205,906	254,807
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	72,511,781	74,164,288
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	18,450	30,606
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)	32,206,659	32,644,855
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	37,182,954	38,042,107
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	69,408,063	70,717,568
19	Revenue less expenses. Subtract line 18 from line 12......	3,103,718	3,446,720
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	81,059,208	86,014,588
21	Total liabilities (Part X, line 26)............	11,568,101	12,991,716
22	Net assets or fund balances. Subtract line 21 from line 20 .....	69,491,107	73,022,872

Sign Here

	Signature of officer	Date

	Type or print name and title.

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


4a	(Code: ) (Expenses $ 57,324,374 including grants of $ 13,966 ) (Revenue $ 71,422,080 )
	The community benefit contribution of Culpeper Regional Hospital is to provide programs and activities that improve access to health care and improve health in our community. Culpeper Regional Hospital is a 70-bed, non-profit, acute care hospital with comprehensive services providing a 24-hour, physician-staffed Emergency Department, Family Birth Center, Surgical Services, Intensive Care Unit and more. CRH provides medical and other health care services to patients regardless of their ability to pay. Our mission is to help people achieve and maintain optimal health by providing the best possible health care services. We will always make the needs of our patients our top priority. We also partner with local non-profit organizations (The Chamber of Commerce and local schools) to support local events and provide community health and wellness programs. All uninsured patients, regardless of income level or county of residence, receive a 20% discount on hospital services and an additional 15% discount for payment within 30 days. In connection with these services, CRH provided charity care, at cost of $1,919,571 (including $475,229 from the provision of free medical care to Culpeper free clinic patients) and incurred shortfalls from Medicare of $7,492,159 and from Medicaid of $1,291,145. Program service revenues are reported net of these amounts, consistent with financial statement reporting. CRH works with local community colleges to provide tours, lectures and internships for students. CRH also provided approximately $30,000 in funds to help address the shortage for these programs. Our health professionals provided community education and outreach programs for approximately 3,800 community members, at a net expense of $213,000. CRH publishes two major community newsletters. Simply Health and Aging Well are published 3 times year; it reaches 50,000 homes in Culpeper and surrounding counties. The cost to CRH for publication and distribution of the newsletters for FY11 was $105,555. For Links to additional community benefit information, please see Culpeper Regional Hospital's website: www.culpeperhospital.com.

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












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












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 57,324,374

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)			(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
(A) Name and Title
(18) DENNIS SMITH DIRECTOR OF PHARMACY	40.0	X		142,348	0	20,268
(19) TEMPLE COATES DIRECTOR REHAB SERVICES	40.0	X		128,326	0	20,752
(20) TRACEY SHIFFLETT DIRECTOR OF BUSINESS OFFICE	40.0	X		128,572	0	3,639
(21) JOHN MAXWELL SENIOR VICE PRESIDENT COO	36.0		X	169,933	0	20,041

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,684,106	0	137,302

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		353,471
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			353,471
			Business Code
2a	PATIENT SERVICES			70,506,407	70,506,407
b	OTHER			676,568	676,568
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			71,182,975
3	Investment income (including dividends, interest
	and other similar amounts).....			2,335,380			2,335,380
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents	12,511
b	Less: rental expenses	9,315
c	Rental income or (loss)	3,196
d	Net rental income or (loss).......			3,196			3,196
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	35,611	2,044
b	Less: cost or other basis and sales expenses
c	Gain or (loss)	35,611	2,044
d	Net gain or (loss)..........			37,655			37,655
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	CAFETERIA			239,056	239,056
b	OUTSIDE CATERING		722,320	12,555		12,555
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			251,611
12	Total revenue. See Instructions....			74,164,288	71,422,031	12,555	2,376,231


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			4,925,980	1	1,540,211
2	Savings and temporary cash investments .......				2
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			8,217,280	4	12,082,591
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............			122,318	7	174,114
8	Inventories for sale or use ..............			1,186,496	8	1,614,802
9	Prepaid expenses and deferred charges ............			374,912	9	732,934
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	70,123,992
b	Less: accumulated depreciation. .....	10b	42,766,990	23,335,051	10c	27,357,002
11	Investments—publicly traded securities ..........			2,542,124	11	2,358,393
12	Investments—other securities. See Part IV, line 11 ......			770,700	12	833,327
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			39,584,347	15	39,321,214
16	Total assets. Add lines 1 through 15 (must equal line 34)...			81,059,208	16	86,014,588
17	Accounts payable and accrued expenses .			5,205,914	17	7,779,850
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........			5,563,534	20	4,313,353
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 ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			798,653	25	898,513
26	Total liabilities. Add lines 17 through 25.....			11,568,101	26	12,991,716
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			69,491,107	27	73,022,872
28	Temporarily restricted net assets .....				28
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			69,491,107	33	73,022,872
34	Total liabilities and net assets/fund balances .....			81,059,208	34	86,014,588