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) MICHAEL E CALLAHAN PHYSICIAN, SECRETARY	40.0	X	X		173,164	16,221
(2) JASON TRONETTI PHYSICIAN, DIRECTOR	40.0	X			313,676	21,296
(3) CHARLES UPDEGRAFF CHAIRMAN	1.0	X	X		0	0
(4) RON CASKEY DIRECTOR	1.0	X			0	0
(5) REVEREND RANDALL HEADLEY 2ND VICE CHAIRMAN	1.0	X	X		0	0
(6) ROBERT MARTIN DIRECTOR THROUGH 10/10	1.0	X			0	0
(7) HOWARD MILLER DIRECTOR THROUGH 9/10	1.0	X			0	0
(8) PAUL PRITCHARD TREASURER	1.0	X	X		0	0
(9) ROBERT SMITH 1ST VICE CHAIRMAN	1.0	X	X		0	0
(10) RUSSELL STREICH DIRECTOR	1.0	X			0	0
(11) SUSAN KEFOVER DIRECTOR THROUGH 4/11	1.0	X			0	0
(12) DAVID BUCKLER DIRECTOR BEG. 10/10	1.0	X			0	0
(13) DAVID CRANDALL DIRECTOR	1.0	X			0	0
(14) JEANNE MIGLICIO DIRECTOR BEG. 10/10	1.0	X			0	0
(15) THOMAS SHAFFER DIRECTOR BEG. 10/10	1.0	X			0	0
(16) EDWARD C PITCHFORD PRESIDENT, CEO, & ASST. SEC.	40.0		X		268,657	22,017
(17) CYNTHIA L HARDESTY VICE PRESIDENT, CNE	40.0			X	151,729	10,421

(A) Name and business address	(B) Description of services	(C) Compensation
JAMES BARKE MD	PHYSICIAN	649,062
FOOT ANKLE INNOV	PHYSICIAN	317,136
BKD LLP	AUDIT/TAX/CONSULTING	105,762


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 3

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21	0
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	977,181	525,078	452,103
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	126,190		126,190
7	Other salaries and wages	22,797,219	19,561,408	3,235,811
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	945,978	805,443	140,535
9	Other employee benefits .......	4,296,532	3,454,435	842,097
10	Payroll taxes ...........	1,693,909	1,425,722	268,187
11	Fees for services (non-employees):
a	Management ......	379,708	379,708
b	Legal .........	115,523		115,523
c	Accounting ...........	108,769		108,769
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	84,000			84,000
f	Investment management fees ......	99,576		99,576
g	Other ..........	14,086,375	13,334,942	751,433
12	Advertising and promotion ....	97,873	2,001	95,872
13	Office expenses .......	13,780,208	12,716,773	1,063,435
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	972,113	813,650	158,463
17	Travel ............	301,693	270,840	30,853
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	245,234	146,572	98,662
20	Interest ...........	1,180,126	1,056,444	123,682
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	2,411,220	2,158,514	252,706
23	Insurance ..............	1,028,588	536,046	492,542
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	3,039,163	3,039,163
b	LICENSES, DUES & SUBSCRIPTIONS	299,596	112,125	187,471
c	RECRUITING	140,622		140,622
d	OTHER AUXILIARY EXPENSES	31,937			31,937
e
f	All other expenses
25	Total functional expenses. Add lines 1 through 24f	69,239,333	60,338,864	8,784,532	115,937
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........		1
2	Savings and temporary cash investments .......	5,018,474	2	6,770,890
3	Pledges and grants receivable, net .........	206,716	3	71,851
4	Accounts receivable, net .........	7,106,477	4	7,510,740
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	981,423	8	1,081,698
9	Prepaid expenses and deferred charges ............	2,099,925	9	1,785,764
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	63,106,763
b	Less: accumulated depreciation. .....	10b	40,093,165	24,055,090	10c	23,013,598
11	Investments—publicly traded securities ..........	10,756,526	11	12,716,424
12	Investments—other securities. See Part IV, line 11 ......	1,171,705	12	1,532,975
13	Investments—program-related. See Part IV, line 11 ..	117,496	13	396,598
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........	1,215,278	15	422,241
16	Total assets. Add lines 1 through 15 (must equal line 34)...	52,729,110	16	55,302,779
	17	Accounts payable and accrued expenses .	13,430,176	17	12,962,644
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........	20,292,611	20	19,534,724
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	10,229	21	14,430
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 ..	2,268,171	23	1,239,449
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities. Complete Part X of Schedule D.....	1,783,094	25	1,395,613
26	Total liabilities. Add lines 17 through 25.....	37,784,281	26	35,146,860
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	10,850,438	27	15,669,621
28	Temporarily restricted net assets .....	426,591	28	205,421
29	Permanently restricted net assets .....	3,667,800	29	4,280,877
	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 .....	14,944,829	33	20,155,919
34	Total liabilities and net assets/fund balances .....	52,729,110	34	55,302,779

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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

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

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

Page 1 of 1 of Part III

Name of organization
CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

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

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

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

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

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

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

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

2a	Lobbying non-taxable amount

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

c	Total lobbying expenditures

d	Grassroots non-taxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

9,940

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

9,940

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
LOBBYING ACTIVITIES	SCHEDULE C, PART II-B, LINE 1I	THE ORGANIZATION IS A MEMBER OF HAP, AHA, AND HCWP. $9,940 OF DUES ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES.

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


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

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

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

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

Yes No

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

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

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

Yes No

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

Part III

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

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

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

(i)

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

(ii)

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

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

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

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

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

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

		(a)Current Year	(b)Prior Year	(c)Two Years Back
1a	Beginning of year balance ....	3,667,800	3,616,355	4,837,234
b	Contributions ........
c	Investment earnings or losses ...	942,900	437,150	-1,006,344
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	329,823	385,705	214,535
f	Administrative expenses ....
g	End of year balance ......	4,280,877	3,667,800	3,616,355

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

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

100.000 %

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)

Yes

(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 .................	1,135,847		1,135,847
b	Buildings ................	26,779,607	14,157,789	12,621,818
c	Leasehold improvements ............	9,812,494	5,259,488	4,553,006
d	Equipment ................	22,938,686	19,505,318	3,433,368
e	Other .................	2,440,129	1,170,570	1,269,559
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........				23,013,598

Schedule D (Form 990) 2010

Page 3

Part VII

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

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








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

Part VIII

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

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









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

Part IX

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

(a) Description				(b) Book value









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

Part X

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

1.(a) Description of Liability		(b) Amount
Federal Income Taxes		0
DUE TO THIRD PARTIES		1,395,613








Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		1,395,613
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	71,310,828
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	69,239,333
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	2,071,495
4	Net unrealized gains (losses) on investments ..........................	4	1,444,493
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV) .................................	8	1,721,486
9	Total adjustments (net). Add lines 4 - 8 .............................	9	3,165,979
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	5,237,474

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	74,806,025
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	1,444,493
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV): ............	2d	1,770,102
e	Add lines 2a through 2d .....................			2e	3,214,595
3	Subtract line 2e from line 1.....................			3	71,591,430
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	-280,602
c	Add lines 4a and 4b.......................			4c	-280,602
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......			5	71,310,828

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	69,568,551
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	361,155
e	Add lines 2a through 2d......................			2e	361,155
3	Subtract line 2e from line 1.....................			3	69,207,396
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	31,937
c	Add lines 4a and 4b.......................			4c	31,937
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......			5	69,239,333

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
ESCROW ACCOUNTS	SCHEDULE D, PART IV, LINE 2B	THE CORPORATION HAS AN ESCROW ACCOUNT FOR THEIR SKILLED NURSING FACILITY PATIENTS WHO REQUEST THE USE OF THE ACCOUNT. THIS AMOUNT IS REPORTED ON FORM 990, PART X, LINE 21.
ENDOWMENT FUND	SCHEDULE D, PART V, LINE 4	THE ENDOWMENT FUND WAS ESTABLISHED TO ALLOW THE HOSPITAL TO PROVIDE HEALTHCARE SERVICES TO POOR AND NEEDY PATIENTS. UNCERTAIN TAX POSITIONS SCHEDULE D, PART X, LINE 2 MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.
OTHER CHANGES IN NET ASSETS	SCHEDULE D, PART XI, LINE 8	DEFINED BENEFIT PENSION COSTS: AMORTIZATION OF NET LOSS 242,842 NET GAIN ARISING DURING YEAR 1,452,260 AUXILIARY NET INCOME (48,616) AUXILIARY TRANSFER TO CCMH 75,000
OTHER REVENUE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12	SCHEDULE D, PART XII, LINE 2D	DEFINED BENEFIT PENSION COSTS: AMORTIZATION OF NET LOSS 242,842 NET GAIN ARISING DURING YEAR 1,452,260 AUXILIARY TRANSFER TO CCMH 75,000
OTHER REVENUE INCLUDED ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1	SCHEDULE D, PART XII, LINE 4B	RENTAL EXPENSES (347,816) SPECIAL EVENT EXPENSE (13,339) AUXILIARY SPECIAL EVENT REVENUE 38,227 AUXILIARY SALES OF INVENTORY 76,779 AUXILIARY COST OF GOODS SOLD (49,937) AUXILIARY INTEREST INCOME 74 AUXILIARY OTHER INCOME 15,410
OTHER EXPENSES INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25	SCHEDULE D, PART XIII, LINE 2D	RENTAL EXPENSES 347,816 SPECIAL EVENT EXPENSES 13,339
OTHER EXPENSES INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1	SCHEDULE D, PART XIII, LINE 4B	OTHER AUXILIARY EXPENSES 31,937

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow

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

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization
CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and e-mail solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.

(i) Name and address of individual or entity (fundraiser)	(ii) Activity	(iii) Did fundraiser have custody or control of contributions?		(iv) Gross receipts from activity	(v) Amount paid to (or retained by) fundraiser listed in col. (i)	(vi) Amount paid to (or retained by) organization
	(ii) Activity	Yes	No	(iv) Gross receipts from activity		(vi) Amount paid to (or retained by) organization
DELTA DEVELOPMENT GROUP INC	GRANT WRITING		No		84,000
Total .................					84,000

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2010

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.

		(a) Event #1 GOLF TOURNAMENT (event type)	(d) Total Events (Add col. (a) through col. (c))
1	Gross receipts . . .	38,227	38,227
2	Less: Charitable contributions . . .	30,227	30,227
3	Gross income (line 1 minus line 2) . . .	8,000	8,000
4	Cash prizes . . .
5	Non-cash prizes . .	4,504	4,504
6	Rent/facility costs . .	3,379	3,379
7	Food and beverages . .	4,606	4,606
8	Entertainment . . .
9	Other direct expenses .	850	850
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........		13,339
11	Net income summary. Combine lines 3 and 10 in column (d)............		-5,339

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (Add col. (a) through col. (c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," Explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," Explain:

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ...........................

YesNo

Schedule G (Form 990 or 990-EZ) 2010

Page 3

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Provide the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

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

Identifier	ReturnReference	Explanation
FUNDRAISING ACTIVITIES	SCHEDULE G, PART I, LINE 2B	THE ORGANIZATION HIRED DELTA DEVELOPMENT GROUP, INC., FOR GRANT WRITING SERVICES. THE AGREEMENT PROVIDED FOR A MONTHLY FEE FOR PROFESSIONAL FUNDRAISING SERVICES AS WELL AS REIMBURSEMENT OF ADDITIONAL FUNDRAISING EXPENSES.

Schedule G (Form 990 or 990-EZ) 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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other

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

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

Yes

200% 250% 300% 350% 400% Other

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

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

Yes

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

Yes

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

Yes

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) ..	631,213		631,213	0.910 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	12,553,658	8,223,671	4,329,987	6.250 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	13,184,871	8,223,671	4,961,200	7.160 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	96,734	23,973	72,761	0.110 %
f Health professions education (from Worksheet 5) ..	366,055		366,055	0.530 %
g Subsidized health services (from Worksheet 6) ..	22,923,622	17,270,015	5,653,607	8.160 %
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	1,092		1,092
jTotal Other Benefits ...	23,387,503	17,293,988	6,093,515	8.800 %
kTotal. Add lines 7d and 7j. ..	36,572,374	25,517,659	11,054,715	15.960 %

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	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	2	66	5,940	5,940	0.010 %
4	Environmental improvements
5	Leadership development and training for community members	12	156	4,858	4,858	0.010 %
6	Coalition building	4		3,956	3,956	0.010 %
7	Community health improvement advocacy	20	540	1,260	1,260
8	Workforce development	3	216	447	447
9	Other
10	Total	41	978	16,461	16,461	0.030 %

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).....

1,502,381

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

235,874

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).....

21,123,777

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

20,598,431

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

525,346

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	CHARLES COLE MEMORIAL HOSPITAL 1001 EAST 2ND STREET COUDERSPORT,PA16915	X	X	X	X

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

Name of Hospital Facility:CHARLES COLE MEMORIAL 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?10
Name and address		Type of Facility (Describe)
1	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
2	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
3	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
4	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
5	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
6	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
7	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
8	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
9	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
10	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY

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 7G:		SEVERAL RURAL HEALTH CLINICS WERE INCLUDED IN THE COMPUTATION OF SUBSIDIZED HEALTH SERVICES ON LINE 7G. CCMH PROVIDES PRIMARY CARE TO THE SURROUNDING COUNTIES AT THESE RURAL HEALTH CENTERS. THESE SERVICES ARE PROVIDED IN RURAL AREAS WHERE THERE WOULD BE A SHORTAGE OF QUALITY MEDICAL CARE WITHOUT THE SERVICES. CCMH CONTINUES TO PROVIDE THESE SERVICES AS A BENEFIT TO THE COMMUNITY DESPITE KNOWING THAT FINANCIAL SHORTFALLS WILL BE SUSTAINED. PART III, LINE 4: THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS, WHICH IS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT OR THIRD-PARTY PAYER. LINE 2 WAS DETERMINED BY TAKING THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS TIMES THE RATIO OF PATIENT CARE COST TO CHARGES FROM WORKSHEET 2, LINE 11. LINE 3 WAS DETERMINED BY TAKING THE BAD DEBT EXPENSE AT COST (LINE 2) TIMES THE PERCENT OF PERSONS BELOW THE POVERTY LEVEL FOR 2008 BASED ON US CENSUS BUREAU DATA.
PART III, LINE 8:		MEDICARE DATA COMPUTED USING THE MEDICARE COST REPORT FILED WITH CMS WAS UTILIZED FOR THE COMPUTATIONS IN PART III, SECTION B. MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT, AS CCMH IS CLASSIFIED AS A CRITICAL ACCESS HOSPITAL. THIS CLASSIFICATION SHOWS THAT CCMH IS IN A MEDICALLY UNDERSERVED AREA AND AT A HEALTH PROFESSIONAL SHORTAGE AREA. THIS DEMONSTRATES THAT CCMH IS THE ONLY REASONABLE SOURCE OF HOSPITAL CARE AVAILABLE TO MEDICARE BENEFICIARIES IN OUR SERVICE AREA, AND LIKEWISE TREATS ALL BENEFICIARIES IN OUR SERVICE AREA THAT PRESENT THEMSELVES FOR CARE, DESPITE KNOWING WE WILL GENERALLY LOSE MONEY CARING FOR MEDICARE PATIENTS. ADDITIONALLY, SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.
PART III, LINE 9B:		EFFORTS ARE MADE TO IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR CHARITY CARE IN ACCORDANCE WITH THE HOSPITAL'S CHARITY CARE POLICY OR THE PHYSICIAN NETWORK SLIDING FEE SCALE PRIOR TO THE STATEMENT PROCESS WHEN POSSIBLE.
PART V, SECTION B, LINE 19D:		ALL PATIENTS REGARDLESS OF ABILITY TO PAY ARE BILLED THE SAME AMOUNT FOR THEIR SERVICES. FOR CUSTOMERS THAT HAVE NO INSURANCE (SELF-PAY) WE OFFER 40% DISCOUNT IF BILL IS PAID WITHIN 2 WEEKS.
PART V, SECTION B, LINE 21:		ALL PATIENTS ARE CHARGED THE SAME REGARDLESS OF PAYOR.
NEEDS ASSESSMENT:		CHARLES COLE MEMORIAL HOSPITAL ENGAGED OKLAHOMA STATE UNIVERSITY IN COMPLETING A SERVICE AREA (4 COUNTIES) COMMUNITY HEALTH NEEDS ASSESSMENT WITH THE PROCESS BEGINNING IN JANUARY 2010 AND CONCLUDING IN MARCH 2010 WHEN CHARLES COLE MEMORIAL HOSPITAL RECEIVED OUTCOMES FROM THE SURVEY. SURVEYS WERE CONDUCTED BY TELEPHONE BY OKLAHOMA STATE UNIVERSITY. QUESTIONS WERE DETERMINED AT THE RECOMMENDATION OF OKLAHOMA STATE UNIVERSITY AND REVISED, AS DEEMED NECESARY, BY CCMH. A TOTAL OF 200 PHONE SURVEYS WERE COMPLETED AND 48 ONLINE SURVEYS WERE SUBMITTED FROM ALL SERVICE AREA ZIP CODES. RESULTS WERE TALLIED AND ANALYZED BY OKLAHOMA STATE UNIVERSITY AND THEN PRESENTED TO CCMH AND A GROUP OF APPROXIMATELY 100 INDIVIDUALS FROM OUR COMMUNITY BENEFIT ADVISORY COMMITTEES (NOW KNOWN AS CORPORATE ADVISORS), CCMH PUBLIC RELATIONS COMMITTEE (A BOARD OF DIRECTOR'S SUB-COMMITTEE AND NOW KNOWN AS THE COMMUNITY RELATIONS COMMITTEE), CCMH LEADERSHIP AND CCMH BOARD OF DIRECTORS. IN ADDITION TO THE RECENT COMMUNITY HEALTH NEEDS ASSESSMENT, CCMH DETERMINES HEALTHCARE NEEDS OF THE COMMUNITIES WHICH WE SERVE THROUGH SURVEYS OF OUR COMMUNITY BENEFIT ADVISORY COMMITTEE MEMBERS, INDIVIDUAL RECOMMENDATIONS, BOARD OF DIRECTORS RECOMMENDATIONS, COMMUNITY EVENT SATISFACTION SURVEYS, AND LOCAL AND STATE HEALTHCARE TRENDS.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:		THE PATIENT FINANCIAL COUNSELOR CONTACTS SELF-PAY PATIENTS/GUARANTORS TO DISCUSS PAYMENT ARRANGEMENTS. IF THEY ARE UNABLE TO PAY - SHE EXPLAINS THE PROCESS OF APPLYING FOR CHARITY WHICH INCLUDES APPLYING FOR PA MEDICAL ASISSTANCE FIRST AND IF THEY ARE DENIED OR HAVE A PORTION TO PAY, THEN THEY CAN APPLY FOR CHARITY. THE CHARITY APPLICATION IS ON THE BACK OF OUR SELF-PAY STATEMENTS. ALSO, THE HOSPITAL OWNED PHYSICIAN PRACTICES ARE AWARE OF THIS PROGRAM AND REFER PATIENTS/GUARANTORS TO THE PATIENT FINANCIAL COUNSELOR.
COMMUNITY INFORMATION:		CCMH SERVES PATIENTS MAINLY FROM POTTER, MCKEAN, TIOGA, CAMERON AND ELK COUNTIES IN NORTHCENTRAL PA. ALL OF THE COUNTIES THAT WE SERVE ARE CONSIDERED RURAL AND MOUNTAINOUS. CAMERON COUNTY CURRENTLY HAS THE HIGHEST UNEMPLOYMENT RATE IN THE STATE AND ALL OF THE COUNTIES SERVED ARE BATTLING THE EFFECTS OF THE ECONOMY AND JOB LOSS. OUR POPULATION IS ALSO AGING AS THE AREA OFFERS LITTLE FOR A YOUNGER DEMOGRAPHIC IN THE WAY OF EMPLOYMENT, EDUCATION AND CULTURE.
PROMOTION OF COMMUNITY HEALTH:		THE MISSION OF CHARLES COLE MEMORIAL HOSPITAL INDICATES THAT THE HOSPITAL RESPONDS TO THE HEALTHCARE NEEDS OF THE COMMUNITIES IT SERVES AND IS LARGELY DEPENDENT ON PROVIDING SERVICES AND CARE TO THOSE INDIVIDUALS WHO MAY NOT HAVE THE RESOURCES TO BE AWARE OF, ABLE TO PAY FOR, OR HAVE THE EDUCATION/KNOWLEDGE ABOUT CARE, PROGRAMS AND SERVICES THAT ARE AVAILABLE TO THEM. THROUGH VARIOUS ACTIVITIES CHARLES COLE REACHES OUT TO OUR COMMUNITIES TO EDUCATE, IMPROVE HEALTH, PREVENT AND TREAT DISEASE AND SUPPORT INDIVIDUALS AND GROUPS. CHARLES COLE, IN COOPERATION WITH COMMUNITY BASED GROUPS SUCH AS ROTARY, PROVIDE FIVE COMPREHENSIVE BLOOD ANALYSIS ANNUALLY. COMPREHENSIVE BLOOD ANALYSIS SCREENINGS ARE PROVIDED IN FIVE RURAL COMMUNITIES: GALETON, SMETHPORT, PORT ALLEGANY, SHINGLEHOUSE AND COUDERSPORT. CBA'S SCREEN OVER 30 OF THE MOST COMMON BLOOD TESTS THAT DETECT HEALTH ISSUES SUCH AS CORONARY HEART DISEASE, LIVER DISEASE, KIDNEY DISEASE, CANCER, THYROID DISEASE, DIABETES, ANEMIA, BONE DISEASE AND RESPIRATORY DISEASE. THESE SCREENINGS ARE PROVIDED AT A FRACTION OF THE COST OF HAVING THESE TESTS PERFORMED THROUGH A FAMILY PHYSICIAN. ALL PARTICIPANTS AND THEIR PRIMARY MEDICAL PROVIDER ARE SENT THE RESULTS AND PROVIDERS FOLLOW-UP WITH INDIVIDUALS WHOSE SCREENING RESULTS INDICATE ABNORMALITIES. FOR MANY INDIVIDUALS WHO ARE UNINSURED OR UNDERINSURED AND LIKELY WOULD NOT SEEK MEDICAL CARE UNTIL IT WAS EMERGENT, THESE EVENTS PROVIDE AN AVENUE TO MONITOR THEIR HEALTH AND DETECT POTENTIAL ISSUES BEFORE THEY BECOME EMERGENT. IN ADDITION, THE LOCAL CO-SPONSORS RECEIVE A PORTION OF THE PROCEEDS FROM THESE EVENTS AND UTILIZE THE FUNDS TO PROVIDE SCHOLARSHIPS AND SUPPORT TO LOCAL STUDENTS AND PROJECTS TO BENEFIT THE COMMUNITY. ANNUALLY, CHARLES COLE PARTNERS WITH THE AREA AGENCY ON AGING AND THE PENNSYLVANIA DEPARTMENT OF HEALTH TO ADMINISTER SEASON INFLUENZA AND PNEUMOCCOCAL VACCINE TO COUNTY SENIORS, THE INDIGENT, THE HOUSE-BOUND AND THE UNINSURED AT NO COST. FY2010 800 NO-COST INFLUENZA VACCINES AND 123 PNEUMOCOCCAL VACCINES WERE ADMINISTERED THROUGH 9 CLINICS IN 7 COMMUNITIES. IN MANY CASES THE UNDERSERVED POPULATIONS ARE MORE LIKELY TO BECOME ILL AND POTENTIALLY FACE EMERGENT HEALTH NEEDS FROM VACCINE-PREVENTABLE DISEASE. BY PROVIDING CLINICS AT COUNTY SENIOR CENTERS AND IN RURAL COMMUNITY SETTINGS MANY INDIVIDUALS WHO WOULD LIKELY NOT RECEIVE THESE COMMON VACCINES CAN BE IMMUNIZED AT NO COST AND IN CLOSE PROXIMITY TO THEIR HOMES. IN ADDITION, WITH THE OUTBREAK OF THE H1N1 INFLUENZA VIRUS IN THE FALL OF 2009, CCMH ADMINISTERED APPROXIMATELY 5500 DOSES OF H1N1 VACCINE TO ANY INDIVIDUAL WHO MET CRITERIA. ALSO IN CONJUNCTION WITH THE AREA AGENCY ON AGING, CHARLES COLE PROVIDES NO-COST EDUCATION TO COUNTY SENIOR CENTERS. IN FY 2010, CCMH PROVIDED 7 HEALTH EDUCATION PROGRAMS, EACH PRESENTED AT 4 SENIOR CENTERS FOR A TOTAL OF 30+ SESSIONS. TOPICS INCLUDED IMMUNIZATIONS, OSTEOPOROSIS, HEEL SCREENINGS, WINTER SKIN & FOOT CARE, THE DIABETIC FOOT & GOUT, INCONTINENCE AND GASTROINTESTINAL ISSUES IN SENIORS. FINALLY, AS AN ON-GOING EFFORT TO PROVIDE FULL-SPECTRUM CANCER CARE TO INDIVIDUALS IN RURAL NORTHCENTRAL PENNSYLVANIA, THE PATTERSON CANCER CARE CENTER PHYSICIANS AND STAFF PROVIDED APPROXIMATELY 170 NO-COST CANCER SCREENINGS. SCREENINGS INCLUDED SCREENINGS FOR PROSTATE, COLORECTAL AND SKIN CANCER. SCREENINGS WERE PERFORMED BY ONCOLOGY PHYSICIANS WHO SPECIALIZE IN THE DETECTION, DIAGNOSIS AND TREATMENT OF CANCER. INDIVIDUALS PARTICIPATING IN THESE SCREENINGS WERE BOTH MALE AND FEMALE, ADULT AND SENIOR AND UNINSURED/UNDERINSURED. IN ADDITION TO THE SCREENINGS, PARTICIPANTS WERE ALSO EDUCATED ON HEALTHY HABITS TO REDUCE RISK OF CANCER AND SIGNS AND SYMPTOMS OF CANCER. ALONG WITH MANY OTHER PROGRAMS SUCH AS SUPPORT GROUPS, SPEAKER'S BUREAU, WORKFORCE DEVELOPMENT, ECONOMIC SUPPORT, COMMUNITY LEADERSHIP, PARTNERSHIPS WITH LOCAL CIVIC, GOVERNMENT, SCHOOL DISTRICTS AND COMMUNITY GROUPS, CHARLES COLE MEMORIAL HOSPITAL CONTINUES EFFORTS TO ASSURE THAT HEALTHCARE, IN ALL FORMS, IS ACCESSIBLE AND AVAILABLE TO THOSE WHO MAY OTHERWISE GO WITHOUT.
OTHER INFORMATION:		CCMH PROVIDES THE COMMUNITY WITH SPACE FOR EVENTS, MEETINGS AND PROGRAMS SUCH AS SUPPORT GROUPS AND YOUTH SPORTS. CCMH'S EMPLOYEE GIVING CLUB, HEART OF COLE, HAS A DESIGNATED GROUP THAT FOCUSES ON COMMUNITY CONNECTIONS. THE GROUP ANNUALLY UTILIZES APPROXIMATELY $10,000 ON COMMUNITY CONNECTIONS INCLUDING DONATIONS, IN FY09 SPECIFICALLY TO SERVE INDIVIDUALS AND FAMILIES THROUGH MONETARY AND NON-PERISHABLE FOOD DONATIONS TO LOCAL FOOD BANKS AND TO PURCHASE OF HEALTHCARE-RELATED ITEMS TO BE USED AS GIVE-AWAYS AT COMMUNITY EVENTS. CHARLES COLE STRIVES TO LIVE UP TO ITS NON-PROFIT MISSION EVERY DAY, PROVIDING EXCELLENT HEALTHCARE SERVICES TO OUR AREA AND LISTENING AND RESPONDING TO THE COMMUNITIES WE SERVE. IN AN EFFORT TO PLAN FOR THE UNIQUE NEEDS OF COMMUNITIES IN THE SERVICE AREA, FIVE COMMUNITY BENEFIT ADVISORY COMMITTEES WERE ESTABLISHED AS A MAJOR INITIATIVE TO DEEPEN AND STRENGTHEN ITS CONNECTION WITH THE COMMUNITY AND TO LINK COMMUNITY BENEFIT ACTIVITIES TO STRATEGIC AND OPERATIONAL PLANS. THE ROLE OF THE COMMITTEES IS TO IDENTIFY THE NEEDS AND CONCERNS OF THE COMMUNITY, ADVISE ABOUT THE BEST WAY TO PARTNER WITH THE COMMUNITY, AID IN THE DEVELOPMENT OF MEANINGFUL COMMUNITY PROGRAMS AND ACTIVITIES, AND PROMOTE IMPROVED COMMUNICATIONS BETWEEN THE HOSPITAL AND THE COMMUNITY. THE HOSPITAL PROVIDES DEDICATED ADMINISTRATIVE TIME TO PLANNING AND CONDUCTING FIVE CBAC MEETINGS IN THE COMMUNITIES WE SERVE THREE TIMES PER YEAR. CCMH REACHED THE GOAL OF DOUBLING PARTICIPATION/MEMBERS OF THE CBAC GROUPS FROM 50 INDIVIDUALS TO 100 INDIVIDUALS. LASTLY, CCMH OFTEN PARTNERS WITH FUNDING FOUNDATIONS TO PROVIDE HEALTH SPECIFIC IMPROVEMENT INITIATIVES IN THE COMMUNITIES WHICH WE SERVE. AS AN EXAMPLE, CCMH, WITH FUNDING FROM THE GEORGE A. & MARGARET MEE FOUNDATION, PROVIDED COMPREHENSIVE NO-COST PHYSICALS TO THE UNINSURED AND UNDER INSURED POPULATION IN CAMERON COUNTY. IN ADDITION A FAMILY FITNESS PROGRAM WAS OFFERED IN CAMERON COUNTY GEARED TO EDUCATE YOUTH AND THEIR PARENTS ON THE IMPORTANCE OF GOOD HEALTH. THE FAMILY FITNESS CHALLENGE INCLUDES EXERCISE, EDUCATION, HEALTHY EATING, HEALTH INDICATOR GATHERING AND MONITORING. FINALLY, VISION TESTING EQUIPMENT AND NO-COST SCREENINGS WERE PROVIDED THROUGH CCMH BY A LOCAL OPHTHEMOLOGIST TO RESIDENTS MEETING CRITERIA IN CAMERON COUNTY. THIS IS JUST ONE EXAMPLE OF PARTNERSHIPS IN WHICH CCMH IS CLOSELY INVOLVED THAT PROMOTE HEALTH AND ADDRESS COMMUNITY NEEDS.

Schedule H (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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

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

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

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

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported in prior Form 990 or Form 990-EZ
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) MICHAEL E CALLAHAN	(i) (ii)	172,316 0	0 0	848 0	3,878 0	12,343 0	189,385 0	0 0
(2) EDWARD C PITCHFORD	(i) (ii)	238,630 0	0 0	30,027 0	6,113 0	15,904 0	290,674 0	0 0
(3) JASON TRONETTI	(i) (ii)	196,958 0	116,555 0	163 0	6,087 0	15,209 0	334,972 0	0 0
(4) CYNTHIA L HARDESTY	(i) (ii)	133,912 0	0 0	17,817 0	3,813 0	6,608 0	162,150 0	0 0
(5) BRADLEY F GIANNOTTI	(i) (ii)	881,458 0	0 0	16,400 0	4,515 0	15,209 0	917,582 0	0 0
(6) CHRISTAN M CARAMIA	(i) (ii)	477,332 0	0 0	365 0	5,979 0	16,809 0	500,485 0	0 0
(7) SAKET PRASAD	(i) (ii)	543,795 0	0 0	17,048 0	6,052 0	16,104 0	582,999 0	0 0
(8) TERRANCE FOUST	(i) (ii)	555,013 0	0 0	499 0	6,050 0	6,787 0	568,349 0	0 0
(9) CELSO BACKES	(i) (ii)	376,003 0	0 0	4,983 0	4,862 0	0 0	385,848 0	0 0

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
BONUS	SCHEDULE J, PART I, LINE 7	NO DIRECTORS EARNED A BONUS FOR PARTICIPATING IN THE EXECUTIVE TEAM INCENTIVE COMPENSATION PROGRAM. EACH PARTICIPANT HAD AN ESTABLISHED TARGET TOTAL COMPENSATION BASED ON INDUSTRY SURVEYS AND THE INCENTIVE PROGRAM COMPRISED APPROXIMATELY 10% OF THE TARGETED TOTAL COMPENSATION. THE BONUS WAS BASED ON OVERALL PERFORMANCE. JASON TRONETTI'S BONUS WAS CALCULATED BY RVU'S BASED ON PRODUCTIVITY AND AN ESTABLISHED FORMULA.

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(b) Description of transaction	(c) Corrected?
1(a) Name of disqualified person	(b) Description of transaction	Yes	No

Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.

(a) Name of interested person and purpose	(b) Loan to or from the organization?		(c)Original principal amount	(d)Balance due	(e) In default?		(f) Approved by board or committee?		(g)Written agreement?
(a) Name of interested person and purpose	To	From	(c)Original principal amount	(d)Balance due	Yes	No	Yes	No	Yes	No






Total ............... $

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b)Relationship between interested person and the organization	(c)Amount of grant or type of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2010

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) COLE CARE	COMMON BOARD MEMBERS	6,276,659	RENT, DIVIDENDS, SERVICES		No
(2) EDMOND HARDESTY	HUSBAND OF C. HARDESTY	126,190	EMPLOYEE OF HOSPITAL		No

Part V

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Identifier	Return Reference	Explanation
ORGANIZATION'S MISSION	FORM 990, PART I, LINE 1	CHARLES COLE MEMORIAL HOSPITAL IS A FULL SERVICE, COMPREHENSIVE HEALTH SYSTEM, SERVING POTTER, MCKEAN, CAMERON, AND TIOGA COUNTIES IN RURAL, NORTH CENTRAL PA AND PORTIONS OF NEW YORK STATE AND IS THE ONLY HOSPITAL IN POTTER COUNTY (COUDERSPORT, PA). CCMH IS A CRITICAL ACCESS HOSPITAL PROVIDING PRIMARY, EMERGENCY, AND SPECIALTY CARE, AS WELL AS REHABILITATION AND WELLNESS SERVICES TO PATIENTS WITHIN A 50-MILE RADIUS. CHARLES COLE STRIVES TO LIVE UP TO ITS NON-PROFIT MISSION EVERY DAY, PROVIDING EXCELLENT HEALTHCARE SERVICES TO OUR AREA AND LISTENING AND RESPONDING TO THE COMMUNITIES WE SERVE. IN AN EFFORT TO PLAN FOR THE UNIQUE NEEDS OF COMMUNITIES IN THE SERVICE AREA, FIVE COMMUNITY BENEFIT ADVISORY COMMITTEES WERE ESTABLISHED AS A MAJOR INITIATIVE TO DEEPEN AND STRENGTHEN OUR CONNECTION WITH THE COMMUNITY AND TO LINK COMMUNITY BENEFIT ACTIVITIES TO STRATEGIC AND OPERATIONAL PLANS. THE ROLE OF THE COMMITTEES ARE TO IDENTIFY THE NEEDS AND CONCERNS OF THE COMMUNITY, ADVISE ABOUT THE BEST WAY TO PARTNER WITH THE COMMUNITY, AID IN THE DEVELOPMENT OF MEANINGFUL COMMUNITY PROGRAMS AND ACTIVITIES, AND PROMOTE IMPROVED COMMUNICATIONS BETWEEN THE HOSPITAL AND THE COMMUNITY. THE HOSPITAL PROVIDES DEDICATED ADMINISTRATIVE TIME TO PLANNING AND CONDUCTING FIVE CBAC MEETINGS IN THE COMMUNITIES WE SERVE THREE TIMES PER YEAR. PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4 LINE 4B IN ADDITION TO THE FAMILY AND INTERNAL MEDICINE SERVICES AT RHCS, PHYSICIAN PRACTICES ALSO PROVIDE SPECIALTY CARE INCLUDING PEDIATRICS, GASTROENTEROLOGY, ORTHOPEDICS, PHYSIATRY, SURGERY, PODIATRY, OBSTETRICS/GYNECOLOGY AND ONCOLOGY. COLLECTIVELY, PHYSICIAN PRACTICES REPORTED 94,400 PATIENT VISITS LAST YEAR. LINE 4C INPATIENT SATISFACTION RANKS IN THE TOP 6% IN OUR OB SERVICES AND TOP 16% IN OUR IP SERVICES ACROSS THE NATION. IN ADDITION TO THE HOSPITAL'S ACUTE CARE FLOORS, CHARLES COLE CARES FOR PATIENTS IN ITS 49-BED LONG TERM CARE UNIT WHICH REPORTED 15,600 DAYS LAST YEAR. A 10-BED INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT ADMITTED 200 PATIENTS LAST YEAR. LINE 4D THE ORGANIZATION ALSO OFFERS CARDIO-PULMONARY SERVICES, CLINICAL SERVICES, CLINICS, AND CORPORATE SERVICES.
SIGNIFICANT CHANGES TO ORGANIZATIONAL DOCUMENTS	FORM 990, PART VI, SECTION A, LINE 4	THE ORGANIZATION AMENDED ITS BYLAWS IN JULY 2010. SIGNIFICANT CHANGES ARE AS FOLLOWS: FUNCTIONS AND QUALIFICATIONS FOR MEMBERS WERE ADDED. THEY INCLUDE THE PROMOTION OF THE PROGRAMS AND GOALS OF THE HOSPITAL, THE EDUCATION OF PUBLIC CONTACTS ON HEALTH CARE ISSUES AND SERVICES AVAILABLE THROUGH THE HOSPITAL, PROVIDING A LINK BETWEEN THE HOSPITAL AND OTHER INSTITUTIONS AND COMMUNITITES, ATTENDENCE OF REGULAR MEETINGS, PROVIDING SPECIAL ASSISTANCE ON PROJECTS OR ISSUES WHEN REQUESTED, PARTICIPATING IN FUNDRAISING EFFORTS TO BENEFIT HOSPITAL PROGRAMS, AND BEING A CITIZEN IN GOOD STANDING. NEW MEMBERS (ADVISORS), AFTER BEING NOMINATED BY THE EXECUTIVE COMMITTEE, ARE NOW ELECTED BY A TWO THIRDS VOTE OF VOTING MEMBERS AT A MEETING AT WHICH QUORUM IS PRESENT. AN ACTIVE ADVISOR SERVES A FIVE YEAR TERM, WITH NO LIMIT TO THE NUMBER OF TERMS HE OR SHE MAY SERVE. AN HONORARY ADVISOR MAY BE ELECTED BY THE ACTIVE ADVISORS AND SERVES FOR LIFE, IN RECOGNITION OF DISTINGUISHED ACHIEVEMENT OR FAITHFUL SERVICE TO THE HOSPITAL. NO ADVISOR SHOULD BE AN EMPLOYEE OF THE HOSPITAL OR ITS AFFILIATES, OR HAVE ANY VESTED RIGHT OR INTEREST IN THE HOSPITAL'S ASSETS, FUNCTIONS, AFFAIRS, OR FRANCHISES. THE NUMBER OF ADVISORS SHOULD BE AT LEAST 50 BUT NOT MORE THAN 100, EXCLUSIVE OF HONORARY ADVISORS. HONORARY ADVISORS MAY ATTEND ALL MEETINGS BUT ARE NOT ENTITLED TO VOTE ON ANY MATTERS. MEMBERS OF THE BOARD OF DIRECTORS MAY REMOVE (BY MAJORITY VOTE) ANY ADVISOR WHO IS DECLARED OF UNSOUND MIND, IS CONVICTED OF A FELONY, FAILS TO MEET ATTENDANCE REQUIREMENTS WITHOUT DUE CAUSE, FAILS TO FULFILL THEIR RESPONSIBILITIES AS ADVISOR, COMMITS FRAUDULENT OR DISHONEST ACTS, OR PERFORMS BEHAVIOR THAT IS DISRUPTIVE TO THE HOSPITAL OR REFLECTS ADVERSELY ON THE HOSPITAL. STANDING COMMITTEES ARE ALL CONSIDERED BOARD COMMITTEES AND INCLUDE EXECUTIVE, PERFORMANCE EXCELLENCE, COMMUNITY BENEFIT COUNCIL, QUALITY AND SAFETY COUNCIL, AND FINANCE COMMITTEES. THE EXECUTIVE COMMITTE NOW OVERSEES THE AUDIT, CORPORATE COMPLIANCE, COMPENSATION, AND NOMINATING FUNCTIONS, AND MUST MEET AT LEAST ANNUALLY WITH THE MEDICAL STAFF EXECUTIVE COMMITTEE AND PRESIDENT/CEO. THE BYLAWS NO LONGER INCLUDE THE OPTION FOR MEMBERS OF THE CORPORATION TO AMEND THE BYLAWS BY PROPOSED RECOMMENDATION BY AT LEAST 25% OF THE CORPORATION MEMBERSHIP, THEN VOTE AT A SPECIAL MEMBERSHIP MEETING. THE BYLAWS MAY ONLY BE AMENDED BY A TWO THIRDS VOTE OF THE BOARD OF DIRECTORS. MEMBERS FORM 990, PART VI, SECTION A, LINES 6 & 7A The members of the corporation, the Charles Cole Memorial Hospital, shall be known as Community Benefit Advisors ("Advisors"), whose functions and qualifications shall include the following: (a) promote the programs, goals and objectives of Charles Cole Memorial Hospital; (b) educate their public contacts, both on health care issues and on services and programs available through Charles Cole Memorial Hospital, and seek their services when necessary and appropriate; (c) provide an important link between Charles Cole Memorial Hospital, the other institutions and businesses which they represent, and the communities served by the Hospital; (d) attend regular meetings, to share information on activities and take appropriate action to support and guide Charles Cole Memorial Hospital; (e) provide special assistance on projects and issues when requested; (f) participate in fundraising efforts to benefit patient care programs for Charles Cole Memorial Hospital; and (g) be a citizen in good standing, as determined by the Executive Committee of the Board, in a community served by the Hospital. The members shall be divided into two classes: (a) Active Advisors (b) Honorary Advisors The Advisors shall annually elect: (a) Successors to the Board of Directors whose terms expire. (b) Honorary Directors and Honorary Advisors. Upon nomination by the Executive Committee per section 5.2.2.(e) of these bylaws, all Advisors shall be elected by a two thirds vote of the members present and voting at a duly called meeting of the members which a quorum is present. (a) An Active Advisor of Charles Cole Memorial Hospital shall be a member for a term of five (5) years after his election, or until his earlier resignation. There is no limit on the number of terms an Advisor can serve. (b) An Honorary Advisor may be elected by the Active Advisors and shall serve for life, in recognition of meritorious or faithful service to Charles Cole Memorial Hospital or in recognition of distinguished achievement. (c) Each Advisor owes a duty of undivided and unqualified loyalty to the organization. Advisors may not use their positions to profit personally or to assist others in profiting in any way at the expense of the organization. (d) Advisors shall avoid all conflicts of interest and the appearance of any conflict of interest. A conflict of interest occurs in any situation in which one is potentially not able to remain impartial or maintain objectivity in choosing between the interests of the organization and one's personal interests or the interests of third parties. To avoid the appearance of a conflict of interest, an Advisor shall not participate in the making of any decision or recommendation concerning a matter which may result in any benefit or financial gain, either directly or indirectly, to the Advisor or a member of his/her immediate family. In addition, full disclosure of the pertinent facts regarding the potential conflict of interest should be provided by the Advisor. (e) No Advisor shall have any vested right, interest or privilege of, in, or to the assets, functions, affairs or franchises of the Corporation or any such right, interest or privilege which may be transferable or inheritable, or which shall continue if his membership ceases. No Advisor shall be an employee of the Hospital or any of its affiliates. (f) Advisors shall include representatives from various economic, social and occupational groups broadly representative of the demographic characteristics of the communities served by the Hospital, and shall all have an interest in and commitment to further the health and well-being of the citizens of the Hospital's service area. (g) The Secretary of the Board shall act as liaison to the Community Benefit Advisors. The number of Advisors shall not be less than fifty (50) nor more than one hundred (100), exclusive of Honorary Advisors. Every Active Advisor shall be entitled to one (1) vote at any meeting of the Advisors in which a vote is taken for any election or on any matter or transaction. In the case of voting for the election of Directors, each Advisor must cast one (1) vote for each position to be filled or the ballot will be void as it pertains to the election of Directors. Voting for Directors shall be by written ballot by First Class Mail, postmarked no later than twenty (20) days prior to the date selected for the Annual meeting. Every Advisor shall be entitled in returning his ballot for the annual election of Directors, to direct that his vote be withheld from one (1) or more of the candidates submitted by the Nominating Committee and any such Advisor may, on his ballot, may set forth the name of any person for whom he wishes to record his vote for a Director of the Corporation. Results of the election process will be announced at the annual meeting of the Advisors. Honorary Advisors shall receive notices of and may attend all meetings of the Advisors but shall not be entitled to vote on any matter.
FORM 990 REVIEW PROCESS	FORM 990, PART VI, SECTION B, LINE 11B	THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE 990 IS THEN REVIEWED BY THE ACCOUNTING DEPARTMENT AND THE CONTROLLER. IT IS THEN PRESENTED TO THE AUDIT / COMP COMMITTEE FOR REVIEW. AFTER THE AUDIT / COMP COMMITTEE HAS REVIEWED, A FULL COPY IS DISTRIBUTED TO THE BOARD OF DIRECTORS and THE COMMITTEE WILL REPORT THEIR REVIEW OF FORM 990 TO THE ENTIRE BOARD OF DIRECTORS PRIOR TO THE CEO'S FINAL SIGNATURE.
CONFLICT OF INTEREST POLICY	FORM 990, PART VI, SECTION B, LINE 12C	MEMBERS OF THE BOARD OF DIRECTORS; BOARD COMMITTEES; MANAGEMENT EMPLOYEES; AND MEDICAL STAFF WITH ADMINISTRATIVE RESPONSIBILITIES ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE LEVELS AT WHICH ACTUAL CONFLICTS ARE REVIEWED ARE THE COMPLIANCE OFFICER AND AUDIT COMMITTEE OF THE BOARD OF DIRECTORS. RESTRICTIONS INCLUDE: A MEMBER OF THE BOARD/BOARD COMMITTEE MUST DISCLOSE THE EXISTENCE OF HIS/HER FINANCIAL INTEREST. A VOTING MEMBER OF ANY COMMITTEE WHOSE SCOPE OF RESPONSIBILITIES INCLUDES COMPENSATION MATTERS AND WHO RECEIVES COMPENSATION, DIRECTLY OR INDIRECTLY, FROM THE HOSPITAL FOR SERVICES IS PRECLUDED FROM VOTING ON MATTERS PERTAINING TO THAT MEMBER'S COMPENSATION. PHYSICIANS WHO RECEIVE COMPENSATION, DIRECTLY OR INDIRECTLY, FROM THE HOSPITAL, WHETHER AS EMPLOYEES OR INDEPENDENT CONTRACTORS, ARE PRECLUDED FROM MEMBERSHIP ON ANY COMMITTEE WHOSE PRIMARY SCOPE OF RESPONSIBILITIES INCLUDES COMPENSATION MATTERS. A MANAGEMENT EMPLOYEE, OR A MEDICAL STAFF MEMBER WITH ADMINISTRATIVE RESPONSIBILITIES MUST DISCLOSE TO THE SENIOR LEADER THE EXISTENCE OF THE FINANCIAL INTEREST AND ALL RELATED MATERIAL FACTS.
COMPENSATION DETERMINATION	FORM 990, PART VI, SECTION B, LINE 15A	A REVIEW WAS CONDUCTED IN AUGUST 2010 FOR PRESIDENT & CEO EDWARD PITCHFORD BY 3C COMPENSATION CONSULTING CONSORTIUM, LLC, LOCATED IN PITTSBURGH, PENNSYLVANIA. THE BOARD WOULD HAVE TO APPROVE ANY INCREASE RECOMMENDED BY THE AUDIT/COMPENSATION COMMITTEE.
DOCUMENT AVAILABILITY	FORM 990, PART VI, SECTION C, LINE 19	THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS CAN BE VIEWED ONSITE THROUGH A WRITTEN REQUEST TO THE ORGANIZATION'S CORPORATE COMPLIANCE OFFICER. REQUESTS FOR FINANCIAL STATEMENTS AND 990'S ARE FORWARDED TO THE FINANCE / ACCOUNTING DEPARTMENT AND ARE OPEN FOR PUBLIC INSPECTION.
OTHER CHANGES IN NET ASSETS	FORM 990, PART XI, LINE 5	UNREALIZED GAINS ON INVESTMENTS 1,444,493 AMORTIZATION OF NET LOSS 242,842 NET GAIN ARISING DURING YEAR 1,452,260 OTHER AUXILIARY (77,729) --------------- TOTAL OTHER CHANGES 3,061,866

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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) HENDORN INC DBA COLE MANOR 1001 EAST SECOND STREET COUDERSPORT,PA16915 23-1972659	RESIDENT CARE	PA	501(C)(3)	11A I	NA
(2) HAMOTCOLE VENTURES INC 1001 EAST SECOND STREET COUDERSPORT,PA16915 27-3172100	REAL ESTATE	PA	501(C)(3)	11A I	NA

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	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

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) COLE CARE INC 1001 EAST 2ND STREET COUDERSPORT,PA16915 25-1497347	DURABLE MED EQUIP	PA	NA	C CORPORATION	7,699,947	932,148	100.000 %

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

Yes

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

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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) COLE CARE INC	A	193,661
(2) COLE CARE INC	L	6,029,196
(3) COLE CARE INC	K	53,802
(4) HENDORN INC	K	276,854
(5) HENDORN INC	L	54,900
(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: CCMH PROVIDES EXCELLENT HEALTH CARE SERVICES BY PROVIDING INPATIENT, OUTPATIENT AND PRIMARY CARE SERVICES TO THE SURROUNDING COMMUNITY. SEE SCHEDULE O FOR MORE INFORMATION.
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	10
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	691
6	Total number of volunteers (estimate if necessary) ....	6	82
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	70,457
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	69,098

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	692,259	350,224
9	Program service revenue (Part VIII, line 2g) .........	63,883,574	69,567,713
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	882,589	1,031,244
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	63,394	361,647
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	65,521,816	71,310,828
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4) ....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	29,387,358	30,837,009
16a	Professional fundraising fees (Part IX, column (A), line 11e)....	19,904	84,000
b	Total fundraising expenses (Part IX, column (D), line 25) 115,937
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	36,903,321	38,318,324
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	66,310,583	69,239,333
19	Revenue less expenses. Subtract line 18 from line 12......	-788,767	2,071,495
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	52,729,110	55,302,779
21	Total liabilities (Part X, line 26)............	37,784,281	35,146,860
22	Net assets or fund balances. Subtract line 21 from line 20 .....	14,944,829	20,155,919

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 $ 16,852,645 including grants of $ ) (Revenue $ 37,283,295 )
	CCMH OFFERS OUTPATIENT SERVICES, EXCEEDING 351,200 VISITS ANNUALLY THROUGHOUT THE HOSPITAL'S FOUR-COUNTY AREA AND INCLUDING IMAGING, LAB, AND REHABILITATION SERVICES. OUTPATIENT SURGERIES EXCEED 4,400 ANNUALLY. THE PATTERSON CANCER CARE CENTER OFFERS FULL SERVICE RADIATION AND MEDICAL ONCOLOGY SERVICES AND HOUSES AN AMERICAN CANCER SOCIETY PATIENT RESOURCE CENTER ONSITE. THE CANCER CENTER IS HOME TO A VARIETY OF SUPPORT GROUPS, AS WELL AS FREQUENT FREE CANCER SCREENINGS FOR THE PUBLIC. CCMH'S HOME HEALTH AND HOSPICE SERVICES ASSIST PATIENTS THROUGHOUT THE REGION, WITH A GROWING NUMBER OF REFERRALS AND LOWER INFECTION RATES AMONG STATE AND NATIONAL AVERAGES.

4b	(Code: ) (Expenses $ 14,710,615 including grants of $ ) (Revenue $ 11,299,546 )
	CHARLES COLE MEMORIAL HOSPITAL PROVIDES PRIMARY CARE TO ITS SURROUNDING COMMUNITIES. THE HOSPITAL PROVIDES PRIMARY CARE TO THE SURROUNDING COMMUNITIES IN FOUR COUNTIES AT RURAL HEALTH CENTERS (RHCS), LOCATED IN COUDERSPORT, GALETON, ULYSSES, WESTFIELD, SHINGLEHOUSE, PORT ALLEGANY, ELDRED, SMETHPORT, AND EMPORIUM. FOUR OF THOSE LOCATIONS ALSO INCLUDE WELLNESS AND REHABILITATION CENTERS, MAKING IT MORE CONVENIENT FOR PATIENTS TO RECEIVE THE CARE THEY NEED CLOSE TO HOME. ONE OUTLYING CENTER OFFERS IMAGING SERVICES, WHILE ALL RHCS PROVIDE LAB DRAWS SO PATIENTS DON'T HAVE TO DRIVE TO RECEIVE NECESSARY TESTING. SEE SCHEDULE O FOR FURTHER DETAIL.

4c	(Code: ) (Expenses $ 11,319,571 including grants of $ ) (Revenue $ 18,016,788 )
	CHARLES COLE MEMORIAL HOSPITAL OFFERS VARIOUS INPATIENT SERVICES. CCMH ADMITTED 1,980 PATIENTS LAST YEAR (5,400 ACUTE CARE DAYS) TO INPATIENT SERVICES INCLUDING MEDICAL/SURGICAL, INTENSIVE CARE AND OBSTETRICS UNITS. CCMH'S 24-HOUR EMERGENCY DEPARTMENT ADMITTED 840 PATIENTS LAST YEAR AND SAW 9,400 VISITS LAST YEAR. THE HOSPITAL'S MATERNITY UNIT WELCOMED 250 BABIES INTO THE WORLD LAST YEAR AND ALSO SUPPORTS MOTHERS-TO-BE WITH REGULAR LAMAZE AND BREASTFEEDING SUPPORT PROGRAMS AND THE HEALTHY BEGINNINGS PLUS PROGRAM FOR LOW INCOME MOTHERS. SEE SCHEDULE O FOR FURTHER DETAIL.

4d	Other program services. (Describe in Schedule O.)
	(Expenses $ 17,456,033 including grants of $ ) (Revenue $ 2,968,084 )
4e	Total program service expenses$ 60,338,864

(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) BRADLEY F GIANNOTTI PHYSICIAN	40.0	X	897,858	0	19,724
(19) CHRISTAN M CARAMIA PHYSICIAN	40.0	X	477,697	0	22,788
(20) SAKET PRASAD PHYSICIAN	40.0	X	560,843	0	22,156
(21) TERRANCE FOUST PHYSICIAN	40.0	X	555,512	0	12,837
(22) CELSO BACKES PHYSICIAN	40.0	X	380,986	0	4,862

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,780,122	0	152,322

				(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		30,227
d	Related organizations...1d
e	Government grants (contributions)1e		214,375

f	All other contributions, gifts, grants, and similar amounts not included above1f		105,622
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			350,224
			Business Code
2a	PATIENT SERVICE REVENUE		621,990	67,487,450	67,487,450
b	OTHER REVENUE		621,990	2,080,263	2,080,263
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			69,567,713
3	Investment income (including dividends, interest
	and other similar amounts).....			157,026			157,026
4	Income from investment of tax-exempt bond proceeds..			53,561			53,561
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents	336,762
b	Less: rental expenses	347,816
c	Rental income or (loss)	-11,054
d	Net rental income or (loss).......			-11,054			-11,054
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	3,742,029	1,151,269
b	Less: cost or other basis and sales expenses	3,251,508	821,133
c	Gain or (loss)	490,521	330,136
d	Net gain or (loss)..........			820,657			820,657
8a	Gross income from fundraising events (not including $ 30,227 of contributions reported on line 1c). See Part IV, line 18 ...
	a		8,000
b	Less: direct expenses ...b		13,339
c	Net income or (loss) from fundraising events..			-5,339			-5,339
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		76,779
b	Less: cost of goods sold ..b		49,937
c	Net income or (loss) from sales of inventory..			26,842			26,842
Miscellaneous Revenue			Business Code
11a	GAIN ON INVESTMENT IN EQUITY INVESTEE		900,099	129,727			129,727
b	INCOME FROM INVESTMENT IN SUBSIDIARIES		900,099	92,929		70,457	22,472
c	GAIN ON EXTINGUISHMENT OF DEBT		900,099	128,542			128,542
d	All other revenue ....
e	Total. Add lines 11a–11d ......			351,198
12	Total revenue. See Instructions....			71,310,828	69,567,713	70,457	1,322,434


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........				1
2	Savings and temporary cash investments .......			5,018,474	2	6,770,890
3	Pledges and grants receivable, net .........			206,716	3	71,851
4	Accounts receivable, net .........			7,106,477	4	7,510,740
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			981,423	8	1,081,698
9	Prepaid expenses and deferred charges ............			2,099,925	9	1,785,764
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	63,106,763
b	Less: accumulated depreciation. .....	10b	40,093,165	24,055,090	10c	23,013,598
11	Investments—publicly traded securities ..........			10,756,526	11	12,716,424
12	Investments—other securities. See Part IV, line 11 ......			1,171,705	12	1,532,975
13	Investments—program-related. See Part IV, line 11 ..			117,496	13	396,598
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........			1,215,278	15	422,241
16	Total assets. Add lines 1 through 15 (must equal line 34)...			52,729,110	16	55,302,779
17	Accounts payable and accrued expenses .			13,430,176	17	12,962,644
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........			20,292,611	20	19,534,724
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			10,229	21	14,430
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 ..			2,268,171	23	1,239,449
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities. Complete Part X of Schedule D.....			1,783,094	25	1,395,613
26	Total liabilities. Add lines 17 through 25.....			37,784,281	26	35,146,860
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			10,850,438	27	15,669,621
28	Temporarily restricted net assets .....			426,591	28	205,421
29	Permanently restricted net assets .....			3,667,800	29	4,280,877
	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 .....			14,944,829	33	20,155,919
34	Total liabilities and net assets/fund balances .....			52,729,110	34	55,302,779