Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| (1)
MANGOLD MEMORIAL HOSPITAL |
751424965 | 3 | No | Yes | Yes | 0 | |||
| Total | |||||||||
| 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. | ||||||
| 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). | ||||||






| 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.) | ||||||
| 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.). | ||||||




| Facts And Circumstances Test |
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| Explanation |
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| THE ORGANIZATION INCLUDES MEMBERS FROM THE SURROUNDING RURAL AREA HOSPITALS AND HOSPITAL DISTRICTS WHO MEET AS THE GOVERNING BODY TO DETERMINE THE INDIGENT CARE NEEDS OF THE AREAS INCLUDED IN THE ORGANIZATIONS TARGETED AREA. THE ORGANIZATION THEN EXPENDS FUNDS TO COVER THOSE INDIGENT CARE NEEDS WHICH ULTIMATELY BENEFIT EACH OF THE SUPPORTED ORGANIZATIONS LISTED IN LINE 11(H) OF SCHEDULE A. THE ORGANIZATION DOESN'T KEEP RECORDS OF THE AMOUNT OF FUNDS BENEFITING THE INDIVIDUAL SUPPORTED ORGANIZATIONS AS THOSE EXPENSES MAY BENEFIT MORE THAN ONE OF THE SUPPORTED ORGANIZATIONS LISTED. |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| MANAGEMENT DELEGATED | FORM 990, PAGE 6, PART VI, LINE 3 | THE ORGANIZATION DELEGATED ITS CONTROL OVER MANAGEMENT DUTIES TO DISCOVERY HEALTHCARE CONSULTING GROUP, 2950 50TH STREET, LUBBOCK, TEXAS, 79413. |
| CLASSES OF MEMBERS OR STOCKHOLDERS | FORM 990, PAGE 6, PART VI, LINE 6 | THE ORGANIZATION CONSISTS OF ONE CLASS OF MEMBERS. |
| ELECTION OF MEMBERS AND THEIR RIGHTS | FORM 990, PAGE 6, PART VI, LINE 7A | MEMBERS ARE ELECTED AS A RESULT OF FINDING OTHER PUBLICY SUPPORTED HOSPITALS OR PUBLIC ENTITIES DOMICILED IN THE STATE OF TEXAS WHO DESIRE TO AFFILIATE WITH EACH IN ORDER TO IMPROVE HEALTH CARE DELIVERY IN THEIR COMMUNITIES. |
| DECISIONS SUBJECT TO APPROVAL OF MEMBERS | FORM 990, PAGE 6, PART VI, LINE 7B | THE GOVERNING BODY CONSISTS ENTIRELY OF DIRECTORS/MEMBERS AND AS SUCH ALL DECISIONS OF THE GOVERNING BODY ARE THEREBY CONTEMPORANEOUSLY APPROVED BY THE MEMBERS. |
| ORGANIZATION'S PROCESS USED TO REVIEW FORM 990 | FORM 990, PAGE 6, PART VI, LINE 11B | THE GOVERNING BODY REVIEWS THE FORM 990 AT THE MEETING FOLLOWING THE COMPLETION OF THE RETURN. |
| ENFORCEMENT OF CONFLICTS POLICY | FORM 990, PAGE 6, PART VI, LINE 12C | THE ORGANIZATION REQUIRES EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER TO ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON A) HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, B) HAS READ AND UNDERSTANDS THE POLICY, C)HAS AGREED TO COMPLY WITH THE POLICY, AND D) UNDERSTANDS THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OF MORE OF ITS TAX-EXEMPT PURPOSES. IN ADDITION, THE ORGANIZATION CONDUCTS PERIODIC REVIEWS. |
| GOVERNING DOCUMENTS DISCLOSURE EXPLANATION | FORM 990, PAGE 6, PART VI, LINE 19 | THE ORGANIZATION PROVIDES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS TO THE PUBLIC UPON REQUEST. |
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