TY 2012 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
BENNETT CONTRACTING, 693 PEARL STREETALBANYNY12202	CONSTRUCTION	210,880
MEDICAL STAFFING NETWORK, 901 Yamato Rd Suite 110BOCO RATONFL33431	STAFF NURSE SERVICES	127,774
ATLAS HEALTHCARE LINEN, 414 WEST TAYLOR STREETSYRACUSENY132023441	LAUNDRY SERVICE	115,788


2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of 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 United States. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. 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 ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	9,770,855	6,851,943	2,918,912
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	66,152	50,329	15,823
9	Other employee benefits .......	1,370,652	930,076	440,576
10	Payroll taxes ...........	717,302	504,281	213,021
11	Fees for services (non-employees):
a	Management ......	446,685	23,500	423,185
b	Legal .........	51,614		51,614
c	Accounting ...........	100,500		100,500
d	Lobbying ...........	7,830		7,830
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	2,242,320	2,105,812	136,508	0
12	Advertising and promotion ....	53,337		53,337
13	Office expenses .......	2,413,518	2,135,173	278,345
14	Information technology ......	903,518	306,277	597,241
15	Royalties ..	0
16	Occupancy ...........	0
17	Travel ............	36,287	7,158	29,129
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	7,650	2,432	5,218
20	Interest ...........	79,541		79,541
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	1,330,629	626,823	703,806
23	Insurance ..............	135,270		135,270
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	PURCHASED SERVICES	3,221,453	2,649,805	571,648
b	BAD DEBTS	2,183,780	2,183,780
c	UTILITIES	504,314	430,573	73,741
d	OTHER DIRECT EXPENSES	66,322	738	65,584
e	All other expenses	156,436	14,042	142,394
25	Total functional expenses. Add lines 1 through 24e	25,865,965	18,822,742	7,043,223	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	6,103,758	1	9,407,974
2	Savings and temporary cash investments .........	122,925	2	123,670
3	Pledges and grants receivable, net ...........	68,983	3	73,155
4	Accounts receivable, net .............	3,042,254	4	2,572,908
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	158,889	8	151,843
9	Prepaid expenses and deferred charges ..........	146,416	9	147,352
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	18,692,606
b	Less: accumulated depreciation .....	10b	10,774,848	8,903,136	10c	7,917,758
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 .....	0	12	0
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	221,884	15	318,345
16	Total assets. Add lines 1 through 15 (must equal line 34)......	18,768,245	16	20,713,005
	17	Accounts payable and accrued expenses .........	1,757,128	17	1,736,366
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	0
20	Tax-exempt bond liabilities .............	1,590,000	20	1,470,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	162,195	23	206,131
24	Unsecured notes and loans payable to unrelated third parties ....	1,357,569	24	2,280,714
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	311,728	25	283,956
26	Total liabilities. Add lines 17 through 25.........	5,178,620	26	5,977,167
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	13,365,019	27	14,416,279
28	Temporarily restricted net assets ...........	45,916	28	140,869
29	Permanently restricted net assets ...........	178,690	29	178,690
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........	13,589,625	33	14,735,838
34	Total liabilities and net assets/fund balances ........	18,768,245	34	20,713,005

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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

2012

Open to Public
Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

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 described in 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. See section 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 - Non-functionally integrated

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 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 monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. 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—2011. If the organization did not check a 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—2012. 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—2011. 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) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(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.)..

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 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. 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—2011. 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) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

Additional Data

Software ID:
Software Version:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

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, total 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 total 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 on line H of its
Form 990-EZ or on Part I, 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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 2

Name of organization Bassett Hospital of Schoharie County

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total 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) Total 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) Total 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) Total 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) Total 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) Total 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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 3

Name of organization Bassett Hospital of Schoharie County

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Page 4

Name of organization
Bassett Hospital of Schoharie County

Employer identification number

14-1772971

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total 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

$
Use duplicate copies of Part III if additional space is needed.

(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) (2012)

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

2012

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 35c (Proxy Tax), then
Round Bullet

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

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

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 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 function 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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

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 SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

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) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

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)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(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? ..........................

Yes

7,830

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

7,830

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 carry over 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) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

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

Section 162(e) nondeductible 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; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
Schedule C, Part II-B, LIne 11		Iroquois Healthcare Alliance dues allocate 44.4% towards general lobbying activities. Total dues paid in 2012 = $8,053. Healthcare Association of New York State dues allocate 28.6% towards general lobbying activities. Total dues paid in 2012 = $14,875.

Schedule C (Form 990 or 990EZ) 2012

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, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

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 can 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 education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 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, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax 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 section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, 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 (ASC 958), 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 XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), 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 (ASC 958) 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 Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

Using the organization’s acquisition, 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 XIII.

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 XIII 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 XIII. Check here if the explanation has been provided in Part XIII ........

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	301,615	300,787	299,789	298,476	293,947
b	Contributions ........
c	Net investment earnings, gains, and losses	745	828	998	1,313	4,529
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......	302,360	301,615	300,787	299,789	298,476

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

100.000 %

The percentages in lines 2a, 2b, and 2c should equal 100%.

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	10,214		10,214
b	Buildings ................	11,148,204	5,593,748	5,554,456
c	Leasehold improvements ............
d	Equipment ................	7,534,188	5,181,100	2,353,088
e	Other .................
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				7,917,758

Schedule D (Form 990) 2012

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) must 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) must 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) must 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) Book value
Federal income taxes		0
INTEREST RATE SWAP AGREEMENT		251,198
ASSET RETIREMENT OBLIGATIONS		32,758







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		283,956
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	24,802,135
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-2,183,780
e	Add lines 2a through 2d .....................			2e	-2,183,780
3	Subtract line 2e from line 1.....................			3	26,985,915
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 XIII.) ...........	4b
c	Add lines 4a and 4b.......................			4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	26,985,915

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........			1	23,655,922
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 XIII.) ............	2d	-26,263
e	Add lines 2a through 2d......................			2e	-26,263
3	Subtract line 2e from line 1.....................			3	23,682,185
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 XIII.) ............	4b	2,183,780
c	Add lines 4a and 4b.......................			4c	2,183,780
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	25,865,965

Part XIII

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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
Part V, Line 4		ENDOWMENT FUNDS OF $178,690 HELD WITH INTEREST EARNED UNRESTRICTED FOR GENERAL HOSPITAL EXPENDITURES. ENDOWMENT FUNDS OF $37,500 WITH INTEREST EARNED TO BE USED FOR NURSING SCHOLARSHIPS.
Part X, Line 2		The hospital is a not-for-profit corporation as described in section 501(c)(3) of the Internal Revenue Code and is exempt from Federal income taxes pursuant to section 501(a) of the IRC. The Hospital recognizes income tax positions when it is more-likely than-not that the position will be sustainable based on the merits of the position. Management has concluded that there are no material tax liabilities that need to be recorded.
Part XI, Line 2d		BAD DEBT $2,183,780
Part XII, line 2d		INTEREST EXPENSE DUE TO POSITIVE ADJUSTMENT ON INTEREST RATE SWAP AGREEMENT OF ($27,772). CHANGE IN INTEREST IN NET ASSETS OF FRIENDS OF BASSETT, INC. OF $1,509.
Part XII, Line 4b		BAD DEBT $2,183,780

Schedule D (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

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

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

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

Yes

100% 150% 200% Other 300 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

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

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did 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.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	187,905	74,089	113,816	0.480 %
b	Medicaid (from Worksheet 3, column a) ....	3,259,974	892,513	2,367,461	9.990 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	3,447,879	966,602	2,481,277	10.470 %
Other Benefits		10,542		10,542	0.040 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	10,542		10,542	0.040 %
f	Health professions education (from Worksheet 5) ..	1,179		1,179	0.010 %
g	Subsidized health services (from Worksheet 6) ..	5,138,638	4,614,019	524,619	2.220 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	8,884		8,884	0.030 %
j	Total. Other Benefits ..	5,159,243	4,614,019	545,224	2.300 %
k	Total. Add lines 7d and 7j .	8,607,122	5,580,621	3,026,501	12.770 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012

Schedule H (Form 990) 2012

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(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	5,949	5,949	0.020 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	5,949	5,949	0.020 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did 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. Explain in Part VI the methodology used by the organization to estimate this amount. ......

985,938

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

51,425

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

5,429,006

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

6,193,059

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

-764,053

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

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(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) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	BASSETT HOSPITAL OF SCHOHARIE COUNTY 178 Grandview Drive Cobleskill,NY12043	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	BASSETT HOSPITAL OF SCHOHARIE COUNTY
Name of hospital facility or facility reporting group

For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

If “Yes,” indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20

In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? 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 ....................

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................

Did the hospital facility make its CHNA report widely available to the public? .............

If “Yes,” indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 300.% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11		No
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: % If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12		No
	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)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to 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 on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the patients regarding the patients’ bills

Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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?..........

Yes

If “No,” indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals 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? ............................

If “Yes,” explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? .........................

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any 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.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
Part I, Line 3C		Bassett Hospital of Schoharie County (BHSC) is a not-for-profit healthcare organization that renders medical care to all persons in need of such care, regardless of their ability to pay. To support patients who may have difficulty paying their medical bills, the Community Service Program is available. Under the hospital policy governing the Community Services Program, Bassett Hospital of Schoharie County provides a level of uncompensated care each year to persons unable to pay the total cost of the hospital services rendered. CSP eligibility is limited to services for those persons who are determined ineligible for Medicaid within 60 days prior to the application and whose annual family gross income, as determined by an application for Medicaid within the six months prior to an application, does not exceed 300% of the Federal Poverty Income Guidelines (FPIG), which are updated annually. An application for the CSP Free Care requires verification of income for the six months immediately preceding the application and, if family income is below the Medicaid guidelines, a Medicaid application is also required.
Part I, line 6a		The Bassett Hospital of Schoharie County community benefits report is contained in a report prepared by Bassett Healthcare Network.
Part I, Line 7		For sections (a) charity care at cost, (b) unreimbursed Medicaid, (f) health professions education, the costing methodology applied is a cost-to-charge ratio calculation, as used on filed state and federal cost reports. Indirect costs were applied to subsidized health services, sections (e) community health improvement; portions of (f) health professions education, and (i) cash and in-kind contributions to community groups, which are comprised of the direct salary costs for hospital staff whose time was compensated by the hospital for time spent participating in activities that qualify as community benefits plus the current fiscal year FICA rate. Part 1, Line 7, column (f) is calculated by dividing column (e), net community benefit expense, by total expense. The bad debt expense of $2,183,780 was subtracted from the total expense value used to calculate the percentages in Part 1, Line 7, Column f.
Part II		The hospital's community building activities focused on representation to community coalitions related to identified community health priorities; on costs of coalition meetings; and on participation with a small business/economic development organization called Cobleskill Partnership Inc. (CPI), which addresses the hospital neighborhood in downtown Cobleskill. The hospital participated in a community partnership between Schoharie County Health Department, Cornell University Cooperative Extension, Schoharie County Community Action Program and BHSC was expanded and formalized to form the Healthier Lifestyles Coalition of Schoharie County. This group met regularly to establish and offer community improvement activities focused on improving nutrition and increasing physical activity. The hospital has also played a leadership role, together with the county health department, in the formation and implementation of a new collaborative coalition, called Healthy Families Schoharie, which involves community health efforts aimed at women, babies, and children. Among the services provided are education, links to community health resources, car seat safety checks, and an extended home visiting program to follow children from birth through age 5. The hospital also plays a leadership role in the Creating Healthy Places Partnership, which is an advisory board comprised of agencies throughout Schoharie County that direct the planning and implementation of a 5-year, $875,000 New York State Department of Health Creating Healthy Places Grant. The hospital receives no portion of these grant funds but provides representation on the advisory board. The mission of the grant is to make Schoharie County a healthier place to live, work, and play by implementing policy, systems, and environmental change that will promote increased access to fresh fruits and vegetables and support a more active lifestyle for all community members, which is in alignment with prevention and health priorities identified in the hospital's community health assessment. Also in line with the identified priorities in the assessment is hospital representation on the NY Connects coalition committee, which works to improve access to health services and resources for the elderly in our rural communities with a goal to promote independent living, access to quality healthcare, and the appropriate utilization of institution-based services.
Part III, Line 4		Bassett Hospital of Schoharie County uses the ratio of cost-to-charges methodology from Worksheet 2, Ratio of Patient Care Cost-to-Charges. The description of how the organization accounts for discounts and for payments on patient accounts in determining bad debt expense is contained in the text of the following audited financial statement footnote; also included in this footnote is the description of the method the organization uses to determine the amount that reasonably could be attributable to patients who likely would qualify for financial assistance under the hospital's charity care policy, if sufficient information had been available to make a determination of their eligibility. Footnote text: The Hospital has adopted a formal charity care policy whereby patients in need of medical services, who meet certain criteria under the policy, are treated without regard to their ability to pay for such services. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The Hospital maintains records to identify and monitor the level of charity care it provides. The level of charity care, measured on the basis of established costs, is approximately $101,000 and $113,000 for 2012 and 2011, respectively. The cost of charity care provided was determined based on the application of a ratio of overall Hospital costs to patient charges. Included in net patient service revenue for 2012 and 2011 is approximately $755,000 and $591,000, respectively, from uncompensated care pools and income from restricted endowments to offset a portion of the cost of charity care. The Hospital grants credit without collateral to patients, most of whom are local residents and are insured under third-party agreements. Services rendered to individuals when payment is expected and ultimately not received are written off to the allowance for estimated uncollectible accounts. Additions to the allowance for estimated uncollectible accounts are made by means of the provision for bad debts. Accounts written off as uncollectible are deducted from the allowance and subsequent recoveries are added. The amount of the provision for bad debts is based upon management's assessment of historical and expected net collections, business and economic conditions, trends in federal and state governmental health care coverage and other collection indicators. Accounts receivable are presented net of allowances for estimated uncollectible accounts of approximately $1,710,000.
Part III, Line 8		Bassett Hospital of Schoharie County used Medicare-approved costs from the 2012 Medicare Cost Report, which employ a cost-to-charge ratio methodology. The hospital believes it is part of its charitable purpose to provide medical services to the elderly population even if the costs of the services are not fully covered by Medicare. Therefore, the hospital believes the shortfall on Part III, Line 7 should be considered as part of its community benefit.
Part III, Line 9b		For patients, or guarantors, who do not qualify for complete charity care assistance, the hospital must undertake to ensure understanding of obligations and satisfaction of obligations. The hospital employs a third-party self-pay billing agency, in compliance with existing laws and regulations, to recover self-pay accounts receivable, preserve the patient-provider relationship to the maximum extent possible, and keep the necessity of referring accounts to third party bad debt collection or law firms to a minimum. This agency is Medical Self-Pay Accounts Receivable Services, LLC (MedSPAR). As a structure of the hospital's Unified Charity Care, Self-Pay Billing & Collection Policy, Bassett Hospital of Schoharie County must ensure that bad debt collection policies of any third-party agency retained for outside debt collection reflect the mission and values of the hospital, as well as refrain from any conduct that violates the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, as well as any applicable state law or regulations. Under the MedSPAR Credit and Collection Policy (Doc. No. 1), responsible parties pleading indigence or inability to establish an installment plan must complete an application for the hospital's charity care or Community Services Program. The patient will be forwarded the application and informed that their accounts will be temporarily suspended from further billing for 30 days. The responsible party may make interest-free monthly installment payments not to exceed 10 percent of gross monthly income (which must be verified by a copy of a current paystub or equivalent proof of income), according to a set schedule based on account balance and maximum number of months in which installments must be made.
Part V, Section B, Line 20d		Bassett Hospital of Schoharie County recognizes that services will be provided equally to all patients without regard to their ability to pay for such services. Charge schedules are, therefore, uniform. Billings to patients are based on these charge schedules.
Part VI, Question 2		Needs Assessment: A variety of data are used regularly to assess the healthcare needs of the community served by Bassett Hospital of Schoharie County, including data from Patient Satisfaction Surveys, the NYS Department of Health, the Schoharie County Behavioral Risk Factor Surveillance Survey, the Schoharie County Community Health Assessment, and the NYS Prevention Agenda, which identified priority health indicators to be used by NYS hospitals, providers, and county health departments in assessing and setting local/regional priorities. The Prevention Agenda also identifies a common set of healthcare priorities from which hospitals and county health departments in New York State are expected to choose when developing implementation strategies for addressing community healthcare needs. Community partners involved in assessing community health needs in Schoharie County included: Schoharie County Health Department; Bassett primary care group; community-based organizations; and county social service, mental health, youth and aging agencies. Bassett Hospital of Schoharie County contracts with Health Stream Research to obtain benchmarking data on patient satisfaction in order to assess how the hospital is perceived to be meeting patient needs. Data from written surveys carried out among a statistically significant random sample of inpatients and outpatients is used to improve patient care and inform official quality improvement activities. Data collected from this instrument include a comprehensive overview of key, evidence-based quality indicators -- from timeliness of care to communications, patient safety, discharge instruction, medication issues, and more. The hospital receives quarterly reports. Health Stream Research is a national leader in providing customized patient satisfaction data to more than 1000 hospitals in the United States. (www.healthstreamresearch.com). The hospital also utilizes information from the standardized, publicly reported HCAHPS (Hospital Care Quality Information from the Consumer Perspective) survey of patients' perspectives of hospital care. The HCAHPS reporting and survey are required by the Center for Medicare Services (CMS) to allow standard, objective, valid comparisons to be made across hospitals nationally, regionally, and locally. Reports are received quarterly and since 2008 have been published nationally on the CMS and NYS Department of Health websites. The survey methodology and results are in the public domain. (www.hcahpsonline.org). Additionally, the hospital's needs assessment activities are informed by initiatives and studies carried out by the Bassett Healthcare Network Research Institute, including the Upstate Health and Wellness Study 2009. This project assessed health indicators, identified rural-urban health disparities, and provided baseline data to assist community healthcare planning in the rural region served by Bassett, including Schoharie County. It is a collaborative effort between the Research Institute, county health departments, and regional community services organizations.
Part VI, Question 3		Patient Education of Eligibility for Assistance: Bassett Hospital of Schoharie County (BHSC) is a not-for-profit healthcare organization that renders medical care to all persons in need of such care, regardless of their ability to pay. As required by NYS Department of Health, the hospital prominently posts notices throughout the facility stating clearly that emergency care is to be provided regardless of ability to pay. The list of patient rights is also posted throughout the hospital. Information about federal and state government health coverage plans and how to access them is also posted and is readily available at key points of patient contact, including, but not limited to, registration stations. Bassett Hospital of Schoharie County offers a Community Service Plan to patients who need financial assistance. A major component of the program is to actively identify patients who may be eligible for charity care. The process begins with an organizational policy and procedure that defines the program and serves as an education tool for all BHSC employees. The policy is updated annually, distributed to key personnel, and is posted in the online policy and procedure manual that is accessible to all employees. As part of the intake process, patients receive a CRH-specific financial aid brochure describing financial assistance options. The brochure describes federal and state government programs, as well as the hospital's Community Service Plan, and is written in plain language that addresses low literacy levels in the county (1 in 5 county residents read at the 3rd grade level or lower according to Literacy Volunteers of Schoharie County). It is also available at key points of service, including nurse's stations, waiting rooms, the ER, and other high-traffic public areas. In addition to postings containing contact information and the distribution of the BHSC-specific financial aid brochure, patient education is supported by a four-page, plain-language brochure that is included with the Community Service Plan application itself. Community Service Plan Brochure/Applications are readily available at all facilities in the Bassett Healthcare Network and all clinics. Clinical and support staff are made aware of the program and are able to direct patients to specialists who can assist in the application process. All patients who are registered as "self pay" are provided a Community Services Plan Brochure/Application in person. A listing of all self-pay accounts is produced and reviewed daily to insure that a Community Services Plan Brochure/Application has been provided. The self-pay billing office identifies patients who may require additional help understanding the program during the billing and collections process. Contact information for the Community Service Plan is included in patient bills. Self-pay accounts for patients who have been approved for Community Services within the prior 120 days are automatically included with prior approval. In Schoharie County, facilitated enrollment in government health insurance programs is handled by several community agencies/organizations (SCCAP, FidelisCare), as well as Bassett Medical Center. BHSC makes referrals to them by means of a form that can be signed by the patient and faxed. Additionally, a representative from FidelisCare was available one day per week on-site at the hospital throughout 2012. Patient registrars and customer service providers from the Business Office are trained to understand these programs and the process for helping patients access them. They provide one-on-one assistance with access, information, and appointment scheduling for facilitated enrollment. Additionally, the hospital's Business Services Manager provides one-on-one counseling to patients who need help paying their bills, including referral to facilitated enrollment for Medicaid and other government programs.
Part VI, Question 4		Community Information: Bassett Hospital of Schoharie County's primary service area encompasses all of Schoharie County, with a population of 32,099 (U.S. Census 2012 estimate), and a portion of neighboring Schenectady County, including the towns of Delanson and Duanesburg. Located in Cobleskill, NY, Bassett Hospital of Schoharie County is the only hospital in Schoharie County. Schoharie County is located at the far western edge of New York State's Capital District. A primarily rural area, Schoharie County covers a land area of approximately 622 square miles, with a population density of just 52.7 persons per square mile (U.S. Census 2010). Schoharie County has a strong agricultural heritage, and farming remains a dominant sector of its economy, with agricultural sales totaling $30 million per year (Schoharie County Chamber of Commerce). People age 65 and over make up 17.5 percent of the population, while the New York State average is 14.1 percent (U.S. Census 2012). Ninety-six percent of the population is white, with Hispanics making up 2.9 percent of the population and Blacks 1.3 percent (U.S. Census 2012). American Indian and Asian persons together represent 1.1 percent of the population, at 0.3 percent and 0.8 percent, respectively, and persons of two or more races make up 1.3 percent (U.S. Census 2012). Educational levels, unemployment, and poverty are identified barriers to the health of residents of Schoharie County (Schoharie County Health Assessment 2010-13, Schoharie County Dept. of Health). With an unemployment rate of 9 percent (April 2013, U.S. Bureau of Labor Statistics), the median household income in Schoharie County is $50,795 (US Census 2007-2011), which is nearly $6,156 less than the New York State median. The percentage of residents with incomes below the federal poverty guidelines is 10.7 percent (US Census State 2007-2011). Seventeen percent of Schoharie County residents lack health insurance (Schoharie County Community Health Assessment 2010 - 2013). Of the hospital's patients, 14% were Medicaid patients in 2012. Schoharie County is a federally designated Health Professional Shortage Area in the disciplines of Primary Care, Mental Health, and Dental (hrsa.gov). The percentage of the population with a high school degree is slightly higher than the New York State average: 87.2 percent for Schoharie County compared to 84.6 percent for the state. However, the percentage of the population with a college degree or higher is 12 percent lower than the New York State average: 20.5 percent for Schoharie County compared to 32.5 percent for the state (U.S. Census 2007-2011). One in five residents is able to read only at a level that makes it impossible to read and understand healthcare instructions and the information needed to find employment (Literacy Volunteers of Schoharie County).
Part VI, Question 5		Promotion of Community Health: A majority of the Basset Hospital of Schoharie County Board of Trustees is comprised of community volunteers who reside in the hospital's primary service area and who are neither employees nor contractors of the organization, nor family members thereof. Currently there are a total of 16 members on the Basset Hospital of Schoharie County Board of Trustees, of whom 11 are community volunteer board members who live in the service area. Four board members are executive-level employees of the Bassett Healthcare Network (BHN). One board member, who is trust advisor of The Clark Estates, Inc., holds a place on the various boards of BHN entities. As a not-for-profit hospital, Bassett Hospital of Schoharie County reinvests surplus funds toward equipment/technology improvements in patient care and patient safety, as well as infrastructure upgrades mandated by Joint Commission and government/regulatory requirements and deemed necessary to keep the hospital accredited and able to continue serving the health needs. In 2012, these projects totaled approximately $226,000. For example, in 2012, work continued on a 10-year project (2004 - 2014) that will enhance building systems and meet standards set by the Joint Commission, which is the accreditation entity for hospitals nationwide. The project involved extension of sprinklers, heating and cooling improvements, and asbestos abatement, all targeted to enhance patient safety. Similarly, other investments were made to replace aging, increasingly unreliable equipment and to secure medical technology and equipment advances that will insure that the only hospital in the county continues to offer its patients safe, quality patient care that meets accepted standards of care. This included the 2012 implementation of the Electronic Medical Record. The new system means a BHSC patient's information will be readily and accurately available to the appropriate healthcare providers throughout the Bassett network. Moreover, electronic medical record systems nationally are expected to lead to significant improvements in patient safety and quality of care, along with improvements in efficiency and coordination of care among multiple providers. Other examples of equipment/technology improvements made to improve health care in 2012 include new ultrasound equipment with 3D and 4D imaging to help doctors to diagnose and treat a variety of conditions, with a pricetag of $150,000. This equipment will help enable the hospital to continue to deliver appropriate, high-quality, safe emergency, preventitive, inpatient, and outpatient healthcare to our patients and to our rural, aging community (portions of the county are a federally designated rural area). Additionally, renovations in the hospital inpatient area will ensure ADA compliance and further the goals of the hospital's NICHE designation, which was attained in 2011 (Nurses Improving Care for Health System Elders). Community health improvement and education are key strategies in the hospital's plan of response to the community's health priorities and needs. The hospital's initiatives are largely guided by the New York State Department of Health Public Health Prevention Agenda. They are chosen and coordinated in close collaboration with the Schoharie County Department of Health and Bassett Healthcare Network, in particular reflecting the county's health assessment and the Bassett Health and Wellness Survey. Strategies focus on access, education and awareness. Hospital programs and efforts that address Prevention Agenda-related community health improvement and education priorities include the following: Diabetes community education and evidence-based support program; Senior Lunch and Learn education series; Stroke Support Group; Space and in-kind contribution of professional services for cancer and Alzheimer's support groups; contributions to non-profit community organizations; in-kind services contributed by staff to not-for-profit organizations and community groups; staff time spent coordinating events not sponsored by the hospital, such as blood drives and Marathon for a Better Life for the benefit of cancer patients/survivors in the community; and employee time spent on community health-related boards and other community involvement; The hospital helps to protect the health access, safety, and independence of vulnerable populations living in poverty through financially supported provision of the Lifeline personal response system; Provision of a program specifically requested by the Middleburgh Central School District to acclimate kindergarten students to the emergency room, medical imaging, and other hospital services which they may encounter. The hospital also provides community benefits services not easily counted or portrayed quantitatively. In 2012, these included regular educational displays in public areas of the hospital on a variety of health/wellness; a community newsletter dedicated in large part to educational messages intended to improve health knowledge, attitudes, skills/behaviors related to prevention priorities; private, individual staff donations to specific patients in need; and hundreds of hours of staff volunteer time in a wide-range of activities that promote the health of the community.
Part VI, Question 6		Affiliated Health Care System: Bassett Hospital of Schoharie County is part of Bassett Healthcare Network, which provides services in more than 20 communities spanning 5,600 square miles and seven counties. The network focuses its community services programs in the counties where the six affiliated hospitals and greatest patient populations are located. Otsego County - population 61,917; Delaware County - population 47,559; Herkimer County - population 64,160 (according to the 2011 U.S. Census estimates); and Schoharie County - population 32,578 (U.S. Census 2011 estimate), a. Bassett - an acute care inpatient teaching facility, an outpatient primary and specialty care center, a regional network of 26 community-based outpatient health centers, 19 school-based health centers, 2 ambulatory surgery centers, and a fully salaried medical staff in Cooperstown, Otsego County b. O'Connor Hospital - critical access hospital in Delhi, Delaware County c. Bassett Hospital of Schoharie County (dba Cobleskill Regional Hospital) - acute care facility in Cobleskill, Schoharie County d. Little Falls Hospital - critical access hospital in Little Falls, Herkimer County e. Tri-Town Regional Hospital - 24/7 emergency care facility in Sidney, Delaware County f. A.O. Fox Hospital -- acute care facility in Oneonta, Otsego County g. Valley Health Services - residential health care and rehabilitation facility h. At Home Care - certified home care agency i. First Community Care of Bassett - medical supply company All of the above (a-i) make up Bassett Healthcare Network and provide health services to this seven-county region in central New York.
Part VI, Question 7		State Filing of Community Benefit Report: New York State

Schedule H (Form 990) 2012

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

2012

Open to Public Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

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 or provision of all of 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 filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is 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) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(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 as deferred in prior Form 990
(A) Name and Title		(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)	(F) Compensation reported as deferred in prior Form 990
(1)NICHOLAS J NICOLETTATREASURER	(i) (ii)	376,575	107,000		23,096	3,436	510,107
(2)JEFFREY J WOEPPELVICE CHAIR	(i) (ii)	197,600			17,596	4,481	219,677
(3)GERALD D GROFF MDTRUSTEE	(i) (ii)	372,650		3,649	23,096	2,179	401,574
(4)JOSEPH R SELLERS MDTRUSTEE	(i) (ii)	205,500		509	18,201	986	225,196
(5)ERIC H STEINPRESIDENT/CEO	(i) (ii)	164,410			10,266	3,823	178,499
(6)ROBERT A LANCEY MD MBATRUSTEE	(i) (ii)	521,554	2,520		18,096	14,562	556,732

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Part I, Line 3		The Chief executive officer's salary is paid by a related organization under a management services agreement. The bassett hospital of schoharie county reviews the formal process that is used to determine the base compensation of the ceo. The ceo work plan and accomplishments for the year are reviewed. Salary changes are based on market, work plan and accomplishments. The ceo's salary is submitted as part of the management services agreement which is approved by the board.

Schedule J (Form 990) 2012

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

2012

Open to Public
Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

Identifier	Return Reference	Explanation
PART VI - SECTION B - NUMBER 11A		The 990 is reviewed by the Executive Finance Committee, which has been assigned that responsibility by the Board of Trustees. All trustees are made aware that the 990 is available for review in the Administrative Office upon request.
PART VI-SECTION B - NUMBER 12C		MEMBERS OF THE BOARD OF TRUSTEES COMPLETE CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY. A SUMMARY OF RESULTS IS REPORTED EACH YEAR AT THE ANNUAL MEETING OF THE BOARD OF TRUSTEES.
PART VI-SECTION B - NUMBER 15A		ANNUAL REVIEW IS DONE BY THE ASSESSMENT OF PRESIDENT/CEO'S PERFORMANCE BY EACH MEMBER OF THE BOARD OF TRUSTEES,SENIOR MANAGEMENT,ADMINISTRATIVE AND CLINICAL LEADERSHIP, AND ACTIVE MEDICAL STAFF. THE ASSESSMENT TOOL ADDRESSES PERFORMANCE MEASURES THAT RELATE TO THE ORGANIZATION'S MISSION AND STRATEGY THAT IS IDENTIFIED IN THE INSTITUTION'S ANNUAL OPERATING PLAN AND BY SPECIFIC ITERATION BY THE BOARD OF TRUSTEES. INFORMATION RECEIVED IS SUMMARIZED AND PRESENTED TO THE EXECUTIVE AND FINANACE COMMITTEE FOR REVIEW AND CONCLUSION.
PART VI-SECTION C - NUMBER 19		GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC BY REQUEST OF THE ADMINISTRATIVE OFFICE.
PART XI - NUMBER 5	CHANGES IN NET ASSETS OR FUND BALANCE	$27,772 INTEREST RATE SWAP AGREEMENT (1,509) CHANGE IN INTEREST IN NET ASSETS OF FRIENDS OF BASSETT $26,263 TOTAL CHANGE IN NET ASSETS OR FUND BALANCE
FORM 990, PART X - PREPAID EXPENSES AND DEFERRED CHARGES		PREPAID EXPENSES 147,352

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

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

2012

Open to Public Inspection

Name of the organization

Bassett Hospital of Schoharie County

Employer identification number

14-1772971

Part I

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

(a) Name, address, and EIN (if applicable) 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" to 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 entity?
(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) Thurston Corporation One Atwell Road Cooperstown,NY13326 13-3218680	supportingorg	NY	501(c)(3)	11c	NA		No
(2) FRIENDS OF BASSETT ONE ATWELL ROAD COOPERSTOWN,NY13326 23-7041610	SOLICITS CONT	NY	501(c)(3)	7	THURSTON		No
(3) MARY IMOGENE BASSETT HOSPITAL ONE ATWELL ROAD COOPERSTOWN,NY13326 13-5596796	HEALTH CARE	NY	501(c)(3)	3	THURSTON		No
(4) AURELIA OSBORNE FOX MEMORIAL HOSPITAL SO ONE NORTON AVENUE ONEONTA,NY13820 15-0539039	HEALTH CARE	NY	501(c)(3)	3	THURSTON		No
(5) TEMPLETON FOUNDATION ONE ATWELL ROAD COOPERSTOWN,NY13326 13-3317084	REAL ESTATE	NY	501(c)(3)	9	THURSTON		No
(6) BASSETT REGIONAL CORPORATION ONE ATWELL ROAD COOPERSTOWN,NY13326 13-3522783	PLAN & POLICY	NY	501(c)(3)	11B	THURSTON		No
(7) O'CONNOR HOSPITAL 460 ANDES ROAD DELHI,NY13753 16-1540394	HEALTH CARE	NY	501(c)(3)	3	BRC		No
(8) TRI TOWN REGIONAL HEALTHCARE 43 PEARL STREET SIDNEY,NY13838 26-0169584	HEALTH CARE	NY	501(c)(3)	3	BRC		No
(9) LITTLE FALLS HOSPITAL 140 BURWELL STREET LITTLE FALLS,NY13365 15-0533578	HEALTH CARE	NY	501(c)(3)	3	BRC		No
(10) VALLEY HEALTH SERVICES 690 WEST GERMAN STREET HERKIMER,NY13350 22-2511614	HEALTH CARE	NY	501(c)(3)	3	BRC		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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" to 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	(i) Section 512(b)(13) controlled entity?
(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	Yes	No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

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

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

Yes

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

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

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Yes

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-s)	(c) Amount involved	(d) Method of determining amount involved
(1) BASSETT REGIONAL CORPORATION	C	100,000	CASH

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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)	(e) Are all partners section 501(c)(3) organizations?		(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 entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(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

Schedule R (Form 990) 2012

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: PROVISION OF HEALTH CARE SERVICES TO RESIDENTS OF SCHOHARIE COUNTY AND THE SURROUNDING REGION.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	16
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	12
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	306
6	Total number of volunteers (estimate if necessary) .............	6	55
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	780,348	408,922
9	Program service revenue (Part VIII, line 2g) .........	25,216,492	26,272,938
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	21,487	-139,819
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	267,037	443,874
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	26,285,364	26,985,915
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)	12,054,484	11,924,961
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	16,500	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	13,437,979	13,941,004
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	25,508,963	25,865,965
19	Revenue less expenses. Subtract line 18 from line 12.......	776,401	1,119,950
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	18,768,245	20,713,005
21	Total liabilities (Part X, line 26).............	5,178,620	5,977,167
22	Net assets or fund balances. Subtract line 21 from line 20.....	13,589,625	14,735,838

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 18,822,742 including grants of $ ) (Revenue $ 26,272,938 )
	PROVISION OF HOSPITAL CARE TO RESIDENTS OF SCHOHARIE COUNTY AND THE SURROUNDING AREA. IN 2012, THE NUMBER OF INPATIENTS CARED FOR WAS 748 AND THE NUMBER OF OUTPATIENTS CARED FOR WAS 66,763.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses18,822,742

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)		(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
(1) Nancy S Bellinger........................................................................ Trustee	1.0 .......................	X		0	0	0
(2) STEVEN C COLE........................................................................ TRUSTEE	1.0 .......................	X		0
(3) MACDONALD J HOLMES DVM........................................................................ TRUSTEE EMERITUS	1.0 .......................	X		0
(4) STEVEN KROLL........................................................................ TRUSTEE	1.0 .......................	X		0
(5) HENRY LAMONT PE........................................................................ TRUSTEE	1.0 .......................	X		0
(6) PETER D LOPEZ........................................................................ TRUSTEE	1.0 .......................	X		0
(7) SUSAN K MCGIVER........................................................................ TRUSTEE EMERITA	1.0 .......................	X		0
(8) RENEE SCIALDO SHEVAT PHD........................................................................ TRUSTEE	1.0 .......................1.0	X		0
(9) RANDY L CRAPSER........................................................................ TRUSTEE	1.0 .......................	X		0
(10) ANNE CALDWELL MYERS PHD........................................................................ 2ND VICE CHAIR	1.0 .......................	X	X	0
(11) NICHOLAS J NICOLETTA........................................................................ TREASURER	2.0 .......................51.5	X	X		483,575	26,532
(12) JEFFREY J WOEPPEL........................................................................ VICE CHAIR	2.0 .......................48.0	X	X		197,600	22,077
(13) JOSEPH R SELLERS MD........................................................................ TRUSTEE	1.0 .......................40.0	X			206,009	19,187
(14) EDWIN KINTZ........................................................................ Trustee	1.0 .......................	X		0
(15) GEORGE KONTA CPA........................................................................ Trustee	1.0 .......................	X		0
(16) ROBERT A LANCEY MD MBA........................................................................ TRUSTEE	1.0 .......................40.0	X			524,074	32,658
(17) ERIC H STEIN........................................................................ PRESIDENT/CEO	.......................40.0		X		164,410	14,089

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)				(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) BARBARA E DICOCCO........................................................................ CHAIR	1.0 .......................2.5	X			0
(19) GLENN A PERRONE........................................................................ SECRETARY	1.0 .......................3.5	X			0
(20) LEANNA I JENSEN........................................................................ TRUSTEE	38.0 .......................		X		125,398		8,083
(21) JOAN MILLER........................................................................ SENIOR DIRECTOR QUALITY RES	38.0 .......................		X		111,542		6,960
(22) SUSAN OAKES-FERRUCCI........................................................................ VICE PRESIDENT PATIENT SVC/CNO	38.0 .......................4.0		X		131,736		12,035
(23) DAVID DE SANDO........................................................................ DIRECTOR OF PHARMACY	38.0 .......................		X		142,420		6,967
(24) GERALD D GROFF MD........................................................................ TRUSTEE	.......................42.0			X		376,299	25,275

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	511,096	1,951,967	173,863

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		215,381
e	Government grants (contributions)1e		189,586

f	All other contributions, gifts, grants, and similar amounts not included above1f		3,955

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			408,922
			Business Code
2a	NET PATIENT SERVICE REVENUE		900099	26,272,938	26,272,938
b
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			26,272,938
3	Investment income (including dividends, interest, and other similar amounts).......			30,460			30,460
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		26,650
b	Less: cost or other basis and sales expenses		196,929
c	Gain or (loss)		-170,279
d	Net gain or (loss)..........			-170,279			-170,279
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	OTHER OPERATING REVENUE		900099	214,143			214,143
b	COFFEE SHOP REVENUE		900099	68,542			68,542
c	LIFELINE REVENUE		900099	110,472			110,472
d	All other revenue ....			50,717			50,717
e	Total. Add lines 11a–11d ......			443,874
12	Total revenue. See Instructions......			26,985,915	26,272,938		304,055


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			6,103,758	1	9,407,974
2	Savings and temporary cash investments .........			122,925	2	123,670
3	Pledges and grants receivable, net ...........			68,983	3	73,155
4	Accounts receivable, net .............			3,042,254	4	2,572,908
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			158,889	8	151,843
9	Prepaid expenses and deferred charges ..........			146,416	9	147,352
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	18,692,606
b	Less: accumulated depreciation .....	10b	10,774,848	8,903,136	10c	7,917,758
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			0	12	0
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			221,884	15	318,345
16	Total assets. Add lines 1 through 15 (must equal line 34)......			18,768,245	16	20,713,005
17	Accounts payable and accrued expenses .........			1,757,128	17	1,736,366
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	0
20	Tax-exempt bond liabilities .............			1,590,000	20	1,470,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			162,195	23	206,131
24	Unsecured notes and loans payable to unrelated third parties ....			1,357,569	24	2,280,714
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			311,728	25	283,956
26	Total liabilities. Add lines 17 through 25.........			5,178,620	26	5,977,167
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			13,365,019	27	14,416,279
28	Temporarily restricted net assets ...........			45,916	28	140,869
29	Permanently restricted net assets ...........			178,690	29	178,690
	Organizations that do not follow SFAS 117 (ASC 958), 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 ...........			13,589,625	33	14,735,838
34	Total liabilities and net assets/fund balances ........			18,768,245	34	20,713,005