TY 2011 Form 990

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	1,431	1,431
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	126,907		126,907
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	7,266,670	6,944,395	322,275
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	211,870	211,870
9	Other employee benefits .......	1,098,983	1,060,234	38,749
10	Payroll taxes ...........	575,717	558,886	16,831
11	Fees for services (non-employees):
a	Management ......	5,395	5,395
b	Legal .........
c	Accounting ...........	16,958	16,958
d	Lobbying ...........
e	Professional fundraising. See Part IV, line 17..
f	Investment management fees ......
g	Other ..........	6,828,181	3,250,216	3,577,965
12	Advertising and promotion ....	187		187
13	Office expenses .......	1,681,186	1,585,351	95,835
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	923,285	923,285
17	Travel ............	32,410	28,377	4,033
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	198,129	198,129
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	874,714	830,978	43,736
23	Insurance ..............	112,031	112,031
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	MEDICAL SUPPLIES	11,805,975	11,805,975
b	PROVISION FOR BAD DEBTS	4,647,355	4,647,355
c	MISCELLANEOUS OTHER EXP	252,155	142,271	109,884
d
e
f	All other expenses
25	Total functional expenses. Add lines 1 through 24f	36,659,539	32,323,137	4,336,402	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
	1	Cashnon-interest-bearing ..........	207,928	1	105,525
2	Savings and temporary cash investments .......		2
3	Pledges and grants receivable, net .........		3
4	Accounts receivable, net .........	2,420,327	4	5,429,280
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	356,567	8	1,019,226
9	Prepaid expenses and deferred charges ............	55,085	9	81,704
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	16,883,104
b	Less: accumulated depreciation. .....	10b	9,485,775	4,900,109	10c	7,397,329
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 ......		12
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........		14
15	Other assets. See Part IV, line 11 ...........		15
16	Total assets. Add lines 1 through 15 (must equal line 34)...	7,940,016	16	14,033,064
	17	Accounts payable and accrued expenses .	1,348,806	17	5,278,726
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........		20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	17,948	25	54,897
26	Total liabilities. Add lines 17 through 25.....	1,366,754	26	5,333,623
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	6,573,262	27	8,699,441
28	Temporarily restricted net assets .....		28
29	Permanently restricted net assets .....		29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	6,573,262	33	8,699,441
34	Total liabilities and net assets/fund balances .....	7,940,016	34	14,033,064

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Other

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

Page 2

Part II

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

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

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

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

Section C. Computation of Public Support Percentage

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

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

16a

33 1/3% support test—2011. 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—2010. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2011. 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—2010. 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) 2011

Page 3

Part III

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

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(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) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. 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—2010. 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) 2011

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2011

Name of organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

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) (2011)

Page 2

Name of organization WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
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) (2011)

Page 3

Name of organization WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
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) (2011)

Page 4

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization
WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

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) (2011)

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

2011

Open to Public Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

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 170(h)(4)(B)(ii)? ....................................

Yes No

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

Part III

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

If the organization elected, as permitted under SFAS 116 (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 XIV, 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 Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

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

Part V

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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 XIV 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 .................	30,500		30,500
b	Buildings ................	7,787,383	4,393,334	3,394,049
c	Leasehold improvements ............	2,413,278	108,228	2,305,050
d	Equipment ................	6,213,948	4,682,151	1,531,797
e	Other .................	437,995	302,062	135,933
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				7,397,329

Schedule D (Form 990) 2011

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
LIABILITY INSURANCE		54,897








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		54,897
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

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

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

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

Part XIV

Supplemental Information

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

Identifier	Return Reference	Explanation
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	THE WELLMONT HEALTH SYSTEM ENTITIES ARE PRIMARILY CLASSIFIED AS ORGANIZATIONS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(A) AS ENTITIES DESCRIBED IN SECTION 501(C)(3)OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN INCLUDED FOR THESE ENTITIES IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE OPERATIONS OF WELLMONT HEALTH SYSTEM ARE SUBJECT TO STATE AND FEDERAL INCOME TAXES WHICH ARE ACCOUNTED FOR IN ACCORDANCE WITH ASC 740, INCOME TAXES; HOWEVER, SUCH AMOUNTS ARE NOT MATERIAL.

Schedule D (Form 990) 2011

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

2011

Open to Public Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

Part I

Charity Care 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) to determine 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

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

Yes

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

	(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Financial Assistance at cost (from Worksheet 1) ..			670,480		670,480	2.090 %
b Medicaid (from Worksheet 3, column a) .....			5,293,170	4,928,953	364,217	1.140 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....			5,963,650	4,928,953	1,034,697	3.230 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	8	683	73,431		73,431	0.200 %
f Health professions education (from Worksheet 5) ..			38,100		38,100	0.100 %
g Subsidized health services (from Worksheet 6) ..
h Research (from Worksheet 7)
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....	77		10,306		10,306	0.030 %
jTotal Other Benefits ...	85	683	121,837		121,837	0.330 %
kTotal. Add lines 7d and 7j. ..	85	683	6,085,487	4,928,953	1,156,534	3.560 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

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.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development	1	10	95	95
9	Other
10	Total	1	10	95	95

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? ..........................

Enter the amount of the organization's bad debt expense........

937,771

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

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

Section B. Medicare

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

8,078,279

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

7,458,739

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

619,540

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

(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) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	HAWKINS COUNTY MEMORIAL HOSPITAL 851 LOCUST STREET ROGERSVILLE,TN37857	X	X

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

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

HAWKINS COUNTY MEMORIAL HOSPITAL

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet the community health needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. ....		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.0% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10		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.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	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 web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection 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)
16	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?..........		16	Yes
	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)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19	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.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

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) 2011

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; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
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.

Identifier	ReturnReference	Explanation
EXCLUSIONS FROM PERCENT OF TOTAL EXPENSE	PART I LINE 7 COLUMN F	BAD DEBT EXPENSE OF 4647355 WAS INCLUDED ON FORM 990 PART IX LINE 25 COLUMN A BUT WAS SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGES IN THIS COLUMN PART I LINE 7 FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST FOR WORKSHEET 2 THE RATIO OF PATIENT CARE COSTTOCHARGES WAS USED TO DETERMINE THE COSTS FOR AMOUNTS IN LINES 7A AND 7B COLUMN C THE COSTS INCLUDED IN THE COSTTOCHARGE RATIO INCLUDED THE COSTS FROM ALL PATIENT SEGMENTS ACTUAL COSTS FROM THE GENERAL LEDGER WERE USED FOR AMOUNTS IN LINES 7F AND 7I COLUMN C
COMMUNITY BUILDING ACTIVITIES	PART II	HEALTH OCCUPATIONS STUDENTS OF AMERICA HOSAWORKS WITH VARIOUS DEPARTMENTS AND LEADERS AT HAWKINS COUNTY MEMORIAL HOSPITAL REGARDING FUTURE CAREERS IN HEALTHCARE AND HOW TO INTERVIEW FOR MEDICAL JOBS STUDENTS ALSO SHADOW WITH OUR LOCAL HOSPITAL REPRESENTATIVES TO GAIN A BETTER UNDERSTANDING OF FUTURE HEALTHCARE OPPORTUNITIES
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	THE COST REPORTED ON LINE 2 IS CALCULATED AS THE BAD DEBT EXPENSE FROM THE GENERAL LEDGER TIMES THE RATIO OF COST TO CHARGES AS CALCULATED ON WORKSHEET 2 THERE ARE NO AMOUNTS REPORTED ON LINE 3 DISCOUNTS ON PATIENT ACCOUNTS ARE NOT INCLUDED IN BAD DEBT EXPENSE PAYMENTS ON PATIENT ACCOUNTS THAT HAVE PREVIOUSLY BEEN WRITTEN OFF AS BAD DEBT ARE USED TO REDUCE BAD DEBT EXPENSE A THIRD PARTY VENDOR IS USED TO HELP DETERMINE THE AMOUNT THAT REASONABLY COULD BE ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE POLICY TEXT OF NOTE TO FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE NET PATIENT SERVICE REVENUE IS REPORTED ON THE ACCRUAL BASIS IN THE PERIOD IN WHICH SERVICES ARE PROVIDED AT THE ESTIMATED NET REALIZABLE AMOUNTS EXPECTED TO BE COLLECTED NET PATIENT SERVICE REVENUE INCLUDES AMOUNTS ESTIMATED BY MANAGEMENT TO BE REIMBURSABLE BY PATIENTS AND VARIOUS THIRDPARTY PAYORS UNDER PROVISIONS OF REIMBURSEMENT FORMULAS IN EFFECT INCLUDING RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS ESTIMATED RETROACTIVE ADJUSTMENTS ARE ACCRUED IN THE PERIOD RELATED SERVICES ARE RENDERED AND ADJUSTED IN FUTURE PERIODS AS FINAL AND OTHER SETTLEMENTS ARE DETERMINED WELLMONT PROVIDES CARE TO PATIENTS WHO MEET CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES BECAUSE WELLMONT DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE THEY ARE NOT INCLUDED IN NET PATIENT SERVICE REVENUE PATIENT ACCOUNTS RECEIVABLE ARE REPORTED NET OF BOTH AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AND AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS THE CONTRACTUAL ALLOWANCE REPRESENTS THE DIFFERENCE BETWEEN ESTABLISHED BILLING RATES AND ESTIMATED REIMBURSEMENT FROM MEDICARE TENNCARE MEDICAID AND OTHER THIRDPARTY PAYMENT PROGRAMS WELLMONTS POLICY DOES NOT REQUIRE COLLATERAL OR OTHER SECURITY FOR PATIENT ACCOUNTS RECEIVABLE WELLMONT ROUTINELY OBTAINS ASSIGNMENT OF OR IS OTHERWISE ENTITLED TO RECEIVE PATIENT BENEFITS PAYABLE UNDER HEALTH INSURANCE PROGRAMS PLANS OR POLICIES
NEEDS ASSESSMENT	PART VI	LINE NUMBER 1 PART VI LINE 2 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC EXAMINES THE HEALTHCARE NEEDS OF THE COMMUNITIES IT SERVES BY CONDUCTING PHYSICIAN NEEDS ASSESSMENTS FOR ITS HOSPITALS AS PART OF THIS EFFORT WELLMONT REVIEWS ITS SERVICE AREA AND DEMOGRAPHICS EXAMINES PHYSICIAN DEMOGRAPHICS AND CONDUCTS FOCUS GROUPS IT MAKES A DETERMINATION OF PHYSICIAN NEED WHILE CALCULATING ITS PHYSICIAN SURPLUSES AND DEFICITS AND HIGHLIGHTING ITS RECRUITMENT PRIORITIES AND PLANS WELLMONT ANNUALLY DETERMINES ITS PRIMARY SECONDARY AND TERTIARY MARKETS THROUGH THE USE OF COUNTYBYCOUNTY ANALYSIS TO IDENTIFY THE FOLLOWING CUSTOMER GROUPS PATIENTS AND POTENTIAL PATIENTS COMMUNITYEMPLOYER GROUPS AND LOCAL PHYSICIANS THE HEALTH SYSTEM ALSO RELIES ON THE EXPERTISE OF CONSULTANTS TO PERIODICALLY REVIEW ALL FACETS OF OPERATIONS AND MAKE RECOMMENDATIONS FOR CHANGES
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	LINE NUMBER 1 PART VI LINE 3 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC PROACTIVELY INFORMS PATIENTS OF THE FINANCIAL ASSISTANCE POLICY BY POSTING THE POLICY ON ITS WEBSITE AS WELL AS POSTING THE POLICY AT POINTS OF REGISTRATION IN THE HOSPITAL WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC USES PROGRAM ELIGIBILITY SPECIALISTS WHO CONTACT THE UNINSURED PATIENT POPULATION THESE SPECIALISTS DISCUSS THE VARIOUS GOVERNMENTAL ASSISTANCE PROGRAMS THAT ARE AVAILABLE TO PATIENTS IN ORDER TO DETERMINE IF THE PATIENT WOULD QUALIFY FOR ANY OF THESE PROGRAMS THE SPECIALISTS WILL WORK WITH THE PATIENTS TO COMPLETE ANY NECESSARY APPLICATIONS AND WILL HELP THEM THROUGH THE QUALIFICATION PROCESS
COMMUNITY INFORMATION	PART VI	LINE NUMBER 1 PART VI LINE 4 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INCS PRIMARY SERVICE AREA IS HAWKINS AND HANCOCK COUNTIES OF TENNESSEE WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC IS THE ONLY HOSPITAL IN HAWKINS COUNTY AND ITS SISTER FACILITY HANCOCK COUNTY HOSPITAL IS THE ONLY HOSPITAL IN HANCOCK COUNTY THE DEMOGRAPHICS OF THESE COUNTIES ARE AS FOLLOWS HAWKINS POPULATION 56671 MEDIAN HOUSEHOLD INCOME 36795 HANCOCK POPULATION 6737 MEDIAN HOUSEHOLD INCOME 22052 APPROXIMATELY 265 OF OUR PATIENTS ARE MEDICAID RECIPIENTS AND 115 ARE UNINSURED AND HAWKINS COUNTY IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	LINE NUMBER 1 PART VI LINE 5 THE MEDICAL STAFF OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC LIKE ALL WELLMONT HEALTH SYSTEM HOSPITALS IS OPEN TO ALL QUALIFIED PHYSICIANS EXCEPT FOR SOME OF ITS HOSPITAL BASED DEPARTMENTS SUCH AS ANESTHESIOLOGY EMERGENCY MEDICINE PATHOLOGY AND RADIOLOGY ANY SURPLUS OF REVENUES AND GAINS IN EXCESS OF EXPENSES AND LOSSES FOR WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC LIKE ALL WELLMONT HEALTH SYSTEM HOSPITALS IS USED TO FURTHER THE WELLMONT HEALTH SYSTEM MISSION AND VISION WHICH ARE WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION AND WE WILL DELIVER THE BEST HEALTH CARE ANYWHERE THIS WOULD INCLUDE IMPROVEMENTS IN FACILITIES AS WELL AS OPERATIONS FOR PATIENT CARE
AFFILIATED HEALTH CARE INFORMATION	PART VI	LINE NUMBER 1 PART VI LINE 6 WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL IS AN AFFILIATE OF WELLMONT HEALTH SYSTEM WELLMONT HEALTH SYSTEM WELLMONT IS A TENNESSEE NONPROFIT CORPORATION BASED IN KINGSPORT TENNESSEE AND A PREMIER PROVIDER OF HEALTHCARE SERVICES IN NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA WELLMONT WAS FORMED IN JULY 1996 WITH THE MERGER OF BRISTOL MEMORIAL HOSPITAL IN BRISTOL TENNESSEE AND HOLSTON VALLEY MEDICAL CENTER IN KINGSPORT TENNESSEE WELLMONT HAS GROWN TO INCLUDE SIX ADDITIONAL HOSPITALS AN INTEGRATED PHYSICIAN NETWORK AND SEVERAL AMBULATORY SITES WELLMONT HOSPITALS OFFER A BROAD SCOPE OF SERVICES RANGING FROM COMMUNITYBASED ACUTE CARE TO HIGHLY SPECIALIZED TERTIARY SERVICES INCLUDING TWO TRAUMA CENTERS COMPREHENSIVE HEART CARE AND CANCER CARE CENTERS WELLMONT OWNS AND OPERATES AN INTEGRATED HEALTH CARE DELIVERY SYSTEM PROVIDING INPATIENT OUTPATIENT AND OTHER HEALTH CARE SERVICES AT MULTIPLE LOCATIONS IN NORTHEAST TENNESSEE AND SOUTHWEST VIRGINIA CURRENTLY WELLMONT OWNS AND OPERATES SIX ACUTE CARE HOSPITAL FACILITIES AND ONE CRITICAL ACCESS HOSPITAL WITH A TOTAL OF 1253 LICENSED BEDS AND THROUGH A JOINT VENTURE PARTNERS TO OPERATE AN ADDITIONAL ACUTE CARE HOSPITAL FACILITY WITH 100 LICENSED BEDS THE ACUTE CARE FACILITIES OWNED BY WELLMONT INCLUDE HOLSTON VALLEY MEDICAL CENTER BRISTOL REGIONAL MEDICAL CENTER MOUNTAIN VIEW REGIONAL MEDICAL CENTER IN NORTON VIRGINIA LEE REGIONAL MEDICAL CENTER IN PENNINGTON GAP VIRGINIA LONESOME PINE HOSPITAL IN BIG STONE GAP VIRGINIA WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL IN ROGERSVILLE TENNESSEE AND THE CRITICAL ACCESS HOSPITAL HANCOCK COUNTY HOSPITAL IN SNEEDVILLE TENNESSEE WELLMONT IS THE MAJORITY PARTNER WITH ADVENTIST HEALTH SYSTEM AT TAKOMA REGIONAL HOSPITAL AN ACUTE CARE HOSPITAL IN GREENEVILLE TENNESSEE WELLMONT ALSO DIRECTLY OR INDIRECTLY CONTROLS OWNS OR IS AFFILIATED WITH VARIOUS NONPROFIT AND FORPROFIT CORPORATIONS AND OTHER ORGANIZATIONS THAT CURRENTLY PROVIDE HEALTH CARE AND HEALTH CARERELATED SERVICES THROUGHOUT THE SERVICE AREA IN ADDITION TO THE HOSPITAL CAMPUSES AND AMBULATORY CARE CENTERS DESCRIBED ABOVE WELLMONT ALSO OPERATES MEDICAL CLINICS AMBULATORY SURGERY CENTERS COMPREHENSIVE CANCER CARE CENTERS AND IMAGING FACILITIES
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	TENNESSEE VIRGINIA
HAWKINS COUNTY MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 15E	PART V LINE 15E	OTHER ACTIONS INCLUDE GARNISHMENT OF WAGES
HAWKINS COUNTY MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 16E	PART V LINE 16E	OTHER ACTIONS INCLUDE GARNISHMENT OF WAGES
HAWKINS COUNTY MEMORIAL HOSPITAL LINE NUMBER 1 PART V LINE 19D	PART V LINE 19D	WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL INC FOLLOWS TENNESSEE STATUTE WHICH IS 175 OF AVERAGE COST FOR ITS HOSPITALS

Schedule H (Form 990) 2011

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

2011

Open to Public Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

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 the expenses described above? If "No," complete Part III to explain....

Yes

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

Yes

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

Yes

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

Yes

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? .........................

Yes

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

Cat. No. 50053T

Schedule J (Form 990) 2011

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 column (E) for that individual.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) MARGARET DENARVAEZ	(i) (ii)	721,998	231,000	15,332	14,126	5,674	988,130
(2) ELIZABETH WARD THROUGH 110611	(i) (ii)	384,808	107,663	435,366		8,596	936,433
(3) TRACEY P MOFFATT	(i) (ii)	304,541	55,945	72,452		6,532	439,470
(4) JOHN HOWARD	(i) (ii)	268,284	38,672	51,790		8,904	367,650
(5) GREG NEAL	(i) (ii)	47,005 188,020	7,203 28,812	194 776	2,856 11,425	1,965 7,859	59,223 236,892
(6) SHERRI IVES	(i) (ii)	125,483	17,685	141	6,833	9,824	159,966
(7) FRED PELLE	(i) (ii)	197,258		417	9,354	5,356	212,385
(8) E DALE POE	(i) (ii)	157,229	22,073	194		12,322	191,818

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation
FRINGE OR EXPENSE EXPLANATION	SCHEDULE J, PAGE 1, PART I, LINE 1A	CHARTER TRAVEL AND TRAVEL FOR COMPANIONS WELLMONT HEALTH SYSTEM PROVIDED AIRPLANE TRAVEL FOR ITS EXECUTIVES THROUGH A PARTIAL OWNERSHIP OF AN AIRPLANE. ON OCCASION, TRAVEL WAS PROVIDED FOR EXECUTIVES AND THEIR COMPANIONS FOR PERSONAL USE. WELLMONT HEALTH SYSTEM FOLLOWED IRS GUIDELINES AND INCLUDED THE APPROPRIATE AMOUNTS IN THEIR TAXABLE COMPENSATION. HOUSING ALLOWANCE WELLMONT HEALTH SYSTEM OFFERED A HOUSING ALLOWANCE FOR JOHN HOWARD, SR. VP OF LEGAL AFFAIRS, DURING THE FISCAL YEAR ENDED JUNE 30, 2012. THE HOUSING ALLOWANCE PAID TO THE EXECUTIVE WAS INCLUDED IN HIS TAXABLE COMPENSATION. HEALTH OR SOCIAL CLUB DUES DURING THE FISCAL YEAR ENDED JUNE 30, 2012, WELLMONT HEALTH SYSTEM PROVIDED COUNTRY CLUB MEMBERSHIPS TO MARGARET DENARVAEZ, TRACEY P. MOFFATT, AND JOHN HOWARD. THESE AMOUNTS ARE INCLUDED IN THEIR TAXABLE COMPENSATION.
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS	SCHEDULE J, PAGE 1, PART I, LINE 4	ELIZABETH WARD (THROUGH 11/06/11) 435,000 0 0
COMPENSATION CONTINGENT UPON NET EARNINGS OF RELATED ORG	SCHEDULE J, PAGE 1, PART I, LINE 6B	INCENTIVE COMPENSATION IS BASED ON MEETING BUDGETED OPERATING MARGIN GOALS.
OTHER ADDITIONAL INFORMATION	SCHEDULE J, PART III	PART I, LINE 4B: WELLMONT HEALTH SYSTEM HAS AN EXECUTIVE RETIREMENT PROGRAM THAT INCLUDED MARGARET DENARVAEZ, ELIZABETH WARD, AND JOHN HOWARD FOR THE FISCAL YEAR ENDING JUNE 30, 2012. THIS PROGRAM HAS A TARGET BENEFIT OF 60% OF THE HIGHEST THREE YEAR AVERAGE SALARY (LESS EMPLOYER PROVIDER BENEFITS) AND THE EXECUTIVE MUST HAVE TWENTY YEARS OF SERVICE TO RECEIVE THE FULL BENEFIT. THE EXECUTIVE MAY RETIRE EARLY AT AGE 60 AND RECEIVE REDUCED BENEFITS. THERE WERE NO PAYMENTS MADE UNDER THIS PROGRAM FOR THE FISCAL YEAR ENDING JUNE 30, 2012.

Schedule J (Form 990) 2011

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

2011

Open to Public
Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

Identifier	Return Reference	Explanation
FIRST ACCOMPLISHMENT DESCRIPTION	FORM 990, PAGE 2, PART III, LINE 4A	THE COSTS AND REVENUES ASSOCIATED WITH THE PHYSICIANS AND OTHER PROVIDERS WITHIN THESE CORPORATIONS WHO PROVIDE INDISPENSABLE SERVICES TO PATIENTS OF WELLMONT HEALTH SYSTEM. THERE ARE ALSO FUNDS AND SERVICES THAT ARE PROVIDED THAT DO NOT MEET THE SPECIFIC DEFINITIONS OF THE IRS INSTRUCTIONS, SUCH AS CONTRIBUTIONS TO COMMUNITY ORGANIZATIONS THAT DO NOT MEET THE DEFINITION OF "RESTRICTED TO ONE OR MORE OF THE ACTIVITIES DESCRIBED IN THE TABLE IN PART I, LINE 7" OF SCHEDULE H-HOSPITALS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A PUBLIC TRUST. THIS HOSPITAL, LIKE THE OTHER WELLMONT HEALTH SYSTEM FACILITIES OF WHICH IT IS A MEMBER, WAS BORN OF ITS COMMUNITY'S COMMITMENT TO SUPERIOR HEALTH CARE FOR ITS CITIZENS. IT IS OUR MISSION TO DELIVER SUPERIOR HEALTH CARE WITH COMPASSION TO THE PEOPLE WE SERVE. IT IS OUR VISION TO DELIVER THE BEST HEALTH CARE ANYWHERE. CONSISTENT WITH THIS MISSION, WE HAVE WORKED TOWARD IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES, AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. OVERALL, WE RETURNED MORE THAN 1,156,534 IN BENEFITS TO OUR COMMUNITY IN FISCAL YEAR 2012, INCLUDING 11,034,697 OF UNREIMBURSED COSTS FOR INDIGENT AND MEDICAID PATIENTS AND 121,837 FOR OTHER COMMUNITY ACTIVITIES. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A 50-BED FACILITY IN ROGERSVILLE, TENNESSEE. WE PROVIDE A WIDE VARIETY OF SERVICES, INCLUDING EMERGENCY CARE, PHYSICAL AND OCCUPATIONAL THERAPIES, SURGERY, ORTHOPEDIC CARE, INTENSIVE CARE, OUTPATIENT SPECIALTY CLINICS, LABORATORY SERVICES, AUDIOLOGY SERVICES, CARDIOVASCULAR SERVICES, RESPIRATORY THERAPY, SLEEP EVALUATIONS AND TREATMENT, INFUSION, SPINE REHABILITATION SERVICES AND DIAGNOSTIC IMAGING. IN FISCAL YEAR 2012, WE PROVIDED SERVICES TO 1,322 INPATIENTS; WE HAD 33,913 OUTPATIENT ENCOUNTERS; WE HAD 805 INPATIENT AND OUTPATIENT SURGICAL CASES; AND WE HAD 18,223 EMERGENCY ROOM VISITS. WE ARE MINDFUL OF OUR RESPONSIBILITIES AS ONE OF HAWKINS COUNTY'S LARGEST COMPANIES. HUNDREDS OF FAMILIES COUNT ON US FOR THEIR LIVELIHOODS. OUR AREA RELIES ON US AS A DRIVER OF ECONOMIC DEVELOPMENT. IT IS OUR DUTY AS A CORPORATE CITIZEN TO SUPPORT THOSE ENDEAVORS AND CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. AND WE ALSO RECOGNIZE IT IS OUR RESPONSIBILITY TO CARE FOR THOSE IN NEED - REGARDLESS OF THEIR ABILITY TO PAY. IT IS OUR COMMITMENT - INDEED, IT IS OUR MISSION - TO SUPPORT THE CAUSES AND DEVELOP THE INITIATIVES THAT WILL PROPEL OUR COMMUNITY TOWARD A BETTER, BRIGHTER, HEALTHIER AND MORE VIBRANT FUTURE. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING THAT SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS, WRITING OFF 3,322,726 OF CHARGES AND INCURRING COSTS OF 670,480. THE WELLMONT CANCER CENTER RECENTLY OPENED AN ONCOLOGY OFFICE AND INFUSION CENTER IN HAWKINS COUNTY, OFFERING PATIENTS CONVENIENT ACCESS TO CANCER SERVICES IN A HEALING ENVIRONMENT. THE NEW FACILITY, LOCATED IN THE ALLANDALE OUTPATIENT CAMPUS, OFFERS SEVERAL PATIENT AMENITIES, FROM HEATED CHAIRS AND MASSAGES TO WINDOWS THROUGHOUT THE FACILITY THAT PROVIDE BEAUTIFUL VIEWS OF BAYS MOUNTAIN. WE SUPPORT AND ENCOURAGE OUR EMPLOYEES TO GIVE THEIR TIME TO AREA NOT-FOR-PROFIT ORGANIZATIONS, WHICH INCLUDED THE AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY, THE ROGERSVILLE HERITAGE ASSOCIATION, CIVIC GROUPS LIKE KIWANIS AND ROTARY, VARIOUS UNITED WAY AGENCIES, AND THE ROGERSVILLE AREA CHAMBER OF COMMERCE AND ITS PROGRAMS. MANY OF OUR EMPLOYEES ALSO SERVE IN COMMUNITY RESCUE SQUADS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. WILL NOT SUCCEED IN OUR MISSION WITHOUT CONTINUALLY REINVESTING IN OUR MOST PRECIOUS RESOURCE - OUR PEOPLE. TO THAT END, WE PROVIDED ON-THE-JOB TRAINING TO NURSING CANDIDATES AT A DIRECT COST OF 8,446. THIS PROGRAM UTILIZES NURSING STAFF THAT HAVE COMPLETED A DEGREE BUT NOT YET PASSED BOARD CERTIFICATION. THIS PROVIDES INVALUABLE EXPERIENCE FOR NEW NURSES, WHO ARE SUPERVISED BY BOARD CERTIFIED NURSES DURING THIS TIME. WE ALSO PROVIDED EDUCATIONAL OPPORTUNITIES TO STUDENTS IN OTHER MEDICAL DISCIPLINES, SUCH AS RADIOLOGY. OTHER EDUCATIONAL PROGRAMS WERE PROVIDED TO OUR EXISTING STAFF FOR CONTINUING MEDICAL EDUCATION AT A DIRECT COST OF 29,653.
CLASSES OF MEMBERS OR STOCKHOLDERS	FORM 990, PAGE 6, PART VI, LINE 6	THE BUSINESS AND AFFAIRS OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. (THE CORPORATION) SHALL BE GOVERNED EXCLUSIVELY BY THE BOARD OF DIRECTORS. THE CORPORATION'S BOARD OF DIRECTORS IS DESIGNATED BY WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION. IN ADDITION TO SUCH RIGHTS OF APPROVAL AND CONSENT AS MAY BE RESERVED TO THE SOLE MEMBER OF THE CORPORATION PURSUANT TO APPLICABLE LAW, TRANSACTIONS OF THE FOLLOWING MATTERS BY THE CORPORATION SHALL REQUIRE THE PRIOR APPROVAL OF WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION: A) IMPLEMENTATION OF CORPORATION'S ANNUAL BUDGET, B) INCURRING ANY LOAN OR OTHER INDEBTEDNESS FOR BORROWED MONEY, C) ACQUISITION OF ANY EQUIPMENT OR PERSONAL PROPERTY FOR A PURCHASE PRICE IN EXCESS OF 50,000 OR THE ACQUISITION OF ANY REAL ESTATE, REGARDLESS OF PURCHASE PRICE, D) THE UNDERTAKING OF CERTAIN CONTRACTUAL COMMITMENTS, E) ENTERING INTO ANY PLAN OF MERGER OR CONSOLIDATION, F) ACQUISITION OF SUBSTANTIALLY ALL OF THE ASSETS OF ANY OTHER LEGAL ENTITY, AND G) INSTITUTION OF ANY LITIGATION BY OR ON BEHALF OF CORPORATION.
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	SEE FORM 990, PART VI, SECTION A, LINE 6 FOR EXPLANATION.
DECISIONS SUBJECT TO APPROVAL OF MEMBERS	FORM 990, PAGE 6, PART VI, LINE 7B	SEE FORM 990, PART VI, SECTION A, LINE 6 FOR EXPLANATION.
OFFICERS WHO CANNOT BE REACHED	FORM 990, PAGE 6, PART VI, LINE 9	ELIZABETH WARD (THROUGH 11/06/11)
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S FORM 990 IS REVIEWED BY THE SENIOR VICE PRESIDENT OF FINANCE, THE CORPORATE CONTROLLER, AND THE MANAGER OF ACCOUNTING FOR WELLMONT HEALTH SYSTEM, AND THE BOARD OF DIRECTORS OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. PRIOR TO FILING. ANY QUESTIONS OR COMMENTS ARISING FROM THE INITIAL REVIEW ARE ADDRESSED TO ENSURE THE RETURN IS COMPLETE AND ACCURATE. ANY CHANGES OR CORRECTIONS ARE IDENTIFIED, REVISED IN THE RETURN, AND REVIEWED BY THE INDIVIDUALS LISTED ABOVE PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT. ANY POTENTIAL CONFLICTS ARE DISCUSSED WITH THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT AS THEY ARISE. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE GOVERNED BY WELLMONT HEALTH SYSTEM'S CONFLICT OF INTEREST POLICY. WELLMONT HEALTH SYSTEM ALSO HAS A POLICY ON BUSINESS PRACTICES THAT DISCUSSES CONFLICT OF INTEREST AND INFORMS THE WORKFORCE TO DISCLOSE ANY ISSUES TO THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, FOR RESOLUTION. WELLMONT HEALTH SYSTEM ALSO USES A HOTLINE THAT ALLOWS ANONYMOUS REPORTING OF POSSIBLE CONFLICT OF INTEREST SITUATIONS FOR INVESTIGATION BY THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE COMPENSATION OF MARGARET DENARVAEZ, THE PRESIDENT AND CEO OF WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND THE BOARD OF DIRECTORS. MARGARET DENARVAEZ IS ALSO ON THE PRESIDENT OF THE BOARD OF DIRECTORS (08/01/11 TO PRESENT) OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. THE COMPENSATION OF ELIZABETH WARD, THE FORMER EXECUTIVE VICE-PRESIDENT AND CHIEF FINANCIAL OFFICER (THROUGH 11/06/11) OF WELLMONT HEALTH SYSTEM, WAS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND BOARD OF DIRECTORS. ELIZABETH WARD WAS ALSO THE FORMER PRESIDENT OF THE BOARD OF DIRECTORS OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. GREG NEAL IS THE PRESIDENT AND CEO OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. GREG NEAL'S COMPENSATION IS PAID BY WELLMONT HEALTH SYSTEM THROUGH INTERCOMPANY TRANSACTIONS. WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF GREG NEAL. FRED PELLE WAS THE FORMER PRESIDENT AND CEO OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. FRED PELLE'S COMPENSATION WAS PAID BY WELLMONT HEALTH SYSTEM THROUGH INTERCOMPANY TRANSACTIONS. WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF FRED PELLE. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IS COMPLETED ON AN ANNUAL BASIS. THE LAST COMPENSATION DELIBERATION AND REVIEW PROCESS FOR MARGARET DENARVAEZ AND ELIZABETH WARD WAS COMPLETED MARCH 15, 2011.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	THE COMPENSATION OF TRACEY P. MOFFATT, THE CHIEF OPERATIONS OFFICER OF WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS. TRACEY P. MOFFATT IS ALSO THE TREASURER OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. THE COMPENSATION OF JOHN HOWARD, THE PRESIDENT AND CEO OF WELLMONT MEDICAL ASSOCIATES, INC. AND GENERAL COUNSEL FOR WELLMONT HEALTH SYSTEM IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS. JOHN HOWARD IS ALSO THE SECRETARY OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. CHRISTOPHER B. HOBSON IS THE CFO OF WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. (07/01/11 TO PRESENT). WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF CHRISTOPHER B. HOBSON. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IN COMPLETED ON AN ANNUAL BASIS. THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS REVIEWED THE SALARY AND MARKET COMPENSATION DATA FOR TRACEY P. MOFFATT AND JOHN HOWARD ON NOVEMBER 17, 2011.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. WELLMONT HEALTH SYSTEM'S AUDITED FINANCIAL STATEMENTS AND QUARTERLY UNAUDITED FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ELECTRONIC MUNICIPAL MARKET ACCESS WEBSITE.
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 5	376,107 CAPITAL CONTRIBUTION 4,939,481 INTERCOMPANY CHARGE FROM AFFILIATE -------- 5,315,588 TOTAL OTHER CHANGES IN NET ASSETS ========
CHANGE IN FINANCIAL REVIEW PROCESS	FORM 990, PAGE 12, PART XII, LINE 2C	WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S FINANCIAL STATEMENTS ARE INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF WELLMONT HEALTH SYSTEM. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC.'S FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2012 WERE AUDITED AS PART OF WELLMONT HEALTH SYSTEM'S CONSOLIDATED FINANCIAL STATEMENTS. WELLMONT HEALTH SYSTEM HAS AN AUDIT COMMITTEE WHICH ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT AUDITOR. THIS REVIEW PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

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

2011

Open to Public Inspection

Name of the organization

WELLMONT HAWKINS COUNTY MEMORIAL
HOSPITAL INC

Employer identification number

62-1816368

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) WELLMONT HEALTH SYSTEM 1905 AMERICAN WAY KINGSPORT,TN37660 62-1636465	HEALTHCARE	TN	501C3	3	NA		No
(2) WELLMONT MADISON HOUSE 1905 AMERICAN WAY KINGSPORT,TN37660 62-1308216	HEALTHCARE	TN	501C3	9	WHS		No
(3) WELLMONT FOUNDATION INC 1905 AMERICAN WAY KINGSPORT,TN37660 58-1594191	HEALTHCARE	TN	501C3	7	WHS		No
(4) WELLMONT CARDIOLOGY SERVICES 1905 AMERICAN WAY KINGSPORT,TN37660 26-3557623	HEALTHCARE	TN	501C3	3	WHS		No
(5) WELLMONT IMAGING SERVICES INC 1905 AMERICAN WAY KINGSPORT,TN37660 86-1103148	HEALTHCARE	TN	501C3	11A	WHS		No
(6) WELLMONT MEDICAL ASSOCIATES INC 1905 AMERICAN WAY KINGSPORT,TN37660 27-0898372	HEALTHCARE	TN	501C3	7	WHS		No
(7) WELLMONT SLEEP SERVICES 1905 AMERICAN WAY KINGSPORT,TN37660 27-3777167	HEALTHCARE	TN	501C3	3	WHS		No
(8) TAKOMA REGIONAL HOSPITAL INC 401 TAKOMA AVENUE GREENVILLE,TN37734 51-0603966	HEALTHCARE	TN	501C3	3	WHS		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2011

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) HOLSTON VALLEY IMAGING CENTER 103 WEST STONE DRIVE KINGSPORT,TN37660 20-2043285	HEALTHCARE	TN	N/A				No			No
(2) SAPLING GROVE AMBULATORY SURGERY 220 MEDICAL PARK BOULEVARD BRISTOL,TN37620 20-4450153	HEALTHCARE	TN	N/A				No			No
(3) HOLSTON VALLEY AMBULATORY SURGERY 103 WEST STONE DRIVE KINGSPORT,TN37660 62-1816864	HEALTHCARE	TN	N/A				No			No
(4) HOLSTON VALLEY IMAGING CENTER 103 WEST STONE DRIVE KINGSPORT,TN37660 20-2043285	HEALTHCARE	TN	N/A				No			No
(5) SAPLING GROVE AMBULATORY SURGERY 220 MEDICAL PARK BOULEVARD BRISTOL,TN37620 20-4450153	HEALTHCARE	TN	N/A				No			No
(6) HOLSTON VALLEY AMBULATORY SURGERY 103 WEST STONE DRIVE KINGSPORT,TN37660 62-1816864	HEALTHCARE	TN	N/A				No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity
(1) WELLMONT INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1320035	PHYS SVCS	TN	N/A
(2) MEDICAL MALL PHARMACY INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1565006	MED SVCS	TN	N/A
(3) WELLMONT PHYSICIAN SERVICES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1567353	PHYS SVCS	TN	N/A
(4) WELLMONT HEALTH SERVICES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1254373	HEALTHCARE	TN	N/A
(5) WPS PROVIDERS INC 1905 AMERICAN WAY KINGSPORT,TN37660 20-5564642	PHYS SVCS	TN	N/A
(6) MCOT INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1325938	MED SVCS	TN	N/A
(7) MEDICAL LAUNDRY OF TRI-CITIES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1482226	MED SVCS	TN	N/A
(8) WELLMONT INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1320035	PHYS SVCS	TN	N/A
(9) MEDICAL MALL PHARMACY INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1565006	MED SVCS	TN	N/A
(10) WELLMONT PHYSICIAN SERVICES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1567353	PHYS SVCS	TN	N/A
(11) WELLMONT HEALTH SERVICES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1254373	HEALTHCARE	TN	N/A
(12) WPS PROVIDERS INC 1905 AMERICAN WAY KINGSPORT,TN37660 20-5564642	PHYS SVCS	TN	N/A
(13) MCOT INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1325938	MED SVCS	TN	N/A
(14) MEDICAL LAUNDRY OF TRI-CITIES INC 1905 AMERICAN WAY KINGSPORT,TN37660 62-1482226	MED SVCS	TN	N/A

Schedule R (Form 990) 2011

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

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

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

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

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1) WELLMONT FOUNDATION INC	C	53,835	NEED
(2) WELLMONT HEALTH SYSTEM	C	376,107	CAPITAL CONTRIBUTION
(3) WELLMONT HEALTH SYSTEM	J	196,914	RENTAL AGREEMENT
(4) MCOT INC	L	91,871	PERCENTAGE OF AMT COLLECT
(5) WELLMONT LAUNDRY OF TRI-CITIES INC	L	81,017	INVOICES
(6) WELLMONT HEALTH SYSTEM	L	3,605,705	INVOICES

Schedule R (Form 990) 2011

Page 4

Part VI

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

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

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(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) 2011

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: WE DELIVER SUPERIOR HEALTH CARE WITH COMPASSION.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	3
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	0
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	289
6	Total number of volunteers (estimate if necessary) ....	6
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) .........	130,404	53,835
9	Program service revenue (Part VIII, line 2g) .........	22,422,386	41,547,274
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	972	1,585
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	159,859	2,498,612
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	22,713,621	44,101,306
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	26,055	1,431
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	8,922,498	9,280,147
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	13,260,802	27,377,961
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	22,209,355	36,659,539
19	Revenue less expenses. Subtract line 18 from line 12.......	504,266	7,441,767
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	7,940,016	14,033,064
21	Total liabilities (Part X, line 26).............	1,366,754	5,333,623
22	Net assets or fund balances. Subtract line 21 from line 20.....	6,573,262	8,699,441

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 32,323,137 including grants of $ 1,431 ) (Revenue $ 44,011,784 )
	WELLMONT HEALTH SYSTEM PREPARES A CONSOLIDATED COMMUNITY BENEFIT REPORT WHICH INCLUDES THE ACTIVITIES OF ALL ITS OPERATIONS AND AFFILIATES. IN CONTRAST, AN INTERNAL REVENUE SERVICE (IRS) FORM 990 IS FILED FOR EACH TAX EXEMPT CORPORATION (7 SEPARATE FORM 990S), AND THERE IS NO SUCH IRS FORM FOR THE TAXABLE CORPORATIONS. IN ADDITION, THE IRS INSTRUCTIONS TO FORM 990 HAVE SPECIFIC DEFINITIONS, METHODS AND WORKSHEETS TO CALCULATE THE COMMUNITY BENEFITS TO BE INCLUDED ON THE FORM 990. AS A RESULT, THERE ARE SIGNIFICANT DIFFERENCES BETWEEN THE COMMUNITY BENEFITS REPORTED IN THE CONSOLIDATED COMMUNITY BENEFIT REPORT AND THE VARIOUS FORM 990S. FOR EXAMPLE, THERE ARE SIGNIFICANT LOSSES INCURRED IN THE TAXABLE CORPORATIONS THAT CANNOT BE REFLECTED IN THE VARIOUS FORM 990S, THE LARGEST OF WHICH ARE THE COSTS AND REVENUES ASSOCIATED WITH THE PHYSICIANS AND OTHER PROVIDERS WITHIN THESE CORPORATIONS WHO PROVIDE INDISPENSABLE SERVICES TO PATIENTS OF WELLMONT HEALTH SYSTEM. THERE ARE ALSO FUNDS AND SERVICES THAT ARE PROVIDED THAT DO NOT MEET THE SPECIFIC DEFINITIONS OF THE IRS INSTRUCTIONS, SUCH AS CONTRIBUTIONS TO COMMUNITY ORGANIZATIONS THAT DO NOT MEET THE DEFINITION OF "RESTRICTED TO ONE OR MORE OF THE ACTIVITIES DESCRIBED IN THE TABLE IN PART I, LINE 7" OF SCHEDULE H-HOSPITALS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A PUBLIC TRUST. THIS HOSPITAL, LIKE THE OTHER WELLMONT HEALTH SYSTEM FACILITIES OF WHICH IT IS A MEMBER, WAS BORN OF ITS COMMUNITY'S COMMITMENT TO SUPERIOR HEALTH CARE FOR ITS CITIZENS. IT IS OUR MISSION TO DELIVER SUPERIOR HEALTH CARE WITH COMPASSION TO THE PEOPLE WE SERVE. IT IS OUR VISION TO DELIVER THE BEST HEALTH CARE ANYWHERE. CONSISTENT WITH THIS MISSION, WE HAVE WORKED TOWARD IMPROVING OUR COMMUNITY'S ACCESS TO QUALITY, AFFORDABLE HEALTH CARE, EDUCATING OUR REGION'S CAREGIVERS, IMPROVING THE HEALTH STATUS OF OUR COMMUNITIES, AND CONTRIBUTING TO THE OVERALL QUALITY OF LIFE IN THE AREAS WE SERVE. OVERALL, WE RETURNED MORE THAN 1,156,534 IN BENEFITS TO OUR COMMUNITY IN FISCAL YEAR 2012, INCLUDING 11,034,697 OF UNREIMBURSED COSTS FOR INDIGENT AND MEDICAID PATIENTS AND 121,837 FOR OTHER COMMUNITY ACTIVITIES. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. IS A 50-BED FACILITY IN ROGERSVILLE, TENNESSEE. WE PROVIDE A WIDE VARIETY OF SERVICES, INCLUDING EMERGENCY CARE, PHYSICAL AND OCCUPATIONAL THERAPIES, SURGERY, ORTHOPEDIC CARE, INTENSIVE CARE, OUTPATIENT SPECIALTY CLINICS, LABORATORY SERVICES, AUDIOLOGY SERVICES, CARDIOVASCULAR SERVICES, RESPIRATORY THERAPY, SLEEP EVALUATIONS AND TREATMENT, INFUSION, SPINE REHABILITATION SERVICES AND DIAGNOSTIC IMAGING. IN FISCAL YEAR 2012, WE PROVIDED SERVICES TO 1,322 INPATIENTS; WE HAD 33,913 OUTPATIENT ENCOUNTERS; WE HAD 805 INPATIENT AND OUTPATIENT SURGICAL CASES; AND WE HAD 18,223 EMERGENCY ROOM VISITS. WE ARE MINDFUL OF OUR RESPONSIBILITIES AS ONE OF HAWKINS COUNTY'S LARGEST COMPANIES. HUNDREDS OF FAMILIES COUNT ON US FOR THEIR LIVELIHOODS. OUR AREA RELIES ON US AS A DRIVER OF ECONOMIC DEVELOPMENT. IT IS OUR DUTY AS A CORPORATE CITIZEN TO SUPPORT THOSE ENDEAVORS AND CAUSES THAT IMPROVE THE QUALITY OF LIFE IN OUR REGION. AND WE ALSO RECOGNIZE IT IS OUR RESPONSIBILITY TO CARE FOR THOSE IN NEED - REGARDLESS OF THEIR ABILITY TO PAY. IT IS OUR COMMITMENT - INDEED, IT IS OUR MISSION - TO SUPPORT THE CAUSES AND DEVELOP THE INITIATIVES THAT WILL PROPEL OUR COMMUNITY TOWARD A BETTER, BRIGHTER, HEALTHIER AND MORE VIBRANT FUTURE. REGARDLESS OF RACE, RELIGION, ETHNICITY OR ABILITY TO PAY, WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. TREATS ALL PATIENTS FOR MEDICALLY NECESSARY CONDITIONS. RECOGNIZING THAT SOME PATIENTS CANNOT AFFORD ESSENTIAL MEDICAL SERVICES, WE PROVIDED CARE FOR INDIGENT PATIENTS, WRITING OFF 3,322,726 OF CHARGES AND INCURRING COSTS OF 670,480. THE WELLMONT CANCER CENTER RECENTLY OPENED AN ONCOLOGY OFFICE AND INFUSION CENTER IN HAWKINS COUNTY, OFFERING PATIENTS CONVENIENT ACCESS TO CANCER SERVICES IN A HEALING ENVIRONMENT. THE NEW FACILITY, LOCATED IN THE ALLANDALE OUTPATIENT CAMPUS, OFFERS SEVERAL PATIENT AMENITIES, FROM HEATED CHAIRS AND MASSAGES TO WINDOWS THROUGHOUT THE FACILITY THAT PROVIDE BEAUTIFUL VIEWS OF BAYS MOUNTAIN. WE SUPPORT AND ENCOURAGE OUR EMPLOYEES TO GIVE THEIR TIME TO AREA NOT-FOR-PROFIT ORGANIZATIONS, WHICH INCLUDED THE AMERICAN HEART ASSOCIATION, AMERICAN CANCER SOCIETY, THE ROGERSVILLE HERITAGE ASSOCIATION, CIVIC GROUPS LIKE KIWANIS AND ROTARY, VARIOUS UNITED WAY AGENCIES, AND THE ROGERSVILLE AREA CHAMBER OF COMMERCE AND ITS PROGRAMS. MANY OF OUR EMPLOYEES ALSO SERVE IN COMMUNITY RESCUE SQUADS. WELLMONT HAWKINS COUNTY MEMORIAL HOSPITAL, INC. WILL NOT SUCCEED IN OUR MISSION WITHOUT CONTINUALLY REINVESTING IN OUR MOST PRECIOUS RESOURCE - OUR PEOPLE. TO THAT END, WE PROVIDED ON-THE-JOB TRAINING TO NURSING CANDIDATES AT A DIRECT COST OF 8,446. THIS PROGRAM UTILIZES NURSING STAFF THAT HAVE COMPLETED A DEGREE BUT NOT YET PASSED BOARD CERTIFICATION. THIS PROVIDES INVALUABLE EXPERIENCE FOR NEW NURSES, WHO ARE SUPERVISED BY BOARD CERTIFIED NURSES DURING THIS TIME. WE ALSO PROVIDED EDUCATIONAL OPPORTUNITIES TO STUDENTS IN OTHER MEDICAL DISCIPLINES, SUCH AS RADIOLOGY. OTHER EDUCATIONAL PROGRAMS WERE PROVIDED TO OUR EXISTING STAFF FOR CONTINUING MEDICAL EDUCATION AT A DIRECT COST OF 29,653.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 32,323,137

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(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) MARGARET DENARVAEZ PRESIDENT/WH	1.00	X	X			0	968,330	19,800
(2) ELIZABETH WARD THROUGH 110611 PRESIDENT/WH	1.00	X	X			0	927,837	8,596
(3) TRACEY P MOFFATT TREASURER/WH	1.00	X	X			0	432,938	6,532
(4) JOHN HOWARD SECR/WMA PRE	1.00	X	X			0	358,746	8,904
(5) GREG NEAL PRESIDENT/CE	8.00		X			54,402	217,608	24,105
(6) CHRISTOPHER B HOBSON CFO-WHCMH	16.00		X			39,290	58,936	16,122
(7) SHERRI IVES VP OF PATIEN	40.00			X		0	143,309	16,657
(8) GEORGIA SHUCK PHARMACIST	40.00			X		121,821	0	4,548
(9) ALEXANDER GEORGE PHARMACIST	40.00			X		119,713	0	4,196
(10) GARY COLLINS CRNA	40.00			X		106,810	0	3,202
(11) MARVIN POWERS CRNA	40.00			X		105,957	0	3,202
(12) FRED PELLE PRESIDENT/CE					X	0	197,675	14,710
(13) E DALE POE CFO-WHCMH					X	0	179,496	12,322

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	547,993	3,484,875	142,896

(A) Name and business address	(B) Description of services	(C) Compensation
UT SURGICAL ASSOCIATES 1437 WEST MORRIS BLVD MORRISTOWN,TN37813	MEDICAL SERVCS	350,000




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 1

				(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		38,335
e	Government grants (contributions)1e		15,500

f	All other contributions, gifts, grants, and similar amounts not included above1f
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			53,835
			Business Code
2a	PATIENT CARE REVENUE - NET		621,990	41,539,540	41,539,540
b	MEDICAL RECORDS FEES		621,990	4,557	4,557
c	PHYSICAL THERAPY REVENUE		624,100	3,177	3,177
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			41,547,274
3	Investment income (including dividends, interest
	and other similar amounts).....			85			85
4	Income from investment of tax-exempt bond proceeds..
5	Royalties............
		(i) Real	(ii) Personal
6a	Gross rents	44,720
b	Less: rental expenses	10,618
c	Rental income or (loss)	34,102
d	Net rental income or (loss).......			34,102			34,102
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		3,748
b	Less: cost or other basis and sales expenses		2,248
c	Gain or (loss)		1,500
d	Net gain or (loss)..........			1,500			1,500
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..
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...
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..
Miscellaneous Revenue			Business Code
11a	MEANINGFUL USE FUNDS		900,099	2,269,124	2,269,124
b	MISCELLANEOUS REVENUE		900,099	121,365	121,365
c	CAFETERIA/ VENDING REVENUE		722,210	74,021	74,021
d	All other revenue ....
e	Total. Add lines 11a–11d ......			2,464,510
12	Total revenue. See Instructions....			44,101,306	44,011,784		35,687


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			207,928	1	105,525
2	Savings and temporary cash investments .......				2
3	Pledges and grants receivable, net .........				3
4	Accounts receivable, net .........			2,420,327	4	5,429,280
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			356,567	8	1,019,226
9	Prepaid expenses and deferred charges ............			55,085	9	81,704
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	16,883,104
b	Less: accumulated depreciation. .....	10b	9,485,775	4,900,109	10c	7,397,329
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 ......				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........				14
15	Other assets. See Part IV, line 11 ...........				15
16	Total assets. Add lines 1 through 15 (must equal line 34)...			7,940,016	16	14,033,064
17	Accounts payable and accrued expenses .			1,348,806	17	5,278,726
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........				20
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			17,948	25	54,897
26	Total liabilities. Add lines 17 through 25.....			1,366,754	26	5,333,623
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			6,573,262	27	8,699,441
28	Temporarily restricted net assets .....				28
29	Permanently restricted net assets .....				29
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			6,573,262	33	8,699,441
34	Total liabilities and net assets/fund balances .....			7,940,016	34	14,033,064