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






| 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.") . | 2,840 | 8,534 | 3,023 | 966 | 2,220 | 17,583 |
| 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...... | 1,035,700 | 1,057,376 | 1,158,709 | 1,317,907 | 1,309,544 | 5,879,236 |
| 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. | 1,038,540 | 1,065,910 | 1,161,732 | 1,318,873 | 1,311,764 | 5,896,819 |
| 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.) | 5,896,819 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 1,038,540 | 1,065,910 | 1,161,732 | 1,318,873 | 1,311,764 | 5,896,819 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 191 | 191 | 126 | 148 | 74 | 730 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 191 | 191 | 126 | 148 | 74 | 730 |
| 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.). | 1,038,731 | 1,066,101 | 1,161,858 | 1,319,021 | 1,311,838 | 5,897,549 |




| Facts And Circumstances Test |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| 01. Form 990 governing body review (Part VI, line 11) | THE 990 WAS REVIEWED BY THE CFO AND CEO A COPY OF THE 990 WAS PROVIDED TO THE TRUSTEES OF THE BOARD FOR THEIR REVIEW PRIOR TO FILING | |
| 02. Conflict of interest policy compliance (Part VI, line 12c) | A CONFLICT OF INTEREST FORM IS COMPLETED ANNUALLY THIS PROCESS IS MONITORED FOR COMPLIANCE BY THE CEO AND THE CHAIRMAN OF THE BOARD WHEN A CONFLICT EXISTS THE ENTIRE BOARD IS NOTIFIED THE BOARD MEMBER WITH THE CONFLICT DOES NOT VOTE ON ANY ISSUE RELATED TO THE CONFLICT OF INTEREST | |
| 03. CEO, executive director, top management comp (Part VI, line 15a) | FOR THE CEO WHO IS EMPLOYED BY A RELATED ENTITY WITH THE SAME BOARD OF TRUSTEES THE BOARD APPOINTS A PERSONNEL COMMITTEE TO REVIEW PERFORMANCE AND SET SALARY ANNUALLY THE MEMBERS ARE INDEPENDENT BOARD MEMBERS THEY USE AN INDEPENDENT CEO COMPENSATION SURVEY PROVIDED BY THE MICHIGAN HEALTH AND HOSPITAL ASSOCIATION THIS PROCESS LAST TOOK PLACE DURING THE FICAL YEAR COVERED BY THIS FILING | |
| 04. Other officer or key employee compensation (Part VI, line 15b | THE OTHER OFFICERS EMPLOYED BY A RELATED ENTITY WITH THE SAME BOARD OF TRUSTEES ARE REVIEWED BY THE CEO USING AN INDEPENDENT SURVEY COMPILED BY THE HOSPITAL COUNCIL OF EAST CENTRAL MICHIGAN THE BOARD PERSONNEL COMMITTEE REVIEWS THE CEOS RECOMENDATIONS THIS PROCESS LAST TOOK PLACE DURING THE FISCAL YEAR COVERED BY THIS FILING | |
| 05. Governing documents, etc, available to public (Part VI, line 19) | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST FORM 990 IS AVAILABLE ON GUIDESTAR AND AVAILABLE AT THE ORGANIZATION UPON REQUEST | |
| 06. General explanation attachment | FORM 990 PART VI LINE 14 THE ORGANIZATION DOES NOT HAVE ITS OWN WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY HOWEVER THE ORGANIZATION DOES USE THE MHA PROVIDED GUIDELINES SCHEDULE R PART II - PRIMARY ACTIVITY - HILLS AND DALES HEALTHCARE CORP TO RECEIVE AND ASSIST IN MANAGING EXCESS FUNDS ON BEHALF OF THE HEALTHCARE RELATED SUBSIDIARIES FORM 990 PART VII LINE 1A COLUMN B SOME INDIVIDUALS ON PART VII DEVOTED TIME TO RELATED ORGANIZATIONS THOSE HOURS AND INDIVIDUALS ARE LISTED AS FOLLOWS BARBARA BUTUCEL - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS BEVERLY FRANK - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS DANNY HAAG - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS DAVID WEILER - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS JUDY BROWN - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS LAMBERT ALTHAVER - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS MARY CUNNINGHAM - HILLS & DALES GENERAL HOSPITAL INC - 2 HOURS NANCY WADE MD - HILLS & DALES GENERAL HOSPITAL INC - 42 HOURS ORVIL BEECHER - HILLS & DALES GENERAL HOSPITAL INC - 4 HOURS PAT CURTIS - HILLS & DALES GENERAL HOSPITAL INC -2 HOURS DR SCOTT GREIB - HILLS & DALES GENERAL HOSPITAL INC - 52 HOURS MICHAEL J FALATKO - HILLS & DALES GENERAL HOSPITAL INC - 40 HOURS JEAN ANTHONY - HILLS & DALES GENERAL HOSPITAL INC - 40 HOURS THOMAS BARDWELL - HILLS & DALES GENERAL HOSPITAL INC - 40 HOURS KENNETH BARANSKI - HILLS & DALES GENERAL HOSPITAL INC - 40 HOURS BARBARA BUTUCEL - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS BEVERLY FRANK - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS DANNY HAAG - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS DAVID WEILER - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS JUDY BROWN - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS LAMBERT ALTHAVER - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS MARY CUNNINGHAM - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS ORVIL BEECHER - HILLS & DALES HEALTHCARE CORPORATION - 4 HOURS PAT CURTIS - HILLS & DALES HEALTHCARE CORPORATION -2 HOURS NANCY WADE MD - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS DR SCOTT GREIB - HILLS & DALES HEALTHCARE CORPORATION - 2 HOURS MICHAEL J FALATKO - HILLS & DALES HEALTHCARE CORPORATION - 1 HOUR JEAN ANTHONY - HILLS & DALES HEALTHCARE CORPORATION - 1 HOUR THOMAS BARDWELL - HILLS & DALES HEALTHCARE CORPORATION - 1 HOUR KENNETH BARANSKI - HILLS & DALES HEALTHCARE CORPORATION - 1 HOUR BARBARA BUTUCEL - HILLS & DALES FOUNDATION - 1 HOUR LAMBERT ALTHAVER - HILLS & DALES FOUNDATION - 1 HOUR MICHAEL J FALATKO - HILLS & DALES FOUNDATION - 1 HOUR JEAN ANTHONY - HILLS & DALES FOUNDATION - 1 HOUR THOMAS BARDWELL - HILLS & DALES FOUNDATION - 1 HOUR KENNETH BARANSKI - HILLS & DALES FOUNDATION - 1 HOUR BARBARA BUTUCEL - SELAD CORPORATION - 1 HOUR BEVERLY FRANK - SELAD CORPORATION - 1 HOUR DANNY HAAG - SELAD CORPORATION - 1 HOUR DAVID WEILER - SELAD CORPORATION - 1 HOUR JUDY BROWN - SELAD CORPORATION - 1 HOUR LAMBERT ALTHAVER - SELAD CORPORATION - 1 HOUR MARY CUNNINGHAM - SELAD CORPORATION - 1 HOUR ORVIL BEECHER - SELAD CORPORATION - 1 HOUR PAT CURTIS - SELAD CORPORATION - 1 HOUR NANCY WADE MD - SELAD CORPORATION - 1 HOUR DR SCOTT GREIB - SELAD CORPORATION - 1 HOUR MICHAEL J FALATKO - SELAD CORPORATION - 1 HOUR JEAN ANTHONY - SELAD CORPORATION - 1 HOUR THOMAS BARDWELL - SELAD CORPORATION - 1 HOUR KENNETH BARANSKI - SELAD CORPORATION - 1 HOUR |
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