Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 10-01-2012 , 2012, and ending 09-30-2013
BCheck if applicable:
CName of organization
The Fauquier Hospital Incorporated
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
500 Hospital Drive
Suite
Room/suite
City or town, state or country, and ZIP + 4
Warrenton, VA20186
D Employer identification number

54-0573701
E Telephone number

G Gross receipts $ 128,395,072
F Name and address of principal officer:
Rodger H Baker
500 Hospital Dr
Warrenton,VA20186
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.fauquierhealth.org
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1954
M State of legal domicile: VA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF THE COMMUNITY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 13
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 1,122
6 Total number of volunteers (estimate if necessary) ............. 6 300
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 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 270,244 794,388
9 Program service revenue (Part VIII, line 2g) ......... 134,281,386 120,255,314
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 5,188,605 7,212,120
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -3,827 120,571
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 139,736,408 128,382,393
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 63,095 129,629
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 63,777,051 60,159,217
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 67,611,313 59,189,977
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 131,451,459 119,478,823
19 Revenue less expenses. Subtract line 18 from line 12....... 8,284,949 8,903,570
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 234,682,832 237,338,864
21 Total liabilities (Part X, line 26)............. 87,820,773 81,250,261
22 Net assets or fund balances. Subtract line 21 from line 20..... 146,862,059 156,088,603
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF THE COMMUNITY.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 89,865,389 including grants of $ 129,629 ) (Revenue $ 120,255,314 )
THE COMMUNITY BENEFIT CONTRIBUTION OF FAUQUIER HOSPITAL INCLUDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN OUR COMMUNITIES. IN ORDER TO PORTRAY THE FULL BREADTH OF OUR CONTRIBUTION, OUR COMMUNITY BENEFIT INFORMATION IS DESCRIBED BELOW: 1. ORGANIZATIONAL COMMITMENT TO PROVIDING COMMUNITY BENEFIT: THE FAUQUIER HOSPITAL, INC. (FH) IS A 97-BED, NOT-FOR-PROFIT, ACUTE CARE FACILITY ESTABLISHED IN 1954 TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES FOR THE COMMUNITIES IT SERVES. OUR MISSION IS TO RESTORE, PROMOTE AND MAINTAIN THE HEALTH OF OUR COMMUNITY. FH IS THE ONLY HOSPITAL IN OUR PRIMARY SERVICE AREA OF FAUQUIER COUNTY WITH A POPULATION OF 76,599. OUR SERVICE AREA IS GROWING AND AGING, WITH OVERALL PROJECTED GROWTH BETWEEN 2013-2018 OF 3.8% AND WITH THE 45+ POPULATION COMPRISING 47% OF THE TOTAL IN 2018. TO ADDRESS THE GROWING AND CHANGING HEALTH CARE NEEDS RESULTING FROM THESE POPULATION CHANGES, FH CONTINUES TO SUPPORT FIFTEEN EMPLOYED PHYSICIANS, AN ENDOCRINOLOGIST, AN OBSTETRICS/GYNECOLOGIST ,FAMILY MEDICINE PHYSICIANS, A RHEUMATOLOGIST, NEUROLOGIST, INFECTIOUS DISEASE, INTERNAL MEDICINE AND GENERAL SURGERY. THROUGH PARTNERSHIPS WITH OTHER HEALTH CARE ORGANIZATIONS WE OPERATE A RETAIL HOME HEALTH SUPPLIES STORE AND A CANCER CENTER. WE ALSO PARTNER WITH LOCAL NON-PROFIT ORGANIZATIONS (E.G. FAUQUIER FREE CLINIC, THE CHAMBER OF COMMERCE, SCHOOLS AND CHURCHES) AND NATIONAL ORGANIZATIONS (E.G. THE AMERICAN CANCER SOCIETY) TO SUPPORT LOCAL EVENTS AND PROVIDE COMMUNITY HEALTH AND WELLNESS PROGRAMS. THESE COMMUNITY BENEFITS ACTIVITIES ARE COORDINATED BY TWO FULL-TIME COMMUNITY OUTREACH STAFF, SUPPORTED BY ADMINISTRATIVE AND CLINICAL DEPARTMENTS, AND OUR AUXILIARY VOLUNTEERS AS NEEDED. WE HAVE A FINANCIAL ASSISTANCE PROGRAM THAT PROVIDES FREE CARE FOR RESIDENTS OF FAUQUIER AND RAPPAHANNOCK COUNTIES WHO ARE WITHIN 200% OF THE FEDERAL POVERTY GUIDELINES. THE FINANCIAL ASSISTANCE PROGRAM ALSO PROVIDES FREE CARE TO PATIENTS WHO RESIDE IN OTHER AREAS WHO ARE WITHIN 100% OF THE FEDERAL POVERTY GUIDELINES. ALL UNINSURED PATIENTS, REGARDLESS OF INCOME LEVEL OR COUNTY OF RESIDENCE, RECEIVE A 38% DISCOUNT ON HOSPITAL SERVICES AND THE OPTION FOR AN INTEREST-FREE PAYMENT PLAN FOR BALANCES. EVERY UNINSURED PATIENT IS CONTACTED EITHER DURING THEIR STAY OR THE DAY AFTER AN OUTPATIENT VISIT TO DISCUSS FINANCIAL NEEDS. PATIENTS WHO DO NOT MEET THE REQUIREMENTS FOR STATE FUNDING ARE GIVEN A FINANCIAL AID FORM AND ASSISTANCE WITH COMPLETING THE NECESSARY PAPERWORK. THROUGH THE CONTINUING CARE FUND, THE HOSPITAL OFFERS ASSISTANCE TO INDIVIDUALS WHO HAVE INADEQUATE FINANCIAL MEANS TO COVER THE COSTS OF POST-HOSPITALIZATION HEALTH SERVICES, SUCH AS NURSING CARE; THE COST OF THIS PROGRAM TO FH IN FY13 WAS $96,846.64. IN FY13, WE PROVIDED $6,637,025 IN FREE MEDICAL CARE, WHICH INCLUDES $232,261 OF CARE PROVIDED TO FREE CLINIC PATIENTS. 2. ORGANIZATIONAL DESCRIPTION FOR TAX EXEMPTION: FH OFFERS ALL PATIENTS IMPARTIAL ACCESS TO TREATMENT OR ACCOMMODATIONS THAT ARE AVAILABLE OR MEDICALLY INDICATED, REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, RELIGION, OR SOURCE OF PAYMENT FOR CARE. OUR 24-HOUR EMERGENCY DEPARTMENT IS OPEN TO EVERYONE IN THE COMMUNITY, REGARDLESS OF ABILITY TO PAY. WE HAVE AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN OUR AREA. THE MAJORITY OF THE MEMBERS OF OUR GOVERNING BODIES FOR BOTH OUR HOSPITAL AND HEALTH SYSTEM ARE INDEPENDENT REPRESENTATIVES OF THE COMMUNITIES WE SERVE. TO HELP TRAIN AND EDUCATE HEALTH CARE PROFESSIONALS, FH WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS; FH STAFF PROVIDED APPROXIMATELY 17,063 HOURS AT A COST OF APPROXIMATELY $506,903. FH PARTICIPATES IN MEDICARE, MEDICAID, ANDCHAMPUS/TRICARE STANDARD. 3. DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS: FAUQUIER FREE CLINIC (FFC). FFC PROVIDES PRIMARY HEALTH AND DENTAL CARE TO UNINSURED RESIDENTS OF FAUQUIER AND RAPPAHANNOCK COUNTIES. FH PROVIDED LABORATORY, CARDIOLOGY/NEUROLOGY/PULMONARY SERVICES, AND RADIOLOGY SERVICES AT NO CHARGE TO FCC PATIENTS FOR A TOTAL COST OF $232,261. A TOTAL OF 798 HOURS OF FREE CLINICAL CARE WERE PROVIDED BY COMMUNITY PHYSICIANS AND CLINICAL STAFF. TO HELP FFC EXPAND ITS SERVICES TO MEET THE NEEDS OF A GROWING POPULATION, FH LEASED A BUILDING IN APRIL 2006 TO THE FFC FOR $1 PER YEAR FOR 10 YEARS; THE RENTAL VALUE FY13 WAS $85,284. IN ADDITION, FH CONTRIBUTED $5,000 IN UNRESTRICTED FUNDS. COMMUNITY HEALTH EDUCATION, SCREENINGS AND OUTREACH PROGRAMS FAUQUIER HEALTH PROVIDED HEALTH EDUCATION AND HEALTH SCREENINGS AT 106 LOCAL EVENTS FOR 2,678 PEOPLE. FH ALSO OFFERS TOURS OF THE HOSPITAL AND SPEAKERS FOR LOCAL SCHOOLS AND COMMUNITY ORGANIZATIONS TO BUILD RELATIONSHIPS WITHIN THE COMMUNITY, PROMOTE COLLABORATION IN MANAGING HEALTH AND WELLNESS, AND EDUCATE THE COMMUNITY ON THE HEALTH SYSTEM. THE TOTAL COMMUNITY BENEFIT OF THESE SERVICES WAS $56,613. TWO OF SEVERAL FH PUBLICATIONS ARE A COMMUNITY NEWSLETTER, HEALTHY HAPPENINGS, INTENDED TO EDUCATE THE PUBLIC ABOUT HEALTH ISSUES AND HEALTH CARE AND HOSPITAL SERVICES. PUBLISHED QUARTERLY HEALTHY HAPPENINGS, REACHES 100,000 HOMES IN FAUQUIER AND SURROUNDING COUNTIES. The SENIOR LIVING publication is published twice a year and REACHES 37,000 individuals who are 55 and older. THE COST TO FH FOR PUBLICATION AND DISTRIBUTION OF THese NEWSLETTERs IN FY13 WAS $344,208. EMERGENCY SERVICES. FH PROVIDES MEDICAL OVERSIGHT, DIRECTION, AND ORDERS TO PARAMEDICS IN THE FIELD AND EN-ROUTE TO THE HOSPITAL. OUR EMERGENCY DEPARTMENT OFFERS 24-HOUR ACCESS TO MEDICAL SERVICES AND HELICOPTER TRANSPORT FOR CRITICALLY ILL OR INJURED INDIVIDUALS, AND ALSO RESTOCKS MEDICAL BOXES AND PROVIDES CLEAN LINENS FOR RESCUE SQUADS AT A COST TO THE HOSPITAL OF APPROXIMATELY $54,769. SUPPORT GROUPS AND COMMUNITY GROUPS. FH SPONSORED, ASSISTED, OR PROVIDED MEETING SPACE FOR THREE SUPPORT GROUPS THAT MET WEEKLY OR MONTHLY, at a cost to FH of $860. ADDITIONALLY, FH PROVIDED MEETING SPACE OR CASH DONATIONS FOR SEVERAL NON-PROFIT COMMUNITY GROUPS, (E.G. The American Red Cross, FAUQUIER FREE CLINIC AND American Cancer Society Fauquier Chapter), with a fair market VALUE OF THE MEETING SPACE of $29,963. CASH DONATIONS TOTALED $14,715. FH EMPLOYEES PROVIDED REPRESENTATION ON COMMUNITY BOARDS AND COALITIONS AT AN EXPENSE OF $73,814. PHYSICIAN REFERRAL. THE HOSPITAL ASSISTED 2,417 PEOPLE WITH THE PHYSICIAN REFERRAL PROGRAM, WHICH HELPS THE COMMUNITY WITH QUESTIONS ON PHYSICIANS, APPOINTMENTS, CLASSES AND PROGRAMS REGISTRATION, AND HEALTH RESOURCES AVAILABLE THROUGH THE HOSPITAL OR IN THE COMMUNITY. IT COST FH $31,733 TO PROVIDE THIS SERVICE IN FY13. 4. LINKS TO ADDITIONAL COMMUNITY BENEFIT INFORMATION * FAUQUIER HOSPITAL WEBSITE - WWW.FAUQUIERHEALTH.ORG * FAUQUIER ASSISTANCE INFORMATIONN - http://www.fauquierhealth.org/patients.financial-assistance-policy
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 expensesMediumBullet89,865,389
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part II........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IVClick to see attachment
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV... Click to see attachment
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H.... Click to see attachment
20a
Yes
 
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................ Click to see attachment
24a
Yes
 
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
No
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
No
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
No
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
187
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
1,122
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
13
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
13
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
VA
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletDARRYL WHITE500 HOSPITAL DRWarrentonVA20186 (540) 316-5000
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) RODGER BAKER........................................................................
PRESIDENT/CEO
 29.0
.......................11.0 		X   X       1,087,052 0 72,527
(2) MARSHALL DOELLER........................................................................
CHAIRMAN
 3.0
.......................3.0 		X   X       0 0 0
(3) REV JENNINGS HOBSON........................................................................
VICE CHAIRMAN
 3.0
.......................3.0 		X   X       0 0 0
(4) JOHN MCCARTHY........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(5) KEVIN CARTER........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(6) MARK VAN DE WATER........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(7) SUSAN RUBIN........................................................................
TRUSTEE
 3.0
.......................6.0 		X           0 0 0
(8) CAREN EASTHAM........................................................................
TRUSTEE
 3.0
.......................6.0 		X           0 0 0
(9) MARY LEIGH MCDANIEL........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(10) ADAM WINICK MD........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(11) JOSHUA JAKUM MD........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(12) ROBIN GULICK........................................................................
SECRETARY/TREASURER
 3.0
.......................3.0 		X   X       0 0 0
(13) RAYMOND KNOTT........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(14) JANELLE DOWNES........................................................................
TRUSTEE
 3.0
.......................3.0 		X           0 0 0
(15) LYNN SAMUEL MD........................................................................
MEDICAL STAFF PRESIDENT
 3.0
.......................3.0 		X           0 0 0
(16) LIONEL PHILLIPS........................................................................
VP FINANCE/CFO
 30.0
.......................10.0 		    X       305,716 0 21,251
(17) LINDA SHARKEY........................................................................
VP PATIENT CARE/CNE
 40.0
.......................0.0 		      X     188,183 0 13,526
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) KATHERINE REEVES........................................................................
VP HUMAN RESOURCES
 30.0
.......................10.0 		      X     160,014 0 658
(19) GREGORY BENGSTON........................................................................
VP BUS DEV & PROF SERVICES
 30.0
.......................10.0 		      X     180,031 0 20,024
(20) MARY SMITH........................................................................
VICE PRESIDENT SENIOR SERVICES
 30.0
.......................10.0 		        X   198,128 0 7,818
(21) TRACY TURMAN........................................................................
VP SUPPORT SERVICES
 40.0
.......................0.0 		        X   134,220 0 18,446
(22) CHRISTINE CONNOLLY........................................................................
president faquier foundation
 0.0
.......................40.0 		        X   178,450 0 21,554
(23) ANHTAI NGUYEN........................................................................
chief medical officer
 40.0
.......................0.0 		        X   263,838 0 21,638














1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 2,695,632 0 197,442
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet58
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
VIRGINIA EMERGENCY MEDICINE ASSOCIA, 4094 MAJESTIC LNFAIRFAXVA22033 HEALTH CARE 1,472,541
TWIN CONTRACTING CORP, 12700 SUNRISE VALLEY DRIVE STE 100RESTONVA20191 SERVICES 1,199,933
POINT TO POINT INC, 23240 CHAGRIN BLVD STE 200CLEVELANDOH44122 MARKETING SERVICES 855,401
API HEALTHCARE CORP, 1550 INNOVVATION WAYHARTFORDWI530278720 INFORMATION SYSTEMS 838,648
ALLIANCE HEALTHCARE SERVICES, PO BOX 96485CHICAGOIL606936485 HEALTH CARE 769,611
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet20
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 793,869
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		519
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 794,388
Program Service Revenue Business Code
2a NET PATIENT REV   116,597,971 116,597,971    
b OTHER OPERATING   2,686,752 2,686,752    
c THERAPY SERVICES   941,925 941,925    
d OTHER MISC   28,666 28,666    
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 120,255,314
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 4,671,509     4,671,509
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory 2,540,611  
b Less: cost or other basis and sales expenses    
c Gain or (loss) 2,540,611  
d Net gain or (loss)..........MediumBullet 2,540,611     2,540,611
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..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a 133,250
b Less: cost of goods sold ..b 12,679
c Net income or (loss) from sales of inventory..MediumBullet 120,571     120,571
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 0
12 Total revenue. See Instructions......MediumBullet 128,382,393 120,255,314   7,332,691
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
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 21 129,629 129,629
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 1,781,671 0 1,781,671 0
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 46,885,518 39,201,620 7,683,898 0
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 1,326,833 1,068,770 258,063  
9 Other employee benefits ....... 6,654,376 5,360,127 1,294,249  
10 Payroll taxes ........... 3,510,819 2,827,979 682,840  
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 838,509   838,509  
c Accounting ........... 98,513   98,513  
d Lobbying ........... 0      
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 208,500   208,500  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 0      
12 Advertising and promotion .... 582,425   582,425  
13 Office expenses ....... 1,105,138 480,657 624,481  
14 Information technology ...... 3,477,702   3,477,702  
15 Royalties .. 0      
16 Occupancy ........... 2,091,008 1,822,478 268,530  
17 Travel ............ 447,504 144,548 302,956  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 2,408,963 2,408,963    
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 9,065,302 7,001,280 2,064,022  
23 Insurance .............. 611,341 334,722 276,619  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a BLOOD BANK 745,496 745,496    
b COLLECTION 880,948   880,948  
c CONTRACT SERVICES 6,200,146 3,394,707 2,805,439  
d SUPPLIES AND DRUGS 20,124,987 19,813,707 311,280  
e All other expenses 10,303,495 5,130,706 5,172,789  
25 Total functional expenses. Add lines 1 through 24e 119,478,823 89,865,389 29,613,434 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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 0 1 0
2 Savings and temporary cash investments ......... 13,843,903 2 10,620,274
3 Pledges and grants receivable, net ........... 0 3 0
4 Accounts receivable, net ............. 14,330,729 4 16,841,817
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
0 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 2,666,534 8 2,610,494
9 Prepaid expenses and deferred charges .......... 1,051,598 9 716,796
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 184,113,489
b Less: accumulated depreciation ..... 10b 120,508,225 63,687,855 10c 63,605,264
11 Investments—publicly traded securities .......... 115,518,544 11 128,426,207
12 Investments—other securities. See Part IV, line 11 ..... 8,803,724 12 9,235,188
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ............... 0 14 0
15 Other assets. See Part IV, line 11 ........... 14,779,945 15 5,282,824
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 234,682,832 16 237,338,864
Liabilities 17 Accounts payable and accrued expenses ......... 8,773,562 17 8,082,980
18 Grants payable ................. 0 18 0
19 Deferred revenue ................ 0 19 0
20 Tax-exempt bond liabilities ............. 73,688,750 20 66,529,322
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
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.................... 5,358,461 25 6,637,959
26 Total liabilities. Add lines 17 through 25......... 87,820,773 26 81,250,261
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 138,238,824 27 147,030,557
28 Temporarily restricted net assets ........... 0 28 0
29 Permanently restricted net assets ........... 8,623,235 29 9,058,046
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet 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 ........... 146,862,059 33 156,088,603
34 Total liabilities and net assets/fund balances ........ 234,682,832 34 237,338,864
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
128,382,393
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
119,478,823
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
8,903,570
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
146,862,059
5
Net unrealized gains (losses) on investments ...............
5
6,481,037
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-6,158,063
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
156,088,603
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
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.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
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.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
 
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
 
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
 
h
Provide the following information about the supported organization(s).
(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 monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..            
6 Public support. Subtract line 5 from line 4.            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
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
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......            
3 Gross receipts from activities that are not an unrelated trade or business under section 513..            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge..            
6 Total. Add lines 1 through 5.            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons...            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support (Subtract line 7c from line 6.)            
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
 
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
The Fauquier Hospital Incorporated
  		Employer identification number

54-0573701
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


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
The Fauquier Hospital Incorporated
  		Employer identification number

54-0573701
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
The Fauquier Hospital Incorporated
  		Employer identification number

54-0573701
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 (c) Use 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 (c) Use 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 (c) Use 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 (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID:  
Software Version:  
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
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 $  
2
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:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance .... 8,623,235 7,688,981 8,050,596 7,627,551 7,434,788
b Contributions ........ 519 616 739 699 1,135
c Net investment earnings, gains, and losses 689,130 1,188,611 -99,088 648,318 442,346
d Grants or scholarships .....          
e Other expenditures for facilities
and programs ........ 		238,906 240,718 250,195 213,797 237,296
f Administrative expenses .... 15,932 14,255 13,071 12,175 13,422
g End of year balance ...... 9,058,046 8,623,235 7,688,981 8,050,596 7,627,551
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet100.000 %
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   584,539 584,539
b Buildings ................   75,521,727 37,062,591 38,459,136
c Leasehold improvements ............   2,353,281 2,331,807 21,474
d Equipment ................   97,627,356 76,681,092 20,946,264
e Other .................   8,026,586 4,432,735 3,593,851
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 63,605,264
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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.)Small Bullet  
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.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
DUE TO THIRD PARTY PAYERS 2,828,157
ACCRUED INTEREST PAYABLE 699,838
CAPITAL LEASE 726,634
PROFESSIONAL LIABILITY 2,383,330





Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 6,637,959
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
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 XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII 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 XIII.) ............ 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 XIII.) ............ 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 XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Sch D Part XIV   The Fauquier Hospital Endowment Fund (the Trust) is an irrevocable trust created by the Chichester DuPont System in 1959. A local bank was designated as the trustee and remits income from the Trust to the Hospital semiannually. The income may be employed by the Hospital to further its work in such manner as the Board of Trustees of the Hospital determines.
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Part I
General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in region (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total expenditures
for and investments
in region
Central America and the Caribbean     Investments   19,304,115
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....     19,304,115
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b)     19,304,115
For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter ....MediumBullet
 
3
Enter total number of other organizations or entities .......................MediumBullet
 
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................
2 Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organizationmay be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A).......................................
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713)................................................
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 5
Part V
Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
Identifier ReturnReference Explanation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2012
Additional Data


Software ID:  
Software Version:  



SCHEDULE H (Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet Attach to Form 990. MediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...
1a
Yes
 
b
If "Yes," was it a written policy? .......................
1b
Yes
 
2
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.
3
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.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
%
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: .........
3b
 
No
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
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"? ..............

4

 

No
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......
5b
Yes
 
c
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? ..............
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? ..........
6a
Yes
 
b
If "Yes," did the organization make it available to the public? ..............
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (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) .. 		    6,110,727   6,110,727 5.110 %
b Medicaid (from Worksheet 3,
column a) .... 		    7,826,862 6,488,655 1,338,207 1.120 %
c Costs of other means-tested
government programs (from
Worksheet 3, column b) . 		           
d Total Financial Assistance
and Means-Tested
Government Programs . 		    13,937,589 6,488,655 7,448,934 6.230 %
Other Benefits
     1,232,988 28,981 1,204,007 1.010 %
e Community health
improvement services and
community benefit operations
(from Worksheet 4) ..
f Health professions education
(from Worksheet 5) .. 		    565,913   565,913 0.470 %
g Subsidized health services
(from Worksheet 6) .. 		    7,666,698 4,080,808 3,585,890 3.000 %
h Research (from Worksheet 7)            
i Cash and in-kind
contributions for community
benefit (from Worksheet 8) 		    88,529   88,529 0.070 %
j Total. Other Benefits ..     9,554,128 4,109,789 5,444,339 4.550 %
k Total. Add lines 7d and 7j .     23,491,717 10,598,444 12,893,273 10.780 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing     2,135   2,135  
2 Economic development            
3 Community support            
4 Environmental improvements     564   564  
5 Leadership development and training for community members            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total     2,699   2,699  
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
2,905,145
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
 
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
37,467,346
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
51,378,937
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-13,911,591
8
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:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
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.......................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?1
Name, address, and primary website address 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital Research Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 The Fauquier Hospital Incorporated
500 Hospital Drive
Warrenton,VA20186 		X X         X      
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
The Fauquier Hospital
Name of hospital facility or facility reporting group  
For single facility filers only: line Number of Hospital Facility (from Schedule H, Part V, Section A) 1
Yes No
Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
1 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9.................... 1 Yes  
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
2 Indicate the tax year the hospital facility last conducted a CHNA: 20 11
3 In conducting its most recent CHNA, did the hospital facility take into account input from representatives of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................... 3 Yes  
4 Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI................................ 4   No
5 Did the hospital facility make its CHNA report widely available to the public? ............. 5 Yes  
If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
b
c
6 If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply to date):
a
b
c
d
e
f
g
h
i
7 Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........ 7   No
8a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ........................... 8a   No
b If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ...... 8b    
c If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Financial Assistance Policy Yes No
9 Did the hospital facility have in place during the tax year a written financial assistance policy that:
Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care? 9 Yes  
10 Used federal poverty guidelines (FPG) to determine eligibility for providing free care?........... 10 Yes  
If "Yes," indicate the FPG family income limit for eligibility for free care: 200.%
If "No," explain in Part VI the criteria the hospital facility used.
11 Used FPG to determine eligibility for providing discounted care?................. 11   No
If “Yes,” indicate the FPG family income limit for eligibility for discounted care:   %
If "No," explain in Part VI the criteria the hospital facility used.
12 Explained the basis for calculating amounts charged to patients?................. 12 Yes  
If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a
b
c
d
e
f
g
h
13 Explained the method for applying for financial assistance?................... 13 Yes  
14 Included measures to publicize the policy within the community served by the hospital facility?....... 14 Yes  
If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a
b
c
d
e
f
g
Billing and Collections
15 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?....... 15 Yes  
16 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a
b
c
d
e
17 Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?.......... 17   No
If “Yes,” check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

18 Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):
a
b
c
d
e
Policy Relating to Emergency Medical Care
Yes No
19 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?.......... 19 Yes  
If “No,” indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)
20 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
b
c
d
21 During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................ 21   No
If “Yes,” explain in Part VI.
22 During the tax year, did the hospital facility charge any FAP-eligible individuals an amount equal to the gross charge for any service provided to that individual? ......................... 22   No
If “Yes,” explain in Part VI.
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2012
Schedule H (Form 990) 2012
Page
Part VI
Supplemental Information
Complete this part to provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8 Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
Identifier ReturnReference Explanation
Part I, Line 3c   ALL PATIENTS WHO ARE RESIDENTS OF FAUQUIER OR RAPPAHANNOCK COUNTIES, WHOSE ANNUAL HOUSEHOLD INCOME LEVELS ARE AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINES, ARE ELIGIBLE FOR FREE CARE. THIS PROCESS REQUIRES AN APPLICATION AND VERIFICATION OF ALL SOURCES OF INCOME. In addition, aLL PATIENTS WHO ARE NON RESIDENTS OF FAUQUIER OR RAPPAHANNOCK COUNTIES AND WHOSE ANNUAL HOUSEHOLD INCOME FALLS AT OR BELOW 100% OF THE FEDERAL POVERTY GUIDELINES ARE ALSO ELIGIBLE FOR FREE CARE AFTER COMPLETING THE SAME APPLICATION AND INCOME VERIFICATION PROCESS. BEFORE FINAL COLLECTION ACTION, ACCOUNTS ARE PUT THROUGH CREDIT SCORING SOFTWARE TO HELP IDENTIFY THOSE PATIENTS WHO MIGHT BE ELIGIBLE FOR FINANCIAL ASSISTANCE BUT HAVE NOT CONTACTED OUR OFFICE UP TO THAT POINT. IF THE SOFTWARE INDICATES THAT THE PATIENT'S INCOME LEVEL MEETS FINANCIAL ASSISTANCE ELIGIBILITY, THE ACCOUNT IS WRITTEN OFF TO CHARITY AND FURTHER COLLECTION ACTIVITY IS NOT PURSUED. Furthermore, all uninsured patients that do not qualify under the hospital's Financial assistance policy are eligible for a 38% discount on hospital Services and have the option of an interest free payment plan for any balances.
Part I, Line 6a   Fauquier Health prepares its own community benefit report, which it posts on the hospital and foundation's websites. In addition, a hard copy of the community benefit report is sent out to approximately 10,000 community leaders and donors.
Part I, Line 7   PART I, LINE 7G FAUQUIER HEALTH, AS PART OF ITS MEDICAL STAFF DEVELOPMENT PLAN, IDENTIFIES SPECIFIC PHYSICIAN SPECIALTY SHORTAGES IN THE COMMUNITY AND RECRUITS PHYSICIANS TO THE COMMUNITY TO PROVIDE PATIENT SERVICES IN THOSE AREAS OF IDENTIFIED COMMUNITY NEED. THE PHYSICIANS ARE EMPLOYED BY A WHOLLY OWNED HOSPITAL AFFILIATE, FAUQUIER HEALTH PHYSICIANS SERVICES, LLC. THE COST OF OPERATING THIS PHYSICIAN PRACTICE AND MAKING THESE SPECIALTIES AVAILABLE TO THE COMMUNITY WITHOUT REGARD TO THE PATIENT'S ABILITY TO PAY EXCEEDS THE REVENUE COLLECTED. THE NECESSARY SUBSIDY IS PROVIDED BY THE FAUQUIER HOSPITAL. THESE SPECIALTIES INCLUDED INFECTIOUS DISEASE, RHUMATOLOGY, NEUROLOGY, ENDOCRINOLOGY, OBSTETRICS, ONCOLOGY, ENT AND PRIMARY CARE.
Part II   FAUQUIER HEALTH'S COMMUNITY BUILDING ACTIVITIES SUPPORT THE HEALTH OF THE COMMUNITY BY OFFERING COMMUNITY SUPPORT; ENVIRONMENTAL IMPROVEMENTS; AND PHYSICAL IMPROVEMENTS AND HOUSING. COMMUNITY SUPPORT - THE DISASTER READINESS SUPPLIES PREPARE OUR COMMUNITY FOR POTENTIAL DISASTERS SUCH AS NATURAL DISASTERS, ELECTRICITY OUTAGES OR DIRTY BOMBS FOR A TIME PERIOD OF 96 HOURS. IN ADDITION, THE HOSPITAL SERVES AS A DEFAULT SAFE HAVEN FOR HOME BOUND INDIVIDUALS WHO ARE ON OXYGEN. SUPPORT OF FIRST NIGHT HELPS SUPPORT HEALTHY AND SAFE ACTIVITIES FOR THE COMMUNITY TO BE INVOLVED IN FOR NEW YEARS EVE. IN ADDITION, CONTRIBUTIONS SUPPORTED EXERCISE ACTIVITIES AND PLAYGROUND EQUIPMENT FOR A LOCAL SCHOOL. ENVIRONMENTAL IMPROVEMENTS - FAUQUIER HEALTH'S ANNUAL MEDICATION AND SHARPS COLLECTION EVENT HELPS TO SAFELY DISPOSE OF 136 GALLONS OF SHARPS AND 330 LBS OF MEDICATIONS. RATHER THAN COMMUNITY MEMBERS FLUSHING MEDICATIONS INTO THE GROUND WATER OR DISPOSING OF SHARPS AT THE LANDFILL, FAUQUIER HEALTH COLLECTS THEM AND WORKS WITH A MEDICAL WASTE MANAGEMENT COMPANY THAT DISPOSES OF THE ITEMS. LASTLY THE PHYSICAL IMPROVEMENTS AND HOUSING ACTIVITIES HELPED ORGANIZE AND RENOVATE THE FACILITIES AT AT LOCAL NON-PROFIT THAT OFFERS SHELTER AND EDUCATION FOR THE HOMELESS; A FOOD PANTRY AND FREE CLOTHING TO INDIVIDUALS IN NEED.
Part III, Line 2   The hospital's calculated ratio of cost to charge was applied to the total bad debt expense for the reporting year to arrive at the cost of the organization's bad debt expense. The ratio of patient care cost to total charges is developed in Schedule H, Worksheet 2 and applied to the total charges for Bad Debt Expense to arrive at the amount in Part III, Section A, Line 2. The cost from Line 2 is then adjusted down to represent the estimated portion of Bad Debt Expense that would qualify for the Hospital's financial assistance policy, i.e. Charity care. The corresponding cost should be included as a community benefit.
Part III, Line 4   Accounts Receivable are reported net of allowances for the excess of charges over the payments on patient accounts to be received from third party payers and estimates of uncollectible amounts. The system's policy is to write-off all patient accounts that have been identified as uncollectable. Any allowance for doubtful accounts is recorded for accounts not yet written off that may become uncollectable in future periods based on managment's assessment of historical and expected net collections for each of its major payers. Management regularly reviews data about these major payer sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payers, and others for services rendered, and include estimated retroactive revenue adjustments due to future audits, reviews and investigations. Retroactive adjustments are considered in the recognition of revenue on an estimated basis in the period the related services are rendered, and such amounts are adjusted in future periods as adjustments become known or as years are no longer subject to such audits, reviews and investigations. During the 2012 tax year, Fauquier Hospital periodically employed credit scoring software to help identify patients that might be eligible for financial assistance under the Hospital's financial assistance policy, which had not completed a financial assistance application. If the software indicated that the patient's income level met financial assistance eligibility under the Hospital's financial assistance policy, then the account was written off to charity and further collection activity was not pursued. As a result of the periodic use of such credit scoring software throughout the year, it is difficult to estimate the amount of the bad debt expense attributable to patients that might qualify for financial assistance under the Hospital's financial assistance policy. Therefore, the Hospital has reported $0.
Part III, Line 8   The shortfall for Medicare is not currently included/considered in community benefit. However, the shortfall is due to the reimbursement from Medicare falling short of the cost incurred to provide care to the Medicare population served by The Fauquier Hospital. As with the shortfall experienced for the Medicaid population, the Medicare shortfall should be considered a community benefit as well. It is part of the organization's mission to provide the best possible care to elderly patients within our community, and the organization believes providing such care has improved the overall health of the community. By providing such care to Medicare patients, the governme nt's burden for caring for such individuals is lessened. The Medicare cost report was utilized as outlined in the Schedule H, Part III, Section B, Worksheet B, which utilizes the cost to charge ratio developed within the Medicare Cost Report to determine the allowable cost.
Part III, Line 9b   Fauquier Hospital's Financial Assistance policy contains the following provision on collection practices for those patients who qualify for financial assistance: Fauquier Hospital management shall develop policies and procedures for internal and external collection practices (including actions the hospital may take in the event of non-payment, including collections action and reporting to credit agencies) that take into account the extent to which the patient qualifies for charity care or discounted care; a patient's good faith efforts to apply for governmental assistance programs or financial assistance from Fauquier Hospital, and a patient's good faith effort to comply with his or her payment agreements with Fauquier Hospital. Fauquier Hospital will not impose extraordinary collections actions such as lawsuits, wage garnishments, arrests, body attachments, liens on residences, or other similar legal actions against any patient without first making reasonable efforts to determine whether that patient is eligible for financial assistance under this financial assistance policy. "Reasonable efforts" include notifications by the hospital of this financial assistance policy upon admission and in written and oral communications with the patient regarding the patient's bill, including invoices and telephone calls before collection action or reporting to credit agencies is initiated. If a patient is found to qualify for financial assistance after collection actions have started, all collection activity is immediately stopped, notifications are sent to the credit bureau if necessary and patients are not charged for collection fees. If a patient is found to qualify for financial assistance after making payments towards their balance, the payments are refunded to the patient.
Part V, Line 3   FAUQUIER HOSPITAL CONSULTED WITH COMMUNITY HEALTH SOLUTIONS OF RICHMOND, VIRGINIA, TO CONDUCT THE HEALTH NEEDS ASSESSMENT. INPUT WAS REQUESTED FROM 60 COMMUNITY STAKEHOLDERS VIA AN ONLINE SURVEY INCLUDING LOCAL EMS, UNITED WAY, PUBLIC AND PRIVATE SCHOOLS.
Part V, Line 5c   In addition to sharing the Health Needs Assessment on the Fauquier Health website, it was distributed to the community stakeholders who were invited to take part in the online survey; the Warrenton office of the Rappahannock Rapidan Health Department as well as anyone who requests a copy of the assessment.
Part V, Line 7   The Fauquier Hospital's health needs assessment identified and evaluated the global community health needs of our primary service area of Fauquier and Rappahannock Counties. Of the many community service gaps and health needs identified, Fauquier Health chose the area of greatest need and where the greatest impact could be made. Those topics are transportation, health education, aging services and early detection and screening in addition to leading causes of death, which are: cancer, heart disease, diabetes and Alzheimer's. Childhood obesity, a community health concern is also being addressed. To help address transportation, Fauquier Health supported with a donation, Voltran, a local nonprofit that coordinates volunteers who drive individuals to medical appointments. In addition Fauquier Health partnered with Virginia Regional Transit and Culpeper Hospital to contribute towards a bus route through the rural, southern part of the county to bring people to the hospital. To address health education and leading causes of death, the hospital hosts free, monthly health lectures on various topics identified in the assessment such as cancer, heart disease, Alzheimers, diabetes, congestive heart failure and chronic obstructive pulmonary disease. The annual health fair provides health screenings for b/p, cholesterol, blood glucose, breast and PSA screenings. Fauquier Health addresses diabetes, by providing diabetes education including lectures, support groups, self-management classes, screenings, counseling and cooking demos. Free mammograms are provided to women turning 40 to provide breast cancer screenings. To address aging services, Fauquier Health facilitates support groups for Alzheimer's, dementia, cancer, caregivers and diabetes. In addition, Fauquier partners with the local community service board and Aging Together to host Medicare/Medicaid counseling and a Falls Symposium and Alzheimer's/Dementia workshop. Fauquier Health partnered with three community organizations to address childhood obesity through an 8 week summer camp program that highlighted physical activity and nutrition. The health needs identified that the hospital is not addressing are those that the hospital believes are better handled by other local organizations or government entities. Examples include, low birth weights which are addressed by the local health department and social services. Dental care is not the expertise of the hospital so is addressed by the local health department and the local free clinic. Behavioral health is currently addressed by the local community services board, however the hospital is exploring initiatives to address the need in the community. The hospital supports the local free clinic financially and with donated lab and radiology services to provide care to the uninsured population. The results of the health needs assessment are continually being reviewed and considered by Fauquier Hospital leadership. They are considering options into incorporating the health needs identified into the hospital's strategic plan for the years to come.
Part V, Line 14g   In addition to publishing the Financial Assistance Policy on the hospital's website, signage is posted strategically throughout the hospital (including all inpatient, outpatient, ancillary and emergency department registration offices) which indicates that financial assistance is available and provides contact information for financial counselors who can help with the application process. Notifications regarding the policy are available in both English and Spanish, the primary languages spoken by the population served by Fauquier Hospital. Representatives of our Financial Assistance Eligibility partners, Advanced Patient Advocacy, also direct all patients who are screened for state or federal assistance programs but do not qualify to the hospital financial counselors for hospital charity screening.
Part VI, Line 2, Needs Assessment   Fauquier Health assesses the health needs of the community by conducting a health needs assessment every three years as well as continually communicating with the community stakeholders who are serving our areas residents. For example, Fauquier Health meets regularly with the Fauquier Free Clinic leadership and provides financial and in-kind assistance to the Clinic which serves the uninsured in Fauquier and Rappahannock Counties.
Part VI, Line 3, Patient education of eligibility for assistance   Notification of Fauquier Hospital's financial assistance program is disseminated by various means, including notification of contact information for financial counselors on all of our billing statements and signage in all of our patient registrations areas. The policy itself is available on the hospital website, which also provides contact information for our financial counselors. Requests for financial assistance may be made at any point in the collection cycle. Every billing statement received by a patient includes the following language: "In meeting your financial obligations for the care provided by Fauquier Hospital we ask that you work with us on any bills that you are having difficulty paying. You will find our staff understanding and eager to help you." This message is followed by a list of telephone numbers that the patient may call to reach the organization's financial counseling staff, hours of operation, and an email address. When patients call the financial counseling telephone number, they are prompted to selections to reach the staff member that is most likely able to help them i.e.: uninsured, Spanish speaking, billing questions, etc. In addition, uninsured inpatients and those with Medicare insurance and no secondary carrier are contacted (usually a personal visit in their hospital room) by an employee of one of our partners, Advanced Patient Advocacy (APA). The APA personnel screen these patients for eligibility for available state or federal programs. If these patients do not meet criteria for these programs, they are then referred to a financial counselor for screening for the hospital's financial assistance program. Outpatients whose accounts meet a threshold of $750 in charges are also contacted by APA by either telephone, letter or both. Uninsured patients who visit our Emergency Department are also given a packet of information that includes a financial assistance application and a business card with the name and contact information for one of our financial counselors. Lastly, we do use Credit Scoring software to help identify patients who might qualify for financial assistance but have not contacted our office. Our financial assistance policy states that we may use this kind of software, which uses information from credit bureaus and screens patients against the criteria of our financial assistance policy.
Part VI, Line 4, Community Information   The Fauquier Hospital, Inc. (FH) is a 97-bed, not-for-profit, acute care facility established in 1954 to provide comprehensive health care services to the rural communities it serves. Our mission is to restore, promote and maintain the health of our community. Fauquier Hospital is the only hospital in our primary service area, which includes Fauquier and minor portions of five surrounding counties. The primary service area has a population of 76,599. The average household income is $108,480. 8.1% of the community residents have incomes below the federal poverty guideline. 19.3% of Fauquier Hospital's patients are Medicaid recipients or self-pay. The following districts within Fauquier County are considered MUA/P by the Health Resources and Services Administration (HRSA): Lee District and Marshall District.
Part VI, Line 5, Promotion of community health   Fauquier Health promotes the health of the community by: * Ensuring that the majority (92%) of the individuals serving on the Fauquier Hospital and Fauquier Health System Board of Directors reside in the primary service area and are not employees or contractors of the organization. * Extending medical staff privileges to all qualified physicians in the community who are interested. * Fauquier Health uses surplus funds to improve patient care by upgrading the tools needed to care for our patients and planning for improvements. Fauquier Health continues to support twelve employed physicians, an Endocrinologist, and Obstetrics/Gynecologist, family medicine physicians, a Rheumatologist, Neurologist, Infectious Disease, Internal Medicine and General Surgery. * THROUGH PARTNERSHIPS WITH OTHER HEALTH CARE ORGANIZATIONS WE OPERATE A RETAIL HOME HEALTH SUPPLIES STORE AND A CANCER CENTER. WE ALSO PARTNER WITH LOCAL NON-PROFIT ORGANIZATIONS (E.G. FAUQUIER FREE CLINIC, THE CHAMBER OF COMMERCE, SCHOOLS AND CHURCHES) AND NATIONAL ORGANIZATIONS (E.G. THE AMERICAN CANCER SOCIETY) TO SUPPORT LOCAL EVENTS AND PROVIDE COMMUNITY HEALTH AND WELLNESS PROGRAMS. THESE COMMUNITY BENEFITS ACTIVITIES ARE COORDINATED BY TWO FULL-TIME COMMUNITY OUTREACH STAFF, SUPPORTED BY ADMINISTRATIVE AND CLINICAL DEPARTMENTS, AND OUR AUXILIARY VOLUNTEERS AS NEEDED. * TO HELP TRAIN AND EDUCATE HEALTH CARE PROFESSIONALS, FH WORKS WITH LOCAL COMMUNITY COLLEGES TO PROVIDE TOURS, LECTURES, AND INTERNSHIPS FOR STUDENTS; FH STAFF PROVIDED APPROXIMATELY 17,063 HOURS AT A COST OF APPROXIMATELY $506,903. * ADDITIONALLY, THE ORGANIZATION PROVIDES ASSISTANCE TO THE FAUQUIER FREE CLINIC (FFC). FFC PROVIDES PRIMARY HEALTH AND DENTAL CARE TO UNINSURED RESIDENTS OF FAUQUIER AND RAPPAHANNOCK COUNTIES. FH PROVIDED LABORATORY, CARDIOLOGY/NEUROLOGY/PULMONARY SERVICES, AND RADIOLOGY SERVICES AT NO CHARGE TO FCC PATIENTS FOR A TOTAL COST OF $232,261. A TOTAL OF 798 HOURS OF FREE CLINICAL CARE WERE PROVIDED BY COMMUNITY PHYSICIANS AND CLINICAL STAFF. TO HELP FFC EXPAND ITS SERVICES TO MEET THE NEEDS OF A GROWING POPULATION, FH LEASED A BUILDING IN APRIL 2006 TO THE FFC FOR $1 PER YEAR FOR 10 YEARS; THE RENTAL VALUE FY13 WAS $85,284. IN ADDITION, FH CONTRIBUTED $5,000 IN UNRESTRICTED FUNDS. * FAUQUIER HEALTH PROVIDED HEALTH EDUCATION AND HEALTH SCREENINGS AT 106 LOCAL EVENTS FOR 2,678 PEOPLE. FH ALSO OFFERS TOURS OF THE HOSPITAL AND SPEAKERS FOR LOCAL SCHOOLS AND COMMUNITY ORGANIZATIONS TO BUILD RELATIONSHIPS WITHIN THE COMMUNITY, PROMOTE COLLABORATION IN MANAGING HEALTH AND WELLNESS, AND EDUCATE THE COMMUNITY ON THE HEALTH SYSTEM. THE TOTAL COMMUNITY BENEFIT OF THESE SERVICES WAS $56,613. * TWO OF SEVERAL FH PUBLICATIONS ARE A COMMUNITY NEWSLETTER, HEALTHY HAPPENINGS AND SENIOR LIVING, INTENDED TO EDUCATE THE PUBLIC ABOUT HEALTH ISSUES AND HEALTH CARE AND HOSPITAL SERVICES. PUBLISHED QUARTERLY HEALTHY HAPPENINGS, REACHES 100,000 HOMES IN FAUQUIER AND SURROUNDING COUNTIES. The SENIOR LIVING publication is published twice a year and REACHES 37,000 individuals who are age 55 and older. THE COST TO FH FOR publication and distribution of these newletters in FY13 WAS $344,208. * FH PROVIDES MEDICAL OVERSIGHT, DIRECTION, AND ORDERS TO PARAMEDICS IN THE FIELD AND EN-ROUTE TO THE HOSPITAL. OUR EMERGENCY DEPARTMENT OFFERS 24-HOUR ACCESS TO MEDICAL SERVICES AND HELICOPTER TRANSPORT FOR CRITICALLY ILL OR INJURED INDIVIDUALS, AND ALSO RESTOCKS MEDICAL BOXES AND PROVIDES CLEAN LINENS FOR RESCUE SQUADS AT A COST TO THE HOSPITAL OF APPROXIMATELY $54,769. * FH SPONSORED, ASSISTED, OR PROVIDED MEETING SPACE FOR THREE SUPPORT GROUPS THAT MET WEEKLY OR MONTHLY, at a cost to FH of $860. ADDITIONALLY, FH PROVIDED MEETING SPACE OR CASH DONATIONS FOR SEVERAL NON-PROFIT COMMUNITY GROUPS, (E.G. the American Red Cross, FAUQUIER FREE CLINIC AND American Cancer Society Fauquier Chapter). THE fair market VALUE OF THE MEETING SPACE IS $29,963. CASH DONATIONS TOTALED $14,715. FH EMPLOYEES PROVIDED REPRESENTATION ON COMMUNITY BOARDS AND COALITIONS AT AN EXPENSE OF $73,814. * THE HOSPITAL ASSISTED 2,417 PEOPLE through THE PHYSICIAN REFERRAL PROGRAM, WHICH HELPS THE COMMUNITY WITH QUESTIONS ON PHYSICIANS, APPOINTMENTS, CLASSES AND PROGRAMS REGISTRATION, AND HEALTH RESOURCES AVAILABLE THROUGH THE HOSPITAL OR IN THE COMMUNITY. IT COST FH $31,733 TO PROVIDE THIS SERVICE IN FY13.
Part VI, Line 6, Affiliated health care system   THE ORGANIZATION IS PART OF AN AFFILIATED HEALTH CARE SYSTEM. THE ORGANIZATION OPERATES A 97-BED ACUTE CARE HOSPITAL, WHICH PROVIDES GENERAL MEDICAL AND SURGICAL SERVICES AND OPERATES A 24/7 EMERGENCY ROOM. THE HOSPITAL IS THE ONLY HOSPITAL IN THE PRIMARY SERVICE AREA OF FAUQUIER COUNTY. THE FAUQUIER HEALTH SYSTEM ALSO OPERATES A 113 BED NURSING HOME AND 67 RESIDENT ASSISTED LIVING FACILITY THROUGH ITS RELATED ORGANIZATION FAUQUIER HEALTH SENIOR LIVING, INC. ADDITIONALLY, THE SYSTEM OPERATES A NUMBER OF PHYSICIAN PRACTICES. THE SYSTEM IDENTIFIES SPECIFIC PHYSICIAN SPECIALTY SHORTAGES IN THE COMMUNITY AND EMPLOYS PHYSICIANS IN THOSE SPECIALTY AREAS TO PROVIDE SUCH CARE TO THE COMMUNITY. THE COST OF OPERATING THESE PHYSICIAN PRACTICES, THEREBY MAKING THESE SPECIALTIES AVAILABLE TO THE COMMUNITY (INCLUDING TO THOSE PATIENTS THAT DO NOT HAVE THE ABILITY TO PAY), FAR EXCEEDS THE REVENUE COLLECTED FROM PROVIDING THE SERVICES. AMONG THE SPECIALTIES PROVIDED BY THE PHYSICIAN PRATICES ARE INFECTIOUS DISEASE, RHUMATOLOGY, NEUROLOGY, ENDOCRINOLOGY, OBSTETRICS, ONCOLOGY, ENT AND PRIMARY CARE. IN THE 2010 TAX YEAR, THE SYSTEM ADDED SIX EMPLOYED PHYSICIANS TO ITS STAFF: AN ENDOCRINOLOGIST, AND OBSTETRICS/GYNECOLOGIST AND THREE FAMILY MEDICINE PHYSICIANS. ADDITIONALLY, THE SYSTEM IMPLEMENTED A HOME HEALTH DISEASE MANAGEMENT TRAINING PROGRAM (TO INCLUDE CONGESTIVE HEART FAILURE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND DIABETES) FOR PATIENTS; DEVELOPED A TRANSITION TO HOME PROGRAM THAT ADDRESSES CHRONIC DISEASE MANAGEMENT AND READMISSION RATES FOR PATIENTS; AND UNDERTOOK FEASIBILITY STUDIES FOR A NEONATAL INTENSIVE CARE UNIT AND AN AMBULATORY SURGERY CENTER.
Schedule H (Form 990) 2012
Additional Data


Software ID:  
Software Version:  
Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number
54-0573701
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) The Fauquier Hospital Auxiliary
500 Hospital Drive
Warrenton,VA20186 		501(c)(3) 129,629       to support auxiliary with profits from gift shop






















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
1
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
PART I, LINE 2   THE HOSPITAL PROVIDED A GRANT TO FAUQUIER HOSPITAL AUXILIARY. THE FAUQUIER HOSPITAL AUXILIARY IS A VOLUNTEER ORGANIZATION CLOSELY CONNECTED TO THE FAUQUIER HOSPITAL, WHICH OPERATES A GIFT SHOP, THRIFT SHOP AND ENGAGES IN FUNDRAISING ACTIVITIES ON BEHALF OF THE FAUQUIER HOSPITAL AND ITS TAX-EXEMPT AFFILIATES. THE FAUQUIER HOSPITAL AUXILIARY ALSO PROVIDES SCHOLARSHIPS TO LOCAL HIGH SCHOOL STUDENTS WITH IN THE FAUQUIER HOSPITAL COMMUNITY PERSUING DEGREES IN THE MEDICAL FIELD.
Schedule I (Form 990) 2012


Additional Data


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Software Version:  


Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
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? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
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:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
Yes
 
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)RODGER BAKERPRESIDENT/CEO (i)
(ii)		 450,363
0 		70,000
0 		566,689
0 		60,439
0 		12,088
0 		1,159,579
0 		0
0
(2)LIONEL PHILLIPSVP FINANCE/CFO (i)
(ii)		 232,978
0 		54,739
0 		17,999
0 		12,078
0 		9,173
0 		326,967
0 		0
0
(3)LINDA SHARKEYVP PATIENT CARE/CNE (i)
(ii)		 178,310
0 		0
0 		9,873
0 		0
0 		13,526
0 		201,709
0 		0
0
(4)MARY SMITHVICE PRESIDENT SENIOR SERVICES (i)
(ii)		 182,105
0 		0
0 		16,023
0 		0
0 		7,818
0 		205,946
0 		0
0
(5)KATHERINE REEVESVP HUMAN RESOURCES (i)
(ii)		 151,705
0 		0
0 		8,309
0 		0
0 		658
0 		160,672
0 		0
0
(6)GREGORY BENGSTONVP BUS DEV & PROF SERVICES (i)
(ii)		 170,785
0 		0
0 		9,246
0 		0
0 		20,024
0 		200,055
0 		0
0
(7)TRACY TURMANVP SUPPORT SERVICES (i)
(ii)		 126,979
0 		0
0 		7,241
0 		0
0 		18,446
0 		152,666
0 		0
0
(8)CHRISTINE CONNOLLYpresident faquier foundation (i)
(ii)		 166,371
0 		0
0 		12,079
0 		0
0 		21,554
0 		200,004
0 		0
0
(9)ANHTAI NGUYENchief medical officer (i)
(ii)		 250,822
0 		0
0 		13,016
0 		0
0 		21,638
0 		285,476
0 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
net earnings line 6 Fauquier Hospital has a "Management Performance Incentive Program" (MPIP) under which we award $ to our Director Team for accomplishing a pre-determined, measurable set of tasks related to clinical quality outcomes, patient satisfaction, community outreach and positive operating margins.
nonqualified retirement plan line 4b FAUQUIER HOSPITAL MAINTAINED A SECTION 457(F) NONQUALIFIED DEFERRED COMPENSATION PLAN FOR CERTAIN EMPLOYEES. DURING THE 2011 TAX YEAR. THOSE EMPLOYEES THAT PARTICIPATED IN THE SECTION 457(F) PLAN WERE PERMITTED DEFERRALS INTO THE PLAN (THAT IS, NO CONTRIBUTIONS WERE MADE BY THE CORPORATION). RODGER BAKER $60,439 LIONEL PHILLIPS $12,078 During the 2012 tax year, the CEO/President of the organization received a distribution of $539,240.76 from a Section 457(f) Plan. The distribution from the Section 457(f) Plan stemmed entirely from employee contributions made, annually, to the Plan since its inception in 2006. The Section 457(f) Plan was approved by the Board of Directors and was considered by the Compensation Committee and Board of Directors when determining the reasonable compensation of the CEO/President.
Schedule J (Form 990) 2012

Additional Data


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Software Version:  
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number
54-0573701
Part I
Bond Issues
(a) Issuer name (b) Issuer EIN (c) CUSIP # (d) Date issued (e) Issue price (f) Description of purpose (g) Defeased (h) On
behalf of
issuer 		(i) Pool
financing
Yes No Yes No Yes No
A INDUSTRIAL DEVELOPMENT AUTHORITY FAUQUIER COUNTY
  		54-6001274 312066BXO 02-13-2008 22,687,593 HOSPITAL BUILDING IMPROVEMENTS   X   X   X
B INDUSTRIAL DEVELOPMENT AUTHORITY FAUQUIER CTY VA
  		54-6001274   11-07-2012 44,758,638 2012 refunding 2002 bonds   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired . . . . . . . . . . . . . . 0 0    
2 Amount of bonds legally defeased . . . . . . . . . . . 0 0    
3 Total proceeds of issue . . . . . . . . . . . . . . 22,865,730 50,597,888    
4 Gross proceeds in reserve funds . . . . . . . . . . . . 12,348,704 0    
5 Capitalized interest from proceeds . . . . . . . . . . . 0 0    
6 Proceeds in refunding escrows . . . . . . . . . . . . 0 0    
7 Issuance costs from proceeds . . . . . . . . . . . . 316,697 313,298    
8 Credit enhancement from proceeds . . . . . . . . . . . 0 0    
9 Working capital expenditures from proceeds . . . . . . . . . 0 0    
10 Capital expenditures from proceeds . . . . . . . . . . . 21,200,329 0    
11 Other spent proceeds . . . . . . . . . . . . . . 0 50,284,590    
12 Other unspent proceeds . . . . . . . . . . . . . . 0 0    
13 Year of substantial completion . . . . . . . . . . . . 2009 2005
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? . . . . .   X   X        
15 Were the bonds issued as part of an advance refunding issue? . . . . .   X X          
16 Has the final allocation of proceeds been made? . . . . . . . . X   X          
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . . X   X          
Part III
Private Business Use
A B C D
Yes No Yes No Yes No Yes No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .   X   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .   X   X        
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 2
Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .   X   X        
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .                
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .   X   X        
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .                
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . SchKMediumBullet 0.00000% 0.00000%   %   %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . . SchKMediumBullet 0.00000% 0.00000%   %   %
6 Total of lines 4 and 5 . . . . . . . . . . . . . . . 0.00000% 0.00000%   %   %
7 Does the bond issue meet the private security or payment test? . . . . .   X   X        
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .   X   X        
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of. 0.00000% 0.00000%   %   %
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .   X   X        
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
  X   X        
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T? . . . . .   X   X        
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .   X X          
b Exception to rebate? . . . . . . . .   X   X        
c No rebate due? . . . . . . . . . .
X     X        
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . .   X   X        
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X   X        
b Name of provider . . . . . . . . . 0
  		0
  		 
  		 
 
c Term of hedge . . . . . . . . . .        
d Was the hedge superintegrated? . . . . . .                
e Was a hedge terminated? . . . . . . .                
Schedule K (Form 990) 2012
Schedule K (Form 990) 2012
Page 3
Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . . X     X        
b Name of provider . . . . . . . . . BB&T
  		0
  		 
  		 
 
c Term of GIC . . . . . . . . . . 5.1      
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . . X              
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .   X   X        
7 Has the organization established written procedures to monitor the requirements of section 148? . . .   X   X        
Part V
Procedures To Undertake Corrective Action
A B C D
Yes No Yes No Yes No Yes No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?   X   X        
Part VI
Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).
Identifier Return Reference Explanation
Part II 0 THE TOTAL PROCEEDS OF THE ISSUE EXCEED THE ISSUE PRICE BECAUSE THE TOTAL PROCEEDS REFLECT INVESTMENT EARNINGS ON THE SALES PROCEEDS.
Part II, Line 3 0 Total proceeds of the issue are greater than the issue price because proceeds from the debt service reserve fund ($5,834,024) and principal and interest fund ($366,729) from the 2002 tax-exempt bond issue were allocated to the 2012 tax-exempt bonds.
Part IV, LIne 7 0 Although written procedures have not been adopted, the organization engages a professional third party to regularly perform arbitrage rebate computations on its tax-exempt bonds in accordance with IRS regulations under Section 148. No rebatable arbitrage has been computed for any of the outstanding tax-exempt bonds of the organization.
Part IV, Line 2c, Column A 0 The 2008 bond rebate computation was performed on 2/27/13.
Schedule K (Form 990) 2012

Additional Data


Software ID:  
Software Version:  

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Identifier Return Reference Explanation
990 Review Process Part VI, Line 11 The organization prepares the Form 990 with assistance from an outside accounting firm. Once a draft of the Form 990 is completed, it is submitted to management of the organization for review and comments. After incorporating changes from management, materially complete draft Forms 990 are made available to the Board of the organization, as well as presented by the outside accounting firm to the organization's Audit & Finance Committee. Comments or questions received from the Board are incorporated into a final Form 990, which is signed by the Persident/CEO of the Fauquier Health System, Rodger Baker.
CONFLICTS MONITORING AND ENFORCEMENT PART VI, LINE 12C Under the Conflict of Interest Policy, all Board members, management, and key employees complete an annual disclosure form regarding business relationships that he or she, or any family member, has with any other company that does business with the organization, as well as any business relationships between and among the Board members, management, and key employees. The annual disclosure statements are reviewed by independent legal counsel, the corporate compliance officer, and the audit and compliance committee, who are ultimately responsible if a conflict exists. Any such conflicts would be reported to the full Board. In addition, any person who is covered by the Conflict of Interest Policy has an ongoing obligation to disclose the existence of any actual or potential conflict to the Board or the Board Committee in which the matter arises. Finally, the organization monitors Board member eligibility for any potential conflicts, in order to avoid such conflicts from occurring in the first place.
PROCESS FOR DETERMINING COMPENSATION PART VI, LINE 15 THE ORGANIZATION UTILIZES A COMPENSATION COMMITTEE, AN INDEPENDENT COMPENSATION CONSULTANT, A WRITTEN EMPLOYMENT CONTRACT AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO DETERMINE OFFICER COMPENSATION.
DOCUMENT AVAILABILITY PART VI, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
net assets reconciliation part xi, line 5 NET EQUITY TRANSFERS TO RELATED ORGS $(6,158,063)
corporate member Part VI, Section A, Line 6 Fauquier Health System Inc, is the sole member of the organization.
electing members of the board Part VI, Section A, Line 7 1. General Powers. The business and affairs of the Corporation shall be managed by the Board of Directors, which shall have all voting power except the power to vote on electing, appointing or removing Directors and on implementing amendments to the Articles of Incorporation affecting the voting rights of members, which power is vested in the sole member of the Corporation. 2. Number and Qualification of Directors. The Board of Directors shall consist of no more than ten (10). The number of Directors may be changed by amendment of these By-laws but shall not be less than three. 3. Election of Directors. The President of The Fauquier Hospital, Incorporated (Hospital) shall serve ex officio as a voting director of the corporation and the President of Fauquier Health Senior Living, Inc. (Senior Living) and the Medical Director of Fauquier Health Rehabilitation and Nursing Center shall serve ex officio as non-voting directors of the corporation. All other directors shall be elected by Fauquier Health System, Inc. with one member from that Board also serving as a director of the corporation.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
The Fauquier Hospital Incorporated
 
Employer identification number

54-0573701
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity










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


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) FAUQUIER HEALTH SYSTEM INC

500 HOSPITAL DR

WARRENTON,VA20186
54-1416705 		MGMT COORDINA VA 501(C)(3) 11 TYPE III NONE
 
 
No
(2) FAUQUIER HEALTH FOUNDATION INC

500 HOSPITAL DR

WARRENTON,VA20186
30-0219424 		FUNDRAISING VA 501(C)(3) 7 FAUQ HLTH SY
 
Yes
 
(3) FAUQUIER HEALTH SENIOR LIVING INC

500 HOSPITAL DR

WARRENTON,VA20186
54-1416703 		SKILLED CARE VA 501(C)(3) 9 FAQ HLTH SYS
 
Yes
 








For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No












Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
 
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
Yes
 
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) FAUQUIER HEALTH FOUNDATION

 C 793,869 COST





Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(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 V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


Software ID:  
Software Version: