TY 2012 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
ALLIANCE CORPORATIONPO BOX 1480GLASGOWKY42142	MANAGEMENT SERV	843,354
ALLIANT MANAGEMENT SERVICESPO BOX 35070LOUISVILLEKY40232	FACILITY MGMT C	639,144
HOSPITAL CARE CONSULTANTS17304 PRESTON ROAD SUITE 1400DALLASTX75252	MANAGEMENT SERV	635,000
KENTUCKY HOSPITAL INSURANCE PROGRAM2501 NELSON MILLER PARKWAYLOUISVILLEKY40223	MANAGMENT SERVI	526,350
LABORATORY CORPORATIONPO BOX 12140BURLINGTONNC27216	PROFESSIONAL SE	504,652
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 22

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	13,201,960	1	13,510,428
2	Savings and temporary cash investments .........		2
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	5,813,009	4	6,074,456
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
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
			6
7	Notes and loans receivable, net .............	21,932,540	7	26,330,430
8	Inventories for sale or use ..............	1,478,146	8	1,533,555
9	Prepaid expenses and deferred charges ..........	427,803	9	359,430
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	69,092,851
b	Less: accumulated depreciation .....	10b	29,200,319	39,357,346	10c	39,892,532
11	Investments—publicly traded securities ..........	2,132,422	11	2,131,113
12	Investments—other securities. See Part IV, line 11 .....		12
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........		15
16	Total assets. Add lines 1 through 15 (must equal line 34)......	84,343,226	16	89,831,944
	17	Accounts payable and accrued expenses .........	3,667,957	17	3,815,550
18	Grants payable .................		18
19	Deferred revenue ................		19
20	Tax-exempt bond liabilities .............	16,295,479	20	15,299,875
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
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..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	1,846,110	25	1,546,416
26	Total liabilities. Add lines 17 through 25.........	21,809,546	26	20,661,841
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	62,533,680	27	69,170,103
28	Temporarily restricted net assets ...........		28
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	62,533,680	33	69,170,103
34	Total liabilities and net assets/fund balances ........	84,343,226	34	89,831,944

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

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

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

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

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

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

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

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

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

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

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

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

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

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

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

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

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

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

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

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

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

Section D. Computation of Investment Income Percentage

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

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

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

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

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

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

Page 2

Name of organization GRAYSON COUNTY HOSPITAL FOUNDATION

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

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

Page 3

Name of organization GRAYSON COUNTY HOSPITAL FOUNDATION

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
GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

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

Part III

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

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

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

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No

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


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

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

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	1,063,992		1,063,992
b	Buildings ................	44,618,861	14,569,323	30,049,538
c	Leasehold improvements ............
d	Equipment ................	20,745,305	13,237,556	7,507,749
e	Other .................	2,664,693	1,393,440	1,271,253
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				39,892,532

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes
CAPITAL LEASE		1,419,853
LONG-TERM DEBT		126,563







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,546,416
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	39,044,739
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	-4,867,634
e	Add lines 2a through 2d .....................			2e	-4,867,634
3	Subtract line 2e from line 1.....................			3	43,912,373
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	88,339
c	Add lines 4a and 4b.......................			4c	88,339
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	44,000,712

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........			1	37,275,950
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	37,275,950
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	88,339
c	Add lines 4a and 4b.......................			4c	88,339
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	37,364,289

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
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	THE HOSPITAL IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501 (C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501 (A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN REFLECTED IN THE HOSPITAL'S FINANCIAL STATEMENTS. MANAGEMENT IS NOT AWARE OF ANY ACTIVITY WITHIN THE HOSPITAL DURING THE CURRENT OR PRIOR REPORTING PERIODS THAT WOULD JEOPARDIZE OR OTHEWISE CALL INTO QUESTION THE HOSPITAL'S COMPLIANCE WITH THE ABOVE INTERNAL REVENUE CODE SECTION. THE ORGANIZATION'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) FOR FISCAL YEARS 2011, 2012 AND 2013 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE FOR THREE YEARS AFTER THEY WERE FILED. CURRENTLY, THE HOSPITAL HAS NO REPORTING REQUIREMENTS WITH ANY STATE OR LOCAL JURISDICTIONS. THE HOSPITAL HAS INVESTMENT INTEREST IN TWO COMPANIES. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL'S POLICY FOR RECORDING ANY TAX RELATED INTEREST AND PENALTIES IS TO RECOGNIZE THESE ITEMS AS OPERATING EXPENSES; HOWEVER, NONE WERE INCURRED OR RECORDED DURING THE CURRENT OR PRIOR OPEN OPERATING PERIODS.
REVENUE AMOUNTS INCLUDED IN FINANCIALS - OTHER	SCHEDULE D, PAGE 4, PART XI, LINE 2D	OPERATING LOSS REPORTED UNDER ID 61-1269278 -4,867,634
REVENUE AMOUNTS INCLUDED ON RETURN - OTHER	SCHEDULE D, PAGE 4, PART XI, LINE 4B	VALUE OF DONATED ITEMS 19,587 DONATED SERVICES 68,752
EXPENSE AMOUNTS INCLUDED ON RETURN - OTHER	SCHEDULE D, PAGE 4, PART XII, LINE 4B	DONATED SERVICES 68,752 USE OF DONATED ITEMS 19,587

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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: .........

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

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) ..	1	824	327,054		327,054	0.880 %
b	Medicaid (from Worksheet 3, column a) ....	1	17,702	2,991,118		2,991,118	8.010 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	1	1,908	568,092		568,092	1.520 %
d	Total Financial Assistance and Means-Tested Government Programs .	3	20,434	3,886,264		3,886,264	10.400 %
Other Benefits		18	5,450	9,575	1,011	8,564	0.020 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	18	5,450	9,575	1,011	8,564	0.020 %
f	Health professions education (from Worksheet 5) ..
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)
j	Total. Other Benefits ..	18	5,450	9,575	1,011	8,564	0.020 %
k	Total. Add lines 7d and 7j .	21	25,884	3,895,839	1,011	3,894,828	10.420 %

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)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	1	25,000	25,000	0.070 %
3	Community support	2	4,854	4,854	0.010 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy	4	2,138	2,138	0.010 %
8	Workforce development
9	Other
10	Total	7	31,992	31,992	0.090 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

1,777,519

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. ......

1,265,389

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

Section B. Medicare

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

15,549,360

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

15,018,407

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

530,953

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %
1TWIN LAKES MEDICAL F	MEDICAL PRACTICES	100.000 %
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	GRAYSON COUNTY HOSPITAL FOUNDATION TWIN LAKES REGIONAL MEDICAL CENTER 910 WALLACE AVE LEITCHFIELD,KY42754	X	X	X

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	GRAYSON COUNTY HOSPITAL FOUNDATION
Name of hospital facility or facility reporting group

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

Yes

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

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

Yes

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

A definition of the community served by the hospital facility

Demographics of the community

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

How data was obtained

The health needs of the community

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

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

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

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

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 12

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 ....................

Yes

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

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

Yes

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

Hospital facility’s website

Available upon request from the hospital facility

Other (describe in Part VI)

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

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

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

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

Prioritization of health needs in its community

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

Other (describe in Part VI)

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

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

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

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

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 150.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.0% 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	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........	17	Yes
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individuals to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care? ............................

If “Yes,” explain in Part VI.

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

If “Yes,” explain in Part VI.

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Schedule H (Form 990) 2012

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; Part V, Section A; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
8	Facility reporting group(s). If applicable, for each hospital facility in a facility reporting group provide the descriptions required for Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 10, 11, 12h, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22.

Identifier	ReturnReference	Explanation
OTHER TESTING METHODS FOR FREE OR DISCOUNTED CARE	PART I LINE 3C	TWIN LAKES REGIONAL MEDICAL CENTERS PATIENT FINANCIAL ASSISTANCE PROGRAM UTILIZES THE FEDERAL POVERTY GUIDELINES AND AN ASSET TEST CONSISTING OF RESIDENCE VEHICLES AND CASH INVESTMENTS TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	IN DETERMINING THE AMOUNTS FOR PART 1 LINE 7 COST ACCOUNTING WAS USED THE COSTTOCHARGE RATIO WAS DERIVED FROM WORKSHEET 2 RATIO OF PATIENT CARE COSTTOCHARGES
COMMUNITY BUILDING ACTIVITIES	PART II	TWIN LAKES REGIONAL MEDICAL CENTER HAS AN ONGOING COMMITMENT TO ITS COMMUNITY DUE TO GRAYSON COUNTYS HIGH RATE OF JOBLESSNESS THE HOSPITAL DECIDED IT WAS IN THE COMMUNITYS BEST INTEREST TO SUPPORT LEITCHFIELDS INDUSTRIAL DEVELOPMENT
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	THE TOTAL BAD DEBT EXPENSE AT COST REPRESENTS THE TOTAL AMOUNT EXPECTED TO BE COLLECTED BUT DEEMED UNCOLLECTIBLE BASED ON THE COMMUNITYS DEMOGRAPHICS INCOME LEVEL INDIVIDUAL ASSETS AND HEALTH COVERAGE 7119 WAS DETERMINED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITALS PATIENT FINANCIAL ASSISTANCE PROGRAM FINANCIAL STATEMENT FOOTNOTE DELINQUENT RECEIVABLES ARE WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT OR THIRDPARTY PAYOR IF THE HOSPITAL RECEIVES NO PAYMENT OR COMMUNICATION TO ARRANGE PAYMENT THE ACCOUNT IS SENT TO COLLECTION AND RECOGNIZED AS BAD DEBT AT THAT TIME
COLLECTION PRACTICES EXPLANATION	PART III LINE 9B	IF THE PATIENT DOES NOT HAVE ANY INSURANCE COVERAGE AND THE PATIENT DOES NOT QUALIFY FOR ANY TYPE OF FINANCIAL ASSISTANCE UNDER THE HOSPITALS FINANCIAL ASSISTANCE PROGRAM THEN THE ACCOUNT CAN BE CONSIDERED FOR BAD DEBT PLACEMENT FORTYFIVE DAYS AFTER THE PATIENT RECEIVED THEIR FIRST STATEMENT IF THERE HAS BEEN NO RESPONSE FROM THE PATIENT AFTER A PERIOD OF TIME HAS PASSED WITH NO RESOLUTION THE ACCOUNT WILL BE SENT TO OUR COLLECTION AGENCY
NEEDS ASSESSMENT	PART VI	TWIN LAKES REGIONAL MEDICAL CENTER ASSESSES THE COMMUNITYS HEALTH CARE NEEDS BY OBTAINING INFORMATION FROM A VARIETY OF SOURCES INCLUDING A COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY TWIN LAKES REGIONAL MEDICAL CENTER B DEMOGRAPHIC DATABASES C LOCAL AND REGIONAL HEALTH DEPARTMENTS AND RELATED DATABASES D KENTUCKY HOSPITAL ASSOCIATION REPORTS AND DATABASES E MARKET ANALYSIS F FEEDBACK FROM PHYSICIANS AND EMPLOYEES AND OTHER INTERESTED COMMUNITY GROUPS G HOSPITALGENERATED REPORTS ON UTILIZATION OF SERVICES H BOARD OF DIRECTORS MADE UP OF LOCAL COUNTY RESIDENTS
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	TWIN LAKES REGIONAL MEDICAL CENTER REACHES OUT TO EDUCATE PATIENTS ABOUT THEIR PATIENT FINANCIAL ASSISTANCE PROGRAM A BROCHURE IS AVAILABLE AT SEVERAL LOCATIONS THROUGHOUT THE HOSPITAL INCLUDING THE BUSINESS OFFICE AND REGISTRATION AREA A PDF VERSION OF THE BROCHURE IS POSTED ON THE HOSPITALS WEBSITE THE HOSPITAL RAN A FULL PAGE COLOR AD IN THE TWO LOCAL NEWSPAPERS IN JUNE 2013 THAT INCLUDED THE SAME INFORMATION PROMINENTLY DISPLAYED AT THE TIME OF REGISTRATION SELFPAY PATIENTS ARE GIVEN A BROCHURE ON THE FINANCIAL ASSISTANCE PROGRAM IN ADDITION SELFPAY PATIENTS ARE INFORMED OF FEDERAL STATE AND LOCAL GOVERNMENTAL ASSISTANCE PROGRAMS WITHIN 24 HOURS OF ADMISSION SELFPAY PATIENTS ARE VISITED BY A FINANCIAL COUNSELOR AND INFORMED OF THE AVAILABLE PROGRAMS WHEN POSSIBLE OB PATIENTS ARE CONTACTED ONE WEEK IN ADVANCE AND NOTIFIED OF AVAILABLE PROGRAMS
COMMUNITY INFORMATION	PART VI	THE PRIMARY SERVICE AREA FOR TWIN LAKES REGIONAL MEDICAL CENTER IS GRAYSON COUNTY KY POPULATION 25500 LOCATED 75 MILES SOUTHWEST OF LOUISVILLE KY THE HOSPITALS SECONDARY SERVICE AREA INCLUDES PARTS OF 6 SURROUNDING COUNTIES THE ESTIMATED PERCENTAGE OF PEOPLE LIVING BELOW THE POVERTY LEVEL AS DETERMINED BY THE US CENSUS BUREAU 2009 IS 210 FOR GRAYSON COUNTY AND AN AVERAGE OF 209 FOR THE PRIMARY SERVICE AREA THE AREA IS MOSTLY RURAL WITH A HIGHER PERCENTAGE OF PERSONS OVER THE AGE OF 65 AND A SIGNIFICANTLY LOWER MEDIAN HOUSEHOLD INCOME THAN FOR ALL OF KENTUCKY THE AVERAGE UNEMPLOYMENT RATE IN GRAYSON COUNTY FOR CALENDAR YEAR 2011 WAS 123
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	TWIN LAKES REGIONAL MEDICAL CENTER AND ITS EMPLOYEES HAVE A RICH HISTORY OF PLANNING ANDOR SPONSORING EVENTS DESIGNED TO EDUCATE THE COMMUNITY ON HEALTHY LIVING AND WELLNESS FACTORS EVENTS DURING FYE 2013 INCLUDED THE COMMUNITY BABY SHOWER THE TEDDY BEAR CLINIC HEART HEALTH EXPO MAKE A DIFFERENCE DAY PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES AND HEALTH FAIRS AND SCREENINGS FOR THE COMMUNITY AND PRIVATE ORGANIZATIONS TWIN LAKES REGIONAL MEDICAL CENTER ADHERES TO THE FOLLOWING IRS EXEMPTION REQUIREMENTS A ACCEPT AND TREAT MEDICARE AND MEDICAID PATIENTS B EMERGENCY DEPARTMENT OPEN TO ALL EMERGENT CASES REGARDLESS OF ABILITY TO PAY C OPEN MEDICAL STAFF THAT ALLOWS CREDENTIALED PHYSICIANS TO PRACTICE AT FACILITY D OPERATE UNDER COMMUNITY BOARDS CONTROL IT IS THE MISSION AND ONGOING GOAL OF THE LEADERSHIP AND EMPLOYEES OF TWIN LAKES REGIONAL MEDICAL CENTER TO DO THE BEST JOB POSSIBLE TREATING THE SICK AND INJURED ADDRESSING COMMUNITY WELLNESS NEEDS AND PROMOTING HEALTHY LIVING AT EVERY OPPORTUNITY THROUGH OUR MANY COMMUNITY BENEFIT ACTIVITIES OUR CHARITY CARE PROGRAM AND OUR ACCEPTANCE OF PATIENTS COVERED BY FEDERAL AND STATE PROGRAMS TLRMC MAKES A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE
ADDITIONAL INFORMATION	PART VI	IN ADDITION TO PROVIDING THE COMMUNITY BENEFIT REPORT IN THE LOCAL PAPER TLRMC ALSO PARTICIPATES IN THE STATEWIDE COMMUNITY BENEFIT REPORT WITH KENTUCKY HOSPITAL ASSOCIATION THAT IS PRESENTED TO OUR COMMONWEALTH
GRAYSON COUNTY HOSPITAL FOUNDATION LINE NUMBER 1 PART V LINE 3	PART V LINE 3	IN CONDUCTING THE COMMUNITY HEALTH NEEDS ASSESSMENT TWIN LAKES REGIONAL MEDICAL CENTER DEVELOPED A SURVEY TO GATHER HEALTH INFORMATION AND OPINIONS OF GRAYSON COUNTY RESIDENTS 18 AND OVER THE SURVEY WAS CONDUCTED IN NOVEMBER AND DECEMBER 2012 USING AN ONLINE SURVEY TOOL AND BY DISTRIBUTING PRINTED COPIES IN VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY REGISTRATION CLERKS AT THE HOSPITAL HANDED OUT THE SURVEY TO PATIENTS AND THE FAMILY MEMBERS OF PATIENTS THE ONLINE SURVEY WAS PROMOTED THROUGH NEWSPAPER ADVERTISEMENTS AND BUSINESS CARDS AT THE GRAYSON COUNTY PUBLIC LIBRARY WHICH HAS SEVERAL COMPUTERS WITH INTERNET ACCESS EMAILS WERE SENT TO GRAYSON COUNTY CHAMBER OF COMMERCE MEMBERS AND EMPLOYEES OF THE GRAYSON COUNTY SCHOOL SYSTEM AND THE HOSPITAL PRINTED COPIES WERE DELIVERED TO AN ASSISTED LIVING FACILITY A MULTISTORY SUBSIDIZED HOUSING BUILDING AND THE GRAYSON COUNTY HEALTH DEPARTMENT THE CHNA TEAM AT TWIN LAKES REGIONAL MEDICAL CENTER TABULATED THE RESULTS FROM THE SURVEYS AND SUPPLEMENTED THEM WITH HEALTH STATISTICS AND DEMOGRAPHIC INFORMATION TLRMC THEN INVITED REPRESENTATIVES FROM A VARIETY OF BACKGROUNDS TO A COMMUNITY FORUMFOCUS GROUP ON MARCH 7 2013 TO REVIEW THE SURVEY RESULTS AND PROVIDE RECOMMENDATIONS FOR THE HOSPITALS COMMUNITY BENEFIT FOCUS PROFESSIONS INVITED INCLUDED PHYSICIANS LOCAL GOVERNMENT LEADERS SCHOOL ADMINISTRATORS TEACHERS AND STAFF HEALTH DEPARTMENT PERSONNEL INDUSTRY AND MANUFACTURING REPRESENTATIVES OPTOMETRIST DENTIST HOSPITAL BOARD MEMBERS LAW ENFORCEMENT OFFICIAL COMMUNITY EDUCATION LEADER PUBLIC LIBRARY DIRECTOR AND HOSPITAL LEADERSHIP ONCE THE INFORMATION WAS PRESENTED THE GROUP WAS BROKEN UP INTO SMALLER GROUPS TO FACILITATE DISCUSSIONS EVERY MEMBER WAS ASKED TO RANK THEIR PRIORITIES WITHOUT CONCERN ABOUT THE PRACTICALITY OF THE HOSPITALS ABILITY TO IMPACT THE ISSUES BEING DISCUSSED THESE PRIORITIES WERE THEN PRESENTED TO THE LARGER GROUP
GRAYSON COUNTY HOSPITAL FOUNDATION LINE NUMBER 1 PART V LINE 5C	PART V LINE 5C	LOCAL NEWSPAPERS
GRAYSON COUNTY HOSPITAL FOUNDATION LINE NUMBER 1 PART V LINE 7	PART V LINE 7	THE FOLLOWING NEEDS WERE IDENTIFIED BUT NOT ADOPTED AS TOP PRIORITIES OF THE HOSPITAL AND THE REASONS WHY ALCOHOL ANDOR DRUG ABUSE BEING MET BY OTHER COMMUNITY GROUPS AND PARTNERSHIPS THE HOSPITAL IS ALREADY INVOLVED WITH TEEN PREGNANCY THE RATES IN GRAYSON COUNTY ARE DECREASING AND THIS DID NOT SEEM LIKE AN EFFECTIVE FOCUS FOR THE HOSPITAL LACK OF DENTAL CARE NOT AN AREA THE HOSPITAL CAN MAKE A SIGNIFICANT IMPACT ON PSYCHIATRICMENTAL HEALTH SERVICES SOME SERVICES ALREADY PROVIDED IN THE COMMUNITY AND THE HOSPITAL WOULD HAVE TO PUT SIGNIFICANT RESOURCES INTO MAKING A DIFFERENCE AT THE COST OF OTHER HIGHER PRIORITY NEEDS
GRAYSON COUNTY HOSPITAL FOUNDATION LINE NUMBER 1 PART V LINE 14G	PART V LINE 14G	THE POLICY WAS PROVIDED TO PATIENTS AT REGISTRATION

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

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

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)SHELBY SHELMANPHARMACIST	(i) (ii)	142,888			21,433		164,321

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

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

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
GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number
61-0523298

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
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	GRAYSON COUNTY PUBLIC HOSPITAL DIST GRAYSON COUNTY PUBLIC HOSPITAL DIST	61-0523298	389681BU0	05-01-2004	1,975,000	ACQUISITION OF 35 ACRES ADJACENT TO THE HOSPITAL AND PURCHASE OF CT SCANNER		X		X		X
B	GRAYSON COUNTY PUBLIC HOSPITAL DIST GRAYSON COUNTY PUBLIC HOSPITAL DIST	61-0523298	389681CF2	04-15-2007	5,930,000	REFUND EXISTING 1978, 1993 & 1999 BONDS AND SURGERY DEPARTMENT RENOVATION		X		X		X
C	GRAYSON COUNTY PUBLIC HOSPITAL DIST GRAYSON COUNTY PUBLIC HOSPITAL DIST	61-0523298	218183ER8	12-09-2009	12,530,000	FUND HOSPITAL EXPANSION PROJECT		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .	1,743,796		2,265,986		1,125,343
2 Amount of bonds legally defeased . . . . . . . . . . .
3 Total proceeds of issue . . . . . . . . . . . . . .	1,913,590		5,755,733		12,110,840
4 Gross proceeds in reserve funds . . . . . . . . . . . .	746,068		2,212,841		2,406,531
5 Capitalized interest from proceeds . . . . . . . . . . .
6 Proceeds in refunding escrows . . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . . .	43,750		118,395		207,813
8 Credit enhancement from proceeds . . . . . . . . . . .
9 Working capital expenditures from proceeds . . . . . . . . .
10 Capital expenditures from proceeds . . . . . . . . . . .	1,900,000		502,730		11,281,780
11 Other spent proceeds . . . . . . . . . . . . . .
12 Other unspent proceeds . . . . . . . . . . . . . .
13 Year of substantial completion . . . . . . . . . . . .	2004		2008		2011
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .		X		X		X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X	X			X
16 Has the final allocation of proceeds been made? . . . . . . . .	X		X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X		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		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X		X		X

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

Cat. No. 50193E

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		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		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 . .	%		%		%		%
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 . . . . . . .	%		%		%		%
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .	%		%		%		%
7 Does the bond issue meet the private security or payment test? . . . . .		X		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		X
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.	%		%		%		%
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .		X		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		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		X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .		X		X		X
b Exception to rebate? . . . . . . . .		X		X		X
c No rebate due? . . . . . . . . . .		X		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		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X		X
b Name of provider . . . . . . . . .
c Term of hedge . . . . . . . . . .
d Was the hedge superintegrated? . . . . . .
e Was a hedge terminated? . . . . . . .

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		X
b Name of provider . . . . . . . . .
c Term of GIC . . . . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .		X		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X		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

Part VI

Supplemental Information. Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Identifier	Return Reference	Explanation
DIFFERENCES IN ISSUE PRICE EXPLANATION	SCHEDULE K	GRAYSON COUNTY PUBLIC HOSPITAL DIST THE DIFFERENCE IS DUE TO A BOND DISCOUNT GRAYSON COUNTY PUBLIC HOSPITAL DIST THE DIFFERENCE IS DUE TO A BOND DISCOUNT GRAYSON COUNTY PUBLIC HOSPITAL DIST THE DIFFERENCE IS DUE TO A BOND DISCOUNT

Schedule K (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No






Total ...... $

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) ISAAC MILLER	SON OF DIRECTOR	125,000	PHYSICIAN ASSIST PRO		No
(2) MIDWAY PHARMACY OF CLARKSON INC	DIRECTOR	45,900	RENT OF PHARMACY SPA		No
(3) DR TED ROGERS	DIRECTOR	12,472	RENT OF OFFICE SPACE		No

Part V

Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule L (see instructions).

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE L PART V	ISAAC MILLER IS THE SON OF DIRECTOR BECKY MILLER HE IS PARTICIPATING IN THE PHYSICIAN ASSISTANCE PROGRAM DIRECTOR TREVOR RAY IS A SHAREHOLDER IN MIDWAY PHARMACY OF CLARKSON INC MIDWAY PHARMACY OF CLARKSON INC RENTS SPACE FROM TWIN LAKES REGIONAL MEDICAL CENTER FOR TWO PHARMACY LOCATIONS DR TED ROGERS IS A DIRECTOR OF TWIN LAKES REGIONAL MEDICAL CENTER HIS MEDICAL PRACTICE RENTS OFFICE SPACE FROM TLRMC THE GRAYSON COUNTY HOSPITAL DISTRICT MAINTAINS ALL OF ITS BANK ACCOUNTS AT THE CECILIAN BANK LARRY PERKINS A DIRECTOR OF GRAYSON COUNTY HOSPITAL FOUNDATION INC IS EMPLOYED BY THE CECILIAN BANK THE CASH BALANCES HELD AT JUNE 30 2013 AND 2012 WERE 5501984 AND 5241645 RESPECTIVELY

Schedule L (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Identifier	Return Reference	Explanation
EXPLANATION ON VOLUNTEERS AND TYPES OF SERVICES OR BENEFITS	FORM 990, PAGE 1, PART I, LINE 6	THE TWIN LAKES REGIONAL MEDICAL CENTER (TLRMC) HOSPITAL AUXILIARY EXISTS TO SUPPORT TLRMC IN MEETING THE HEALTH CARE NEEDS OF THE PEOPLE IT SERVES IN THE MOST CARING, COMPASSIONATE, AND EFFECTIVE MANNER POSSIBLE. THE VOLUNTEERS SUPPORT THE EMOTIONAL WELL-BEING OF THE PATIENTS UTILIZING THE HOSPITAL'S SERVICES. THEY PROVIDE A FRIENDLY, CARING AND HELPFUL ATMOSPHERE FOR PATIENTS AND THEIR FAMILIES, AND THE HOSPITAL STAFF. DUTIES INCLUDE STAFFING THE INFORMATION DESK IN THE MAIN LOBBY, PROVIDING GENERAL HOSPITAL INFORMATION AND DIRECTIONS TO PATIENTS AND THE PUBLIC, PROVIDING ESCORTS WHEN NEEDED, AND DELIVERING FLOWERS TO PATIENTS. THEY MAKE SOCK MONKEYS AND OTHER STUFFED ANIMALS FOR CHILDREN COMING TO THE HOSPITAL. THE ANIMALS ARE GIVEN TO THE YOUNG PATIENTS AND THEIR FAMILIES AT NO CHARGE. THE VOLUNTEERS RAISE THE MONEY NEEDED TO PURCHASE ANY SUPPLIES AND DONATE MATERIALS IN ADDITION TO THEIR TIME AND TALENTS. THEY GIVE FLOWERS TO HOSPITALIZED PATIENTS ON CERTAIN HOLIDAYS AND MAKE "SANTA GOING HOME" OUTFITS FOR ALL BABIES BORN AT THE HOSPITAL IN DECEMBER. THE AUXILIARY HAS DONATED THOUSANDS OF DOLLARS IN EQUIPMENT TO THE HOSPITAL THROUGHOUT THE YEARS.
FIRST ACCOMPLISHMENT DESCRIPTION	FORM 990, PAGE 2, PART III, LINE 4A	ADDITIONAL CHARGES ARE WRITTEN OFF DUE TO ARRANGEMENTS WITH MEDICARE, MEDICAID, AND OTHER THIRD PARTIES. THE TOTAL UNREIMBURSED CHARGES FORGONE IN FISCAL YEAR 2013 DUE TO CONTRACTUAL AGREEMENTS WITH PAYERS AMOUNTED TO 66,502,979. ALSO, 696,857 WAS PAID AS A "PROVIDER TAX" TO THE COMMONWEALTH OF KENTUCKY TO HELP DEFRAY THE COSTS OF COVERING INDIGENT PATIENTS UNDER A SPECIAL STATE PROGRAM. WRITE-OFFS FROM PATIENTS "UNWILLING" TO PAY - I.E. BAD DEBTS - ACCOUNTED FOR 5,815,802. THE PRIMARY MISSION OF TWIN LAKES REGIONAL MEDICAL CENTER IS TO HEAL THE SICK, RELIEVE PAIN AND SUFFERING, AND IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE WE SERVE. TLRMC'S VISION IS TO BE RECOGNIZED BY THE PEOPLE WE SERVE AS THE PROVIDER OF CHOICE FOR THEIR HEALTH CARE NEEDS AND AS A LEADING FORCE FOR PROGRESSIVE CHANGE WITHIN OUR COMMUNITY. TO ENHANCE QUALITY, THE HOSPITAL ACTIVELY OPERATES A PERFORMANCE IMPROVEMENT PROGRAM WHICH HELPS IDENTIFY BETTER PATIENT CARE AS WELL AS EFFICIENCIES IN OPERATIONS. TO ENHANCE OUR COMMUNITY, TLRMC PROVES TO BE A DRIVING FORCE IN CHANGE BY EDUCATING THE COMMUNITY ON HEALTH & WELLNESS ISSUES AND BY RECOGNIZING COMMUNITY NEEDS AND WORKING TO FULFILL THOSE NEEDS. THE HOSPITAL CARED FOR 2,741 INPATIENTS AND 92,751 OUTPATIENTS. TO ASSIST THOSE PATIENTS WITH LIMITED RESOURCES, TLRMC ALSO OFFERS A PATIENT FINANCIAL ASSISTANCE PROGRAM. THERE ARE SEVERAL OPTIONS FOR PATIENTS WHO ARE UNINSURED OR UNDERINSURED, AND TLRMC'S PATIENT FINANCIAL SERVICES DEPARTMENT EDUCATES THE PATIENTS OF THE DIFFERENT PROGRAMS. THE HOSPITAL PROVIDED FREE MEETING SPACE TO SEVERAL GROUPS THROUGHOUT THE YEAR AND SEVERAL CLASSES WERE SPONSORED BY THE HOSPITAL THAT EDUCATED INTERESTED COMMUNITY RESIDENTS ON HEALTH & WELLNESS ISSUES. THEY INCLUDE: A. C.P.R. TO HEALTHCARE PROVIDERS AND TO THE COMMUNITY B. GENERAL MEDICAL INFORMATION TO CHILDREN ("TEDDY BEAR" CLINICS) C. PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES D. SUMMER WORK PROGRAM AVAILABLE FOR THOSE INTERESTED IN A HEALTHCARE CAREER E. COUNTYWIDE BABY SHOWER - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT F. SPONSORS THE AMERICAN RED CROSS BLOOD MOBILE TWO OR THREE TIMES EACH YEAR G. PROVIDED HEALTH INFORMATION AT THE RELAY FOR LIFE H. PARTICIPATED IN MAKE A DIFFERENCE DAY, WHICH INCLUDED A DRIVE-THRU FLU SHOT CLINIC I. HEART HEALTH EXPO UPON REQUEST, THE HOSPITAL ALSO PARTICIPATES IN LOCAL EDUCATION BY PROVIDING HOSPITAL EMPLOYEES AS SPEAKERS FOR CLASSROOMS OR CIVIC ORGANIZATIONS SUCH AS THE FOLLOWING EXAMPLES: J. PARTICIPATED IN THE BEL CHEESE HEALTH FAIR K. PARTICIPATED IN THE GCHS HEALTH FAIR L. PARTICIPATED IN THE GCMS COUGAR ZONE M. PARTICIPATED IN THE BIG BROTHERS & BIG SISTERS PROGRAM N. PARTICIPATED IN THE HEAD START AND SAFETY RESOURCE FAIR O. PARTICIPATED IN THE WILKEY CAREER NIGHT P. PARTICIPATED IN READ ACROSS AMERICA Q. PROVIDED SPEAKERS FOR MANY HEALTH FAIRS, SCHOOLS, AND COMMUNITY EVENTS IN ADDITION TO SERVING OUR LOCAL COMMUNITY NEEDS, TLRMC HAS ALSO TAKEN ON MEASURES TO IMPROVE AMERICA. BY PARTICIPATING IN THE CODE GREEN - RECYCLING PROJECT, TLRMC HOPES TO REDUCE WASTE AND IMPROVE THE ENVIRONMENT. TWIN LAKES REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS HAS PLEDGED TO BUY AMERICAN-MADE PRODUCTS WHEN WE CAN FIND A PRODUCT OF EQUAL OR GREATER QUALITY. TLRMC ENCOURAGES OTHER COMPANIES AND INDIVIDUALS TO DO THE SAME.
MANAGEMENT DELEGATED	FORM 990, PAGE 6, PART VI, LINE 3	THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER OF THE HOSPITAL ARE EMPLOYED BY ALLIANT MANAGEMENT SERVICES AND ARE RESPONSIBLE FOR CONTROLLING MANAGEMENT DUTIES.
CLASSES OF MEMBERS OR STOCKHOLDERS	FORM 990, PAGE 6, PART VI, LINE 6	THE ORGANIZATION HAS STOCKHOLDERS. EACH SHARE OF STOCK IS VALUED AT 25. STOCKHOLDERS MUST BE AT LEAST 18 YEARS OLD AND A RESIDENT OF GRAYSON COUNTY, KENTUCKY.
ELECTION OF MEMBERS AND THEIR RIGHTS	FORM 990, PAGE 6, PART VI, LINE 7A	NINE MEMBERS OF THE BOARD OF DIRECTORS ARE ELECTED BY THE STOCKHOLDERS AND THE OTHER MEMBER IS THE PRESIDENT OF THE MEDICAL STAFF (WHOM IS VOTED ON BY THE MEDICAL STAFF).
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	THE FORM 990 IS SUBMITTED TO THE GOVERNING BOARD FOR REVIEW AND APPROVAL BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	CORPORATE COMPLIANCE REQUIRES EACH EMPLOYEE AND BOARD MEMBER TO UPDATE AND SIGN OFF ON A CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS ARE MADE AVAILABLE UPON REQUEST.
OTHER EXPENSES	FORM 990, PART IX, LINE 24E	LABORATORY 1,653,961 0 0 MEDICAL & SURGICAL 844,354 0 0 SURGERY 836,791 0 0 RADIOLOGY 513,760 0 0 WOUND CARE 419,304 0 0 EMERGENCY ROOM 318,927 0 0 NUCLEAR MEDICINE 163,773 0 0 SLEEP CENTER 144,356 0 0 MRI 123,906 0 0 RESPIRATORY THERAPY 114,995 0 0 CT SCANS 98,634 0 0 ANESTHESIOLOGY 95,635 0 0 OBSTETRICS 82,410 0 0 INTENSIVE CARE 71,568 0 0 PHYSICAL THERAPY 36,629 0 0 USE OF DONATED ITEMS 19,587 0 0 SPECIALTY CLINIC 19,068 0 0 INFUSION CENTER 16,336 0 0 CARDIAC 10,903 0 0 NET ASSETS RELEASED FROM 10,000 0 0 OCCUPATIONAL THERAPY 2,989 0 0 FITNESS CENTER 80 0 0
RECONCILIATION OF CHANGES - OTHER	FORM 990, PART XI, LINE 9	OPERATING LOSS REPORTED UNDER ID 61-1269278 -4,867,634 VALUE OF DONATED ITEMS -19,587 DONATED SERVICES -68,752 DONATED SERVICES 68,752 USE OF DONATED ITEMS 19,587
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 9	THE DIFFERENCE REPORTED IS THE OPERATING LOSS REPORTED BY TWIN LAKES MEDICAL FOUNDATION, INC. EIN 61-1269278 - THIS IS REFLECTED ON THE RECONCILIATION TO THE FINANCIAL STATEMENTS ON SCHEDULE D.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

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

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

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) TWIN LAKES MEDICAL FOUNDATION INC 910 WALLACE AVE LEITCHFIELD,KY42754 61-1269278	MEDICAL PR	KY	501C3	9	GCHF GRAYSON COUNTY HOSPITAL FOUNDATION		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(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 VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) TWIN LAKES HOME HEALTH AGENCY LLC 420 WEST PINHOOK SUITE A LAFAYETTE,LA70503 27-1000828	HOME HEALT	LA	N/A	RELATED	353	80,624		No			No	25.000 %

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?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) WTK HOLDINGS INC 910 WALLACE AVE LEITCHFIELD,KY42754 61-0608823	HOLDING CO	KY	GCHF GRAYSON COUNTY HOSPITAL FOUNDATION	C CORP	50,758	2,084,974	100.000 %		No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

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

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

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

Yes

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

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

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

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

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

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

Yes

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

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

Yes

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

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

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

Yes

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

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

Yes

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

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

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) TWIN LAKES MEDICAL FOUNDATION INC	D	4,397,890	FAIR MARKET VALUE
(2) TWIN LAKES MEDICAL FOUNDATION INC	J	285,657	FAIR MARKET VALUE
(3) TWIN LAKES MEDICAL FOUNDATION INC	L	224,635	FAIR MARKET VALUE
(4) TWIN LAKES MEDICAL FOUNDATION INC	O	13,250	FAIR MARKET VALUE
(5) TWIN LAKES MEDICAL FOUNDATION INC	Q	2,829,465	FAIR MARKET VALUE

Schedule R (Form 990) 2012

Page 4

Part VI

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

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

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE QUALITY MEDICAL HEALTHCARE TO THE GRAYSON COUNTY, KENTUCKY AREA.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	10
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	457
6	Total number of volunteers (estimate if necessary) .............	6	42
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	27,509	19,912
9	Program service revenue (Part VIII, line 2g) .........	44,622,217	41,119,006
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	147,981	179,498
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	2,178,130	2,682,296
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	46,975,837	44,000,712
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	11,840,022	12,296,662
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	27,620,959	25,067,627
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	39,460,981	37,364,289
19	Revenue less expenses. Subtract line 18 from line 12.......	7,514,856	6,636,423
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	84,343,226	89,831,944
21	Total liabilities (Part X, line 26).............	21,809,546	20,661,841
22	Net assets or fund balances. Subtract line 21 from line 20.....	62,533,680	69,170,103

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 25,219,860 including grants of $ ) (Revenue $ )
	TWIN LAKES REGIONAL MEDICAL CENTER PROVIDES QUALITY MEDICAL HEALTH CARE SERVICES TO PATIENTS REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR THE ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND FINANCIAL STABILITY OF TWIN LAKES REGIONAL MEDICAL CENTER, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. IN KEEPING WITH ITS COMMITMENT TO SERVE ALL MEMBERS OF THIS AREA, THE HOSPITAL PROVIDES FREE CARE TO THE MOST INDIGENT OF PATIENTS AND WRITES OFF PORTIONS OF BILLS TO OTHER PATIENTS WHO HAVE DEMONSTRATED THE INABILITY TO PAY FOR ALL HEALTH CARE SERVICES RECEIVED. THE AMOUNT OF CHARGES FORGONE RELATED TO "CHARITY CARE" AMOUNTED TO 3,857,955 IN THE FISCAL YEAR ENDING JUNE 30, 2013. ADDITIONAL CHARGES ARE WRITTEN OFF DUE TO ARRANGEMENTS WITH MEDICARE, MEDICAID, AND OTHER THIRD PARTIES. THE TOTAL UNREIMBURSED CHARGES FORGONE IN FISCAL YEAR 2013 DUE TO CONTRACTUAL AGREEMENTS WITH PAYERS AMOUNTED TO 66,502,979. ALSO, 696,857 WAS PAID AS A "PROVIDER TAX" TO THE COMMONWEALTH OF KENTUCKY TO HELP DEFRAY THE COSTS OF COVERING INDIGENT PATIENTS UNDER A SPECIAL STATE PROGRAM. WRITE-OFFS FROM PATIENTS "UNWILLING" TO PAY - I.E. BAD DEBTS - ACCOUNTED FOR 5,815,802. THE PRIMARY MISSION OF TWIN LAKES REGIONAL MEDICAL CENTER IS TO HEAL THE SICK, RELIEVE PAIN AND SUFFERING, AND IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE WE SERVE. TLRMC'S VISION IS TO BE RECOGNIZED BY THE PEOPLE WE SERVE AS THE PROVIDER OF CHOICE FOR THEIR HEALTH CARE NEEDS AND AS A LEADING FORCE FOR PROGRESSIVE CHANGE WITHIN OUR COMMUNITY. TO ENHANCE QUALITY, THE HOSPITAL ACTIVELY OPERATES A PERFORMANCE IMPROVEMENT PROGRAM WHICH HELPS IDENTIFY BETTER PATIENT CARE AS WELL AS EFFICIENCIES IN OPERATIONS. TO ENHANCE OUR COMMUNITY, TLRMC PROVES TO BE A DRIVING FORCE IN CHANGE BY EDUCATING THE COMMUNITY ON HEALTH & WELLNESS ISSUES AND BY RECOGNIZING COMMUNITY NEEDS AND WORKING TO FULFILL THOSE NEEDS. THE HOSPITAL CARED FOR 2,741 INPATIENTS AND 92,751 OUTPATIENTS. TO ASSIST THOSE PATIENTS WITH LIMITED RESOURCES, TLRMC ALSO OFFERS A PATIENT FINANCIAL ASSISTANCE PROGRAM. THERE ARE SEVERAL OPTIONS FOR PATIENTS WHO ARE UNINSURED OR UNDERINSURED, AND TLRMC'S PATIENT FINANCIAL SERVICES DEPARTMENT EDUCATES THE PATIENTS OF THE DIFFERENT PROGRAMS. THE HOSPITAL PROVIDED FREE MEETING SPACE TO SEVERAL GROUPS THROUGHOUT THE YEAR AND SEVERAL CLASSES WERE SPONSORED BY THE HOSPITAL THAT EDUCATED INTERESTED COMMUNITY RESIDENTS ON HEALTH & WELLNESS ISSUES. THEY INCLUDE: A. C.P.R. TO HEALTHCARE PROVIDERS AND TO THE COMMUNITY B. GENERAL MEDICAL INFORMATION TO CHILDREN ("TEDDY BEAR" CLINICS) C. PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES D. SUMMER WORK PROGRAM AVAILABLE FOR THOSE INTERESTED IN A HEALTHCARE CAREER E. COUNTYWIDE BABY SHOWER - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT F. SPONSORS THE AMERICAN RED CROSS BLOOD MOBILE TWO OR THREE TIMES EACH YEAR G. PROVIDED HEALTH INFORMATION AT THE RELAY FOR LIFE H. PARTICIPATED IN MAKE A DIFFERENCE DAY, WHICH INCLUDED A DRIVE-THRU FLU SHOT CLINIC I. HEART HEALTH EXPO UPON REQUEST, THE HOSPITAL ALSO PARTICIPATES IN LOCAL EDUCATION BY PROVIDING HOSPITAL EMPLOYEES AS SPEAKERS FOR CLASSROOMS OR CIVIC ORGANIZATIONS SUCH AS THE FOLLOWING EXAMPLES: J. PARTICIPATED IN THE BEL CHEESE HEALTH FAIR K. PARTICIPATED IN THE GCHS HEALTH FAIR L. PARTICIPATED IN THE GCMS COUGAR ZONE M. PARTICIPATED IN THE BIG BROTHERS & BIG SISTERS PROGRAM N. PARTICIPATED IN THE HEAD START AND SAFETY RESOURCE FAIR O. PARTICIPATED IN THE WILKEY CAREER NIGHT P. PARTICIPATED IN READ ACROSS AMERICA Q. PROVIDED SPEAKERS FOR MANY HEALTH FAIRS, SCHOOLS, AND COMMUNITY EVENTS IN ADDITION TO SERVING OUR LOCAL COMMUNITY NEEDS, TLRMC HAS ALSO TAKEN ON MEASURES TO IMPROVE AMERICA. BY PARTICIPATING IN THE CODE GREEN - RECYCLING PROJECT, TLRMC HOPES TO REDUCE WASTE AND IMPROVE THE ENVIRONMENT. TWIN LAKES REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS HAS PLEDGED TO BUY AMERICAN-MADE PRODUCTS WHEN WE CAN FIND A PRODUCT OF EQUAL OR GREATER QUALITY. TLRMC ENCOURAGES OTHER COMPANIES AND INDIVIDUALS TO DO THE SAME.

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 expenses25,219,860

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) MIKE BOONE........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(2) LINDA FRENCH........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(3) BECKY MILLER........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(4) RON TYRER........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(5) L BRETT ABNEY OD........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(6) LARRY PERKINS........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(7) BARRY JOE CANNON........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(8) TED ROGERS MD........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(9) DARRELL MOLL........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(10) TREVOR RAY........................................................................ DIRECTOR	1.00 .......................	X		0	0	0
(11) SHELBY SHELMAN........................................................................ PHARMACIST	40.00 .......................		X	142,888	0	21,433
(12) CATHERINE D CLEMONS........................................................................ CHIEF OPERAT	40.00 .......................		X	134,124	0	10,810
(13) DAVID FULLER........................................................................ DIRECTOR OF	40.00 .......................		X	132,658	0	13,266
(14) ANITA PLEACHER........................................................................ PHARMACIST	40.00 .......................		X	121,820	0	1,218
(15) DAVID LOGSDON........................................................................ CHIEF NURSIN	40.00 .......................		X	118,549	0	10,811

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	650,039	57,538

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

f	All other contributions, gifts, grants, and similar amounts not included above1f		19,912

g	Noncash contributions included in lines 1a-1f:$		19,587
h	Total. Add lines 1a-1f.......			19,912
			Business Code
2a	PATIENT SERVICES			40,925,190	40,925,190
b	CAFETERIA REVENUE			163,358	163,358
c	FITNESS CENTER & OTHER INCOME			30,458	30,458
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			41,119,006
3	Investment income (including dividends, interest, and other similar amounts).......			179,498			179,498
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	552,275
b	Less: rental expenses	338,505
c	Rental income or (loss)	213,770
d	Net rental income or (loss).......			213,770	213,770
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss)..........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	NONOPERATING GAIN(LOSS)			1,793,081	1,793,081
b	TAX REVENUE			548,356	548,356
c	MANAGEMENT FEES			224,635	224,635
d	All other revenue ....			-97,546	-97,546
e	Total. Add lines 11a–11d ......			2,468,526
12	Total revenue. See Instructions......			44,000,712	43,801,302		179,498

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
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	12,296,662	10,299,096	1,997,566
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........
12	Advertising and promotion ....
13	Office expenses .......
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	890,660		890,660
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	3,198,725	2,790,248	408,477
23	Insurance ..............
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	ADMINISTRATIVE & GENERAL	8,847,726		8,847,726
b	PHARMACY	3,004,719	3,004,719
c	PROVISION FOR BAD DEBTS	1,785,373	1,785,373
d	MATERIALS MANAGEMENT	1,742,458	1,742,458
e	All other expenses	5,597,966	5,597,966
25	Total functional expenses. Add lines 1 through 24e	37,364,289	25,219,860	12,144,429	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			13,201,960	1	13,510,428
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			5,813,009	4	6,074,456
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
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
					6
7	Notes and loans receivable, net .............			21,932,540	7	26,330,430
8	Inventories for sale or use ..............			1,478,146	8	1,533,555
9	Prepaid expenses and deferred charges ..........			427,803	9	359,430
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	69,092,851
b	Less: accumulated depreciation .....	10b	29,200,319	39,357,346	10c	39,892,532
11	Investments—publicly traded securities ..........			2,132,422	11	2,131,113
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........				15
16	Total assets. Add lines 1 through 15 (must equal line 34)......			84,343,226	16	89,831,944
17	Accounts payable and accrued expenses .........			3,667,957	17	3,815,550
18	Grants payable .................				18
19	Deferred revenue ................				19
20	Tax-exempt bond liabilities .............			16,295,479	20	15,299,875
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
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..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			1,846,110	25	1,546,416
26	Total liabilities. Add lines 17 through 25.........			21,809,546	26	20,661,841
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			62,533,680	27	69,170,103
28	Temporarily restricted net assets ...........				28
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			62,533,680	33	69,170,103
34	Total liabilities and net assets/fund balances ........			84,343,226	34	89,831,944