TY 2012 Form 990

(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)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) Kenneth Pierce........................................................................ Chairman	0 .......................	X		0	0	0
(2) Glenn Hunt........................................................................ Vice Chairman	0 .......................	X		0	0	0
(3) Rebecca Bialecki MD........................................................................ 2nd Vice Chairman	0 .......................	X		0	0	0
(4) Cheney Castine........................................................................ Treasurer	0 .......................	X		0	0	0
(5) Tina Sbrega........................................................................ Clerk	0 .......................	X		0	0	0
(6) Roy Lake MD........................................................................ Director	0 .......................	X		0	0	0
(7) John Skrzypczak MD........................................................................ Director	0 .......................	X		0	0	0
(8) Donald Mruk MD........................................................................ Director	0 .......................	X		0	0	0
(9) Mohsen Noreldin MD........................................................................ Director	0 .......................	X		26,580	0	0
(10) Doug Starrett........................................................................ Director	0 .......................	X		0	0	0
(11) Daniel Asquino........................................................................ Director	0 .......................	X		0	0	0
(12) Winfield Brown........................................................................ Director	0 .......................40	X	X	0	526,138	50,699
(13) Robert Chauvin........................................................................ Director	0 .......................	X		0	0	0
(14) Laura Chen MD........................................................................ Director	0 .......................	X		0	0	0
(15) Joyce Fletcher........................................................................ Director	0 .......................	X		0	0	0
(16) John Flick........................................................................ Director	0 .......................	X		0	0	0
(17) James Garrison........................................................................ Director	0 .......................	X		0	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
St Vincent Physician Services123 Summer StreetWorcesterMA01608	ER & Hospitalist Physicians	1,289,078
Healthcare Provider AdvocatesPO Box 2117AmherstMA01004	Patient Accounts Manager & Consulting	512,706
Labcorp of America HoldingsPO Box 12140BurlingtonNC27216	Lab Services	449,122
Navix DiagnosticsPO Box 347203PittsburgPA15251	Nuclear Medicine Consulting	194,116
LocumTenenscomPO Box 405547AtlantaGA30353	Anesthesia Coverage	158,682
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 6

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	0	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0	0
4	Benefits paid to or for members	0	0
5	Compensation of current officers, directors, trustees, and key employees ....	138,264	95,064	43,200	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0	0	0	0
7	Other salaries and wages	8,520,745	8,208,656	312,089	0
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	0	0	0	0
9	Other employee benefits .......	1,203,100	1,139,047	64,053	0
10	Payroll taxes ...........	639,176	605,869	33,307	0
11	Fees for services (non-employees):
a	Management ......	0	0	0	0
b	Legal .........	71,411	0	71,411	0
c	Accounting ...........	5,078	0	5,078	0
d	Lobbying ...........	0	0	0	0
e	Professional fundraising services. See Part IV, line 17	0			0
f	Investment management fees ......	0	0	0	0
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	1,028,199	947,267	80,932	0
12	Advertising and promotion ....	13,846	12,292	1,554	0
13	Office expenses .......	2,768,000	2,460,630	307,370	0
14	Information technology ......	37,010	0	37,010	0
15	Royalties ..	0	0	0	0
16	Occupancy ...........	581,677	581,677	0	0
17	Travel ............	23,338	13,588	9,750	0
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0	0	0	0
19	Conferences, conventions, and meetings ....	8,980	8,980	0	0
20	Interest ...........	19,598	19,598	0	0
21	Payments to affiliates .......	0	0	0	0
22	Depreciation, depletion, and amortization .....	781,188	778,261	2,927	0
23	Insurance ..............	195,913	163,966	31,947	0
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	Professional Fees	1,780,456	849,771	930,685	0
b	Free Care	1,374,961	1,374,961	0	0
c	Physician Fees	1,143,494	1,143,494	0	0
d	Provisions for Bad Debt	557,203	476,755	80,448	0
e	All other expenses	256,246	289,864	-33,618	0
25	Total functional expenses. Add lines 1 through 24e	21,147,883	19,169,740	1,978,143	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	514,085	1	819,734
2	Savings and temporary cash investments .........	0	2	0
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	2,131,811	4	2,209,386
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	424,187	8	162,626
9	Prepaid expenses and deferred charges ..........	109,942	9	27,205
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	17,514,726
b	Less: accumulated depreciation .....	10b	13,439,530	3,809,455	10c	4,075,196
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 .....	1,069,348	12	1,770,983
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......	8,058,828	16	9,065,130
	17	Accounts payable and accrued expenses .........	4,112,296	17	4,113,052
18	Grants payable .................	0	18	0
19	Deferred revenue ................	0	19	74,282
20	Tax-exempt bond liabilities .............	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	737,415	23	984,621
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	4,122,988	25	1,842,937
26	Total liabilities. Add lines 17 through 25.........	8,972,699	26	7,014,892
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	-2,582,242	27	491,051
28	Temporarily restricted net assets ...........	239,635	28	94,938
29	Permanently restricted net assets ...........	1,428,736	29	1,464,249
	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 ...........	-913,871	33	2,050,238
34	Total liabilities and net assets/fund balances ........	8,058,828	34	9,065,130

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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:	12000197
Software Version:	v1.00

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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 ATHOL MEMORIAL HOSPITAL INCORPORATED

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 ATHOL MEMORIAL HOSPITAL INCORPORATED

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
ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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:	12000197
Software Version:	v1.00

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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

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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 ....	1,428,736	968,215	1,039,129	992,383	1,013,033
b	Contributions ........	15,816	359,388	0	0	0
c	Net investment earnings, gains, and losses	1,091	137,402	-28,328	46,746	-20,650
d	Grants or scholarships .....	0	0	0	0	0
e	Other expenditures for facilities and programs ........	-113,554	36,269	42,586	0	0
f	Administrative expenses ....	0	0	0	0	0
g	End of year balance ......	1,559,197	1,428,736	968,215	1,039,129	992,383

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

93.91 %

Temporarily restricted endowment SchDMd Bullet

6.09 %

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		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	0	71,990		71,990
b	Buildings ................	0	8,359,992	5,567,656	2,792,336
c	Leasehold improvements ............	0	0	0	0
d	Equipment ................	0	8,280,713	7,871,874	408,839
e	Other .................	0	802,031	0	802,031
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......					4,075,196

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
(3)Other (A) Donor restricted investments	1,770,983	F








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	1,770,983

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
Estimated Third Party Settlements		1,842,937








Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,842,937
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
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

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

Part XIII

Supplemental Information

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

Identifier	Return Reference	Explanation
SchD_P05_S00_L04	Schedule D, Part V, Line 4	The organization's endowment includes both donor restricted endowment funds and funds designated by the Boad of Directors to function as endowments. As required by GAAP, net assets associated with endowment funds, including funds designated by the Board of Directors to function as endowments, are classified and reported based on the existence or absence of donor-imposed restrictions. The organization has interpreted state law as requiring realized and unrealized gains of premanently restricted net assets to be retained in a temporarily restricted net asset classification until appropriated by the Organization's Board of Directors and expended. State law allows the Board to appropriate as much of the net appreciation of premanently restrictednet assets as is prudent considering the Organization's long and short term needs, present and anticipated financial requirements, expected total return on investments, price-level trends, and general economic conditions.
SchD_P10_S00_L02	Schedule D, Part X, Line 2	Heywood Healthcare, Heywood Hospital, Athol Hospital and HMGI have been determined to be not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code"), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Code. All of the entities are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under IRC section 511 and, as such, be subject to tax at normal corporate rates. In accordance with GAAP, the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years 2009 through the current year remain open for examination by federal and state taxing authorities.

Schedule D (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- TIN:

SCHEDULE G (Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. Form 990-EZ filers are not required to complete this part. right arrow

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

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization
ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and email solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.

(i) Name and address of individual or entity (fundraiser)	(iii) Did fundraiser have custody or control of contributions?
	Yes	No










Total .................

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

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

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2012

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.

		(a) Event #1 Golf Tournament (event type)	(c) Other events (total number)	(d) Total events (add col. (a) through col. (c))
1	Gross receipts . . .	22,938		22,938
2	Less: Contributions . .	20,670		20,670
3	Gross income (line 1 minus line 2) . . .	2,268		2,268
4	Cash prizes . . .	1,330		1,330
5	Noncash prizes . .	50		50
6	Rent/facility costs . .	5,460		5,460
7	Food and beverages .	1,474	0	1,474
8	Entertainment . . .	0	0	0
9	Other direct expenses .	313		313
10	Direct expense summary. Add lines 4 through 9 in column (d) ...........			8,627
11	Net income summary. Combine line 3, column (d), and line 10. ..........			-6,359

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (add col.(a) through col.(c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," explain:

Schedule G (Form 990 or 990-EZ) 2012

Page 3

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ..........................

YesNo

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Enter the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address of the third party:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part I, line 2b, columns (iii) and (v), and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also complete this part to provide any additional information (see instructions).

Identifier	Return Reference	Explanation

Schedule G (Form 990 or 990-EZ) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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 60000 %

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		(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) ..	538,505	352,213	186,292	0.91 %
b	Medicaid (from Worksheet 3, column a) ....	4,863,726	3,807,757	1,055,969	5.15 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .	0	0	0	0 %
d	Total Financial Assistance and Means-Tested Government Programs .	5,402,231	4,159,970	1,242,261	6.06 %
Other Benefits		121,730	2,268	119,462	0.58 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	121,730	2,268	119,462	0.58 %
f	Health professions education (from Worksheet 5) ..	0	0	0	0 %
g	Subsidized health services (from Worksheet 6) ..	0	0	0	0 %
h	Research (from Worksheet 7)	0	0	0	0 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	4,896	0	4,896	0.02 %
j	Total. Other Benefits ..	126,626	2,268	124,358	0.60 %
k	Total. Add lines 7d and 7j .	5,528,857	4,162,238	1,366,619	6.66 %

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

Schedule H (Form 990) 2012

Page

Part II

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

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

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

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

143,408

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. ......

5,292

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).....

3,790,307

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

5,441,078

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

-1,650,771

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2012

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, and primary website address
1	Athol Memorial Hospital 2033 Main Street Athol,MA01331 www.atholhospital.org	X	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)

	Athol Memorial Hospital
Name of hospital facility or facility reporting group

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

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 ........

Yes

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: 200% 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: 600% 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		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Part VI)

Schedule H (Form 990) 2012

Page

Part VFacility Information (continued)

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

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

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

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

Other (describe in Part VI)

Policy Relating to Emergency Medical Care

Yes

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

Yes

If “No,” indicate why:

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

The hospital facility’s policy was not in writing

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

Other (describe in Part VI)

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

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

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

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

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

Other (describe in Part VI)

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

If “Yes,” explain in Part VI.

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

Yes

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
SchH_P01_S00_L06b	Schedule H, Part I, Line 6b	The Organization makes its annual Community Benefit Report available to the public by transmitting the report electronically to the Attorney General's Community Benefit office which then makes it public on their website.
SchH_P01_S00_L07	Schedule H, Part I, Line 7	The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c were based on the cost to charge ratio derived from the supplied Worksheet 2 in the IRS Sch H instructions. The costs for lines 7e through 7i were actual costs incurred.
SchH_P03_S0A_L02	Schedule H, Part III, Section A, Line 2	The cost methodology used for line 2 was based on the cost to charge ratio derived from the supplied Worksheet 2 in the IRS sch H instructions.
SchH_P03_S0A_L03	Schedule H, Part III, Section A, Line 3	The methodology used for line 3 was to take the percent of financial assistance applications that were denied due to inadequate documentation divided by the total applications received for FY13. This amounted to be approximately 3.69% which was applied against the number on line 2. It is our belief that $5,292 in bad debt should be included as community benefits. As a not for profit, patient care is provided to all, regardless of ability to pay for that care. Making quality patient care available to all in our community, regardless of their economic means, qualifies bad debt as a community benefit.
SchH_P03_S0A_L04	Schedule H, Part III, Section A, Line 4	The footnote on bad debt in the organization's audited financial statements can be found on page 8, allowance for doubtful accounts.
SchH_P03_S0B_L08	Schedule H, Part III, Section B, Line 8	The allowable costs on line 6 were obtained from our FY 2013 Medicare Cost Report, worksheet D schedules.
SchH_P03_S0C_L09b	Schedule H, Part III, Section C, Line 9b	Standard Collection Policies and Procedures for Athol Memorial Hospital are as follows: 1. AMH provides patients with information about financial assistance programs available through the Commonwealth of MA, which may cover all or some of their unpaid hospital bill. For those patients that request assistance, the hospital will assist in eligibility screening for and applying for an available public assistance program. These programs include, but are not limited to MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start and the Health Safety Net. When applicable the hospital will also assist patients in applying for coverage of services as a medical hardship based on the patient's documented family income, current and prior insurance coverage and allowable medical expenses. 2. Financial assistance is intended to assist low income patients who do not otherwise have the ability to pay for their healthcare services. Such assistance takes into account each individual's ability to contribute to the cost of his or her care. AMH will work with those patients that are uninsured or underinsured to assist with applying for available financial assistance programs that may cover all or some of their unpaid hospital bills. This assistance is provided for both residents and non-residents of MA, however there may not be coverage in a state public assistance program for medical services received at a MA hospital by a non resident of MA. 3. An initial itemized bill is sent to the party responsible for the patient's personal financial obligations. 4. AMH uses a 4 week billing cycle. Account statements are issued every 28 days following the initial bill. 5. Issuance of subsequent billings, telephone calls, pre-collection letters and other personal contract notices will follow the initial bill as necessary to constitute a genuine effort to contact the party responsible for the obligation. 6. Document alternative efforts to locate the party responsible for the obligation or the correct address on billing returned by the postal service as incorrect address or undeliverable. 7. Documentation of continuous collection action undertaken on a regular, frequent basis will be maintained via paper or electronic media. 8. Documentation of collection efforts will be maintained until audit is complete.
SchH_P05_S0B_L03	Schedule H, Part V, Section B, Line 3	The 2011-2012 Community Health Needs Assessment was completed through compilation of area data available from the US Census, Massachusetts Department of Public Health and other related sources within the State. The Assessment includes a community survey intended to calculate the community's perception of health, barriers to care and unmet needs in the North Quabbin area. Focus groups were held to further investigate, including parents, youth, educators, veterans, elders and health care providers. Community-based health related agencies who provided consultation and input included Athol Board of Health, Tobacco Control Alliance, Northeast Quabbin District Dept of Veteran's Services, Franklin County Dept of Veteran's Services, Montachusett's Veteran's Outreach, Community Center of Franklin County, Community Action, Valuing Our Children, Orange Elementary Schools, RC Mahar Regional School, Athol-Royalston Regional School District, MOC Community Partnership, Athol Council on Aging, Franklin County Home Care, Communities That Care Coalition, Community Coalition for Teens and Dial Self.
SchH_P05_S0B_L14	Schedule H, Part V, Section B, Line 14	Signage is posted throughout the ER, Admissions and Waiting Rooms regarding financial assistance available through the Hospital and are directed to contact the Financial Counselors.
SchH_P05_S0B_L16	Schedule H, Part V, Section B, Line 16	AMH follows its standard collection practices to attempt to resolve balances of Uninsured Patients. 1. An itemized bill is sent to the patient or guarantor. If initial bill is returned as undeliverable, a Financial Counselor will attempt to contact the patient or Guarantor by telephone to obtain current mailing address. If unsuccessful, the account will be referred to an outside Collection Agency for skip tracing and additional collection action. 2. Financial Counselor attempts to contact patient or guarantor either by telephone or written correspondence to establish third party liability, if any. 3. Verbal or written information is given about MassHealth, HSN and other governmental assistance programs and where to apply for assistance. AMH mails the patient or guarantor two additional statements and two pre-collection letters. Subsequent attempts to reach the patient by telephone are made at the pre-collection stage. AMH maintains electronic notes on the patient's account of mail returned as undeliverable and alternative attempts to contact the patient. AMH will request documentation of collection activity from its outside Collection Agencies for accounts referred to skip tracing prior to the normal 120 day ERBD write off requirements. AMH will send a final notice by certified mail for accounts of $1,000 or more where there have been no prior notices returned as incorrect address or undeliverable. AMH's patient billing system operates on a 4 week cycle. After an initial itemized invoice, account statements are generated every 28 days. Patient Account Representatives or Financial Counselors will review Accounts Receivable reports to identify any account not receiving a statement to ensure there is no gap in continuous collection activity of 120 days or greater.
SchH_P05_S0B_L22	Schedule H, Part V, Section B, Line 22	All patients are charged the same amount for services regardless of ability to pay or insurance coverage. Insurance companies pay for patients they cover at negotiated rates with the Hospital, these rates are usually less than the gross charge. All uninsured, underinsured or self pay patients are directed to Financial Counselors to determine if they are eligible for government assistance, check for medical hardships, or if they have access to health insurance or are eligible for a discount.
SchH_P06_S00_L02	Schedule H, Part VI, Line 2	Athol Hospital assesses the health needs of the communities it serves in a variety of ways in addition to the CHNA. The Patient and Family Advisory Council which meets quarterly includes a minimum of 8 patients from Athol and surrounding towns, including Orange, Royalston, Philipston, Petersham, New Salem, Wendell, Warwick and Erving, and two hospital representatives. This council, comprised of former patients and their families, provides general input on community needs, as well asinput on hospital-specific services and opportunities for improvement. In addition, the hospital works closely throughout the year with area social service agencies obtaining input on community health needs including, the Athol Board of Health, Council on Aging, Athol Senior Center, North Quabbin Community Coalition and their Substance Abuse Prevention Taskforce, Erving Board of Health, Erving Senior Center, Royalston Board of Health, Phillipston Board of Health, Athol Area YMCA, Community Health Center of Franklin County, Children's Health and Wellness Taskforce, Tobacco Control Alliance, Montachusetts Veterans Outreach, Athol-Royalston Regional School District, Orange Public Schools and direct community outreach to Athol and surrounding towns, The hospital solicits feedback from social service and nursing staff, as well as physicians regarding patient feedback. The hospital also provides space for/and facilitates support groups which provide feedback on community interests and needs.
SchH_P06_S00_L03	Schedule H, Part VI, Line 3	Athol Memorial Hospital has financial counselors to assist patients to apply for MassHealth, Commonwealth Care, Healthy Start, Children's Medical Security, EAEDC, the Massachusetts Health Safety Net program, Medical Hardship and any other available financial assistance. Financial counseling staff will assist with the application process as well as address billing concerns and provide pre and post service payment assistance. It is the patient or their guarantor's responsibility to provide all necessary information and documentation to determine eligibility for all financial assistance programs and payment plans. 1. Upon admission to the hospital Emergency Room, AMH Registration staff will, as soon as is reasonably possible, make every effort to obtain the financial information necessary to determine responsibility for payment of the bill from the patient or Guarantor. a. If hospital staff is not able to obtain sufficient information to determine financial responsibility at the time of Emergency Room service, a hospital Financial Counselor will attempt to reach the patient or guarantor via telephone and/or written correspondence sent via the US Postal System. b. In the event that the patient has deceased, the hospital Financial Counselor will make reasonable efforts to reach the guarantor, patient's designated Health Care Proxy, or designated Next of Kin in order to obtain financial information necessary to determine responsibility for payment of the hospital bill. 2. Upon admission to the hospital as an Inpatient, AMH Registration staff will make every reasonable effort to obtain the financial information necessary to determine responsibility for payment of the Hospital bill from the patient or guarantor. a. If the patient or guarantor is unable to provide the information needed at the time of admission as an Inpatient, the Patient Financial Advocate and Social Service Staff, with the patient's consent, will make reasonable efforts to contact the relatives, friends, guarantor, and the patient for additional information while the patient is in the Hospital. b. If sufficient patient financial information has not been obtained to assess the ability of the patient or guarantor to pay for services prior to the date of discharge, the Patient Financial Advocate will make reasonable efforts to obtain the necessary information at the time of the patient's discharge. c. If sufficient patient financial information has not been obtained to assess the ability of the patient or guarantor to pay for services at time of discharge, a Financial Counselor will attempt to reach the patient or guarantor by telephone calls and/or written correspondence sent via the US Postal System. d. In the event that the patient has deceased, the hospital Financial Counselor will make reasonable efforts to reach the guarantor, patient's designated Health Care Proxy, or designated Next of Kin in order to obtain financial information necessary to determine responsibility for payment of the bill. 3. When a patient present at AMH for Urgent Outpatient Services hospital Registration staff, will as soon as possible, make every effort to obtain the financial information necessary to determine responsibility for payment of the bill from the patient or guarantor. a. If hospital registration staff is not able to obtain sufficient informaiton to determine financial responsibility at the time of Urgent Outpatient service, a hospital Financial Counselor will attempt to reach the patient or Guarantor via telephone and/or written correspondence via US Postal System. 4. When a patient presents at AMH for an elective or scheduled Outpatient Service, the patient or guarantor must provide hospital registration staff or staff of the receiving department with sufficient information to determine responsibility for payment of the bill. a. If the patient or guarantor is unable to provide sufficient information to determine responsibility for payment of the bill, AMH may choose to defer elective or scheduled Outpatient Services, with consent from the ordering physician, nurse practitioner, or physician assistant, until the patient or guarantor is able to provide necessary financial information.
SchH_P06_S00_L04	Schedule H, Part VI, Line 4	Athol Memorial Hospital, an acute care, not-for-profit community hospital, was founded to provide Inpatient, Outpatient, Emergency Care and Home Care Services for residents of Worcester and Franklin counties. The mission of the Community Benefits Program is to encourage healthy lifestyles through outreach, education and support to the communities we serve (Athol, Erving, New Salem, Orange, Petersham, Philipston, Royalston, Warwick and Wendell). This underlying principle of encouraging health lives guides our existing Community Benefits activities and will be carried forward as we formalize our Community Benefits Plan.
SchH_P06_S00_L05	Schedule H, Part VI, Line 5	Athol Hospital works closely with the community to promote health in areas identified by the 2012 Community Health Needs Assessment (CHNA) through a variety of means. Direct outreach is provided to community members including seniors, shut-ins, and school-aged children through our Community Health Nurse(CHN). The CHN provides a variety of services as needed through local area Health Boards including Athol, Phillipston, Erving and Royalston and through direct services provided at community member homes, senior centers and community health events. Services provided include, but are not limited to, education, blood pressure monitoring, influenza inoculation, prevention efforts for diabetes, behavior health and substance abuse, navigation/access to insurance and community agency assistance and direct care for other chronic conditions. This directly addresses community members with barriers to accessing healthcare as identified in the 2012 CHNA, with barriers including distance and lack of transportation to services, difficulty navigating insurance systems, and management of chronic diseases in adults and children. The hospital also works closely with the Children's Health and Wellness Taskforce addressing poverty-related health issues in children as indicated in the 2012 CHNA including asthma, behavioral health and nutrition, and with the Franklin Hampshire North Quabbin Opiate Prevention Taskforce addressing the highest local priority indicated in the 2012 CHNA - drug abuse in youth and adults. In collaboration with local service agencies, the hospital provides Lifeline systems to 131 subscribers at reduced cost including elderly, disabled, and those with socioeconomic and rural transportation challenges, addressing a significant barrier to care as indicated in the 2012 CHNA.
SchH_P06_S00_L06	Schedule H, Part VI, Line 6	Community Benefit Plans are determined by the Administrative Team of the affiliated healthcare organization, with input from community health-focused staff at member hospitals including Community Health Nurse, Social Workers, Emergency Department staff, Community Relations, CHNA, local educational institutions and area social service agencies. Each hospital focuses on community health activities specific to the community health needs identified in the CHNA related to its determined service area. Each hospital then carries out Community Benefit Plan addressing the health needs of their target areas as determined in the CHNA.
SchH_P06_S00_L07	Schedule H, Part VI, Line 7	Athol Memorial Hospital files an annual Community Benefit Report to the Attorney General's Community Benefit Office in Massachusetts.

Schedule H (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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

Yes

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)Haytham MohamedPhysician	(i) (ii)	431,879 0	0 0	0 0	0 0	26,146 0	458,025 0	0 0
(2)Mark WuPhysician	(i) (ii)	274,997 0	70,383 0	0 0	0 0	12,291 0	357,671 0	0 0
(3)Winfield BrownDirector	(i) (ii)	0 383,569	0 133,569	0 9,000	0 19,261	0 31,438	0 576,837	0 0
(4)Robert CrosbyCFO	(i) (ii)	0 225,978	0 41,469	0 1,158	0 21,255	0 27,703	0 317,563	0 0
(5)Steven PenkaCEO	(i) (ii)	76,883 0	25,000 0	0 0	0 0	15,469 0	117,352 0	0 0
(6)Michael GrimmerCOO	(i) (ii)	0 190,066	0 25,621	0 12,500	0 17,000	0 26,961	0 272,148	0 0

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
SchJ_P01_S00_L07	Schedule J, Part I, Line 7	Dr. Mark Wu has an employment contract with Athol Hospital for a Physician Bonus Award. This Contract states "In each year, your bonus will be calculated based upon Employer receiving net receipts in excess of the Physician Base Salary. In Addition, the Employer will be entitled to recoup up to $30,000 in Personal Insurance Benefits prior to the processing of the Bonus Award. After the Base Salary and the above mentioned Personal Insurance Benefits, the incentive will be split 40% for Hospital and 60% for Physician". For the period of January 1, 2012 through December 31, 2012 Dr. Wu earned $70,383.31 for a bonus incentive. Out of this amount, $40,000 was paid in Fiscal Year 2012 and $30,383.31 was paid in Fiscal Year 2013, with the entire amount being paid in calendar year 2012.
SchJ_P02_S00_L00	Schedule J, Part II	Steven Penka was the former CEO of Athol Memorial Hospital. He terminated on July 16, 2012.

Schedule J (Form 990) 2012

Additional Data

Software ID:	12000197
Software Version:	v1.00

- 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

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

Identifier	Return Reference	Explanation
F990_P06_S0A_L03	Form 990, Part VI, Section A, Line 3	Athol's CFO, Dean Flemming, terminated on October 14, 2011. In October, Athol utilized the services of Healthcare Provider Advocates for an interim CFO, Paul Dabrody. Paul worked with Athol from Oct 2011 through December 2012.
F990_P06_S0B_L11b	Form 990, Part VI, Section B, Line 11b	The Accountant for Athol prepares the form 990 and provides it to the Sr. Accountant and Controller for review. The form is then sent to the CFO for final review. Once approved and signed, the 990 is placed on the Hospital Cyber Board for the Board of Trustees' review. The 990 is then approved by the Board and submitted by the Accounting Department.
F990_P06_S0B_L12c	Form 990, Part VI, Section B, Line 12c	The Board of Trustees review the organization's Conflict of Interest policy annually in order to ensure that the organization's Board of Trustees, Officers and Employees are regularly and consistently monitoring and enforcing it.
F990_P06_S0B_L15	Form 990, Part VI, Section B, Line 15	Salaries are determined by the Board of Directors considering comparable salary information for Officers of other entities of similar size and level of activity.
F990_P06_S0C_L19	Form 990, Part VI, Section C, Line 19	The organization makes the governing documents, conflict of interest policy and financial statements available to the public by providing completed copies to the Executive Assistant, who provides copies upon request.
F990_P07_S0A_L01a	Form 990, Part VII, Section A, Line 1a	Steven Penka, former CEO of Athol, terminated on July 16,2012. James Meehan was elected as the Interim CEO starting in July 2012 and terminating on December 31, 2012 when Heywood Hospital became affiliated with Athol Hospital. AMH utilized the services of Healthcare Provider Advocates for an interim CFO, Paul Dabrody. The amount listed is what was paid to the company for his services. Paul worked with Athol from October 2011 through October 2012.
F990_P11_S00_L09	Form 990, Part XI, Line 9	The amount that makes up the other changes in net assets or fund balance is from inter-corporate transfers from related organizations to support the operations of the Hospital.

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:	12000197
Software Version:	v1.00

- 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

ATHOL MEMORIAL HOSPITAL INCORPORATED

Employer identification number

04-2126583

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) Heywood Healthcare Inc 242 Green Street Gardner,MA01440 22-2720658	Parent Corp	MA	501(c)(3)	7	N/A		No
(2) Heywood Healthcare Charitable Foundation Inc 242 Green Street Gardner,MA01440 22-2720562	Inactive	MA	501(c)(3)	7	Heywood Healthcare Inc		No
(3) Henry Heywood Memorial Hospital 242 Green Street Gardner,MA01440 04-2103581	Hospital	MA	501(c)(3)	3	Heywood Healthcare Inc		No
(4) Heywood Affiliated Medical Group 242 Green Street Gardner,MA01440 04-3163589	Physicians Offices	MA	501(c)(3)	9	Heywood Healthcare Inc		No
(5) Henry Heywood Realty Corp 242 Green Street Gardner,MA01440 04-3327447	Property Holding Corp	MA	501(c)(2)		Heywood Healthcare Inc		No
(6) HHMH Aid Association 242 Green Street Gardner,MA01440 04-2198019	raise funds for hospital	MA	501(c)(3)	9	N/A		No
(7) AMH Auxillary 2033 Main Street Athol,MA01331 04-2126583	raise funds for hospital	MA	501(c)(3)	9	N/A		No
(8) Winchendon Health Foundation 87 Central Street Winchendon,MA01475 04-2113276	Support Organization	MA	501(c)(3)	PF	N/A		No
(9) Heywood Physicians Hospital Organization 242 Green Street Gardner,MA01440 04-3153119	Managed Care Contract	MA	501(c)(3)	9	N/A		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2012

Page 3

Part V

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

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

Yes

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

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

Yes

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

Yes

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

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

Yes

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

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

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:	12000197
Software Version:	v1.00

- TIN:

TY 2012 ReasonableCauseExplanation

Name:

ATHOL MEMORIAL HOSPITAL INCORPORATED

EIN: 04-2126583

Software ID:12000197

Software Version:v1.00

Explanation:

Athol Memorial Hospital submitted form 8868 on January 29, 2014 for an extension to file until May 15, 2014. We received notice# CP211A dated March 31, 2014 approving the form 8868.

1	Briefly describe the organization’s mission or most significant activities: Our vision is to be one of the best independent community hospitals in America. Our mission is to be our communities' trusted choice for exceptional patient-centered care.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	21
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	19
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	279
6	Total number of volunteers (estimate if necessary) .............	6	93
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	439,362	605,945
9	Program service revenue (Part VIII, line 2g) .........	20,349,585	20,306,415
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	119,050	79,416
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	416,990	388,482
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	21,324,987	21,380,258
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	10,987,459	10,501,285
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	12,730,074	10,646,598
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	23,717,533	21,147,883
19	Revenue less expenses. Subtract line 18 from line 12.......	-2,392,546	232,375
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	8,058,828	9,065,130
21	Total liabilities (Part X, line 26).............	8,972,699	7,014,892
22	Net assets or fund balances. Subtract line 21 from line 20.....	-913,871	2,050,238

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 19,169,740 including grants of $ 0 ) (Revenue $ 20,306,415 )
	Athol Memorial Hospital is a critical access hospital (CAH) serving the nine towns of North Quabbin Region. The areas relatively small population is dispersed over a large geographic area. Inherent in the Hospital mission of providing healthcare services are efforts to help improve the health and lives of our community. This intent is the framework for our community benefits activities.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ 0 including grants of $ 0 ) (Revenue $ 0 )
4e	Total program service expenses19,169,740

(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
(18) John Kerney........................................................................ Director	0 .......................	X				0	0	0
(19) Michele Parker MD........................................................................ Director	0 .......................	X				0	0	0
(20) JoAnne Parks........................................................................ Director	0 .......................	X				0	0	0
(21) James Meehan........................................................................ CEO	40 .......................0	X				33,400	0	3,247
(22) Paul Dabrody........................................................................ Acting CFO - Healthcare Provider Advocates	40 .......................		X		X	248,547	0	0
(23) Robert Crosby........................................................................ CFO	0 .......................40		X			0	268,605	48,958
(24) Lucille Songer........................................................................ CNO	40 .......................0		X			95,684	0	20,568
(25) Steven Penka........................................................................ CEO	40 .......................0		X		X	101,883	0	15,469
(26) Michael Grimmer........................................................................ COO	0 .......................40		X			0	228,187	43,961
(27) Haytham Mohamed........................................................................ Physician	40 .......................0			X		431,879	0	26,146
(28) Mark Wu........................................................................ Physician	40 .......................0			X		345,380	0	12,291

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,283,353	1,022,930	221,339

				(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		0
b	Membership dues....1b		0
c	Fundraising events....1c		20,670
d	Related organizations...1d		0
e	Government grants (contributions)1e		402,322

f	All other contributions, gifts, grants, and similar amounts not included above1f		182,953

g	Noncash contributions included in lines 1a-1f:$		1,200
h	Total. Add lines 1a-1f.......			605,945
			Business Code
2a	Ancillary OP Services		622110	17,443,417	17,443,417	0	0
b	Ancillary IP & Routine Services		622110	2,765,617	2,765,617	0	0
c	MRI/PET Scan Income		622110	89,452	89,452	0	0
d	CPR Classes		622110	7,929	7,929	0	0
e
f	All other program service revenue .			0	0	0	0
g	Total. Add lines 2a–2f........			20,306,415
3	Investment income (including dividends, interest, and other similar amounts).......			81,127	0	0	81,127
4	Income from investment of tax-exempt bond proceeds..			0	0	0	0
5	Royalties...........			0	0	0	0
		(i) Real	(ii) Personal
6a	Gross rents	270,886	0
b	Less: rental expenses	0	0
c	Rental income or (loss)	270,886	0
d	Net rental income or (loss).......			270,886	0	0	270,886
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	0	250
b	Less: cost or other basis and sales expenses	0	1,961
c	Gain or (loss)	0	-1,711
d	Net gain or (loss)..........			-1,711	0	0	-1,711
8a	Gross income from fundraising events (not including $ 20,670 of contributions reported on line 1c). See Part IV, line 18 ..
	a		2,268
b	Less: direct expenses ...b		8,627
c	Net income or (loss) from fundraising events..			-6,359		0	-6,359
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a		0
b	Less: direct expenses ...b		0
c	Net income or (loss) from gaming activities...			0	0	0	0
10a	Gross sales of inventory, less returns and allowances .
	a		0
b	Less: cost of goods sold ..b		0
c	Net income or (loss) from sales of inventory..			0	0	0	0
Miscellaneous Revenue			Business Code
11a	Meal Revenue		722212	71,793	0	0	71,793
b	Medical Record Copies		561499	13,547	0	0	13,547
c	Rebates		900099	4,418	0	0	4,418
d	All other revenue ....			34,197	0	0	34,197
e	Total. Add lines 11a–11d ......			123,955
12	Total revenue. See Instructions......			21,380,258	20,306,415	0	467,898


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			514,085	1	819,734
2	Savings and temporary cash investments .........			0	2	0
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			2,131,811	4	2,209,386
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			424,187	8	162,626
9	Prepaid expenses and deferred charges ..........			109,942	9	27,205
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	17,514,726
b	Less: accumulated depreciation .....	10b	13,439,530	3,809,455	10c	4,075,196
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			1,069,348	12	1,770,983
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......			8,058,828	16	9,065,130
17	Accounts payable and accrued expenses .........			4,112,296	17	4,113,052
18	Grants payable .................			0	18	0
19	Deferred revenue ................			0	19	74,282
20	Tax-exempt bond liabilities .............			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			737,415	23	984,621
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			4,122,988	25	1,842,937
26	Total liabilities. Add lines 17 through 25.........			8,972,699	26	7,014,892
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			-2,582,242	27	491,051
28	Temporarily restricted net assets ...........			239,635	28	94,938
29	Permanently restricted net assets ...........			1,428,736	29	1,464,249
	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 ...........			-913,871	33	2,050,238
34	Total liabilities and net assets/fund balances ........			8,058,828	34	9,065,130