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) JOHN THOMPSON DO........................................................................ TRUSTEE	41.00 .......................1.00	X		492,596	0	24,340
(2) FRANK GOUDREAU DO........................................................................ TRUSTEE	41.00 .......................1.00	X		474,462	0	24,013
(3) MICHAEL CARROLL MD........................................................................ TRUSTEE	1.00 .......................40.00	X		0	459,254	25,652
(4) GINA QUINN-SKILLINGS MD........................................................................ TRUSTEE	1.00 .......................40.00	X		0	303,808	25,758
(5) MARY O'HARE MD........................................................................ TRUSTEE	1.00 .......................40.00	X		0	268,489	25,895
(6) DONALD BURGESS MD........................................................................ TRUSTEE	1.00 .......................40.00	X		0	229,602	24,610
(7) WILLIAM FRANK MD........................................................................ TRUSTEE	5.00 .......................1.00	X		19,525	0	0
(8) ROBERT P BAUMAN........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(9) LORI ANN BLACK........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(10) JENNIFER CUTTS MD........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(11) JOAN R FINK........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(12) BERNARD GAINES........................................................................ CHAIRPERSON	1.00 .......................1.00	X	X	0	0	0
(13) GEORGE HISSONG JR........................................................................ VICE-CHAIRPE	1.00 .......................2.00	X	X	0	0	0
(14) RICHARD HULL........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(15) MARK MICKERIZ........................................................................ TRUSTEE	1.00 .......................1.00	X		0	0	0
(16) BRADFORD C PAIGE........................................................................ TREASURER	1.00 .......................1.00	X	X	0	0	0
(17) MERILEE PERKINS........................................................................ SECRETARY	1.00 .......................2.00	X	X	0	0	0

(A) Name and business address	(B) Description of services	(C) Compensation
MAK ANESTHESIA INC156 COUNTRY CLUB ROADSANFORDME04073	ANESTHESIA	633,342
LEONID TEMKIN MD PA239 ARUNDEL ROADKENNEBUNKME04046	ANESTHESIA	564,679
EDWARD BURZON PC1 SARAH PAUL HILLMADBURYNH03823	PHYSICIAN	314,379
THOMAS MOORE MD, 300 SLIGO ROADROLLINSFORDNH03869	PHYSICIAN	300,000
DONALD P LYON MD PAPO BOX 549LIMERICKME04048	PHYSICIAN	256,060
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 13

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	641,501		641,501
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	39,869,149	35,237,002	4,623,798	8,349
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......	6,922,888	6,021,309	900,160	1,419
10	Payroll taxes ...........	2,722,114	2,367,517	353,958	639
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	245,222		245,222
c	Accounting ...........	102,577		102,577
d	Lobbying ...........	13,125		13,125
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	7,331,537	5,175,137	2,156,400
12	Advertising and promotion ....	194,071		193,133	938
13	Office expenses .......	82,827	35,379	47,369	79
14	Information technology ......	490,750	189,205	301,545
15	Royalties ..
16	Occupancy ...........	1,442,117	559,602	882,515
17	Travel ............	14,198	12,234	1,964
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....	122,518	94,108	26,621	1,789
20	Interest ...........	817,718	760,765	56,953
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	3,511,091	3,511,091
23	Insurance ..............	921,617	809,578	112,039
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	SUPPLIES	7,916,788	7,831,473	84,880	435
b	PHYSICIAN FEES	4,286,457	4,286,457
c	TAXES	2,144,889	2,144,889
d	RENTAL & LEASE	1,922,525	1,816,970	105,555
e	All other expenses	1,949,526	1,114,559	817,742	17,225
25	Total functional expenses. Add lines 1 through 24e	83,665,205	71,967,275	11,667,057	30,873
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 .............	5,277	1	5,277
2	Savings and temporary cash investments .........	3,957,864	2	2,455,400
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	9,091,776	4	10,344,259
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6
7	Notes and loans receivable, net .............	851,677	7	851,677
8	Inventories for sale or use ..............	1,417,919	8	1,161,471
9	Prepaid expenses and deferred charges ..........	1,529,545	9	1,015,873
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	78,090,023
b	Less: accumulated depreciation .....	10b	46,076,499	32,760,127	10c	32,013,524
11	Investments—publicly traded securities ..........	11,664,433	11	12,893,054
12	Investments—other securities. See Part IV, line 11 .....	13,142,291	12	14,032,253
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	11,523,119	15	11,045,007
16	Total assets. Add lines 1 through 15 (must equal line 34)......	85,944,028	16	85,817,795
	17	Accounts payable and accrued expenses .........	14,711,137	17	13,061,335
18	Grants payable .................		18
19	Deferred revenue ................		19
20	Tax-exempt bond liabilities .............	9,396,449	20	8,889,806
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	12,148,451	23	10,933,682
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	655,698	25	1,219,640
26	Total liabilities. Add lines 17 through 25.........	36,911,735	26	34,104,463
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	38,367,160	27	39,731,324
28	Temporarily restricted net assets ...........	1,506,154	28	1,610,349
29	Permanently restricted net assets ...........	9,158,979	29	10,371,659
	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 ...........	49,032,293	33	51,713,332
34	Total liabilities and net assets/fund balances ........	85,944,028	34	85,817,795

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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

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part I

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

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

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

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

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

Yes

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

11g(i)

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

11g(ii)

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

11g(iii)

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

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


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

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

Section A. Public Support

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

Section B. Total Support

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

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

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

Section C. Computation of Public Support Percentage

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

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

16a

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

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

17a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

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

Section A. Public Support

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

Section B. Total Support

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

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

Section C. Computation of Public Support Percentage

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

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

Section D. Computation of Investment Income Percentage

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

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

19a

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

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

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

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

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

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

OMB No. 1545-0047

2012

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

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 HENRIETTA D GOODALL HOSPITAL INC

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 HENRIETTA D GOODALL HOSPITAL INC

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
HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part III

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

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

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

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

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2012

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2012

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Yes

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

13,125

Total. Add lines 1c through 1i ...............................

13,125

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

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

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
	SCHEDULE C, PART II-B, LINE 1	HENRIETTA D. GOODALL GOODALL HOSPITAL IS A MEMBER OF THE MAINE HOSPITAL ASSOCIATION (MHA), THE AMERICAN HOSPITAL ASSOCIATION (AHA), AND THE MAINE HEALTHCARE ASSOCIATION (MEHCA). 18.80% OR 6,789 OF THE DUES PAID TO MHA, 23.65% OR 4,020 OF THE DUES PAID TO AHA, AND 31.00% OR 2,315 OF THE DUES PAID TO MEHCA ARE AVAILABLE FOR LOBBYING.

Schedule C (Form 990 or 990EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

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

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

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
1a	Beginning of year balance ....	19,488,835	21,667,901	17,085,103	14,720,200
b	Contributions ........	1,714,897	466,220	1,898,375	642,735
c	Net investment earnings, gains, and losses	2,998,927	-1,610,061	2,691,423	1,962,857
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	1,495,981	1,035,225	7,000	240,689
f	Administrative expenses ....
g	End of year balance ......	22,706,678	19,488,835	21,667,901	17,085,103

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

Board designated or quasi-endowment SchDMd Bullet

54.000 %

Permanent endowment SchDMd Bullet

46.000 %

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

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

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	2,728,106		2,728,106
b	Buildings ................	47,028,708	25,549,697	21,479,011
c	Leasehold improvements ............	4,549,746	2,132,075	2,417,671
d	Equipment ................	20,449,773	16,371,635	4,078,138
e	Other .................	3,333,690	2,023,092	1,310,598
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				32,013,524

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) BENEFICIAL INT. IN PERP. TR.	9,440,011	F
(B) ALTERNATIVE INVESTMENTS	2,716,855	F
(C) INVESTMENT IN REAL PROPERTY	1,875,387	F






Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	14,032,253

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
(1) ESTIMATED SETTLEMENTS WITH MAINECARE				7,108,787
(2) INVESTMENTS IN SUBS & JOINT VENTURES				1,940,829
(3) TRUSTEE HELD FUNDS (BOND FUNDS)				650,595
(4) INSURANCE CAPTIVE				634,401
(5) DUE FROM AFFILIATES				393,228
(6) DEFEREED FINANCING COSTS				139,488
(7) HDG CAPITAL RESERVE CASH				100,199
(8) SYNERNET WORKERS' COMP CAPITAL CONTR				39,633
(9) CONTRIBUTION REC FROM REMAINDER TR				19,955
(10) INTANGIBLE ASSET - ORTHO MED RECORDS				17,892
(11) HDG DUE FROM TEMP NET ASSETS
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				11,045,007

Part X

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

1.(a) Description of liability		(b) Book value
Federal income taxes
INSURANCE CAPTIVE LIABILITY		634,401
EST. SETTLEMENTS DUE TO 3RD PARTY		585,239
PAYORS






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		1,219,640
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
LIABILITY UNDER FIN 48 FOOTNOTE	SCHEDULE D, PAGE 3, PART X	THE ORGANIZATION ANNUALLY EVALUATES ITS TAX STATUS AND TAX POSITIONS TAKEN WITH RESPECT TO ITS OPERATIONS AND FINANCIAL STATEMENT POSTION. TAX YEARS FROM 2009 THROUGH THE CURRENT YEAR ARE OPEN FOR EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES.
SUPPLEMENTAL FINANCIAL INFORMATION	SCHEDULE D, PAGE 4, PART XIII	PART V, LINE IV: UNDER THE POLICY OF THE ORGANIZATION, THE ENDOWMENT ASSETS ARE INVESTED CONSERVATIVELY WITH THE INTENT OF PROVIDING A PREDICTABLE STREAM OF FUNDING TO THE ORGANIZATION FOR PURCHASES OF CAPITAL, EXPANSION PROJECTS AND TO SUPPLEMENT GENERAL OPERATIONS.

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

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

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

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

Yes

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

Yes

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

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? ..........

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

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) ..	718,749		718,749	0.880 %
b	Medicaid (from Worksheet 3, column a) ....	14,682,383	10,295,560	4,386,823	5.380 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	15,401,132	10,295,560	5,105,572	6.260 %
Other Benefits		65,518		65,518	0.080 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	65,518		65,518	0.080 %
f	Health professions education (from Worksheet 5) ..	41,320		41,320	0.050 %
g	Subsidized health services (from Worksheet 6) ..
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	5,120		5,120	0.010 %
j	Total. Other Benefits ..	111,958		111,958	0.140 %
k	Total. Add lines 7d and 7j .	15,513,090	10,295,560	5,217,530	6.400 %

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.

		(c) Total community building expense	(e) Net community building expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	1,800	1,800
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	1,800	1,800

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. ......

3,290,967

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. ......

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).....

23,002,541

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

30,177,600

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

-7,175,059

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 %
1PINE TREE INSURANCE	PROVIDE MALPRACTICE INSURANCE FOR A	25.000 %
2A RECIPROCAL RISK	GROUP OF HEALTHCARE PROVIDERS
3RENTENTION GROUP
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	HENRIETTA D GOODALL HOSPITAL INC 25 JUNE STREET SANFORD,ME04073 WWWGOODALLHOSPITALORG	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)

	HENRIETTA D GOODALL HOSPITAL INC
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 11

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: 200.0% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 250.0% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13		No
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? .........................

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?9
Name and address		Type of Facility (describe)
1	NEWTON CENTER (ELDER CARE) 35 JULY STREET SANFORD,ME04073	NURSING HOME
2	GOODALL HEALTH PARTNERS 25 JUNE STREET SANFORD,ME04073	PHYSICIAN PRACTICES
3	WELLNESS CENTER 13 JULY STREET SANFORD,ME04073	CLINIC
4	GOODALL HEALTH PARTNERS 10 GOODALL DRIVE EAST WATERBORO,ME04070	PHYSICIAN PRACTICES
5	GOODALL HEALTH PARTNERS 272 COTTAGE STREET SANFORD,ME04073	PHYSICIAN PRACTICES
6	THE MEDICAL GROUP 2 LIVEWELL DRIVE KENNEBUNK,ME04043	PHYSICIAN PRACTICES
7	COMMUNITY SERVICES 15 DAIGLE STREET SANFORD,ME04073	COMMUNITY PROGRAMS
8	OCCUPATIONAL HEALTH SERVICES 2 LIVEWELL DRIVE KENNEBUNK,ME04043	CLINIC
9	GOODALL HEALTH CLINICS 2 LIVEWELL DRIVE KENNEBUNK,ME04043	CLINIC
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
COSTING METHODOLOGY EXPLANATION	PART I LINE 7	THE COSTING METHODOLOGY FOR THE AMOUNTS REPORTED IN PART I LINE 7 OF THE SCHEDULE H IS BASED ON A RATIO OF PATIENT CARE COST TO CHARGES THIS COST TO CHARGE RATIO WAS DERIVED FROM WORKSHEET 2 RATIO OF PATIENT CARE COSTTO CHARGES PROVIDED IN THE INSTRUCTIONS FOR SCHEDULE H
BAD DEBT EXPENSE EXPLANATION	PART III LINE 4	HENRIETTA D GOODALL HOSPITAL DOES NOT HAVE A SPECIFIC FOOTNOTE IN THE FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE HENRIETTA D GOODALL HOSPITAL REPORTS ACCOUNTS RECEIVABLE FOR SERVICES RENDERED NET OF ALLOWANCES FOR CONTRACTUAL ADJUSTMENTS THIRD PARTY REIMBURSING AGENCIES FREE CARE AND BAD DEBTS A BAD DEBT ALLOWANCE IS ESTABLISHED FOR ACCOUNTS THE HOSPITAL BELIEVES WILL BECOME UNCOLLECTIBLE THE ALLOWANCE IS ESTABLISHED BY EXAMINING HISTORICAL DATA AGING TRENDS OF COMMERCIAL INSURANCE AND SELFPAY BALANCES AND ECONOMIC TRENDS THE OFFSET TO THE ALLOWANCE ACCOUNT IS TO BAD DEBT EXPENSE ON THE STATEMENT OF OPERATIONS RECOVERIES ON ACCOUNTS PREVIOUSLY WRITTEN OFF ARE ACCOUNTED FOR ON A CASH BASIS AND ARE APPLIED DIRECTLY TO THE PROVISION FOR BAD DEBTS ON THE STATEMENT OF OPERATIONS AMOUNTS WRITTEN OFF OR RECOVERED FROM BAD DEBTS DURING THE YEAR ARE CHARGED AGAINST THE ALLOWANCE ACCOUNT ON THE BALANCE SHEET BAD DEBT EXPENSE REPRESENTS HEALTHCARE SERVICES HENRIETTA D GOODALL HOSPITAL HAS PROVIDED WITHOUT COMPENSATION AS A TAX EXEMPT HOSPITAL HENRIETTA D GOODALL HOSPITAL PROVIDES NECESSARY PATIENT CARE REGARDLESS OF THE PATIENTS ABILITY TO PAY FOR THE SERVICES A PORTION OF HENRIETTA D GOODALL HOSPITALS BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE THAT FOR A VARIETY OF REASONS DO NOT COMPLETE THE FINANCIAL ASSISTANCE APPLICATION PROCESS HENRIETTA D GOODALL HOSPITAL CANNOT DETERMINE THE AMOUNT OF BAD DEBT EXPENSE THAT COULD BE REASONABLY ATTRIBUTABLE TO PATIENTS WHO LIKELY WOULD QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITALS FREE CARE POLICY IN ADDITION BAD DEBT EXPENSE ALSO INCLUDES AMOUNTS FOR SERVICES PROVIDED TO INDIVIDUALS EXPERIENCING DIFFICULT PERSONAL OR ECONOMIC CIRCUMSTANCES RELATED TO A PORTION OF OUR COMMUNITY BASED PATIENT POPULATION THEIR MEDICAL BILLS OFTEN PLACE THESE INDIVIDUALS IN UNTENABLE POSITIONS WHERE THEY ARE NOT ABLE TO HANDLE THEIR PERSONAL DEBT AND THEN THEIR NEW MEDICAL DEBT HOWEVER BECAUSE OF THEIR INCOME LEVELS THEY DO NOT QUALIFY FOR FREE CARE BY PROVIDING NECESSARY HEALTHCARE SERVICES TO THOSE INDIVIDUALS WHO FAIL TO APPLY FOR FINANCIAL ASSISTANCE OR WHO ARE EXPERIENCING PERSONAL OR ECONOMIC CIRCUMSTANCES HENRIETTA D GOODALL HOSPITAL BELIEVES THAT BAD DEBT EXPENSE SHOULD BE INCLUDED AS A COMMUNITY BENEFIT
MEDICARE EXPLANATION	PART III LINE 8	MEDICARE ALLOWABLE COSTS WERE CALCULATED USING A COST TO CHARGE RATIO HENRIETTA D GOODALL HOSPITAL BELIEVES THAT THE MEDICARE SHORTFALL SHOULD BE INCLUDED AS A COMMUNITY BENEFIT BECAUSE GOODALL HOSPITAL HAS A CLEAR MISSION COMMITTMENT TO SERVING ELDERLY PATIENTS AND ADULTS WITH DISABILITIES THROUGH THE PROVISION OF SPECIFIC SUBSIDIZED PROGRAMS DEVELOPED TO HELP IMPROVE THE HEALTH STATUS OF THESE PATIENTS IF THESE CRITICAL SUBSIDIZED PROGRAMS WERE NOT PROVIDED BY H D GOODALL HOSPITAL THEY WOULD BECOME THE OBLIGATION OF THE FEDERAL GOVERNMENT
NEEDS ASSESSMENT	PART VI	GOODALL HOSPITALS BOARD OF TRUSTEES IS MADE UP OF A DIVERSE GROUP OF COMMUNITY MEMBERS THE BOARD OF TRUSTEES REQUIRES A THOROUGH COMMUNITY NEEDS ASSESSMENT ON BEHALF OF THE ORGANIZATION AND DIRECTS THE ORGANIZATION TO ANALYZE AND RESPOND TO THE CURRENT NEEDS ASSESSMENT MAINEHEALTH ALSO PARTICIPATES IN VARIOUS INITIATIVES TO HELP SUPPORT AND PROVIDE UPDATES TO COMMUNITY NEEDS ASSESSMENT PLANNING SOME OF THESE INITIATIVES INCLUDE CLINICAL STARTEGIC PLANNING FINANCIAL PLANNING MANPOWER PLANNING PHYSICIAN RECRUITMENT STRATEGIC PLANNING EMERGENCY PREPAREDNESS PLANNING ALONG WITH THE INTERNAL ASSESSMENTS MOST MEMBER ORGANIZATIONS ALSO REVIEW AND ACT ON MANY OF THE RECOMMENDATIONS PROVIDED BY EXTERNAL GROUPS SUCH AS THE MAINE CENTER FOR DISEASE CONTROL AND PREVENTION AND THE STATE HEALTH PLAN CREATED BY THE ADVISORY COMMITTEE FOR HEALTH SYSTEMS DEVELOPMENT THE CURRENT COMMUNITY NEEDS ASSESSMENT WAS OBTAINED THROUGH PARTICIPATING WITH MAINEHEALTH GOODALLSS PARENT COMPANY AND ITS PARTNERS IN THE ONEMAINE HEALTH COLLABORATIVE EASTERN MAINE HEALTH SYSTEM AND MAINEGENERAL HEALTH THE ONEMAINE HEALTH COMMUNTIY NEEDS ASSESSMENT REPORT WAS RELEASED IN MARCH 2011 THE REPORT IS A COMPREHENSIVE COMPILATION AND ANALYSIS CONTAINING PRIMARY AND SECONDARY HEALTH DATA SOURCES THE REPORT CONTAINS A HEALTH STATUS PROFILE FOR THE STATE AS A WHOLE AND FOR EACH OF MAINES SIXTEEN COUNTIES THE PRIMARY DATA SOURCE WAS A RANDOMIZED TELEPHONE SURVEY THE SAMPLING METHODOLOGY WAS DESIGNED TO PERMIT COMPARISONS AT THE COUNTY LEVEL SECONDARY DATA SOURCES INCLUDE NUMEROUS STATE AND FEDERAL SOURCES THIS REPORT PROVIDES BASELINE DATA ON HUNDREDS OF HEALTH INDICATORS THAT ARE RELEVANT TO HOSPITALS AND COMMUNITIES TO INFORM PLANNING AND EVALUATION ACTIVITIES PLANS CALL FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT TO BE REPLICATED EVERY THREE YEARS MAINEHEALTH WILL HOLD COMMUNITY FORUMS IN PARTNERSHIP WITH EACH MEMBERAND AFFILIATE HOSPITAL IN ORDER TO INCREASE UNDERSTANDING AND USE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT AND TO INFORM IDENTIFICATION AND ACTION ON LOCAL COMMUNITYBASED HEALTH PRIORITIES
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	PART VI	GOODALL HOSPITAL EMPLOYS A FINANCIAL COUNSELOR WHO ASSISTS AND EDUCATES PATIENTS AND THEIR FAMILIES ON FINANCIAL MATTERS CONCERNING THE HOSPITAL CHARITY CARE POLICY AND ELIGIBILITY FOR STATE AND FEDERAL PROGRAMS THIS ASSISTANCE CAN BE AS SPECIFIC AS ASSISTING THE PATIENT ANDOR FAMILIES IN COMPLETING THE VARIOUS FORMS REQUIRED BY MEDICAID AND MEDICARE POSTING OF THE FINANCIAL ASSISTANCE CONTACT INFORMATION IS PRESENT IN ADMISSION AREAS EMERGENCY ROOMS AND OTHER AREAS OF THE ORGANIZATIONS FACILITIES WHERE ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT PATIENT BILLS INCLUDE A SUMMARY OF THE POLICY ALONG WITH FINANCIAL ASSITANCE CONTACT INFORMATION GOODALL HOSPITAL WORKS WITH GOODALLSS SELF PAY PATIENTS ADVANCED PATIENT ADVOCACY PROGRAM THAT SCREEN FOR ALL INPATIENT AND OUTPATIENTS THAT MEET THE APPROPRIATE CRITERIA THIS PROGRAM EFFECTIVELY EDUCATES PATIENTS ABOUT THEIR COVERAGE OPTIONS NAVIGATE COMPLEX PROGRAM CRITERIA AND ENROLL MORE UNINSURED IN PROGRAMS THAT BEST MATCH THEIR NEEDS THE HOSPITALS SENIOR ADVOCATE PROGRAM PROVIDES FREE ADVICES AND SERVICES TO THE ELDERLY MEMBERS OF THE COMMUNITY THIS PROGRAM IS DESIGNED TO BE A CENTRAL POINT OF ACCESS FOR SENIOR CITIZENS TO OBTAIN INFORMATION RESOURCES AND ADVOCACY PROGRAM RESOURCES INCLUDE BUT ARE NOT LIMITED TO MEDICARE RETIREMENT PLANNING HOUSING FINANCIAL ASSISTANCE INSURANCE COUNSELING FRAUD PROTECTION AS WELL AS COMPREHENSIVE ELIGIBLITY SCREENING FROM A HOST OF GOVERNMENT STATE ASSISTANCE PROGRAMS AND OTHER LOCAL FUNDING SOURCES GOODALLS PRESCRIPTION ASSISTANCE PROGRAM IS DESIGNED TO ASSIST THOSE WHO DO NOT QUALIFY FOR OTHER TRADITIONAL ASSISTANCE PROGRAMS SUCH AS MEDICARE PART D OR MAINECARE BUT WHOSE FINANCIAL SITUATION QUALIFIES THEM TO RECEIVE SUPPORT THE COORDINATOR SERVES AS A LIASON BETWEEN THE HEALTHCARE PROVIDER PHARMACEUTICAL COMPANIES AND THE PATIENT THE GOALS OF THIS PROGRAM ARE TO ASSIST INDIVIDUALS WITHOUT PRESCRIPTION DRUG COVERAGE IN NAVIGATING THE SYSTEM OBTAINING THEIR PRESCRIBED MEDICATIONS AND DEVELOPING LONGTERM SOLUTIONS TOWARDS ACQUIRING MEDICATIONS IN THE FUTURE
COMMUNITY INFORMATION	PART VI	GOODALL HOSPITAL SERVICES THE POPULATION OF WESTERN YORK COUNTY MAINE SANFORD IS THE TOWN WITH THE LARGEST POPULATION IN THE HOSPITALS SERVICE AREA WITH A POPULATION OF APPROXIMATELY 21000 WITH AN ELDERLY POPULATION RATE OF 15 AND FAMILIES REPRESENTING 64 OF THIS POPULATION WITH 93 BEING CAUCASIAN THE HOSPITALS MEDICAID VOLUME IS 18 AND IS AMONGST THE HIGHEST IN THE STATE AND REFLECTS THE HIGH PERCENTAGE OF FAMILIES WITH INCOME LESS THAN 100 OF THE FEDERAL POVERTY LEVEL SANFORDS POVERTY RATE IS 17 WHILE THE STATE OF MAINE IS AT 12 72 OF SANFORDS ELEMENTARY SCHOOL CHILDREN ARE ELIGIBLE TO RECEIVE FREE OR SUBSIDIZED MEALS
HEALTH OF COMMUNITY IN RELATION TO EXEMPT PURPOSE	PART VI	A MAJORITY OF THE ORGANIZATIONS GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATIONS PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION NOR FAMILY MEMBERS THEREOF OUR DIRECTORSMANAGERSCOORDINATORS AND EMPLOYEES OF GOODALL HOSPITAL ARE ENCOURAGED TO PARTICIPATE IN THE COMMUNITYS ACTIVIES AND SUPPORT GROUPS THAT BENEFIT THE COMMUNITY AT LARGE EXAMPLES OF THESE ACTIVITIES ARE AS FOLLOWS COLLABORATING WITH THE TOWN LIBRARY TO PRESENT EVENTS AROUND HEALTH AND LITERACY OF THE PERSONS SUPPORT INTRODUCE AND COACH FAMILIES TO PROGRAMS IN WHICH THEY CAN UNDERSTAND THEIR OWN HEALTH AND SAFETY WHICH RESULT ON A FOCUS ON REDUCING PREVENTABLE ILLNESSES AND INJURIES THUS REDUCING HEALTHCARE TREATMENT COSTS AND IMPROVING LIVES LINKING FAMILIES WITH OTHER FAMILIES THAT ARE EXPERIENCING SIMILAR LIFE CIRCUMSTANCES THROUGH COMMUNITY EVENTS THAT INCLUDE THE PARENT AND CHILD PARTICIPATION LEAD SCREENING AND PREVENTION EDUCATION TEST KIT MAILERS AND INFORMATION TO ALERT THE COMMUNITIES OF THE IMPORTANCE OF LEASE TESTING AND TREATMENT IF APPROPRIATE AT YOUNG AGES
AFFILIATED HEALTH CARE INFORMATION	PART VI	MAINEHEALTH IS A NOTFORPROFIT FAMILY OF LEADING HIGHQUALITY PROVIDERS AND OTHER HEALTHCARE ORGANIZATIONS WORKING TOGETHER SO THEIR COMMUNITIES ARE THE HEALTHIEST IN AMERICA RANKED AMONG THE NATIONS TOP 100 INTEGRATED HEALTHCARE DELIVERY NETWORKS MAINEHEALTH IS GOVERNED BY A BOARD OF TRUSTEES CONSISTING OF COMMUNITY AND BUSINESS LEADERS FROM ITS SOUTHERN CENTRAL AND WESTERN REGIONAL SERVICE AREAS THE COLLABORATION OF MAINEHEALTH MEMBERS MAKES IT POSSIBLE TO OFFER A EXTENSIVE RANGE OF CLINICAL INTEGRATION AND COMMUNITY HEALTH PROGRAMS MANY AIMED AT IMPROVING ACCESS TO PREVENTATIVE AND PRIMARY CARE SERVICES MAINEHEALTH INCLUDES THE FOLLOWING MEMBER ORGANIZATIONS LINCOLN COUNTY HEALTHCARE MAINE MEDICAL CENTER MAINE MENTAL HEALTH PARTNERS SPRING HARBOR HOSPITAL PEN BAY HEALTHCARE PEN BAY MEDICAL CENTER SOUTHERN MAINE MEDICAL CENTER HENRIETTA D GOODALL HOSPITAL WALDO COUNTY HEALTHCARE WALDO COUNTY GENERAL HOSPITAL WESTERN MAINE HEALTH CARE STEPHENS MEMORIAL HOSPITAL HOMEHEALTH VISITING NURSES OF SOUTHERN MAINE MAINE PHYSICIAN HOSPITAL ORGANIZATION NORDX LABS SYNERNET MAINEHEALTH ACCOUNTABLE CARE ORGANIZATION AND MAINEHEALTH CARDIOLOGY AFFILIATES OF MAINEHEALTH INCLUDE MAINEGENERAL MEDICAL CENTER MID COAST HOSPITAL NEW ENGLAND REHABILITATION HOSPITAL OF PORTLAND AND ST MARYS REGIONAL HOSPITAL
LIST OF STATES WHERE COMMUNITY BENEFIT REPORT IS FILED	PART VI	MAINE
HENRIETTA D GOODALL HOSPITAL INC LINE NUMBER 1 PART V LINE 3	PART V LINE 3	OVER 3100 YORK DISTRICT RESIDENTS PARTICIPATED IN THIS PROCESS EITHER BY RESPONDING TO A COUNTYWIDE SURVEY ANDOR PARTICIPATING IN COMMUNITY MEETINGS TO IDENTIFY KEY HEALTH ISSUES AND COMMUNITY CONCERNS THIS INFORMATION WAS COLLECTED TO INFORM THE DEVELOPMENT OF COMMUNITY HEALTH IMPROVEMENT PLAN THAT MAXIMIZES RESOURCES TAKES INTO ACCOUNT UNIQUE CIRCUMSTANCES AND NEEDS AND FORMS EFFECTIVE PARTNERSHIPS FOR STRATEGIC ACTION
HENRIETTA D GOODALL HOSPITAL INC LINE NUMBER 1 PART V LINE 5C	PART V LINE 5C	THE ASSESSMENT WAS ALSO MADE AVAILABLE THROUGH OTHER NONHOSPITAL FACILITIES AND ON THE WEB HTTPWWWCTBHORGDOCUMENTSYORKDISTRICTSTRATEGICPLANAPRIL2011PDF
HENRIETTA D GOODALL HOSPITAL INC LINE NUMBER 1 PART V LINE 20D	PART V LINE 20D	THE HOSPITAL USES COST AS THE BASIS FOR MARKUP THE MARKUP TO CHARGE INCLUDES DIFFERING PERCENTAGES BASED ON A TIER COSTING SYSTEM

Schedule H (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

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

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)JOHN THOMPSON DOTRUSTEE	(i) (ii)	492,596			2,500	21,840	516,936
(2)FRANK GOUDREAU DOTRUSTEE	(i) (ii)	474,462			2,500	21,513	498,475
(3)MICHAEL CARROLL MDTRUSTEE	(i) (ii)	365,724	92,569	961	10,000	15,652	484,906
(4)GINA QUINN-SKILLINGS MDTRUSTEE	(i) (ii)	303,071		737	10,000	15,758	329,566
(5)MARY O'HARE MDTRUSTEE	(i) (ii)	267,842		647	9,548	16,347	294,384
(6)DONALD BURGESS MDTRUSTEE	(i) (ii)	229,293		309	9,184	15,426	254,212
(7)PATRICIA APRILEPRESIDENTCEO	(i) (ii)	357,297	38,957		2,500	14,811	413,565
(8)DANIEL D FORGUESCFO	(i) (ii)	195,795	20,000		2,046	10,095	227,936
(9)PETER L CLARK DOPHYSICIAN	(i) (ii)	352,468			2,500	20,050	375,018
(10)JONATHAN P SHILL MDPHDPHYSICIAN	(i) (ii)	312,533	20,000		3,750	2,979	339,262
(11)NINA SHERVIN MDPHYSICIAN	(i) (ii)	327,988			2,500	6,278	336,766
(12)STEVEN E JOHNSON MDPHYSICIAN	(i) (ii)	299,221			2,581	20,793	322,595
(13)ANDREW D POWELL MDPHYSICIAN	(i) (ii)	282,559			2,581	16,957	302,097

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

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

Identifier	Return Reference	Explanation

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization
HENRIETTA D GOODALL HOSPITAL INC

Employer identification number
01-0078060

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	MAINE HEALTH AND HIGHER EDUCATIONAL FACILITIES AUTHORITY	01-0314384	560425D49	09-07-2006	6,020,317	RENOVATE & EQUIPMENT		X		X		X
B	MAINE HEALTH AND HIGHER EDUCATIONAL FACILITIES AUTHORITY	01-0314385	560425H37	07-18-2007	5,108,908	REFI MHHEFA BD 1996A		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired . . . . . . . . . . . . . .
2 Amount of bonds legally defeased . . . . . . . . . . .
3 Total proceeds of issue . . . . . . . . . . . . . .	6,020,317		5,108,908
4 Gross proceeds in reserve funds . . . . . . . . . . . .	522,453		451,093
5 Capitalized interest from proceeds . . . . . . . . . . .
6 Proceeds in refunding escrows . . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . . .	55,514		56,115
8 Credit enhancement from proceeds . . . . . . . . . . .
9 Working capital expenditures from proceeds . . . . . . . . .
10 Capital expenditures from proceeds . . . . . . . . . . .	5,836,740
11 Other spent proceeds . . . . . . . . . . . . . .
12 Other unspent proceeds . . . . . . . . . . . . . .	293,000
13 Year of substantial completion . . . . . . . . . . . .	2007
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .		X		X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X	X
16 Has the final allocation of proceeds been made? . . . . . . . .	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	X		X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . . . . . .		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2012

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use of bond-financed property? . . . . . . . . . . . .		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property? . . . . . . . . . . . . . . . .
c Are there any research agreements that may result in private business use of bond-financed property? . . . . . . . . . . . . . . .		X		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property? .
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . .	%		%		%		%
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government . . . . . . .	%		%		%		%
6 Total of lines 4 and 5 . . . . . . . . . . . . . . .	%		%		%		%
7 Does the bond issue meet the private security or payment test? . . . . .		X		X
8a Has there been a sale or disposition of any of the bond financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?. . . . . . . . . . . . . . . . .		X		X
b If “Yes” to line 8a, enter the percentage of bond-financed property sold or disposed of.	%		%		%		%
c If “Yes” to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? . . . . . . . . . . . . .		X		X
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2?		X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T? . . . . .	X			X
2 If "No" to line 1, did the following apply? . . . .
a Rebate not due yet? . . . . . . . .		X		X
b Exception to rebate? . . . . . . . .		X		X
c No rebate due? . . . . . . . . . .		X		X
If you checked "No rebate due" in line 2c, provide in Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? . . . .		X		X
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X
b Name of provider . . . . . . . . .
c Term of hedge . . . . . . . . . .
d Was the hedge superintegrated? . . . . . .
e Was a hedge terminated? . . . . . . .

Schedule K (Form 990) 2012

Page 3

Part IV

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? . . . . . . . . .		X		X
b Name of provider . . . . . . . . .
c Term of GIC . . . . . . . . . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? . . . . .
6 Were any gross proceeds invested beyond an available temporary period? . . . . . . . .		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?		X

Part VI

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

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE K	MAINE HEALTH AND HIGHER EDUCATIONAL SCHEDULE K PART I BOND ISSUES A ISSUER NAME MAINE HEALTH AND HIGHER EDUCATIONAL FACILITIES AUTHORITY B DESCRIPTION OF PURPOSE RENOVATE HOSPITAL AND PURCHASE EQUIPMENT MAINE HEALTH AND HIGHER EDUCATIONAL SCHEDULE K PART I BOND ISSUES A ISSUER NAME MAINE HEALTH AND HIGHER EDUCATIONAL FACILITIES AUTHORITY B DESCRIPTION OF PURPOSE REFINANCE MHHEFA BOND 1996A

Schedule K (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Part I

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

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

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

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

Part II

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

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






Total ...... $

Part III

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

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

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

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2012

Page 2

Part IV

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

(a) Name of interested person	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person	(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) MARK MICKERIZ	3,869,068	SANFORD INST FOR SAV		No
(2) WILLIAM FRANK	19,525	GOODALL HOSPITAL		No

Part V

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

Identifier	Return Reference	Explanation
ADDITIONAL INFORMATION	SCHEDULE L PART V	SCHEDULE L PART IV BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS A NAME OF PERSON MARK MICKERIZ B RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION MEMBER OF GOODALL HOSPITALS BOARD AND PRESIDENT OF SANFORD INSTITUTE FOR SAVINGS D DESCRIPTION OF TRANSACTION SANFORD INSTITUTE FOR SAVINGS SIS HAS FOUR OUTSTANDING LOANS WITH HENRIETTA D GOODALL HOSPITAL INC THE ORIGINAL AMOUNT OF THE LOANS WERE 7368000 AND AS OF MAY 31 2013 THE OUTSTANDING BALANCE ON THE LOANS WERE 3869680 A NAME OF PERSON WILLIAM FRANK B RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION MEMBER OF GOODALL HOSPITALS BOARD OF TRUSTEES D DESCRIPTION OF TRANSACTION GOODALL HOSPITAL CONTRACTS WITH DR FRANK TO PERFORM VARIOUS DUTIES AT THE HOSPITAL SUCH AS ON CALL IMPACT COVERAGE AND SOME COMMITTIES

Schedule L (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

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

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

Identifier	Return Reference	Explanation
ORGANIZATION'S MISSION	FORM 990 - ORGANIZATION'S MISSION	HENRIETTA D. GOODALL HOSPITAL'S, INC.'S MISSION IS TO SERVE AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF ITS COMMUNITY. HENRIETTA D. GOODALL HOSPITAL, INC. OWNS AND OPERATES H. D. GOODALL HOSPITAL, INC. (ACUTE CARE HOSPITAL), GOODALL HEALTH PARTNERS (A MULTI-SPECIALTY PHYSICIAL AND SURGEON GROUP), THE MEDICAL GROUP (A MULT-SPECIALTY PHYSICIAN AND SURGEON GROUP, GOODALL OUTPATIENT CLINIC (A FACILITY WHERE A VARIETY OF OUTPATIENT SERVICES ARE PERFORMED), GOODALL OUTPATIENT SERVICES-WATERBORO AND GOODALL ELDERCARE SERVICES (A LONG TERM CARE FACILITY) IN YORK COUNTY. YORK COUNTY CONSISTS OF 18 TOWNS AND CITIES LOCATED ON THE SOUTHERN MAINE COAST WITH A POPULATION OF OVER 200,000. HENRIETTA D. GOODALL HOSPITAL, INC. FURTHERS ITS MISSION AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF THE COMMUNITY AND PROVIDES ACCESS TO NEEDED HEALTHCARE SERVICES 365 DAYS A YEAR, 24 HOURS A DAY.
FIRST ACCOMPLISHMENT DESCRIPTION	FORM 990, PAGE 2, PART III, LINE 4A	ASSOCIATED WITH PROVIDING THE COMMUNITY WITH A VARIETY OF SPECIAL COMPLIMENTARY EDUCATIONAL AND INFORMATIONAL SERVICES. GOODALL PROUDLY SPONSORS COMMUNITY ORGANIZATIONS, SCHOOL GROUPS, CIVIC ORGANIZATIONS AND SPECIAL EVENTS (LIKE THE LOCAL BASEBALL TEAM). GOODALL HOSPITAL SPONSORS TWO TO FOUR FREE EDUCATION EVENTS EACH MONTH OF THE YEAR ALONG WITH DOZENS OF SUPPORT GROUPS. GOODALL HOSPITAL ALSO ROUTINELY PARTICIPATES IN HEALTH FAIRS AND BUSINESS EVENTS, PERFORMING BLOOD PRESSURE CHECKS, CHOLESTEROL SCREENINGS AND CPR TRAINING. GOODALL HOSPITAL'S SENIOR ADVOCATE PROVIDES FREE ADVICE AND SERVICES TO ELDERLY MEMBERS OF THE COMMUNITY. SERVICES INCLUDE HELP WITH INSURANCE AND MEDICAL ISSUES, AS WELL AS PERSONAL ISSUES INCLUDING TAX INFORMATION, FINANCES AND HOME NEEDS.
ALL OTHER ACCOMPLISHMENT DESCRIPTION	FORM 990, PAGE 2, PART III, LINE 4D	THE MEDICAL GROUP CONSISTS OF MANY PHYSICIANS WITH MULTI-SPECIALTY SERVICES THAT EXTEND GOODALL HOSPITAL'S EXISTING SERVICES TO KENNEBUNK, ME. THESE PHYSICIANS COMPLEMENT THE HOSPITAL IN MAINTAINING ITS MISSION TO SERVE AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF OUR COMMUNITY. THESE SERVICES INCLUDE (BUT ARE NOT LIMITED TO) FULL SERVICE PRIMARY CARE, WOMEN'S HEALTH, GASTROENTEROLOGY, PULMONARY MEDICINE, ORTHOPEDICS AND PAIN MANAGEMENT. THE MEDICAL GROUP PROVIDED 12,846 IN CHARITY CARE TO THE COMMUNITY. THE NUMBER OF PATIENTS SEEN WERE 10,855 FOR A TOTAL NUMBER OF 27,633 PATIENT DAYS.
SIGNIFICANT CHANGES TO ORGANIZATIONAL DOCUMENTS	FORM 990, PAGE 6, PART VI, LINE 4	HENRIETTA D. GOODALL HOSPITAL AMENDED ITS ARTICLES OF INCORPORTATION AND BYLAWS SO THAT SOUTHERN MAINE HEALTH CARE (SMHC) SERVES AS THE PARENT ORGANIZATION AND SOLE CORPORATE MEMBER OF THE HOSPITAL AND SOUTHERN MAINE MEDICAL CENTER.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990	FORM 990, PAGE 6, PART VI, LINE 11B	THE FORM 990 WAS MADE AVAILABLE TO THE FULL BOARD OF TRUSTEES. THE CFO OF SOUTHERN MAINE HEALTH CARE REVIEWS THE FORM 990 IN DETAIL BEFORE SIGNING THE RETURN.
ENFORCEMENT OF CONFLICTS POLICY	FORM 990, PAGE 6, PART VI, LINE 12C	AS INDICATED IN LINE 12B, GOODALL HOSPTIAL REQUIRES CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES TO COMPLETE AN ANNUAL QUESTIONAIRE CONCERNING ANY POTENTIAL CONFLICTS OF INTEREST. THE ORGANIZATION REVIEWS THE REPSONSES TO THESE DOCUMENTS AND ADDRESSES ANY ISSUES IMMEDIATELY. IN ADDITION, WE HAVE ADDED ANOTHER QUESTIONAIRE THAT SPECIFICALLY ADDRESSES THE CONCERNS REGARDING TRANSACTIONS INVOLVING CURRENT AND FORMER OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES AND CERTAIN PARTIES THAT ARE RELATED TO THESE INDIVIDUALS.
COMPENSATION PROCESS FOR TOP OFFICIAL	FORM 990, PAGE 6, PART VI, LINE 15A	THE BOARD OF DIRECTORS APPROVES COMPENSATION FOR THE CEO AFTER CAREFUL REVEIW OF INDUSTRY SALARY INFORMATION (COMPENSATION STUDY) WITH AN OUTSIDE COMPENSATION CONSULTANT.
COMPENSATION PROCESS FOR OFFICERS	FORM 990, PAGE 6, PART VI, LINE 15B	UNDER THE GUIDANCE OF PROFESSIONAL COMPENSATION CONSULTANTS, THE HR DIRECTOR REVIEWS THE PAY MODEL WITH THE CEO AND COO TO ENSURE THAT THE ORGANIZATION IS ABLE TO RECRUIT AND RETAIN A HIGH QUALIFIED WORKFORCE, WHILE PROVIDING THE NECESSARY STRUCTURE TO EFFECTIVELY MANAGE THE COMPETETIVE ADVANTAGE OF PRODUCTIVITY, TOTAL QUALITY, CUSTOMER SERVICE AND COSTS.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION	FORM 990, PAGE 6, PART VI, LINE 19	DOCUMENTS THAT ARE REQUIRED TO BE OPEN FOR PUBLIC INSPECTION ARE MADE AVAILABLE UPON REQUEST.
OTHER CHANGES IN NET ASSETS EXPLANATION	FORM 990, PART XI, LINE 9	INCREASE IN BENEFICIAL INTEREST IN PERPETUAL TRUST 1,212,004 UNREALIZED GAIN ON TEMPORARY NET ASSETS 122,707 EQUITY TRANSFERS 53,712 LOSS ON EXTINGUISHMENT OF DEBT 143,793 TOTAL OTHER CHANGES IN NET ASSETS: 1,244,630

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

HENRIETTA D GOODALL HOSPITAL INC

Employer identification number

01-0078060

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) MANOR AT PHILLIPSTOWN PLACE INC 25 JUNE STREET SANFORD,ME04073 01-0473857	ELDER CARE	ME	501C3	9	HD GOODALL D GOODALL HOSPITAL INC		No
(2) THE WEBBER HOSPITAL ASSOC DBA SMMC PO BOX 626 BIDDEFORD,ME04005 01-0179500	HOSPITAL	ME	501C3	3	SMHC		No
(3) CANCER CARE CENTER OF YORK COUNTY 22 BRAMHALL STREET PORTLAND,ME04102 20-1600381	MED SVCS	ME	501C3	3	SMHC		No
(4) MAINEHEALTH 110 FREE STREET PORTLAND,ME04101 01-0431680	HEALTHCARE	ME	501C3	11C	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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) GSM REALTY LLC 22 BRAMHALL STREET PORTLAND,ME04102 20-4582952	REAL EST.	ME	SMHC	RELATED	6,750	439,834		No			No	33.330 %

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) JUNE STREET PHARMACY LLC 25 JUNE STREET SANFORD,ME04073 02-0765952	PHARMACY	ME	HD GOODALL D GOODALL HOSPITAL INC	C CORP	963,495	17,822	100.000 %		No
(2) SOUTHERN MAINE HEALTH CARE PO BOX 626 BIDDEFORD,ME04005 46-1211705	HEALTHCARE	ME	N/A						No
(3) SMMC PRIMECARE PHYSICIAN SERVICES PO BOX 626 BIDDEFORD,ME04005 26-3345134	MED SVCS	ME	N/A						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 . . . . . . . . . . . . . . . . . . . . . . .

Yes

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

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

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

Yes

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

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

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

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

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

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

Yes

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

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

Yes

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

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

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

Yes

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

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

Yes

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

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

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

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) MANOR AT PHILLIPSTOWN PLACE INC	K	96,648	COST INCURRED HEALTH INS
(2) MANOR AT PHILLIPSTOWN PLACE INC	N	18,000	COST INCURRED FOR MGT SVC
(3) MANOR AT PHILLIPSTOWN PLACE INC	P	55,952	ACTUAL COSTS INCURRED
(4) MANOR AT PHIILIPSTOWN PLACE INC	K	27,550	COST INCURRED OTHER EXP
(5) JUNE STREET PHARMACY LLC	A	6,642	ACTUAL INTEREST CHARGED
(6) JUNE STREET PHARMACY LLC	K	43,284	COST INCURRED HEALTH INS
(7) JUNE STREET PHARMACY LLC	N	14,998	COST INCURRED FOR MGT SVC
(8) JUNE STREET PHARMACY LLC	K	17,887	COST INCURRED OTHER EXP
(9) JUNE STREET PHARMACY LLC	D	637,589	ACTUAL PRINCIPAL DUE NOTE
(10) JUNE STREET PHARMACY LLC	I	32,420	COST INCURRED RENT
(11) JUNE STREET PHARMACY LLC	P	478,884	REIMBURSEMENT OF EXPENSES
(12) JUNE STREET PHARMACY LLC	R	161,717	EXTINGUISHMENT OF DEBT
(13) JUNE STREET PHARMACY LLC	D	17,873	ACTUAL LOAN AMOUNT
(14) MANOR AT PHILLIPSTOWN PLACE INC	K	96,648	COST INCURRED HEALTH INS
(15) MANOR AT PHILLIPSTOWN PLACE INC	N	18,000	COST INCURRED FOR MGT SVC
(16) MANOR AT PHILLIPSTOWN PLACE INC	P	55,952	ACTUAL COSTS INCURRED
(17) MANOR AT PHIILIPSTOWN PLACE INC	K	27,550	COST INCURRED OTHER EXP
(18) JUNE STREET PHARMACY LLC	A	6,642	ACTUAL INTEREST CHARGED
(19) JUNE STREET PHARMACY LLC	K	43,284	COST INCURRED HEALTH INS
(20) JUNE STREET PHARMACY LLC	N	14,998	COST INCURRED FOR MGT SVC
(21) JUNE STREET PHARMACY LLC	K	17,887	COST INCURRED OTHER EXP
(22) JUNE STREET PHARMACY LLC	D	637,589	ACTUAL PRINCIPAL DUE NOTE
(23) JUNE STREET PHARMACY LLC	I	32,420	COST INCURRED RENT
(24) JUNE STREET PHARMACY LLC	P	478,884	REIMBURSEMENT OF EXPENSES
(25) JUNE STREET PHARMACY LLC	R	161,717	EXTINGUISHMENT OF DEBT
(26) JUNE STREET PHARMACY LLC	D	17,873	ACTUAL LOAN AMOUNT
(27) MANOR AT PHILLIPSTOWN PLACE INC	K	96,648	COST INCURRED HEALTH INS
(28) MANOR AT PHILLIPSTOWN PLACE INC	N	18,000	COST INCURRED FOR MGT SVC
(29) MANOR AT PHILLIPSTOWN PLACE INC	P	55,952	ACTUAL COSTS INCURRED
(30) MANOR AT PHIILIPSTOWN PLACE INC	K	27,550	COST INCURRED OTHER EXP
(31) JUNE STREET PHARMACY LLC	A	6,642	ACTUAL INTEREST CHARGED
(32) JUNE STREET PHARMACY LLC	K	43,284	COST INCURRED HEALTH INS
(33) JUNE STREET PHARMACY LLC	N	14,998	COST INCURRED FOR MGT SVC
(34) JUNE STREET PHARMACY LLC	K	17,887	COST INCURRED OTHER EXP
(35) JUNE STREET PHARMACY LLC	D	637,589	ACTUAL PRINCIPAL DUE NOTE
(36) JUNE STREET PHARMACY LLC	I	32,420	COST INCURRED RENT
(37) JUNE STREET PHARMACY LLC	P	478,884	REIMBURSEMENT OF EXPENSES
(38) JUNE STREET PHARMACY LLC	R	161,717	EXTINGUISHMENT OF DEBT
(39) JUNE STREET PHARMACY LLC	D	17,873	ACTUAL LOAN AMOUNT

Schedule R (Form 990) 2012

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

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

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: HENRIETTA D. GOODALL HOSPITAL'S, INC.'S MISSION IS TO SERVE AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF ITS COMMUNITY. HENRIETTA D. GOODALL HOSPITAL, INC. OWNS AND OPERATES H. D. GOODALL HOSPITAL, INC. (ACUTE CARE HOSPITAL), GOODALL HEALTH PARTNERS (A MULTI-SPECIALTY PHYSICIAL AND SURGEON GROUP), THE MEDICAL GROUP (A MULT-SPECIALTY PHYSICIAN AND SURGEON GROUP, GOODALL OUTPATIENT CLINIC (A FACILITY WHERE A VARIETY OF OUTPATIENT SERVICES ARE PERFORMED), GOODALL OUTPATIENT SERVICES-WATERBORO AND GOODALL ELDERCARE SERVICES (A LONG TERM CARE FACILITY) IN YORK COUNTY. YORK COUNTY CONSISTS OF 18 TOWNS AND CITIES LOCATED ON THE SOUTHERN MAINE COAST WITH A POPULATION OF OVER 200,000. HENRIETTA D. GOODALL HOSPITAL, INC. FURTHERS ITS MISSION AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF THE COMMUNITY AND PROVIDES ACCESS TO NEEDED HEALTHCARE SERVICES 365 DAYS A YEAR, 24 HOURS A DAY.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	19
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	1,099
6	Total number of volunteers (estimate if necessary) .............	6	197
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	222,387
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-62,174

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,446,041	2,300,781
9	Program service revenue (Part VIII, line 2g) .........	87,287,884	78,738,132
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	776,194	849,234
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,177,360	1,856,255
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	91,687,479	83,744,402
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	49,695,968	50,155,652
16a	Professional fundraising fees (Part IX, column (A), line 11e).....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 30,873
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	39,812,989	33,509,553
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	89,508,957	83,665,205
19	Revenue less expenses. Subtract line 18 from line 12.......	2,178,522	79,197
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	85,944,028	85,817,795
21	Total liabilities (Part X, line 26).............	36,911,735	34,104,463
22	Net assets or fund balances. Subtract line 21 from line 20.....	49,032,293	51,713,332

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 49,658,152 including grants of $ ) (Revenue $ 63,058,668 )
	GOODALL HOSPITAL IS A 58 BED HOSPITAL WHICH STRIVES TO MEET THE HEALTH CARE NEEDS OF INDIVIDUALS AND FAMILIES THROUGHOUT YORK COUNTY. GOODALL HOSPITAL OFFERS A BROAD RANGE OF MEDICAL, SURGICAL, DIAGNOSTIC, CLINICAL AND REHABILITATION SERVICES, WELLNESS EDUCATION, SUPPORT GROUPS AND OTHER COMMUNITY OUTREACH PROGRAMS. GOODALL HOSPITAL HAD 21,394 EMERGENCY ROOMS VISITS, 46,963 RADIOLOGY PROCEDURES, 371,628 LABORATORY PROCEDURES, 149 INFANTS BORN, AND 2,506 SURGERY CASES. GOODALL HOSPITAL PROVIDED 1,729,454 IN CHARITY CARE TO THE COMMUNITY. THIS INCLUDES PATIENTS WHO ARE UNDERINSURED OR THOSE WITHOUT ANY INSURANCE. IN ADDITION TO THE CHARITABLE CARE SERVICES, WE ARE CONTINUALLY ABSORBING ALL THE COSTS (CONTINUED ON SCHEDULE O) ASSOCIATED WITH PROVIDING THE COMMUNITY WITH A VARIETY OF SPECIAL COMPLIMENTARY EDUCATIONAL AND INFORMATIONAL SERVICES. GOODALL PROUDLY SPONSORS COMMUNITY ORGANIZATIONS, SCHOOL GROUPS, CIVIC ORGANIZATIONS AND SPECIAL EVENTS (LIKE THE LOCAL BASEBALL TEAM). GOODALL HOSPITAL SPONSORS TWO TO FOUR FREE EDUCATION EVENTS EACH MONTH OF THE YEAR ALONG WITH DOZENS OF SUPPORT GROUPS. GOODALL HOSPITAL ALSO ROUTINELY PARTICIPATES IN HEALTH FAIRS AND BUSINESS EVENTS, PERFORMING BLOOD PRESSURE CHECKS, CHOLESTEROL SCREENINGS AND CPR TRAINING. GOODALL HOSPITAL'S SENIOR ADVOCATE PROVIDES FREE ADVICE AND SERVICES TO ELDERLY MEMBERS OF THE COMMUNITY. SERVICES INCLUDE HELP WITH INSURANCE AND MEDICAL ISSUES, AS WELL AS PERSONAL ISSUES INCLUDING TAX INFORMATION, FINANCES AND HOME NEEDS.

4b	(Code: ) (Expenses $ 10,005,865 including grants of $ ) (Revenue $ 8,723,782 )
	GOODALL HEALTH PARTNERS CONSISTS OF MANY PHYSICIANS WITH MULTI-SPECIALTY SERVICES IN DIFFERENT LOCATIONS THROUGHOUT YORK COUNTY. THESE PHYSICIANS COMPLIMENT THE HOSPITAL IN MAINTAINING ITS MISSIONS TO SERVE AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF OUR COMMUNITY BY SERVING THE POPULOUS. THESE SPECIALTIES INCLUDE (BUT ARE NOT LIMITED TO) CARDIOLOGY, EAR NOSE AND THROAT, FAMILY PRACTICES, WOMEN'S HEALTH, INTERNAL MEDICINE, PEDIATRICS, ORTHO AND GENERAL SURGERY. GOODALL HEALTH PARTNERS PROVIDED 44,569 IN CHARITY CARE TO THE COMMUNITY. THE NUMBER OF PATIENTS SEEN WERE 21,413 FOR A TOTAL NUMBER OF VISITS OF 60,122.

4c	(Code: ) (Expenses $ 6,629,612 including grants of $ ) (Revenue $ 7,821,962 )
	GOODALL HOSPITAL ELDERCARE SERVICES PROVIDE LONG-TERM CARE, MEDICAL SERVICES AND DAYCARE TO OUR SENIOR CITIZENS. ELDERCARE HAD A TOTAL OF 39,238 PATIENT DAYS. WE CONTINUE TO GROW AND ADAPT TO THE NEEDS OF OUR COMMUNITY WITH THIS SERVICE. GOODALL HOSPITAL ELDERCARE PRIDES THEMSELVES BY CREATING A HOME-LIKE, COMFORTABLE ENVIRONMENT FOR THE RESIDENTS AND STAFF. THE NEWTON CENTER FOR REHABILITATION AND NURSING CARE PROMOTES HIGH QUALITY CARE; WITH DEDICATED STAFF, FAMILY EDUCATION AND INVOLVEMENT MAKE THIS PROGRAM SPECIAL. GOODALL HOSPITAL ELDERCARE SERVICES PROVIDED 14,456 IN CHARITY CARE TO THE COMMUNITY.

	(Code: ) (Expenses $ 5,673,646 including grants of $ ) (Revenue $ 4,139,990 )
	THE MEDICAL GROUP CONSISTS OF MANY PHYSICIANS WITH MULTI-SPECIALTY SERVICES THAT EXTEND GOODALL HOSPITAL'S EXISTING SERVICES TO KENNEBUNK, ME. THESE PHYSICIANS COMPLEMENT THE HOSPITAL IN MAINTAINING ITS MISSION TO SERVE AS A LEADER IN IMPROVING THE HEALTH AND WELL-BEING OF OUR COMMUNITY. THESE SERVICES INCLUDE (BUT ARE NOT LIMITED TO) FULL SERVICE PRIMARY CARE, WOMEN'S HEALTH, GASTROENTEROLOGY, PULMONARY MEDICINE, ORTHOPEDICS AND PAIN MANAGEMENT. THE MEDICAL GROUP PROVIDED 12,846 IN CHARITY CARE TO THE COMMUNITY. THE NUMBER OF PATIENTS SEEN WERE 10,855 FOR A TOTAL NUMBER OF 27,633 PATIENT DAYS.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 5,673,646 including grants of $ ) (Revenue $ 4,139,990 )
4e	Total program service expenses71,967,275

(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) ROBERT C QUENTIN........................................................................ TRUSTEE	1.00 .......................1.00	X			0	0	0
(19) ROBERT REINKEN........................................................................ TRUSTEE	1.00 .......................1.00	X			0	0	0
(20) PATRICIA APRILE........................................................................ PRESIDENT/CE	49.00 .......................1.00		X		396,254	0	17,311
(21) DANIEL D FORGUES........................................................................ CFO	40.00 .......................0.00		X		215,795	0	12,141
(22) PETER L CLARK DO........................................................................ PHYSICIAN	40.00 .......................0.00			X	352,468	0	22,550
(23) JONATHAN P SHILL MDPHD........................................................................ PHYSICIAN	40.00 .......................0.00			X	332,533	0	6,729
(24) NINA SHERVIN MD........................................................................ PHYSICIAN	40.00 .......................0.00			X	327,988	0	8,778
(25) STEVEN E JOHNSON MD........................................................................ PHYSICIAN	40.00 .......................0.00			X	299,221	0	23,374
(26) ANDREW D POWELL MD........................................................................ PHYSICIAN	40.00 .......................0.00			X	282,559	0	19,538

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	3,193,401	1,261,153	260,689

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		1,776,927

f	All other contributions, gifts, grants, and similar amounts not included above1f		523,854

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			2,300,781
			Business Code
2a	NET PATIENT SERVICE REVENUE		900099	77,793,830	77,793,830
b	MEDICARE MEANINGFUL USE		900099	721,915	721,915
c	NET PATIENT SERVICE REVENUE		621500	222,387		222,387
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			78,738,132
3	Investment income (including dividends, interest, and other similar amounts).......			563,752			563,752
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	581,477
b	Less: rental expenses	922,107
c	Rental income or (loss)	-340,630
d	Net rental income or (loss).......			-340,630	-340,630
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	3,902,677	5,500
b	Less: cost or other basis and sales expenses	3,599,326	23,369
c	Gain or (loss)	303,351	-17,869
d	Net gain or (loss)..........			285,482			285,482
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	EQUITY IN SUBSIDIARIES		900099	841,980	841,980
b	REBATE REVENUE		900099	419,606	419,606
c	CAFETERIA REVENUE		900099	294,775	294,775
d	All other revenue ....			640,524	640,524
e	Total. Add lines 11a–11d ......			2,196,885
12	Total revenue. See Instructions......			83,744,402	80,372,000	222,387	849,234


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			5,277	1	5,277
2	Savings and temporary cash investments .........			3,957,864	2	2,455,400
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			9,091,776	4	10,344,259
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net .............			851,677	7	851,677
8	Inventories for sale or use ..............			1,417,919	8	1,161,471
9	Prepaid expenses and deferred charges ..........			1,529,545	9	1,015,873
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	78,090,023
b	Less: accumulated depreciation .....	10b	46,076,499	32,760,127	10c	32,013,524
11	Investments—publicly traded securities ..........			11,664,433	11	12,893,054
12	Investments—other securities. See Part IV, line 11 .....			13,142,291	12	14,032,253
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			11,523,119	15	11,045,007
16	Total assets. Add lines 1 through 15 (must equal line 34)......			85,944,028	16	85,817,795
17	Accounts payable and accrued expenses .........			14,711,137	17	13,061,335
18	Grants payable .................				18
19	Deferred revenue ................				19
20	Tax-exempt bond liabilities .............			9,396,449	20	8,889,806
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			12,148,451	23	10,933,682
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			655,698	25	1,219,640
26	Total liabilities. Add lines 17 through 25.........			36,911,735	26	34,104,463
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			38,367,160	27	39,731,324
28	Temporarily restricted net assets ...........			1,506,154	28	1,610,349
29	Permanently restricted net assets ...........			9,158,979	29	10,371,659
	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 ...........			49,032,293	33	51,713,332
34	Total liabilities and net assets/fund balances ........			85,944,028	34	85,817,795