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. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ASPIRUS GRAND VIEW
Employer identification number
38-2908586
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
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).
f
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
..................................................
g
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
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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
.......................
b
33 1/3% support test—2012.
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
.....................
17a
10%-facts-and-circumstances test—2013.
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
.....................................................
b
10%-facts-and-circumstances test—2012.
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
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
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.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
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
........
b
33 1/3% support tests—2012.
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
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
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.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
ASPIRUS GRAND VIEW
Employer identification number
38-2908586
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 1
THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE WHICH CONSISTS OF THE CHAIRPERSON, VICE CHAIRPERSON, SECRETARY, TREASURER, PAST CHAIRPERSON, AND CEO. THIS COMMITTEE HAS THE POWER TO ACT ON BEHALF OF THE ORGANIZATION DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD, SUBJECT TO ANY PRIOR AUTHORIZATION GRANTED BY THE BOARD.
FORM 990, PART VI, SECTION A, LINE 6
ASPIRUS GRAND VIEW'S MEMBERS ARE ASPIRUS, INC., A WISCONSIN NONPROFIT CORPORATION AND GOGEBIC RANGE HEALTH FOUNDATION, A MICHIGAN NONPROFIT CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7A
FOUR MEMBERS OF THE BOARD OF DIRECTORS ARE ELECTED BY ASPIRUS, INC. AND FOUR MEMBERS OF THE BOARD ARE ELECTED BY GOGEBIC RANGE HEALTH FOUNDATION.
FORM 990, PART VI, SECTION A, LINE 7B
ASPIRUS, INC. AND GOGEBIC RANGE HEALTH FOUNDATION HAVE THE FOLLOWING RIGHTS AND RESPONSIBILITIES: (A) INITIATE AND APPROVE ANY CHANGE IN PHILOSOPHY, CHARACTER, OR MISSION OF THE CORPORATION. (B) INITIATE AND APPROVE ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION. (C) AMEND THE BYLAWS OF THE CORPORATION AND ALL SUBSIDIARIES WITH SUPERSEDING AUTHORITY OVER AMENDMENTS ADOPTED BY THE BOARD AS PROVIDED IN THE ARTICLES OF INCORPORATION AND/OR THE BYLAWS. (D) INITIATE AND APPROVE THE ADDITION OF ANY NEW MEMBERS OF THE CORPORATION. (E) APPROVE THE ESTABLISHMENT, TRANSFER OF OWNERSHIP, AND/OR DISSOLUTION OF ANY SUBSIDIARY CORPORATIONS. (F) INITIATE AND APPROVE BORROWING OF MONEY AND OTHER FORMS OF INDEBTEDNESS IN EXCESS OF $5,000,000. (G) APPROVE THE PURCHASE, SALE, LEASE, DISPOSITION, ENCUMBRANCE, OR ALIENATION OF PROPERTY WITH A VALUE IN EXCESS OF $5,000,000. (H) INITIATE AND APPROVE ANY PLAN OF DISSOLUTION, MERGER, OR CONSOLIDATION.
FORM 990, PART VI, SECTION B, LINE 11
THE RETURN IS REVIEWED BY THE ORGANIZATION'S MANAGEMENT. WHEN A FINAL DRAFT OF THE RETURN IS COMPLETE, COPIES OF THE RETURN ARE PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO FILING THE RETURN WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
EACH OFFICER, DIRECTOR, AND KEY EMPLOYEE IS REQUIRED TO FILL OUT AN ANNUAL CONFLICT OF INTEREST FORM. THE FORM IS REVIEWED INITIALLY BY THE COO, THEN BY THE BOARD OF DIRECTORS TO REVIEW ANY POTENTIAL CONFLICTS. EACH PERSON WITH A CONFLICT IS RESTRICTED FROM VOTING ON RELATED MATTERS.
FORM 990, PART VI, SECTION B, LINE 15
THE BOARD OF DIRECTORS HAS A COMPENSATION COMMITTEE WHICH PROVIDES A MORE FORMAL REVIEW PROCESS OVER EXECUTIVE COMPENSATION. THE COMPENSATION COMMITTEE REVIEWS ANNUAL SALARY RECOMMENDATIONS FOR THE COO AND THE CFO. THE COMMITTEE USUES PERFORMANCE EVALUATIONS AND MARKET COMPARABILITY DATA TO MAKE THEIR DECISIONS.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST.
FORM 990, PART VII, SECTION A, COLUMN B
EXPLANATION OF HOURS WORKED: CAROL GOFFNETT, CHARMAINE CHIANTELLO, AND PAULA CHERMSIDE ARE EMPLOYED BY ASPIRUS GRAND VIEW. ASPIRUS GRAND VIEW'S PURPOSE IS TO PROVIDE HEALTH CARE SERVICES TO AREA RESIDENTS AND THOSE IN NEED OF CARE THROUGH THE OPERATION OF ITS HOSPITAL AND ITS SUBSIDIARY ORGANIZATIONS. CAROL GOFFNET, CHARMAINE CHIANTELLO, AND PAULA CHERMSIDE DEVOTE THEIR TIME PROVIDING MANAGEMENT SERVICES TO ASPIRUS GRAND VIEW AND RELATED ORGANIZATIONS. SIDNEY C. SCZYGELSKI, MARIA GULAN, JACOB KEMPEN, AND RICK NEVERS ARE EMPLOYED BY ASPIRUS, INC. AND ITS AFFILIATED ORGANIZATIONS. ASPIRUS, INC'S PURPOSE IS TO SERVE AS A SUPPORTING ORGANIZATION TO MULTIPLE SUBSIDIARY ORGANIZATIONS AS LISTED IN SCHEDULE R, AS WELL AS THE PARTNER HOSPITALS WHICH ASPIRUS, INC. HOLDS A MEMBERSHIP INTEREST IN THE OPERATIONS OF THOSE ADDITIONAL HOSPITALS. THE EMPLOYEES OF ASPIRUS, INC. DEVOTE THEIR TIME PROVIDING MANAGEMENT SERVICES TO THE RELATED ORGANIZATIONS AND AFFILIATED PARTNER HOSPITALS. THESE EMPLOYEES OFTEN WORK HOURS IN EXCESS OF AN AVERAGE OF 40 HOURS EACH WEEK IN ORDER TO FULFILL THIS MISSION. CHRISTOPHER POGLIANO, M.D. IS AN EMPLOYED PHYSICIAN OF ASPIRUS GRAND VIEW SERVICE CORPORATION, A NONPROFIT SUBSIDIARY OF ASPIRUS GRAND VIEW, AND PROVIDES AN AVERAGE OF 40 HOURS PER WEEK OF PHYSICIAN AND MANAGEMENT SERVICES WHILE WORKING FOR ASPIRUS GRAND VIEW SERVICE CORPORATION IN ADDITION TO HIS DUTIES ON THE BOARD OF DIRECTORS FOR ASPIRUS GRAND VIEW. HOURS WORKED AT RELATED ORGANIZATIONS ARE REFLECTED IN LINE 2 OF COLUMN B.
FORM 990, PART IX, LINE 11G
PHYSICIAN PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,925,320. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,925,320. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,959,109. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,959,109. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,416,402. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,416,402.
FORM 990, PART XII, LINE 2C:
ASPIRUS GRAND VIEW'S BOARD OF DIRECTORS PROVIDES OVERSIGHT OF THE INDEPENDENT ACCOUNTANTS AND THE MEMBERS OF THE BOARD MEET WITH THE ACCOUNTANT DURING THE AUDIT PROCESS TO DISCUSS THE AUDIT AND OTHER MATTERS. ASPIRUS GRAND VIEW ALSO IS PROVIDED ADDITIONAL OVERSIGHT OF THE AUDIT PROCESS AND SELECTION OF THE INDEPENDENT ACCOUNTANT THROUGH THE AUDIT COMMITTEE OF ASPIRUS, INC. THERE WAS NO CHANGE TO THIS PROCESS IN THE PAST YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.