TY 2014 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)
(1) Ed Bergeron Jr........................................................................ Trustee	1.00 .......................1.50	X	0	0
(2) John Birkmeyer MD........................................................................ Trustee	1.00 .......................61.50	X	261,699	34,858
(3) Judith A Boule MD........................................................................ Medical Staff President	1.00 .......................41.50	X	324,618	276,540
(4) Wendy Fielding CPA........................................................................ Trustee	1.00 .......................41.50	X	220,559	57,824
(5) Timothy J Fisher MD........................................................................ Trustee	1.00 .......................41.50	X	276,988	74,562
(6) H Roger Hansen........................................................................ Trustee	1.00 .......................2.00	X	0	0
(7) Steve Horton........................................................................ Trustee	1.00 .......................1.50	X	0	0
(8) Nathalie Houder........................................................................ Trustee	1.00 .......................1.50	X	0	0
(9) Lawrence J Jaeger MD........................................................................ Trustee	1.00 .......................41.50	X	317,909	252,282
(10) Judy Kalich........................................................................ Trustee	1.00 .......................1.50	X	0	0
(11) Michael Kapiloff........................................................................ Trustee	1.00 .......................1.50	X	0	0
(12) Mary Ann Kristiansen........................................................................ Trustee	1.00 .......................1.50	X	0	0
(13) Geof Molina........................................................................ Trustee	1.00 .......................1.50	X	0	0
(14) Steven Paris MD........................................................................ Trustee	1.00 .......................41.50	X	357,571	117,329
(15) Leslie T Pitts MD........................................................................ Trustee	1.00 .......................41.50	X	264,764	209,530
(16) Kary Shumway........................................................................ Trustee	1.00 .......................1.50	X	0	0
(17) Katherine Snow........................................................................ Trustee	1.00 .......................1.50	X	0	0

(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)	(F) Estimated amount of other compensation from the organization and related organizations
(18) Sylvia McBeth........................................................................ Chair	2.00 .......................1.50	X	X			0	0	0
(19) Gregg R Tewksbury CPA........................................................................ Vice Chair	1.00 .......................1.50	X	X			0	0	0
(20) Robert Mucha........................................................................ Treasurer	1.00 .......................1.50	X	X			0	0	0
(21) Mary Louise Caffrey........................................................................ Secretary	1.00 .......................1.50	X	X			0	0	0
(22) Arthur W Nichols........................................................................ President	50.00 .......................3.00	X	X			572,249	0	99,303
(23) Don Caruso MD........................................................................ CEO/CMO	11.50 .......................41.50	X	X			0	344,756	254,418
(24) Robert Cochrane........................................................................ CFO	51.00 .......................2.00		X			207,760	0	18,168
(25) Cindi Coughlin........................................................................ CNO	52.00 .......................			X		196,449	0	106,069
(26) Paul Pezone........................................................................ VP Facilities & Support Se	52.00 .......................			X		185,637	0	39,262
(27) Erli Chen........................................................................ Physicist	50.00 .......................				X	233,043	0	44,230
(28) Larry Miller........................................................................ Chief CRNA	50.00 .......................				X	201,108	0	72,699
(29) Julie Green........................................................................ VP, Human Resources	50.00 .......................				X	181,868	0	44,843
(30) Yvonne Goldsberry........................................................................ Sr. Director of Community Health	50.00 .......................				X	168,691	0	33,745
(31) Letasha Heape........................................................................ CRNA	50.00 .......................				X	155,877	0	29,164

(A) Name and business address	(B) Description of services	(C) Compensation
Quest Diagnostics 5763 Collection Center Drive Chicago,IL60693	Lab Diagnostic Services	616,382
New England Medical Transcription Inc PO Box 430 Woolwich,ME04579	Transcription Services	563,367
RF-WORKS 2172 Citygate Drive Columbus,OH43219	Wireless Network Services	484,778
Cheshire Anesthesia Associates 580 Court Street Keene,NH034311718	Anesthesiology Services	455,000
Allscripts LLC 24630 Network Place Chicago,IL606731246	Electronic Health Record Technology	426,384
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 26

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 domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ....
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 ............
4	Benefits paid to or for members ....
5	Compensation of current officers, directors, trustees, and key employees ....	1,424,897	1,162,716	262,181
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 ....	42,504,221	34,676,766	7,827,455
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,808,691	1,475,892	332,799
9	Other employee benefits .......	12,048,473	10,239,334	1,809,139
10	Payroll taxes ...........	3,246,531	2,618,327	628,204
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	217,772		217,772
c	Accounting ...........	64,750		64,750
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ....	25,451,065	23,946,880	1,504,185
12	Advertising and promotion ....	295,286	295,286
13	Office expenses .......	1,152,151	929,210	222,941
14	Information technology ......	374,359	301,921	72,438
15	Royalties ..
16	Occupancy ...........	5,390,734	4,347,627	1,043,107
17	Travel ............	231,315	186,556	44,759
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	1,070,933	863,707	207,226
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	9,751,781	7,864,811	1,886,970
23	Insurance ..............	484,149	390,466	93,683
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	Med Supplies, Drugs, et	26,475,274	26,475,274
b	Bad Debt Expense	8,306,085	8,306,085
c	JOA Gainshare	7,640,000	6,161,660	1,478,340
d	PILOT and MET	7,090,020	7,090,020
e	All other expenses	9,369,946	8,078,761	1,291,185
25	Total functional expenses. Add lines 1 through 24e	164,398,433	145,411,299	18,987,134	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............	25,492,399	1	16,131,280
2	Savings and temporary cash investments .........		2
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	13,248,900	4	16,470,755
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 .............		7
8	Inventories for sale or use ..............	2,338,661	8	2,859,734
9	Prepaid expenses and deferred charges ..........	2,646,392	9	3,240,328
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	204,097,244
b	Less: accumulated depreciation .....	10b	125,616,574	67,062,017	10c	78,480,670
11	Investments—publicly traded securities ..........		11
12	Investments—other securities. See Part IV, line 11 .....	20,014,572	12	21,598,882
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14	394,167
15	Other assets. See Part IV, line 11 ...........	6,784,375	15	5,451,613
16	Total assets. Add lines 1 through 15 (must equal line 34)......	137,587,316	16	144,627,429
	17	Accounts payable and accrued expenses .........	12,675,495	17	14,668,106
18	Grants payable .................		18
19	Deferred revenue ................	34,853	19	10,471
20	Tax-exempt bond liabilities .............	30,131,888	20	29,350,588
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 ..	424,044	23	217,360
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....................	21,737,818	25	21,884,681
26	Total liabilities. Add lines 17 through 25.........	65,004,098	26	66,131,206
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	68,092,699	27	73,914,740
28	Temporarily restricted net assets ...........	4,490,519	28	4,581,483
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	72,583,218	33	78,496,223
34	Total liabilities and net assets/fund balances ........	137,587,316	34	144,627,429

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
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Attach to Form 990 or Form 990-EZ.
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Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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 in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations .............................

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

(i)Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i)Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2014

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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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 VI.)..
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 section 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2014 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2013 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2014. 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—2013. 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—2014. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2013. 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 VI 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) 2014

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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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) 2010	(b) 2011	(c) 2012	(d) 2013	(e) 2014	(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 VI.) ..
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 section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2014 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2013 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2014 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2013 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2014. 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—2013. 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) 2014

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 11a or 11b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations....

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed, (ii) the reasons for each such action, (iii) the authority under the organization's organizing document authorizing such action, and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (a) its supported organizations; (b) individuals that are part of the charitable class benefited by one or more of its supported organizations; or (c) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in IRC 4958(c)(3)(C)), a family member of a substantial contributor, or a 35-percent controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part II of Schedule L (Form 990).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9(a)) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9(a)) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of IRC 4943 because of IRC 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

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

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Schedule A (Form 990 or 990-EZ) 2014

Page 5

Part IV

Supporting Organizations (continued)

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (1) a written notice describing the type and amount of support provided during the prior tax year, (2) a copy of the Form 990 that was most recently filed as of the date of notification, and (3) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2014

Page 6

Part V – Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

1. Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by .035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6
7	Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2014

Page 7

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity
3 Administrative expenses paid to accomplish exempt purposes of supported organizations
4 Amounts paid to acquire exempt-use assets
5 Qualified set-aside amounts (prior IRS approval required)
6 Other distributions (describe in Part VI). See instructions
7Total annual distributions. Add lines 1 through 6.
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions
9 Distributable amount for 2014 from Section C, line 6
10 Line 8 amount divided by Line 9 amount

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2014	(iii) Distributable Amount for 2014
1 Distributable amount for 2014 from Section C, line 6
2 Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2014:
a From 2009.......X
b From 2010.......X
c From 2011.......X
d From 2012.......X
e From 2013.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2014 distributable amount
i Carryover from 2009 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2014 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2014 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2015. Add lines 3j and 4c.
8 Breakdown of line 7:
a From 2010.......X
b From 2011.......X
c From 2012.......X
d From 2013.......
e From 2014.......

Schedule A (Form 990 or 990-EZ) (2014)

Schedule A (Form 990 or 990-EZ) 2014

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2014

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.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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, contributions totaling $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) 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), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions 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 an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled 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 totaling $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 its Form 990PF, Part I, line 2, 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) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 2

Name of organization The Cheshire Medical Center

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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 3

Name of organization The Cheshire Medical Center

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) (2014)

Schedule B (Form 990, 990-EZ, or 990-PF) (2014)

Page 4

Name of organization
The Cheshire Medical Center

Employer identification number

02-0354549

Part III

Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10)
that total more than $1,000 for the year from any one contributor. 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) (2014)

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

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

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) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

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

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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) 2014

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 separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2011	(b) 2012	(c) 2013	(d) 2014	(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) 2014

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)? ....

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

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

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

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

Yes

21,737

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

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

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

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

21,737

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

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Part II-B, Line 1:	A portion of American Hospital Association and NH Hospital Association dues are available for lobbying. During 2014, the amounts available for lobbying were $6,252 and $15,485, respectively.

Schedule C (Form 990 or 990EZ) 2014

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.
Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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 value of contributions to (during year)
3	Aggregate value of 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)

Revenue 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:

Revenue 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) 2014

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, for escrow or custodial account liability?

Yes No

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

Part V

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

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	4,487,520	3,602,059	3,055,274	2,634,569	2,445,561
b	Contributions ........	968,233	272,723	234,785	154,965	168,756
c	Net investment earnings, gains, and losses	414,873	929,038	688,499	484,487	299,947
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	1,223,773	316,300	376,499	218,747	279,695
f	Administrative expenses ....
g	End of year balance ......	4,646,853	4,487,520	3,602,059	3,055,274	2,634,569

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

100.000 %

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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	231,151		231,151
b	Buildings ................	92,248,987	48,056,156	44,192,831
c	Leasehold improvements ............
d	Equipment ................	111,356,871	77,560,418	33,796,453
e	Other .................	260,235		260,235
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				78,480,670

Schedule D (Form 990) 2014

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. 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) Pooled Investments	20,654,035	F
(B) Funded Depreciation Account	944,847	F







Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	21,598,882

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment		(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. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value









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

Part X

Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes
Pension Liability		10,094,198
Due to Related Party		11,790,483







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		21,884,681
2. Liability for uncertain tax positions. 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) 2014

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	161,985,206
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	-698,531
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	303,944
e	Add lines 2a through 2d .....................			2e	-394,587
3	Subtract line 2e from line 1.....................			3	162,379,793
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	1,459,697
c	Add lines 4a and 4b.......................			4c	1,459,697
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	163,839,490

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	163,319,809
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	381,073
e	Add lines 2a through 2d......................			2e	381,073
3	Subtract line 2e from line 1.....................			3	162,938,736
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	1,459,697
c	Add lines 4a and 4b.......................			4c	1,459,697
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	164,398,433

Part XIII

Supplemental Information

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.

Return Reference	Explanation
Part V, Line 4:	Income from the endowments is used to support the Organization's programs.
Part X, Line 2:	The Medical Center and its controlled affiliates are not-for-profit corporations as described in Section 501(c)(3) of the Code, and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management has evaluated its tax positions and concluded that the Medical Center and its controlled affiliates have maintained tax-exempt status, do not have any significant unrelated business income and have taken no uncertain tax positions that require adjustment to or disclosure in the accompanying financial statements. KHS is a for-profit organization and, in accordance with federal and state laws, files a return separate from that of the Foundation. KHS files a consolidated federal income tax return and a state income tax return in New Hampshire. In 2015 and 2014, no federal income taxes were charged to operations due to KHS incurring an operating loss on a consolidated basis. With few exceptions, the Medical Center, Foundation and KHS are no longer subject to income tax examination by the U.S. federal or state tax authorities for years before 2012.
Part XI, Line 2d - Other Adjustments:	Revenue allocated to Cheshire Health Services 303,944. Expenses included in revenue per Audited Financial Statements
Part XI, Line 4b - Other Adjustments:	Expenses included in revenue per Audited Financial Statements 1,459,697.
Part XII, Line 2d - Other Adjustments:	Expenses allocated to Cheshire Health Services 381,073.
Part XII, Line 4b - Other Adjustments:	Expenses included in revenue per Audited Financial Statements 1,459,697.

Schedule D (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE F(Form 990)

Department of the Treasury
Internal Revenue Service

Statement of Activities Outside the United States

Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16. Right pointing arrow large image

Attach to Form 990. Right pointing arrow large image

Information about Schedule F (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization
The Cheshire Medical Center

Employer identification number

02-0354549

Part I

General Information on Activities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 14b.

For grantmakers. Does the organization maintain records to substantiate the amount of its grants

and other assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria

used to award the grants or assistance? ...........................

Yes

For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of its grants and other assistance outside the United States.

Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)

(a) Region		(b) Number of offices in the region	(c) Number of employees, agents, and independent contractors in region	(d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region)	(f) Total expenditures for and investments in region
	Central America and the Caribbean - Antigua & Barbuda, Aruba, Bahamas,	0	0	Investments In Investment Entities Domiciled In Foreign Jurisdictions	3,920,233
















3a	Sub-total .....	0	0		3,920,233
b	Total from continuation sheets to Part I ...	0	0		0
c	Totals (add lines 3a and 3b)	0	0		3,920,233

For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2014

Schedule F (Form 990) 2014

Page 2

Part II

Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.

1 (a) Name of organization		(b) IRS code section and EIN (if applicable)	(a)(c) Region	(b)(d) Purpose of grant	(e) Amount of cash grant	(f) Manner of cash disbursement	(g) Amount of non-cash assistance	(h) Description of non-cash assistance	(i) Method of valuation (book, FMV, appraisal, other)

Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter .... MediumBullet

Enter total number of other organizations or entities ....................... MediumBullet

Schedule F (Form 990) 2014

Schedule F (Form 990) 2014Page 3

Part III

Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.

Part III can be duplicated if additional space is needed.

(a) Type of grant or assistance		(b) Region	(c) Number of recipients	(d) Amount of cash grant	(e) Manner of cash disbursement	(f) Amount of non-cash assistance	(g) Description of non-cash assistance	(h) Method of valuation (book, FMV, appraisal, other)

Schedule F (Form 990) 2014

Page 4

Part IV

Foreign Forms

Schedule F (Form 990) 2014

Page 5

Part V

Supplemental Information
Provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).

ReturnReference	Explanation
Schedule F, Part I, line 3:	The legal owner of The Cheshire Medical Center's foreign investments is a related organization, The Cheshire Health Foundation. Since a portion of the total foreign investments are allocated to the Medical Center's assets on the financial statements, those allocated investments have been disclosed on Schedule F, Part I, line 3 of The Cheshire Medical Center's Form 990. However, any required IRS Forms 926 and other foreign tax reporting obligations are filed by the legal owner, The Cheshire Health Foundation.
Schedule F, Part IV, line 3:	The Cheshire Medical Center did not have an ownership interest in any foreign corporation that is greater than the 10% filing threshold. Accordingly, IRS Form(s) 5471 is not required to be filed.
Schedule F, Part IV, line 4:	The Cheshire Medical Center meets the exception for tax-exempt organizations with respect to filing Form 8621. Accordingly, Form 8621 is not required to be filed for the Hospital.

Schedule F (Form 990) 2014

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the TreasuryInternal Revenue Service

Hospitals

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

Attach to Form 990.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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 22500.0000000000 %

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 criteria used 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? ..........

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..			1,473,000		1,473,000	0.940 %
b	Medicaid (from Worksheet 3, column a) ....			20,378,053	7,609,041	12,769,012	8.180 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .			21,851,053	7,609,041	14,242,012	9.120 %
Other Benefits		26	16,765	1,483,923	109,293	1,374,630	0.880 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	26	16,765	1,483,923	109,293	1,374,630	0.880 %
f	Health professions education (from Worksheet 5) ..	6	1,102	350,157	832	349,325	0.220 %
g	Subsidized health services (from Worksheet 6) ..	2	182	1,305,964		1,305,964	0.840 %
h	Research (from Worksheet 7)	1	43	280,425	117,191	163,234	0.100 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	6	265	251,975	40,472	211,503	0.140 %
j	Total. Other Benefits ..	41	18,357	3,672,444	267,788	3,404,656	2.180 %
k	Total. Add lines 7d and 7j .	41	18,357	25,523,497	7,876,829	17,646,668	11.300 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2014

Schedule H (Form 990) 2014

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	1	21,240	145,942	79,756	66,186	0.040 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	3	4,481	64,019	48,500	15,519	0.010 %
7	Community health improvement advocacy	1		56,878		56,878	0.040 %
8	Workforce development
9	Other	2		454,417		454,417	0.290 %
10	Total	7	25,721	721,256	128,256	593,000	0.380 %

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. ......

3,206,149

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. ......

802,000

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).....

61,719,557

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

72,037,969

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

-10,318,412

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2014

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, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	Cheshire Medical Center 580 Court Street Keene,NH03431 www.cheshire-med.com 00014	X	X	X

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	The Cheshire Medical Center
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a State as a hospital facility in the current tax year or the immediately preceding tax year?.......................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C..........

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 12....................

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 significant 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 Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 13

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C 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 Section C................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Yes

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 (list url): See Part V, Section C

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 13

Is the hospital facility's most recently adopted implementation strategy posted on a website? ........

Yes

If "Yes" (list url): See Part V, Section C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

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)? ...........................

12a

If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? ......

12b

If "Yes" to line 12b, 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) 2014

Page

Part VFacility Information (continued)

	The Cheshire Medical Center
Name of hospital facility or letter of facility reporting group

Yes

Financial Assistance Policy (FAP)

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 included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 225.000000000000%
and FPG family income limit for eligibility for discounted care of 300.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application.

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application.

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process.

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications.

Other (describe in Section C)

Included measures to publicize the policy within the community served by the hospital facility?.......

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url): See Part V, Section C

The FAP application form was widely available on a website (list url): See Part V, Section C

A plain language summary of the FAP was widely available on a website (list url):
See Part V, Section C

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Notice of availability of the FAP was conspicuously displayed throughout the hospital facility

Notified members of the community who are most likely to require financial assistance about availability of the FAP

Other (describe in Section C)

Billing and Collections

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 all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

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 individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

	The Cheshire Medical Center
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility or other authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?.........

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 18. (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 individuals regarding the individuals’ bills

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

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required 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 Section C)

Other (describe in Section C)

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 Section C)

During the tax year, did the hospital facility charge any FAP-eligible individual 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 Section C.

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

If "Yes," explain in Section C.

Schedule H (Form 990) 2014

Page

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
The Cheshire Medical Center	Part V, Section B, Line 5: Needs were prioritized based on data collected from several current assessment processes. Prioritization was completed by the Community Health Needs Assessment Leadership Team. Several hundred people participated in forums and surveys to identify community needs.
The Cheshire Medical Center	Part V, Section B, Line 6b: The Cheshire Medical Center collaborated with Dartmouth-Hitchcock Keene; New Hampsire Department of Health and Human Services; Greater Monadnock Public Health Network (GMPHN); The New Hampshire Hospital Association; Foundation for Healthy Communities; Antioch University New England; Monadnock United Way; New Hampshire Center for Public Policy Studies; Southwestern Regional Planning Commission; and Home Healthcare, Hospice, and Community Services.
The Cheshire Medical Center	Part V, Section B, Line 11: The Cheshire Medical Center has implemented strategies to address all but two of the needs identified in its most recent CHNA. Access to beahvioral health outpatient services is addressed by Community Partners Monadnock Family Services, Phoenix House, and MAPS Counseling Services. Expansion of personal and public transportation options is addressed by Community Partners Monadnock Regional Transportation Management Association, Home Healthcare Hospice and Community Services, American Red Cross, and the Southwest Regional Planning Commission.
The Cheshire Medical Center	Part V, Section B, Line 15e: The contact information for hospital facility staff is provided on the financial information landing page of the website (https://www.cheshire-med.com/patients_visitors/financial_assistance.html) and in the supplemental FAP Brochure, which is available at all registration stations in the hospital. Medical Center staff and administrators are currently in process of updating the FAP, application, and other related materials; contact information will be included in all financial assistance materials going forward.
The Cheshire Medical Center	Part V, Section B, Line 16i: The Cheshire Medical Center's Plain Language Summary was available at all registration desks and by request during the fiscal year. While it was not available on the website during the filing period, it is on the website as of the time of this filing (http://www.cheshire-med.com/images/patients_visitors/Financial_Assistance_Brochure.pdf). Additionally, the Medical Center has a committee that is working to ensure full compliance with final 501(r) regulations in advance of the deadline, which is applicable to fiscal years beginning after December 29, 2015.
The Cheshire Medical Center	Part V, Section B, Line 22d: The State of New Hampshire mandates a discount for all uninsured patients. This discount is equal to the average discount negotiated by the largest (by dollar) three commercial insurers. The Cheshire Medical Center has always been in full compliance with the laws of the State of New Hampshire, and a committee is in place to ensure the hospital is in full compliance with final 501(r) regulations in areas where federal regulations differ from or are more stringent than those issued by the state.
Schedule H, Part V, Section B, Line 7a:	The Cheshire Medical Center's 2013 CHNA is available on the Medical Center's website at: www.cheshire-med.com/images/aboutus/CHNA_2013.pdf.
Schedule H, Part V, Section B, Line 10a:	The Cheshire Medical Center's 2013 CHNA Implementation Strategy is available on the Medical Center's website at: www.cheshire-med.com/images/aboutus/CHNA_2013_Implementation_Plan.pdf.
Schedule H, Part V, Section B, Line 16a:	The Cheshire Medical Center's Financial Assistance Policy is available on the Medical Center's website at: https://www.cheshire-med.com/images/patients_visitors/ Financial_Assistance_Policy.pdf.
Schedule H, Part V, Section B, Line 16b:	The Cheshire Medical Center's FAP application is available on the Medical Center's website at: https://www.cheshire-med.com/images/patients_visitors/ Financial_Assistance_Application.pdf.
Part V, Section B, Line 16	Financial Assistance Policy Website Availability
The Cheshire Medical Center Part V, Section B, line 16a website:	See Part V, Section C
The Cheshire Medical Center Part V, Section B, line 16b website:	See Part V, Section C

Schedule H (Form 990) 2014

Page

Part VFacility Information (continued)

Section D. 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?2
Name and address		Type of Facility (describe)
1	Cheshire Med Center Collecting Station 580-590 Court Street Keene,NH03431	Collecting Station
2	Cheshire Health Services Inc 580-590 Court Street Keene,NH034315400	Non-Emergency Walk In Clinic
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2014

Page

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs 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.

Form and Line Reference	Explanation
Part I, Line 7, Column (f):	The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 8,306,085.
Part II, Community Building Activities:	The Medical Center has been actively engaged since the spring of 2006 in Healthy Monadnock (HM) 2020: to make Keene and the surrounding region the healthiest in the nation by the year 2020. HM2020 promotes broad-based community health messaging and other environmental strategies for prevention and wellness. The "champions program" engages individuals and organizations to take steps to improve health at a personal and institutional level. The Medical Center provides staffing, office space and overall leadership for this initiative. As of June 30, 2015 there were 3,191 individual champions, 120 organizational champions, and 20 school champions. The organization is a founding member of the Council for Health Communities, which has been in existence for over 16 years and has developed a variety of prevention, transportation, referral, and health promotion programs.
Part III, Line 2:	At cost bad debt expense of $3,206,149 is 38.6% of the bad debt reported on The Cheshire Medical Center's Audited Financial Statements, which totals $8,306,085.The amount of bad debt expense reported on Form 990, Part IX, Line 25 is the total amount of the Medical Center's bad debt expense per the audited financial statements, $8,328,320, less $22,235, which is the amount allocated to a related entity, Cheshire Health Services, Inc. The allowance for doubtful accounts, contractual allowances in net patient service revenue, and other revenue and expenses are also accounted for in the calculations reported on this Form 990 but not reported separately in the audited financial statements. See Schedule O footnote for additional information.
Part III, Line 3:	Cheshire Medical Center Management estimates that approximately 25% of bad debt expense (approximately 5 times the region's poverty rate) is an appropriate estimation of patients who would have been eligible for the organization's financial assistance program but did not apply. This estimation is based on the recognition that the financial assistance program is available to residents with incomes of up to three times the federally defined poverty income levels and the assumption that patients who choose not to pay their bills are more likely to fall within the lower income levels. For 2015, the estimated amount of bad debt expense (at cost) attributable to patients who would have been eligible for financial assistance is $802,000.
Part III, Line 4:	Accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Medical Center analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for doubtful accounts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Medical Center analyzes contractually due amounts and provides an allowance for doubtful accounts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which included both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Medical Center records a provision for doubtful accounts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts.The total provision for the allowance for doubtful accounts was $1,753,292, $6,575,028 and $11,397,403 for the 2015 successor period, 2015 predecessor period, and fiscal 2014 predecessor period, respectively. The Medical Center's bad debt write-offs decreased from $11,767,403 for the fiscal 2014 predecessor period to $7,225,028 during the 2015 predecessor period and to $2,003,393 during the 2015 successor period. The decrease in the year-end allowance and bad debt write-offs was a result of collection trends and the overall reduction in self-pay accounts receivable.
Part III, Line 8:	This shortfall should be considered community benefit because we are the only hospital/medical center in Cheshire County, New Hampshire and we are designated by CMS as a Medicare Dependent Hospital (MDH) due to greater than 60% of our average daily census being comprised of Medicare Patients. Our presence in the community allows the residents of Cheshire County, especially the elderly population, to receive comprehensive hospital and medical services close to home.
Part III, Line 9b:	Systems are in place to capture financial assistance accounts prior to a bill going to the patient. FAP eligible patients are not charged more than the amount generally billed.
Part VI, Line 2:	In 2013, a Community Health Needs Assessment (CHNA) was completed with an implementation strategy identified for community benefit activities for the next three years. The 2013 CHNA report summarizes the work of the CHNA Leadership Team and the efforts of other local collaborative groups to assess the needs of our region. Several community partners recently completed community needs assessments, including Healthy Monadnock 2020. The results were used to strengthen and support the needs assessment process. Four community needs were prioritized above the other identified needs: -Behavioral health services: increasing the effectiveness of local services -Urgent care: timely and economical access to services instead of emergency room care -Transportation: increase access to public/private transportation particularly in rural towns -Improved coordination and communication between services: improving linkages between clinical services, faith-based organizations, and informal support networkIn addition to these priorities, the implementation strategy also provides an overview of other CMC/DHK community benefit activities that are aligned with our mission or considered necessary to support ongoing efforts from previously identified community needs. The community health needs identified in the 2013 CHNA provide the basis for the development of the Implementation Strategy. Cheshire Medical Center provides staff for the Healthy Monadnock (HM)2020 initiative and funds the community assessment process through an evaluation partnership contract with Antioch New England University. On November 10, 2011 community members attended Summit II and reviewed 31 core implementation strategies. The (HM 2020) Healthiest community Advisory Board, comprised of 30 community representatives, provides ongoing oversight of the implementation of the strategies and community planning process.The Cheshire Medical Center/Dartmouth Hitchcock Keene Community Advisory Committee reviewed and commented on the community benefit report. The 2013 CHNA, Implementation Strategy and Community Benefit reports for 2009-2015 are available to the public on the Cheshire Medical Center website: www.cheshire-med.org.
Part VI, Line 3:	The Cheshire Medical Center is committed to providing medically necessary care to patients regardless of their ability to pay for services. Non-emergent patients sign a financial responsibility statement upon admission to certify recognition of their responsibility for payment of their bills. However, there will be instances where the patient, due to the lack of funds or third party coverage, will not be able to meet this obligation. The Cheshire Medical Center notifies patients of their potential to obtain assistance through the registration and billing processes. Upon registration, patients without insurance are offered the opportunity to apply for financial assistance. In addition, receptionists and clinicians in all areas are educated to refer patients to the financial assistance process in the event patients express concerns with their ability to pay for services. The application information is posted on the intranet and brochures describing the program are readily available to patients. There are signs posted in Registration and throughout the facility informing patients about financial assistance. Patients are informed of the program availability on any invoices they receive and individuals who attempt to collect patient balances are also trained to refer patients to the financial assistance process. The financial assistance application process is comprehensive and evaluates a patient's eligibility for a variety of federal, state, and local government programs in addition to The Cheshire Medical Center's internally funded financial assistance program.
Part VI, Line 4:	The Cheshire Medical Center is the only hospital in its primary service area ("PSA"). Management defines its PSA as the City of Keene and 19 geographically proximate communities. Towns and cities included in the PSA include Alstead, Chesterfield, Fitzwilliam, Gilsum, Harrisville/Chesham, Keene, Marlborough, Marlow, Nelson/Munsonville, Richmond, Roxbury, Stoddard, Sullivan, Surry, Swanzey, Troy, Walpole, Westmoreland and Winchester, all located in Cheshire County. According to the US Census Bureau, 2014 population estimates: -Medical Center's PSA represented approximately 5.79% of New Hampshire's population. -The PSA's total population is 76,596 with 23,281 residing in Keene, the largest community in the service area. -The median age of residents in Cheshire County is 41.7 with: -14,423 or 19% less than 18 years of age -49,266 or 64% between the ages of 18-64 -12,710 or 17% over the age of 64 -Poverty rate for Cheshire County was 11.7% as compared to 8.9% for the State of New Hampshire. The median household income is $56,139 compared to the state average of $65,986.According to the US Bureau of Labor Statistics, October 2015, the State had an unemployment rate of 3.3% compared to Cheshire County's rate of 2.8%.
Part VI, Line 5:	The Medical Center plays an active role in promoting community health and offers educational programs including classes and workshops. Our clinical staff works closely with our community health staff to develop programs that cover emerging health concerns and are delivered at the right literacy level for our community. The programs offered a variety of chronic disease and wellness topics such as nutrition amd exercise, diabetes prevention and monitoring, high blood pressure prevention and monitoring, cultural diversity, the Health Insurance Marketplace, self-esteem and self-help, elder care services and needs, and retirement and investments. All programs are offered free of charge.In addition, the Medical Center offers several community programs including: Cheshire Smiles, a school-based dental health program for children in grades K-3, provides screening, prevention and restorative dental care for children in Cheshire County schools. The Cheshire Medical Center/Dartmouth-Hitchcock Keene also works in partnership with other community health and human service organizations to meet the dental health needs of underserved populations such as the chronically mentally ill, pregnant women who cannot afford dental care, children identified through the school based Cheshire Smiles Program, and others. The Medical Center sponsors patient visits at Dental Health Works, a public/private program serving underserved residents of Cheshire County. The Cheshire Medical Center also provides leadership and support to the Dental Public Health Task Force, a coalition of dental staff, hospital staff and concerned citizen addressing the oral health needs of adults. The Cheshire Coalition for Tobacco Free Communities addresses the use of tobacco products by people who live and work in the communities served by The Cheshire Medical Center/Dartmouth Hitchcock Keene (CMC/DHK). The Coalition is comprised of hospital staff, healthcare providers, community members and representatives of schools and colleges, law enforcement, clergy and the general public. The group meets monthly working to engage schools and the greater community with tobacco prevention initiatives which include retailer education and enforcement of tobacco laws. The Program Manager, a CMC/DHK employee, actively engages in tobacco-free activities in our local community and coordinates with state agencies and organizations.The Medication Assistance Program addresses the critical need for programs to help low income people afford medications. The Medication Assistance Program provides free or reduced cost medications for acute illnesses and improves access to medications vital to continued good health for patients who require medication on an ongoing basis and who cannot afford it. In fiscal year 2015 the program supplied 1,073 prescriptions to 252 individuals valued at $565,250. This is a significant decrease from fiscal year 2014 (2,318 prescriptions to 401 individuals valued at 1.6 million dollars) in part due to Medicaid Expansion and the Health Insurance options as a result of the Affordable Care Act.Advocates for a Healthy Youth (AFHY) is a community coalition focused on childhood obesity. Through AFHY, CMC/DHK works closely with community health providers, Keene State College, Antioch University New England, Keene Parks and Recreation Center, UNH Cooperative Extension, Keene Housing, and area schools to address the epidemic of childhood obesity. In fiscal year 2015, AFHY supported efforts in several schools, after school programs, and non-profit organizations to implement the 5-2-1-0 message via policy change and educational activities. AFHY implemented the community based Family BeFit program through collaboration with the Keene Family YMCA and Keene State College Dietetic Internship Program.CMC/DHK is a site for the New Hampshire HEAL Initiative. Through our local program, we hope that all residents can live, learn, work, play, and heal in a community where physical activity, healthy eating, and healthy living are the norm. MHEAL is focused on addressing overweight and obesity, physical inactivity, and eating choices in the Greater Monadnock Public Health Region through programs, policies, systems, and environmental changes in two key settings: worksites and foodservice venues. -Worksites: Our worksite wellness initiative is committed to helping local worksites in their efforts to provide a healthy workplace environment. MHEAL's team has worked with over 35 organizations to date to create a culture of health in the workplace by helping employers adopt and promote evidence-based worksite wellness interventions. -Foodservice venues: In partnership with Keene State College, MHEAL helps foodservice venues promote healthier food options to diners through our program called Turn a New Leaf (TANL). Foodservice venues include worksite cafeterias, restaurants, and markets. Through our efforts, 13 venues have adopted the TANL program to date, with a plan to recruit many more over the next two years.Senior Passport is a program for area residents aged 60 years and above. It encompasses low cost complete evening and weekend meals; free health education programs oriented to seniors; exercise programs; and the Cheshire Walkers Program, a walking group that takes organized nature and historic walks. Seven walks are offered each spring and fall. Walks are typically led by a community member with occasional participation by CMC/DHK staff and occur at a variety of locations throughout the region. During fiscal year 2015, 4,469 meals were provided to program members and a total of 175 seniors attended the walking program. This represents about a 20% increase in the number of meals and 15% increase in the number of participants in Cheshire Walkers from last year.Greater Monadnock Public Health Network (GMPHN) is a community health and safety collaborative which works to enhance and improve public health-related services. GMPHN is one of 13 public health networks in the state of New Hampshire. The GMPHN is housed by CMC/DHK and, in collaboration with Cheshire County, is financed with funds provided by the Centers for Disease Control and Prevention, under an agreement with the State of New Hampshire, Department of Health and Human Services, and Division of Public Health Services and a mix of state funding via the general funds. The GMPHN serves all of Cheshire County and the 10 western-most towns in Hillsborough County. The GMPHN strives to increase collaboration and planning across municipal boundaries and the health and safety sectors. Two major focuses of the work is the development of a public health advisory board and the on-going effort for public health emergency preparedness. It is made up of members of each of the coalition communities as well as representatives of regional organizations involved in providing for the public's health and safety. As of June 30, 2015 there are 41 individuals/organizations addressing development of the public health advisory council and 75 member individuals/organizations addressing emergency preparedness.Included within the GMPHN, is the Greater Monadnock Medical Reserve Corps. Developed initially to build local capacity to address public health emergency response needs, the GMMRC also supports local initiatives to address pressing public health activities. Membership included doctors, nurses, EMT/paramedics, pharmacists, veterinarians, other public health professionals, and non-medical/public health members. As of June 30, 2015 the GMMRC has a membership of over 124 individuals.
Part VI, Line 6:	In 2014, the Board of the Medical Center, accompanied by the Board of Dartmouth-Hitchcock, approved an affiliation agreement between the Medical Centers. This agreement is intended to improve, integrate, and streamline patient care between the Medical Centers.The affiliation, which became effective on March 2, 2015, strengthens The Cheshire Medical Center as a regional resource for southwestern New Hampshire and southeastern Vermont. The affiliation will allow more patients to receive care closer to home, will free up bed capacity for tertiary care patients at Dartmouth-Hitchcock Medical Center in Lebanon, and will allow the Cheshire Medical Center to continue its leadership role in population health and the Healthy Monadnock 2020 initiative. Cheshire Medical Center and Dartmouth-Hitchcock have worked together since 1998, by means of a Joint Operating Agreement involving Dartmouth-Hitchcock Keene, a multi-specialty group practice that comprises the majority of Cheshire Medical Center's medical staff. This new affiliation agreement is seen as a natural step that will enable both organizations to more effectively pursue a common vision of the future of health care that is based on creating a sustainable health system, focusing on population health, delivering value-based care, and embracing the opportunities provided by new payment models.In addition to The Cheshire Medical Center and the Dartmouth-Hitchcock Medical Center, the affiliated health care system includes Mary Hitchcock Memorial Hospital, Dartmouth-Hitchcock Clinic, The New London Hospital Association, Windsor Hospital Corporation, and a number of other related organizations whose primary mission is health care in the region. The Cheshire Medical Center and other members of the affiliated health care system operate jointly through interlocking directorates, strategic planning, management, and share identical missions.
Part VI, Line 7, Reports Filed With States	NH

Schedule H (Form 990) 2014

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, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

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....

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including 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? .........

Yes

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2014

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 in column(B) 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)
1John Birkmeyer MDTrustee	(i) (ii)	0 ............................... 211,596	0 ............................... 0	0 ............................... 50,103	0 ............................... 30,458	0 ............................... 4,400	0 ............................... 296,557	0 ............................... 0
2Judith A Boule MDMedical Staff President	(i) (ii)	0 ............................... 284,901	0 ............................... 0	0 ............................... 39,717	0 ............................... 258,941	0 ............................... 17,599	0 ............................... 601,158	0 ............................... 0
3Wendy Fielding CPATrustee	(i) (ii)	0 ............................... 220,289	0 ............................... 0	0 ............................... 270	0 ............................... 37,462	0 ............................... 20,362	0 ............................... 278,383	0 ............................... 0
4Timothy J Fisher MDTrustee	(i) (ii)	0 ............................... 276,988	0 ............................... 0	0 ............................... 0	0 ............................... 54,503	0 ............................... 20,059	0 ............................... 351,550	0 ............................... 0
5Lawrence J Jaeger MDTrustee	(i) (ii)	0 ............................... 317,165	0 ............................... 0	0 ............................... 744	0 ............................... 238,600	0 ............................... 13,682	0 ............................... 570,191	0 ............................... 0
6Steven Paris MDTrustee	(i) (ii)	0 ............................... 329,589	0 ............................... 0	0 ............................... 27,982	0 ............................... 100,968	0 ............................... 16,361	0 ............................... 474,900	0 ............................... 0
7Leslie T Pitts MDTrustee	(i) (ii)	0 ............................... 264,504	0 ............................... 0	0 ............................... 260	0 ............................... 191,801	0 ............................... 17,729	0 ............................... 474,294	0 ............................... 0
8Arthur W NicholsPresident	(i) (ii)	466,891 ............................... 0	57,978 ............................... 0	47,380 ............................... 0	77,642 ............................... 0	21,661 ............................... 0	671,552 ............................... 0	0 ............................... 0
9Don Caruso MDCEO/CMO	(i) (ii)	0 ............................... 342,742	0 ............................... 0	0 ............................... 2,014	0 ............................... 236,579	0 ............................... 17,839	0 ............................... 599,174	0 ............................... 0
10Robert CochraneCFO	(i) (ii)	207,760 ............................... 0	0 ............................... 0	0 ............................... 0	0 ............................... 0	18,168 ............................... 0	225,928 ............................... 0	0 ............................... 0
11Cindi CoughlinCNO	(i) (ii)	163,449 ............................... 0	0 ............................... 0	33,000 ............................... 0	86,924 ............................... 0	19,145 ............................... 0	302,518 ............................... 0	0 ............................... 0
12Paul PezoneVP Facilities & Support Se	(i) (ii)	144,237 ............................... 0	0 ............................... 0	41,400 ............................... 0	20,656 ............................... 0	18,606 ............................... 0	224,899 ............................... 0	0 ............................... 0
13Erli ChenPhysicist	(i) (ii)	188,138 ............................... 0	0 ............................... 0	44,905 ............................... 0	29,339 ............................... 0	14,891 ............................... 0	277,273 ............................... 0	0 ............................... 0
14Larry MillerChief CRNA	(i) (ii)	178,618 ............................... 0	0 ............................... 0	22,490 ............................... 0	63,600 ............................... 0	9,099 ............................... 0	273,807 ............................... 0	0 ............................... 0
15Julie GreenVP, Human Resources	(i) (ii)	134,968 ............................... 0	0 ............................... 0	46,900 ............................... 0	25,637 ............................... 0	19,206 ............................... 0	226,711 ............................... 0	0 ............................... 0
16Yvonne GoldsberrySr. Director of Community Health	(i) (ii)	130,191 ............................... 0	0 ............................... 0	38,500 ............................... 0	18,675 ............................... 0	15,070 ............................... 0	202,436 ............................... 0	0 ............................... 0
17Letasha HeapeCRNA	(i) (ii)	155,877 ............................... 0	0 ............................... 0	0 ............................... 0	6,231 ............................... 0	22,933 ............................... 0	185,041 ............................... 0	0 ............................... 0

Schedule J (Form 990) 2014

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation
Part I, Line 1a	The Cheshire Medical Center does not reimburse expenses for first class travel, housing allowance, health or social club dues, personal services, business use of personal residence, discretionary spending accounts, or provide tax indemnification or gross up payments. The Medical Center does reimburse Board members for companion travel to business related meetings under specific circumstances. All reimbursements are reported on a Form 1099 issued to the Board member. During the calendar year 2014, which is the basis for Form 990, Part VII and Schedule J reporting for the fiscal year ending June 30, 2015, no Board members were reimbursed under this arrangement.
Part I, Line 3	The President of The Cheshire Medical Center is paid by the filing organization and methods use to determine compensation are as noted on Schedule, J, Part I, Line 3. The CEO is paid by Dartmouth-Hithcock Health, a related organization, which uses a compensation committee, an independent consultant, Form 990 of other organizatinos, written employment contract, a compensation survey or study, and approval by the Board or compensation committee to establish the CEO's compensation.
Part I, Line 4b	Dartmouth-Hitchcock, a related organization at the end of the filing period, paid compensation through a SERP to the following individuals listed in Part VII: Stephen A. Paris-$19,669; Judith A. Boule-$38,211. Dartmouth-Hitchcock supplemental retirement plan terms and conditions: An eligible employee is a participant in the Dartmouth-Hitchcock retirement plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC section 401(a)(17) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC sections 401(a)(17) and/or 415.
Part I, Line 7	Senior Management is eligible for incentive compensation at the discretion of the Board based on, but not directly related to, overall organizational financial performance and other discretionary measures.
Form 990, Part VII-A and Schedule J, Part II:	The annual change in the actuarial value of the pension plan for the employees listed below has been reported as part of deferred compensation. The pension plan is held and administered by a related organization, The Cheshire Medical Center. The amounts reported for 2014 are: Arthur Nichols-$43,649 Cynthia Coughlin-$65,909 Paul Pezone-$1,101 Erli Chen-$8,595 Larry Miller-$38,424 Julienne Green-$2,806 Yvonne Goldsberry-$7,332 The present value of the accrued benefit at the beginning of the reporting period, representing accrual over multiple years of service for each participant, was: Arthur Nichols-$829,347 Cynthia Coughlin-$544,606 Paul Pezone-$32,348 Erli Chen-$120,724 Larry Miller-$982,529 Julienne Green-$79,794 Yvonne Goldsberry-$33,435

Schedule J (Form 990) 2014

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

Information about Schedule K (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization
The Cheshire Medical Center

Employer identification number
02-0354549

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	NH Health & Education Facilities Authority	02-0279866		11-15-2012	29,650,000	Refund existing debt, acquisition of equipment		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 . . . . . . . . . . . . . .	29,650,000
4 Gross proceeds in reserve funds . . . . . . . . . . . .	4,777,102
5 Capitalized interest from proceeds . . . . . . . . . . .
6 Proceeds in refunding escrows . . . . . . . . . . . .
7 Issuance costs from proceeds . . . . . . . . . . . .	379,754
8 Credit enhancement from proceeds . . . . . . . . . . .
9 Working capital expenditures from proceeds . . . . . . . . .	554,125
10 Capital expenditures from proceeds . . . . . . . . . . .	4,777,102
11 Other spent proceeds . . . . . . . . . . . . . .
12 Other unspent proceeds . . . . . . . . . . . . . .
13 Year of substantial completion . . . . . . . . . . . .	2013
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? . . . . .	X
15 Were the bonds issued as part of an advance refunding issue? . . . . .		X
16 Has the final allocation of proceeds been made? . . . . . . . .	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? . . . . . . . . . . . . . .	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
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . . . . . .		X

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

Cat. No. 50193E

Schedule K (Form 990) 2014

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
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
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 . .	0 %
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 . . . . . . .	0 %
6 Total of lines 4 and 5 . . . . . . . . . . . . .	0 %
7 Does the bond issue meet the private security or payment test? . . . . .	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
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? . . . . . . . . . . . . .
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

Part IV

Arbitrage

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

Schedule K (Form 990) 2014

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
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
7 Has the organization established written procedures to monitor the requirements of section 148? . . .		X

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
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. Provide additional information for responses to questions on Schedule K (see instructions).

Return Reference	Explanation

Schedule K (Form 990) 2014

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

Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) 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 Benefiting 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) 2014

Page 2

Part IV

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

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) Ed Bergeron	Hired by CMC for construction services	25,125	Edward Bergeron, Trustee of Cheshire Medical Center, is an officer of Bergeron Construction, which performed carpentry for the Hospital during the fiscal year.		No
(2) Jessica Horton	Child of CMC Trustee	37,240	Jessica Horton, who is employed in the Radiology Department of The Cheshire Medical Center, is the child of Steve Horton, a Trustee of The Cheshire Medical Center. The 2014 W-2 compensation paid is in accordance with CMC's standard employment practices and policies.		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2014

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public
Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

Return Reference	Explanation
Form 990, Part VI, Section A, line 4	Significant changes were made to the Articles of Agreement and Bylaws during the year. The Articles of Agreement were amended as follows: Articles III and V were amended by replacing them in their entirety with amended Articles III and V. Additionally, Articles VI and VII were added to the Articles of Agreement. Amended/added articles are as follows: ARTICLE III-PURPOSE The Corporation is established exclusively for the charitable, scientific and educational purposes set forth herein, subject to the provisions of Chapter 292 of the New Hampshire Revised Statutes Annotated, RSA 292 and the provisions of Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the "Code"). The principal purposes for which the Corporation is established are as follows: the operation and maintenance (i) of a general hospital in Keene, New Hampshire, for the surgical and medical care of the sick and injured, and (ii) of medical centers, health care centers, laboratories, clinics, and other medical, surgical, dental, educational, civic and research facilities in Keene and in other cities and towns; the advancement of the knowledge and practice of education and research in medicine, surgery, nursing and all other subjects relating to the care, treatment and healing of humans; the furtherance of (i) the quality and accessibility of health care services, particularly in (but not limited to) the Keene, Cheshire County, Southeastern Vermont and the Greater Monadnock region (collectively referred to as the "Monadnock Region"); (ii) the efficiency of utilization of health care facilities and services,; (iii) the reasonable containment of the cost of health care to the public; and (iv) the goals, initiatives, activities and interests of the integrated health care delivery system developed and conducted by the Sole Member of the Corporation as defined in Article V of these Articles, in coordination with its affiliates including the Corporation (referred to herein as the "Dartmouth-Hitchcock System"); and the improvement of public health in cooperation with federal, state, municipal, and other health departments and offices. All activities and functions of the Corporation shall be conducted in a manner which is consistent with the requirements of Section 501(c)(3) of the Code, including for such purposes the making of distributions to organizations that qualify as exempt organizations under Section 501(c)(3) of the Code, or corresponding section of any future federal tax code, the laws of the State of New Hampshire and the By-Laws of the Corporation. ARTICLE V-MEMBERSHIP The Sole Member of the Corporation shall be Dartmouth-Hitchcock Health ("DHH"), a New Hampshire voluntary corporation. DHH as Sole Member of the Corporation shall have all reserved powers, rights and obligations as set forth in the Corporation's Bylaws. ARTICLE VI-BYLAWS The procedures and policies for the internal governance of the Corporation shall be as set forth in the By-Laws. ARTICLE VII-LIMITATION OF LIABILITY The provisions eliminating or limiting the personal liability of Trustees or officers are: Each Trustee and officer shall be indemnified by the Corporation against personal liability to the Corporation for monetary damages for breach of fiduciary duty as a Trustee or officer, or both, except with respect to: (1) Any breach of the Trustee's or officer's duty of loyalty to the Corporation or the members; (2) acts or omissions which are not in good faith or which involve intentional misconduct or a knowing violation of the law; or (3) any transaction from which the Trustee or officer derived any improper personal benefit. The following changes to the Medical Center's bylaws were made during the tax period: 1. Dartmouth-Hitchcock Health, a New Hampshire voluntary corporation, replaced The Cheshire Health Foundation, as the sole member of The Cheshire Medical Center, with rights and powers over the following actions: -approve or disapprove all material governance, programmatic and financial decisions, including the elimination or addition of any health care services or programs; - appoint 1/3 of the members of the Medical Center's Board of Trustees; -ratify the Medical Center's nomination of 2/3's of the members of the Board of Trustees; -following consultation with the Medical Center's Chairperson of the Board, to remove any Trustee if the Sole Member determines in its reasonable good faith discretion that such removal is in the best interests of the Dartmouth-Hitchcock System; -approve borrowings and material disposition of the Medical Center's assets; -approve the establishment of key strategic relationships, such as ownership or contractual participation in a network, system, affiliation, joint venture, alliance, or similar arrangement with an organization that is not part of the Dartmouth-Hitchcock System or which is not addressed in a strategic plan specific to the Corporation that has been approved by the Sole member; -approve operating and capital budgets and strategic plans; -approve policies relating to educational and research programs and affiliations; -reallocate the assets and resources of the Medical Center and the Sole Member, as appropriate, to serve the overall best interests of the Dartmouth-Hitchcock System; -appoint, evaluate, terminate, and approve the compensation of the Medical Center's President and CEO; -approve the amendments to the Medical Center's Articles of Agreement or By-Laws if such amendment would have the effect of impacting the Sole Member's reserved powers or may reasonably be expected to have a material strategic, competitive, or financial impact on the Dartmouth-Hitchcock System; -approve the dissolution or liquidation of the Medical Center. 2. The Ex Officio Trustees with voting rights were changed from the President & CEO of the Medical Center, the President of the Medical Staff, and the Chair of the Keene Health Alliance Board to the CEO of the Medical Center, the Medical Director of Dartmouth-Hitchcock Keene, the President of the Corporation's Medical Staff, and the President of the Sole Member. 3. The clause "except that certain actions of the Board shall be subject to the requirements of the Partnership Agreement between the Center and The Hitchcock Clinic, etc.," was removed from the Duties and Responsibilities of the Trustees. 4. The Duties and Responsibilities of the Trustees were updated to remove "The Board of Trustees shall have full power and authority to create, prescribe, and/or approve Bylaws, Rules and Regulations regarding the practice of medicine in the Center and to appoint, suspend or remove any practitioner from the Medical Staff in accordance with such Bylaws, Rules and Regulations." 5. Article 3.6, which delineated some Trustee responsibilities as they related the Partnership Agreement with Keene Health Alliance, was struck from the bylaws. 6. The provision regarding compensation of Board members was changed from "The Board of Trustees may approve some form of compensation for Trustees as a whole, or for Trustees holding specific offices." to "The Board of Trustees shall serve as Trustees without compensation, except that reasonable expenses may be reimbursed as approved by the Board. Trustees may also be employed by the Corporation and compensated for their services as the Board may authorize." 7. "The Chairperson and the Vice Chairperson of the Board shall each be selected from the 2/3's of the Trustees nominated by the Medical Center," was added to the bylaws. 8. The responsibilities of the Chairperson were expanded to include, "The Chairperson may execute contracts, deeds, notes, mortgages, bonds and other obligations in the name of the Corporation." 9. The article describing the position of CEO was updated to read: "The Trustees shall select, employ, and contract with a person to be the CEO of the Corporation who shall have all the authority of such a position in a business corporation and who shall be an officer of the Corporation and shall be a full voting member of the Board of Trustees, ex officio. The CEO of the Corporation shall report jointly to the Board of Trustees of the Corporation and the CEO of the Sole Member's President shall have the right to terminate the CEO, following consultation with the Corporation's Chairperson of the Board of Trustees." 10. Article 6.3, "Nomination and Evaluation Processes of the CEO" was added to the bylaws: "All candidates for the position of CEO shall be nominated by a committee of the Corporation's Board of Trustees, of which the Chairperson of the Board of Trustees shall lead and the committee shall include representatives of the Dartmouth-Hitchcock System. The nomination process shall include the ability of the Sole Member's President or designee to interview any candidate for this position. Any candidate nominated by the committee must be approved by both the Corporation's Board of Trustees and the Sole Member's President. The evaluation of the CEO shall be con
Form 990, Part VI, Section A, line 6	The sole member of The Cheshire Medical Center is Dartmouth-Hitchcock Health, a New Hampshire voluntary corporation.
Form 990, Part VI, Section A, line 7a	The sole member has the power to appoint 1/3 of the members of The Cheshire Medical Center's Board of Trustees
Form 990, Part VI, Section A, line 7b	The sole member has the right to ratify The Cheshire Medical Center's nomination of 2/3 or the members of the Board of Trustees; remove Trustees after consultation with the Chaiperson of the Board; approve the dissolution or liquidation of The Cheshire Medical Center; appoint, evaluate, terminate, and approve the compensation of the President and CEO; and other governance decisions as outlined in the response to Form 990, Part VI-A, Line 4.
Form 990, Part VI, Section B, line 11	A copy of the Form 990 is made available for all Board members to review prior to filing. The Board has formally delegated review of the Form 990 to the Finance and Audit Committee. Committee members receive copies of the Form 990 and it is reviewed in a meeting prior to filing.
Form 990, Part VI, Section B, line 12c	Officer, Board Members, and Key Employees annually disclose potential conflicts of interest and are required to recuse themselves from all Board activity related to all conflicts.
Form 990, Part VI, Section B, line 15a	The Cheshire Medical Center/Dartmouth Hitchcock Keene has retained Yaffe & Company, Inc. to provide consultation to the Executive Committee of the Board of Trustees regarding executive compensation, benefits, and perquisites. Yaffe & Company, Inc. is an independent consulting firm with 35 years of service and provides services to not-for-profit hospitals and health systems. Further Yaffe & Company, Inc. has been engaged directly by the Board of Trustees of The Cheshire Medical Center through its Executive Committee to only provide services to the Board. An Executive Committee d/b/a Compensation Committee Charter and Compensation Philosophy (approved by the Board) documents the compensation review process and guidelines so as to provide an orderly structure for executive total compensation decisions. Annually, a multi-tiered approach using independent comparability data is utilized to gauge appropriate comparative market levels of compensation and benefits. An annual performance evaluation is based on subjective and objective criteria which flow from the strategic plan. By way of questionnaire, Board members participate in the performance review process and a summary report is shared with the CEO. Variable pay is awarded based on achievement of specific qualitative and quantitative goals. In conjunction with the Executive Committee, challenging and measurable goals are established for the Office of the President, which provide an alignment between executive compensation and achievement of the hospital's strategic goals.
Form 990, Part VI, Section C, line 19	The Organization makes governing documents, conflict of interest policy and financial statements available to members of the public upon request, through its annual report, and through state and federal filings.
Form 990, Part IX, line 11g	Contract Labor: Program service expenses 12,046,926. Management and general expenses 0. Fundraising expenses 0. Total expenses 12,046,926. Physician/Medical Services: Program service expenses 5,630,576. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,630,576. Other Purchased Services: Program service expenses 2,796,092. Management and general expenses 670,854. Fundraising expenses 0. Total expenses 3,466,946. Data Processing Fees: Program service expenses 2,131,001. Management and general expenses 511,282. Fundraising expenses 0. Total expenses 2,642,283. Outside Lab Fees: Program service expenses 977,655. Management and general expenses 234,565. Fundraising expenses 0. Total expenses 1,212,220. Consulting: Program service expenses 364,630. Management and general expenses 87,484. Fundraising expenses 0. Total expenses 452,114.
Form 990, Part IX, Column D:	Fundraising Expenses: The Cheshire Health Foundation, a related organization, performs all fundraising activities on behalf of The Cheshire Medical Center. All fundraising expenses are reported on the Foundation's separate Form 990.
Form 990, Part XI, line 9:	Application of Push Down Accounting 8,991,498. Pension Liability Adjustment -1,360,710. Transfer to Affiliates -460,309.
Form 990, Part XII, Line 2c:	The audit process has not changed from the prior year.
Form 990, Part VIII-Part XI:	The consolidated audited financial statements for The Cheshire Medical Center and subsidiaries report various revenue, expense, asset, and net asset amounts for the Medical Center inclusive of a related organization, Cheshire Health Services (EIN 43-3379283), which began operation on March 11, 2015. All revenue, expense, and balance sheet items related to Cheshire Health Services have been extracted from amounts reported for the Medical Center on this Form 990 and all accompanying schedules. Cheshire Health Services is a separate legal entity filing its own Form 990, and items related to it have been reported there.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2014

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" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2014

Open to Public Inspection

Name of the organization

The Cheshire Medical Center

Employer identification number

02-0354549

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on 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" on 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) The Cheshire Health Foundation 580 Court Street Keene,NH03431 02-0202220	Management of Board designated, SPF, building, and endowment funds	NH	501(c)(3)	Line 11b, II	The Cheshire Medical Center	Yes
(2) Cheshire Health Services Inc 580 Court Street Keene,NH03431 47-3379283	Walk-In Medical Clinic	NH	501(c)(3)	Line 3	The Cheshire Medical Center	Yes
(3) Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon,NH03756 22-2519596	Physician Services	NH	501(c)(3)	Line 9	Dartmouth- Hitchcock Health		No
(4) Dartmouth-Hitchcock Health One Medical Center Drive Lebanon,NH03756 26-4812335	Supporting Organization	NH	501(c)(3)	Line 11b, II	N/A		No
(5) Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon,NH03756 22-2715483	Supporting Organization	NH	501(c)(3)	Line 11a, I	N/A		No
(6) Everwell Inc One Medical Center Drive Lebanon,NH03756 35-2505275	Supporting Organization	NH	501(c)(3)	Line 11a, I	Dartmouth- Hitchcock Health		No
(7) Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon,NH03756 02-0222140	Hospital	NH	501(c)(3)	Line 3	Dartmouth- Hitchcock Health		No
(8) The New London Hospital Association Inc 273 County Road New London,NH03257 02-0222171	Hospital	NH	501(c)(3)	Line 3	Dartmouth- Hitchcock Health		No
(9) Windsor Hospital Corporation 289 County Road Windsor,VT05089 03-0183721	Hospital	VT	501(c)(3)	Line 3	Dartmouth- Hitchcock Health		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2014

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) Keene Health Alliance 580 Court Street Keene,NH03431 30-0179297	Healthcare	NH		Related	-1,977,000			No		Yes		50.000 %
(2) OneCare VT ACOLIC 111 Colchester Avenue Burlington,VT05401 45-5399218	Shared Saving	NH	N/A

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on 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) Hitchcock Health Connect One Medical Center Drive Lebanon,NH03756 80-0908979	Telehealth	DE	N/A	C					No
(2) Keene Health Enterprises 580 Court Street Keene,NH03431 02-0374999	Investments/Real Estate	NH	Keene Health Services	C			100.000 %	Yes
(3) Keene Health Realty 580 Court Street Keene,NH03431 02-0374998	Investments/Real Estate	NH	Keene Health Services	C	37,589	714,879	100.000 %	Yes
(4) Keene Health Services 580 Court Street Keene,NH03431 02-0374997	Investments/Real Estate	NH	The Cheshire Health Foundation	C	489,340	201,601	100.000 %	Yes

Schedule R (Form 990) 2014

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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) . . . . . . . . . . . . . . . . . . . . .

Yes

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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) The Cheshire Health Foundation	K	72,000	Actual Cash Value
(2) The Cheshire Health Foundation	C	409,829	Actual Cash Value
(3) Cheshire Health Services Inc	L	297,694	Actual Cash Value

Schedule R (Form 990) 2014

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on 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 V-UBI 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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2014

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2014

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: Community health care organization serving as a regional referral center
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	23
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	14
5	Total number of individuals employed in calendar year 2014 (Part V, line 2a) ......	5	1,123
6	Total number of volunteers (estimate if necessary) .............	6	160
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	154,895
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-89,607

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	695,254	1,208,416
9	Program service revenue (Part VIII, line 2g) .........	155,615,611	159,316,387
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,601,362	955,785
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,924,975	2,358,902
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	159,837,202	163,839,490
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	60,554,893	61,032,813
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	98,088,979	103,365,620
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	158,643,872	164,398,433
19	Revenue less expenses. Subtract line 18 from line 12.......	1,193,330	-558,943
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	137,587,316	144,627,429
21	Total liabilities (Part X, line 26).............	65,004,098	66,131,206
22	Net assets or fund balances. Subtract line 21 from line 20.....	72,583,218	78,496,223

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 145,411,299 including grants of $ 0 ) (Revenue $ 161,520,394 )
	The primary purpose of the Cheshire Medical Center is to ensure access to quality health care services to all residents of the Monadnock Region. The Organization's charitable mission is enhanced through the operation of a joint operating partnership agreement with the Hitchcock Clinic. The purpose of the Joint Operating Partnership Agreement is to provide a more extensive and effective health care delivery system to the communities in the Monadnock Region by establishing joint planning and decision making processes, integrating health care services and establishing mechanisms for the reinvestment of resources to improve community health. The financial results of the joint operating partnership are reported annually on Form 1065, U.S. Partnership Return of Income.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses145,411,299

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	2,102,682	2,368,864	1,764,826

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512-514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		409,829
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f		798,587

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			1,208,416
			Business Code
2a	Patient Services		621300	156,722,340	156,722,340
b	Pharmacy and Drugs		446110	1,290,462	1,290,462
c	Food Services		722210	962,133	962,133
d	Miscellaneous Health Services		621300	157,694	157,694
e	Gift Shop Income		453220	103,256	103,256
f	All other program service revenue .			80,502	80,502
g	Total. Add lines 2a–2f........			159,316,387
3	Investment income (including dividends, interest, and other similar amounts).......			409,770			409,770
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)
d	Net rental income or (loss).......
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	546,015
b	Less: cost or other basis and sales expenses	0
c	Gain or (loss)	546,015
d	Net gain or (loss)..........			546,015			546,015
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	Meaningful Use Income		621300	766,389	766,389
b	Childcare Center		624410	620,116	465,221	154,895
c	Rebates and Discounts		621300	98,569	98,569
d	All other revenue ....			873,828	873,828
e	Total. Add lines 11a–11d ......			2,358,902
12	Total revenue. See Instructions......			163,839,490	161,520,394	154,895	955,785


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............			25,492,399	1	16,131,280
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			13,248,900	4	16,470,755
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 .............				7
8	Inventories for sale or use ..............			2,338,661	8	2,859,734
9	Prepaid expenses and deferred charges ..........			2,646,392	9	3,240,328
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	204,097,244
b	Less: accumulated depreciation .....	10b	125,616,574	67,062,017	10c	78,480,670
11	Investments—publicly traded securities ..........				11
12	Investments—other securities. See Part IV, line 11 .....			20,014,572	12	21,598,882
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14	394,167
15	Other assets. See Part IV, line 11 ...........			6,784,375	15	5,451,613
16	Total assets. Add lines 1 through 15 (must equal line 34)......			137,587,316	16	144,627,429
17	Accounts payable and accrued expenses .........			12,675,495	17	14,668,106
18	Grants payable .................				18
19	Deferred revenue ................			34,853	19	10,471
20	Tax-exempt bond liabilities .............			30,131,888	20	29,350,588
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 ..			424,044	23	217,360
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....................			21,737,818	25	21,884,681
26	Total liabilities. Add lines 17 through 25.........			65,004,098	26	66,131,206
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			68,092,699	27	73,914,740
28	Temporarily restricted net assets ...........			4,490,519	28	4,581,483
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			72,583,218	33	78,496,223
34	Total liabilities and net assets/fund balances ........			137,587,316	34	144,627,429

1	Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes,"the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................	Yes	No
2	Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A; do not file with Form 990)............................	Yes	No
3	Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................	Yes	No
4	Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If “Yes,” the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)...............................................	Yes	No
5	Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................	Yes	No
6	Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713; do not file with Form 990).....................................	Yes	No