TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) LINDA FRENCH...................................................................... DIRECTOR	1.00 .................	X			0	0
(2) BECKY MILLER...................................................................... DIRECTOR	1.00 .................	X			0	0
(3) RON TYRER...................................................................... DIRECTOR	1.00 .................	X			0	0
(4) L BRETT ABNEY OD...................................................................... DIRECTOR	1.00 .................	X			0	0
(5) LARRY PERKINS...................................................................... DIRECTOR	1.00 .................	X			0	0
(6) EDWIN MCKINNEY...................................................................... DIRECTOR	1.00 .................	X			0	0
(7) IAN NUNNALLY MD...................................................................... DIRECTOR	1.00 .................	X			0	0
(8) DAVID DOWNS...................................................................... DIRECTOR	1.00 .................	X			0	0
(9) TREVOR RAY...................................................................... DIRECTOR	1.00 .................	X			0	0
(10) KEVIN BROOKS...................................................................... DIRECTOR	1.00 .................	X			0	0
(11) TAREK EL-MASRI MD...................................................................... DIRECTOR	1.00 .................	X			0	0
(12) SCOTT ARNDELL...................................................................... CFO	40.00 .................		X		0	0
(13) ANGELA GIBSON...................................................................... PHARMACIST	40.00 .................			X	136,450	0
(14) CATHERINE D CLEMONS...................................................................... CHIEF OPERAT	40.00 .................			X	133,036	18,000
(15) ANITA PLEACHER...................................................................... PHARMACIST	40.00 .................			X	127,947	1,279
(16) DAVID LOGSDON...................................................................... CHIEF NURSIN	40.00 .................			X	124,051	6,989
(17) RICHARD DONOVAN...................................................................... PHARMACIST	40.00 .................			X	121,193	18,000

(A) Name and business address	(B) Description of services	(C) Compensation
ALLIANT MANAGEMENT SERVICES PO BOX 35070 LOUISVILLE,KY40232	FACILITY MGMT C	695,512
LABORATORY CORPORATION PO BOX 12140 BURLINGTON,NC27216	PROFESSIONAL SE	657,228
KENTUCKY HOSPITAL INSURANCE PROGRAM 2501 NELSON MILLER PARKWAY LOUISVILLE,KY40223	MANAGMENT SERVI	531,476
THE MORRIS CENTER FOR SPORTS MEDICIN PO BOX 6890 EVANSVILLE,IN47719	PROFESSIONAL SE	417,026
PROASSURANCE CASUALTY COMPANY PO BOX 952295 DALLAS,TX753952295	PROFESSIONAL SE	369,343
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 25

- 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.
right arrow

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

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

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

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

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ))

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 990-EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 2015 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2014 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2015. 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—2014. 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—2015. 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—2014. 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) 2015

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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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) 2011	(b) 2012	(c) 2013	(d) 2014	(e) 2015	(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 2015 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2014 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2014 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2015. 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—2014. 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) 2015

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 (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) 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 section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

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

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 9a) 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 9a) 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 section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b 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

Schedule A (Form 990 or 990-EZ) 2015

Page 5

Part IV

Supporting Organizations (continued)

Yes

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

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, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) 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) 2015

Page 6

Part V

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

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

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) 2015

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

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 2015 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-2015	(iii) Distributable Amount for 2015
1 Distributable amount for 2015 from Section C, line 6
2 Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions)
3 Excess distributions carryover, if any, to 2015:
a
b
c
d From 2013.......
e From 2014.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2015 distributable amount
i Carryover from 2010 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2015 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2015 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions)
6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions)
7 Excess distributions carryover to 2016. Add lines 3j and 4c.
8 Breakdown of line 7:
a
b
c Excess from 2013.......
d From 2014.......
e From 2015.......

Schedule A (Form 990 or 990-EZ) (2015)

Schedule A (Form 990 or 990-EZ) 2015

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) 2015

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

2015

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other 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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2

Name of organization GRAYSON COUNTY HOSPITAL FOUNDATION

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 3

Name of organization GRAYSON COUNTY HOSPITAL FOUNDATION		Employer identification number 61-0523298

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) (2015)

Schedule B (Form 990, 990-EZ, or 990-PF) (2015)

Page 4


Name of organization GRAYSON COUNTY HOSPITAL FOUNDATION			Employer identification number 61-0523298
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.) $ 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) (2015)

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," on 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

2015

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on 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" on 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on 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 on 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 on 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) 2015

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
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" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages on 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" on 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' on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land ...	744,229		744,229
b	Buildings	42,353,276	18,862,834	23,490,442
c	Leasehold improvements
d	Equipment ...	23,130,212	17,106,248	6,023,964
e	Other ...	2,779,115	1,632,401	1,146,714
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				31,405,349

Schedule D (Form 990) 2015

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' on 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)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on 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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

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

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
CAPITAL LEASE	1,176,231
LONG-TERM DEBT	218,343
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,394,574
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) 2015

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	42,903,468
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................			2e
3	Subtract line 2e from line 1..................			3	42,903,468
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	82,213
c	Add lines 4a and 4b....................			4c	82,213
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	42,985,681

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	42,233,257
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	3,926,115
e	Add lines 2a through 2d....................			2e	3,926,115
3	Subtract line 2e from line 1...................			3	38,307,142
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	82,213
c	Add lines 4a and 4b.....................			4c	82,213
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	38,389,355

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
SCHEDULE D, PAGE 3, PART X	THE HOSPITAL AS WELL AS THE FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. ACCORDINGLY, NO PROVISION FOR INCOME TAXES HAS BEEN REFLECTED IN THE HOSPITAL'S FINANCIAL STATEMENTS. MANAGEMENT IS NOT AWARE OF ANY ACTIVITY WITHIN THE HOSPITAL OR FOUNDATION DURING THE CURRENT OR PRIOR REPORTING PERIODS THAT WOULD JEOPARDIZE OR OTHERWISE CALL INTO QUESTION THE HOSPITAL OR FOUNDATION'S COMPLIANCE WITH THE ABOVE INTERNAL REVENUE CODE SECTION. THE ORGANIZATION'S FEDERAL RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) FOR FISCAL YEARS 2014, 2015 AND 2016 ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE FOR THREE YEARS AFTER THEY WERE FILED. CURRENTLY, THE HOSPITAL AND FOUNDATION HAVE NO REPORTING REQUIREMENTS WITH ANY STATE OR LOCAL TAX JURISDICTIONS. THE HOSPITAL HAS INVESTMENT INTEREST IN THREE COMPANIES AS DESCRIBED IN NOTE 8. THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL AND FOUNDATION'S POLICY FOR RECORDING ANY TAX RELATED INTEREST AND PENALTIES IS TO RECOGNIZE THESE ITEMS AS OPERATING EXPENSES; HOWEVER, NONE WERE INCURRED OR RECORDED DURING THE CURRENT OR PRIOR OPEN OPERATING PERIODS.
SCHEDULE D, PAGE 4, PART XI, LINE 4B	VALUE OF DONATED ITEMS 12,939 DONATED SERVICES 69,274
SCHEDULE D, PAGE 4, PART XII, LINE 2D	OPERATING LOSS REPORTED UNDER ID 61-1269278 3,926,115
SCHEDULE D, PAGE 4, PART XII, LINE 4B	DONATED SERVICES 69,274 USE OF DONATED ITEMS 12,939

Schedule D (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on 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

2015

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

If the organization used factors other than FPG in determining eligibility, describe in Part VI the 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? . . . . . .

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	1	135	50,742		50,742	0.130 %
b	Medicaid (from Worksheet 3, column a) . . . . .	1	27,762	3,254,106	295,243	2,958,863	7.710 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	2	27,897	3,304,848	295,243	3,009,605	7.840 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	10	30,910	2,058	2,400
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .
j	Total. Other Benefits . .	10	30,910	2,058	2,400
k	Total. Add lines 7d and 7j .	12	58,807	3,306,906	297,643	3,009,605	7.840 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015

Schedule H (Form 990) 2015

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	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	1		25,000	25,000	0.070 %
3	Community support	2	3,000	1,697	1,697
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	3	3,000	26,697	26,697	0.070 %

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. ......

1,150,958

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. ......

566,856

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).....

13,332,685

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

19,014,239

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

-5,681,554

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2015

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	GRAYSON COUNTY HOSPITAL FOUNDATION TWIN LAKES REGIONAL MEDICAL CENTER 910 WALLACE AVE LEITCHFIELD,KY42754	X	X	X

Schedule H (Form 990) 2015

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	GRAYSON COUNTY HOSPITAL FOUNDATION
Name of hospital facility or letter of facility reporting group	TWIN LAKES REGIONAL MEDICAL CENTER

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 16

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

6 a

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

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): WWW.TLRMC.COM

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

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

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

If "Yes" (list url):

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

12b

If "Yes" on 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) 2015

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	GRAYSON COUNTY HOSPITAL FOUNDATION
Name of hospital facility or letter of facility reporting group	TWIN LAKES REGIONAL MEDICAL CENTER

Yes

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 150.000000000000% and FPG family income limit for eligibility for discounted care of 400.000000000000%

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):

WWWTLRMCCOM

The FAP application form was widely available on a website (list url):

A plain language summary of the FAP was widely available on a website (list url):

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) 2015

Page 6

Part VFacility Information (continued)

	GRAYSON COUNTY HOSPITAL FOUNDATION
Name of hospital facility or letter of facility reporting group	TWIN LAKES REGIONAL MEDICAL CENTER

Yes

Did the hospital facility or other authorized 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?............

Yes

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 19. (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) 2015

Page 7

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
FACILITY 1, GRAYSON COUNTY HOSPITAL FOUNDATION - PART V, LINE 5	IN CONDUCTING THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), TWIN LAKES REGIONAL MEDICAL CENTER (TLRMC) DEVELOPED A SURVEY TO GATHER HEALTH INFORMATION AND OPINIONS OF GRAYSON COUNTY RESIDENTS 18 AND OVER. THE SURVEY WAS CONDUCTED IN SEPTEMBER AND OCTOBER 2015 USING AN ONLINE SURVEY TOOL AND BY DISTRIBUTING PRINTED COPIES IN VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY. REGISTRATION CLERKS AT THE HOSPITAL HANDED OUT THE SURVEY TO PATIENTS AND FAMILY MEMBERS. THE ONLINE SURVEY WAS PROMOTED THROUGH NEWSPAPER ADVERTISEMENTS, BUSINESS CARDS AND ON THE TLRMC FACEBOOK PAGE. EMAILS WITH A LINK TO THE SURVEY WERE SENT TO GRAYSON COUNTY CHAMBER OF COMMERCE MEMBERS, LOCAL INDUSTRIES, AND EMPLOYEES OF THE GRAYSON COUNTY SCHOOL SYSTEM AND THE HOSPITAL. PRINTED COPIES WERE DELIVERED TO AN ASSISTED LIVING FACILITY, THE GRAYSON COUNTY HEALTH DEPARTMENT, BIG CLIFTY MEDICAL COMPLEX AND THE CANEYVILLE FAMILY PRACTICE. INFORMATION GAPS THAT LIMITED THE ABILITY OF TLRMC TO ASSESS THE COMMUNITY'S HEALTH NEEDS WERE IDENTIFIED. THE PRIMARY OBSTACLE WAS REACHING ELDERLY, LOW-INCOME AND/OR RURAL RESIDENTS DUE TO A LACK OF INTERNET ACCESS AND WILLINGNESS TO PARTICIPATE. TLRMC MADE EFFORTS TO REACH THESE INDIVIDUALS WITH WRITTEN SURVEYS. 757 GRAYSON COUNTY RESIDENTS PARTICIPATED IN THE SURVEY. THE QUESTIONS WERE IN THREE PRIMARY CATEGORIES: DEMOGRAPHICS, PERSONAL HEALTH INFORMATION, AND PERCEIVED HEALTH NEEDS OF THE COMMUNITY. THE TWIN LAKES REGIONAL MEDICAL CENTER'S CHNA TEAM TABULATED THE RESULTS FROM THE SURVEYS (ONLINE AND PRINTED) AND SUPPLEMENTED THEM WITH HEALTH STATISTICS AND DEMOGRAPHIC INFORMATION. TLRMC THEN INVITED REPRESENTATIVES FROM A VARIETY OF BACKGROUNDS TO A COMMUNITY FORUM/FOCUS GROUP ON FEBRUARY 2, 2016 TO REVIEW THE SURVEY RESULTS AND PROVIDE RECOMMENDATIONS FOR THE HOSPITAL'S COMMUNITY BENEFIT FOCUS. PROFESSIONS REPRESENTED INCLUDED PHYSICIANS; SCHOOL ADMINISTRATORS, TEACHERS AND STAFF; THE GRAYSON COUNTY HEALTH DEPARTMENT; LOCAL INDUSTRY/MANUFACTURING; HOSPITAL BOARD MEMBERS; LAW ENFORCEMENT; AND HOSPITAL LEADERSHIP. ONCE THE INFORMATION WAS PRESENTED A GROUP DISCUSSION WAS HELD. ATTENDEES WERE ASKED FOR THEIR TOP HEALTH PRIORITIES WITHOUT CONCERN ABOUT THE PRACTICALITY OF THE HOSPITAL'S ABILITY TO IMPACT THE ISSUES. THESE RESULTS WERE THEN PRESENTED TO THE POPULATION HEALTH COMMITTEE FOR THEIR CONSIDERATION AND INPUT. TO PUT THE 2012 CHNA REPORT INTO ACTION, TWIN LAKES REGIONAL MEDICAL CENTER CREATED THE POPULATION HEALTH COMMITTEE. THIS GROUP OF PEOPLE WORKS ON IMPROVING THE HEALTH OF OUR COMMUNITY GUIDED BY THE COMMUNITY HEALTH FOCUS POINTS SET IN THE 2012 CHNA. THE POPULATION HEALTH COMMITTEE IS MADE UP OF HOSPITAL EMPLOYEES, INDUSTRIAL LEADERS, THE GRAYSON COUNTY SCHOOLS SUPERINDENDENT, REGISTERED DIETICIANS, A PHARMACIST, A REPRESENTATIVE FROM THE KENTUCKY CANCER PROGRAM AND A REPRESENTATIVE FROM THE GRAYSON COUNTY HEALTH DEPARTMENT. THE TWIN LAKES REGIONAL MEDICAL CENTER CEO CHAIRS THE COMMITTEE. THE POPULATION HEALTH COMMITTEE MEETS MONTHLY TO DISCUSS AND IMPLEMENT PLANS ON IMPROVING THE HEALTH OF THE COMMUNITY. ON FRIDAY, MARCH 4, 2016, THE POPULATION HEALTH COMMITTEE MET TO CONSIDER THE INPUT OF THE COMMUNITY FOCUS GROUP, THE SIZE AND SEVERITY OF THE NEEDS, AVAILABLE DATA, AND THE ABILITY TO HAVE AN IMPACT AS A HOSPITAL. THE COMMITTEE MADE THEIR RECOMMENDATIONS OF COMMUNITY HEALTH FOCUS POINTS TO THE HOSPITAL. AFTER CAREFULLY CONSIDERING THE RESULTS OF THE COMMUNITY HEALTH SURVEY, THE MOST RECENT HEALTH AND DEMOGRAPHIC INFORMATION AVAILABLE, AND INPUT FROM THE COMMUNITY FORUM/FOCUS GROUP AND THE POPULATION HEALTH COMMITTEE, THE FOLLOWING NEEDS WERE IDENTIFIED BY HOSPITAL LEADERSHIP AS THE COMMUNITY HEALTH FOCUS POINTS FOR TWIN LAKES REGIONAL MEDICAL CENTER IN 2016 - 2019. SMOKING, INFORMATION/AWARENESS OF HEALTH ISSUES, LACK OF PHYSICAL ACTIVITY OPTIONS, AND NUTRITION/OBESITY. THE 2015 COMMUNITY HEALTH NEEDS ASSESSMENT WAS APPROVED BY THE BOARD OF DIRECTORS FOR TWIN LAKES REGIONAL MEDICAL CENTER ON TUESDAY, MARCH 15, 2016. THE PUBLICATION OF THIS REPORT IS ANOTHER STEP TO A HEALTHIER GRAYSON COUNTY. IT IS THE INTENTION OF TWIN LAKES REGIONAL MEDICAL CENTER THAT THE CONTENTS OF THIS REPORT BE USED TO INFORM GRAYSON COUNTY RESIDENTS OF WHAT THEIR FELLOW CITIZENS THINK ARE THE MOST IMPORTANT HEALTH ISSUES IN THEIR COMMUNITY. ADDITIONALLY, TLRMC HOPES THIS REPORT WILL SERVE AS A FOUNDATION TO BUILD LASTING RELATIONSHIPS BETWEEN TWIN LAKES REGIONAL MEDICAL CENTER, COMMUNITY PARTNERS AND RESIDENTS OF GRAYSON COUNTY. IN ORDER TO ADDRESS THE PRIORITIZED NEEDS, TLRMC WILL ENGAGE KEY INTERNAL AND COMMUNITY PARTNERS. CUSTOMIZED STRATEGIES HAVE BEEN DEVELOPED AND WILL BE CONTINUED. THE STRATEGIES INCLUDE, BUT ARE NOT LIMITED TO, MODIFYING POLICIES, PUBLIC AND PRIVATE; PROVIDING SUPPORT, INFORMATION AND INCENTIVES; IMPROVING ACCESS; ENHANCING SKILLS; AND CHANGING CONSEQUENCES. FOLLOW-UP SURVEYS WILL MEASURE THE SUCCESS OF EACH INITIATIVE AND PROVIDE THE NEXT AREAS OF FOCUS FOR THE HOSPITAL. TO INFORM THE PUBLIC AND PARTNERS OF OUR GOALS AND TO INCREASE AWARENESS OF OUR PLAN, TWIN LAKES REGIONAL MEDICAL CENTER WILL PUBLISH THE FULL CHNA REPORT ON THE HOSPITAL'S WEBSITE (WWW.TLRMC.COM), PROMOTE THE REPORT ON SOCIAL MEDIA CHANNELS SUCH AS FACEBOOK AND TWITTER, AND SUBMIT TO LOCAL NEWS MEDIA. PRINTED COPIES WILL BE AVAILABLE FOR THE PUBLIC AT THE HOSPITAL AS WELL.
FACILITY 1, GRAYSON COUNTY HOSPITAL FOUNDATION - PART V, LINE 7D	LOCAL NEWSPAPERS.
FACILITY 1, GRAYSON COUNTY HOSPITAL FOUNDATION - PART V, LINE 11	THE FOLLOWING NEEDS WERE IDENTIFIED BUT NOT ADOPTED AS TOP PRIORITIES OF THE HOSPITAL AND THE REASONS WHY. ALCOHOL AND/OR DRUG ABUSE - BEING MET BY OTHER COMMUNITY GROUPS AND PARTNERSHIPS THE HOSPITAL IS ALREADY INVOLVED WITH. TEEN PREGNANCY - THE RATES IN GRAYSON COUNTY ARE DECREASING AND THIS DID NOT SEEM LIKE AN EFFECTIVE FOCUS FOR THE HOSPITAL. LACK OF DENTAL CARE - NOT AN AREA THE HOSPITAL CAN MAKE A SIGNIFICANT IMPACT ON. PSYCHIATRIC/MENTAL HEALTH SERVICES - SOME SERVICES ALREADY PROVIDED IN THE COMMUNITY AND THE HOSPITAL WOULD HAVE TO PUT SIGNIFICANT RESOURCES INTO MAKING A DIFFERENCE AT THE COST OF OTHER HIGHER PRIORITY NEEDS.
FACILITY 1, GRAYSON COUNTY HOSPITAL FOUNDATION - PART V, LINE 16I	THE POLICY WAS PROVIDED TO PATIENTS AT REGISTRATION.

Schedule H (Form 990) 2015

Page 8

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?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2015

Page 9

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 3C - OTHER INCOME BASED CRITERIA FOR FREE OR DISCOUNTED CARE	TWIN LAKES REGIONAL MEDICAL CENTER'S PATIENT FINANCIAL ASSISTANCE PROGRAM UTILIZES THE FEDERAL POVERTY GUIDELINES AND AN ASSET TEST CONSISTING OF RESIDENCE, VEHICLES, AND CASH INVESTMENTS TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE.
PART I, LINE 7 - COSTING METHODOLOGY EXPLANATION	IN DETERMINING THE AMOUNTS FOR PART 1, LINE 7, COST ACCOUNTING WAS USED. THE COST-TO-CHARGE RATIO WAS DERIVED FROM WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES.
PART III, LINE 2 - BAD DEBT EXPENSE METHODOLOGY	THE TOTAL BAD DEBT EXPENSE AT COST REPRESENTS THE TOTAL AMOUNT EXPECTED TO BE COLLECTED, BUT DEEMED UNCOLLECTIBLE. BASED ON THE COMMUNITY'S DEMOGRAPHICS, INCOME LEVEL, INDIVIDUAL ASSETS, AND HEALTH COVERAGE, 49.25% WAS DETERMINED TO BE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE HOSPITAL'S PATIENT FINANCIAL ASSISTANCE PROGRAM.
BAD DEBT EXPENSE FOOTNOTE TO FINANCIAL STATEMENTS	DELINQUENT RECEIVABLES ARE WRITTEN OFF BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT OR THIRD-PARTY PAYOR. IF THE HOSPITAL RECEIVES NO PAYMENT OR COMMUNICATION TO ARRANGE PAYMENT THE ACCOUNT IS SENT TO COLLECTION AND RECOGNIZED AS BAD DEBT AT THAT TIME.
PART III, LINE 8 - MEDICARE EXPLANATION	TWIN LAKES REGIONAL MEDICAL CENTER BELIEVES THAT ALL OF THE 5.7 MILLION MEDICARE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT. THE COSTS TO CARE FOR THE ELDERLY AND MEDICARE PATIENTS ARE ABSORBED BY THE HOSPITAL DUE TO LACK OF REIMBURSEMENTS FROM MEDICARE. THE HOSPITAL CONTINUES TO PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVES THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST OF MEDICARE BENEFICIARIES. THEREFORE, TWIN LAKES REGIONAL MEDICAL CENTER IS FULFILLING A COMMUNITY NEED BY CARING FOR MEDICARE PATIENTS, WHO TYPICALLY HAVE LOW, FIXED INCOMES, AND RELIEVING THE GOVERNMENT FOR THEIR LACK OF PROVIDING SUFFICIENT PAYMENTS TO COVER THE COST FOR CARING FOR THEM.
PART III, LINE 9B - COLLECTION PRACTICES EXPLANATION	IF THE PATIENT DOES NOT HAVE ANY INSURANCE COVERAGE, AND THE PATIENT DOES NOT QUALIFY FOR ANY TYPE OF FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE PROGRAM, THEN THE ACCOUNT CAN BE CONSIDERED FOR BAD DEBT PLACEMENT FORTY-FIVE DAYS AFTER THE PATIENT RECEIVED THEIR FIRST STATEMENT IF THERE HAS BEEN NO RESPONSE FROM THE PATIENT. AFTER A PERIOD OF TIME HAS PASSED WITH NO RESOLUTION, THE ACCOUNT WILL BE SENT TO OUR COLLECTION AGENCY.
PART VI, LINE 2 - NEEDS ASSESSMENT	TWIN LAKES REGIONAL MEDICAL CENTER ASSESSES THE COMMUNITY'S HEALTH CARE NEEDS BY OBTAINING INFORMATION FROM A VARIETY OF SOURCES INCLUDING: A. COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY TWIN LAKES REGIONAL MEDICAL CENTER B. DEMOGRAPHIC DATABASES C. LOCAL AND REGIONAL HEALTH DEPARTMENTS AND RELATED DATABASES D. KENTUCKY HOSPITAL ASSOCIATION REPORTS AND DATABASES E. MARKET ANALYSIS F. FEEDBACK FROM PHYSICIANS AND EMPLOYEES AND OTHER INTERESTED COMMUNITY GROUPS G. HOSPITAL-GENERATED REPORTS ON UTILIZATION OF SERVICES H. BOARD OF DIRECTORS MADE UP OF LOCAL, COUNTY RESIDENTS
PART VI, LINE 3 - PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE	TWIN LAKES REGIONAL MEDICAL CENTER REACHES OUT TO EDUCATE PATIENTS ABOUT THEIR PATIENT FINANCIAL ASSISTANCE PROGRAM. A BROCHURE IS AVAILABLE AT SEVERAL LOCATIONS THROUGHOUT THE HOSPITAL INCLUDING THE BUSINESS OFFICE AND REGISTRATION AREA. A PDF VERSION OF THE BROCHURE IS POSTED ON THE HOSPITAL'S WEBSITE. THE HOSPITAL ALSO PUBLISHED THE COMMUNITY BENEFITS REPORT IN THE TWO LOCAL NEWSPAPERS IN JUNE 2016, WHICH INCLUDED THE SAME INFORMATION PROMINENTLY DISPLAYED. WHEN SELF PAY PATIENTS PRESENT TO THE HOSPITAL FOR SERVICES, THE REGISTRAR DIRECTS THE PATIENTS TO THE FINANCIAL COUNSELOR FOR ASSISTANCE ON MEDICAID/COMMERCIAL PLANS AVAILABLE THROUGH THE ACA. ALSO, AT THAT TIME OUR FINANCIAL ASSISTANCE PROGRAM IS ALSO APPLIED TO THEIR PERSONAL SITUATION FOR POSSIBLE HELP.
PART VI, LINE 4 - COMMUNITY INFORMATION	THE PRIMARY SERVICE AREA FOR TWIN LAKES REGIONAL MEDICAL CENTER IS GRAYSON COUNTY, KY (POPULATION 26,000) LOCATED 75 MILES SOUTHWEST OF LOUISVILLE, KY. THE HOSPITAL'S SECONDARY SERVICE AREA INCLUDES PARTS OF 6 SURROUNDING COUNTIES. THE ESTIMATED PERCENTAGE OF PEOPLE LIVING BELOW THE POVERTY LEVEL, AS DETERMINED BY THE U.S. CENSUS BUREAU, IS 21.7% FOR THE PRIMARY SERVICE AREA. THE AREA IS MOSTLY RURAL WITH A HIGHER PERCENTAGE OF PERSONS OVER THE AGE OF 65 AND A SIGNIFICANTLY LOWER MEDIAN HOUSEHOLD INCOME COMPARED TO THE STATE OF KENTUCKY. THE UNEMPLOYMENT RATE FOR THE MOST RECENT 12 MONTHS AVERAGED 6.8%.
PART VI, LINE 5 - PROMOTION OF COMMUNITY HEALTH	TWIN LAKES REGIONAL MEDICAL CENTER AND ITS EMPLOYEES HAVE A RICH HISTORY OF PLANNING AND/OR SPONSORING EVENTS DESIGNED TO EDUCATE THE COMMUNITY ON HEALTHY LIVING AND WELLNESS FACTORS. EVENTS DURING FYE 2016 INCLUDED THE COMMUNITY BABY SHOWER, NUTRITION DAY AT LOCAL SCHOOLS, CPR CLASSES, PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES, AND HEALTH FAIRS AND SCREENINGS FOR THE COMMUNITY AND PRIVATE ORGANIZATIONS. TWIN LAKES REGIONAL MEDICAL CENTER ADHERES TO THE FOLLOWING IRS EXEMPTION REQUIREMENTS: A. ACCEPT AND TREAT MEDICARE AND MEDICAID PATIENTS B. EMERGENCY DEPARTMENT OPEN TO ALL EMERGENT CASES, REGARDLESS OF ABILITY TO PAY C. OPEN MEDICAL STAFF THAT ALLOWS CREDENTIALED PHYSICIANS TO PRACTICE AT FACILITY D. OPERATE UNDER COMMUNITY BOARD'S CONTROL IT IS THE MISSION AND ONGOING GOAL OF THE LEADERSHIP AND EMPLOYEES OF TWIN LAKES REGIONAL MEDICAL CENTER TO DO THE BEST JOB POSSIBLE TREATING THE SICK AND INJURED, ADDRESSING COMMUNITY WELLNESS NEEDS AND PROMOTING HEALTHY LIVING AT EVERY OPPORTUNITY. THROUGH OUR MANY COMMUNITY BENEFIT ACTIVITIES, OUR CHARITY CARE PROGRAM AND OUR ACCEPTANCE OF PATIENTS COVERED BY FEDERAL AND STATE PROGRAMS, TLRMC MAKES A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE IN THE COMMUNITIES WE SERVE.
ADDITIONAL INFORMATION	IN ADDITION TO PROVIDING THE COMMUNITY BENEFIT REPORT IN THE LOCAL PAPER, TLRMC ALSO PARTICIPATES IN THE STATE-WIDE COMMUNITY BENEFIT REPORT WITH KENTUCKY HOSPITAL ASSOCIATION THAT IS PRESENTED TO OUR COMMONWEALTH.

Schedule H (Form 990) 2015

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" on 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

2015

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
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 on Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

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

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

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

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

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on 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," on line 6a or 6b, describe in Part III.

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

Were any amounts reported on 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" on 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) 2015

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 on 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 on 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)
1CATHERINE D CLEMONSCHIEF OPERATING OFFI	(i) (ii)	133,036 -------------	-------------	-------------	18,000 -------------	-------------	151,036 -------------	-------------

Schedule J (Form 990) 2015

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

Schedule J (Form 990) 2015

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

2015

Open to Public
Inspection

Name of the organization
GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number
61-0523298

Part I

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	GRAYSON COUNTY PUBLIC HOSPITAL DIST GRAYSON COUNTY PUBLIC HOSPITAL DIST	61-0523298	389681CF2	04-15-2007	5,930,000	REFUND EXISTING 1978, 1993 & 1999 BONDS AND SURGERY DEPARTMENT RENOVATION		X		X		X
B	GRAYSON COUNTY PUBLIC HOSPITAL DIST GRAYSON COUNTY PUBLIC HOSPITAL DIST	61-0523298		08-28-2014	9,970,000	REFUND EXISTING 2009 BOND ISSUE.		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	4,435,258		200,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	5,755,733		9,970,000
4 Gross proceeds in reserve funds .............	1,755,094		1,717,418
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	118,395		131,358
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	502,730
11 Other spent proceeds .............
12 Other unspent proceeds .............
13 Year of substantial completion .............	2008		2014
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue? ....		X		X
15 Were the bonds issued as part of an advance refunding issue? .....	X		X
16 Has the final allocation of proceeds been made? ..........	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X

Part III

Private Business Use

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

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

Cat. No. 50193E

Schedule K (Form 990) 2015

Page 2

Part III

Private Business Use (Continued)

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

Part IV

Arbitrage

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

Schedule K (Form 990) 2015

Page 3

Part IV

Arbitrage (Continued)

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

Part V

Procedures To Undertake Corrective Action

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
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		X

Part VI

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

Return Reference	Explanation

Schedule K (Form 990) 2015

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

2015

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Excess Benefit Transactions (section 501(c)(3), 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) 2015

Page 2

Part IV

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

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) ISAAC MILLER	SON OF DIRECTOR	175,000	PHYSICIAN ASSIST PRO		No
(2) MIDWAY PHARMACY OF CLARKSON INC	DIRECTOR	52,524	RENT OF PHARMACY SPA		No
(3) DR TAREK EL-MASRI	DIRECTOR	37,884	RENT OF OFFICE SPACE		No
(4) FUTURE DESIGNS INC	DIRECTOR	3,669	PURCHASE OF BLDG MAT		No

Part V

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

Return Reference

Explanation

SCHEDULE L, PART V

ISAAC MILLER IS THE SON OF DIRECTOR BECKY MILLER. HE IS PARTICIPATING IN THE PHYSICIAN ASSISTANCE PROGRAM. DIRECTOR TREVOR RAY IS A SHAREHOLDER IN MIDWAY PHARMACY OF CLARKSON, INC. MIDWAY PHARMACY OF CLARKSON, INC. RENTS SPACE FROM TWIN LAKES REGIONAL MEDICAL CENTER FOR TWO PHARMACY LOCATIONS. DR. TAREK EL-MASRI IS A DIRECTOR OF TWIN LAKES REGIONAL MEDICAL CENTER. HIS MEDICAL PRACTICE RENTS OFFICE SPACE FROM TLRMC. KEVIN BROOKS IS A SHAREHOLDER IN FUTURE DESIGNS, INC. FUTURE DESIGNS, INC. SOLD BUILDING MATERIALS TO TLRMC. THE GRAYSON COUNTY HOSPITAL DISTRICT MAINTAINS ALL OF ITS BANK ACCOUNTS AT THE CECILIAN BANK. LARRY PERKINS AND DAVID DOWNS, BOTH DIRECTORS OF GRAYSON COUNTY HOSPITAL FOUNDATION, INC., ARE EMPLOYED BY THE CECILIAN BANK. THE CASH BALANCES HELD AT JUNE 30, 2016 AND 2015 WERE 17,445,257 AND 4,562,465, RESPECTIVELY.

Schedule L (Form 990 or 990-EZ) 2015

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

2015

Open to Public
Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Return Reference	Explanation
FORM 990, PAGE 1, PART I, LINE 6	THE TWIN LAKES REGIONAL MEDICAL CENTER (TLRMC) HOSPITAL AUXILIARY EXISTS TO SUPPORT TLRMC IN MEETING THE HEALTH CARE NEEDS OF THE PEOPLE IT SERVES IN THE MOST CARING, COMPASSIONATE, AND EFFECTIVE MANNER POSSIBLE. THE VOLUNTEERS SUPPORT THE EMOTIONAL WELL-BEING OF THE PATIENTS UTILIZING THE HOSPITAL'S SERVICES. THEY PROVIDE A FRIENDLY, CARING AND HELPFUL ATMOSPHERE FOR PATIENTS AND THEIR FAMILIES, AND THE HOSPITAL STAFF. DUTIES INCLUDE STAFFING THE INFORMATION DESK IN THE MAIN LOBBY, PROVIDING GENERAL HOSPITAL INFORMATION AND DIRECTIONS TO PATIENTS AND THE PUBLIC, PROVIDING ESCORTS WHEN NEEDED, AND DELIVERING FLOWERS TO PATIENTS. THEY VOLUNTEER IN THE SPECIALTY CLINIC, OUTPATIENT SURGERY AND EMERGENCY DEPARTMENT. THE VOLUNTEERS OPERATE THE GIFT SHOP LOCATED IN THE HOSPITAL. THEY MAKE SOCK MONKEYS AND OTHER STUFFED ANIMALS FOR CHILDREN COMING TO THE HOSPITAL. THE ANIMALS ARE GIVEN TO THE YOUNG PATIENTS AND THEIR FAMILIES AT NO CHARGE. THE VOLUNTEERS RAISE THE MONEY NEEDED TO PURCHASE ANY SUPPLIES AND DONATE MATERIALS IN ADDITION TO THEIR TIME AND TALENTS. THEY GIVE FLOWERS TO HOSPITALIZED PATIENTS ON CERTAIN HOLIDAYS AND MAKE "SANTA GOING HOME" OUTFITS FOR ALL BABIES BORN AT THE HOSPITAL IN DECEMBER. THE AUXILIARY HAS DONATED THOUSANDS OF DOLLARS IN EQUIPMENT TO THE HOSPITAL THROUGHOUT THE YEARS.
FORM 990, PAGE 2, PART III, LINE 4A	ADDITIONAL CHARGES ARE WRITTEN OFF DUE TO ARRANGEMENTS WITH MEDICARE, MEDICAID, AND OTHER THIRD PARTIES. THE TOTAL UNREIMBURSED CHARGES FORGONE IN FISCAL YEAR 2016 DUE TO CONTRACTUAL AGREEMENTS WITH PAYERS AMOUNTED TO 89,190,839. ALSO, 696,857 WAS PAID AS A "PROVIDER TAX" TO THE COMMONWEALTH OF KENTUCKY TO HELP DEFRAY THE COSTS OF COVERING INDIGENT PATIENTS UNDER A SPECIAL STATE PROGRAM. WRITE-OFFS FROM PATIENTS "UNWILLING" TO PAY - I.E. BAD DEBTS - ACCOUNTED FOR 4,163,652. THE PRIMARY MISSION OF TWIN LAKES REGIONAL MEDICAL CENTER IS TO HEAL THE SICK, RELIEVE PAIN AND SUFFERING, AND IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE WE SERVE. TLRMC'S VISION IS TO BE RECOGNIZED BY THE PEOPLE WE SERVE AS THE PROVIDER OF CHOICE FOR THEIR HEALTH CARE NEEDS AND AS A LEADING FORCE FOR PROGRESSIVE CHANGE WITHIN OUR COMMUNITY. TO ENHANCE QUALITY, THE HOSPITAL ACTIVELY OPERATES A PERFORMANCE IMPROVEMENT PROGRAM WHICH HELPS IDENTIFY BETTER PATIENT CARE AS WELL AS EFFICIENCIES IN OPERATIONS. TO ENHANCE OUR COMMUNITY, TLRMC PROVES TO BE A DRIVING FORCE IN CHANGE BY EDUCATING THE COMMUNITY ON HEALTH & WELLNESS ISSUES AND BY RECOGNIZING COMMUNITY NEEDS AND WORKING TO FULFILL THOSE NEEDS. THE HOSPITAL CARED FOR 2,314 INPATIENTS AND 94,937 OUTPATIENTS. TO ASSIST THOSE PATIENTS WITH LIMITED RESOURCES, TLRMC ALSO OFFERS A PATIENT FINANCIAL ASSISTANCE PROGRAM. THERE ARE SEVERAL OPTIONS FOR PATIENTS WHO ARE UNINSURED OR UNDERINSURED, AND TLRMC'S PATIENT FINANCIAL SERVICES DEPARTMENT EDUCATES THE PATIENTS OF THE DIFFERENT PROGRAMS. BASED ON THE RESULTS OF OUR LATEST COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), TWIN LAKES REGIONAL MEDICAL CENTER CREATED THE POPULATION HEALTH COMMITTEE. THIS GROUP IS MADE UP OF HOSPITAL EMPLOYEES AND REPRESENTATIVES FROM THE LOCAL HEALTH DEPARTMENT, SCHOOL SYSTEM, LOCAL FACTORIES, EXTENSION SERVICE LEADERS, GOVERNMENT OFFICIALS AND OTHERS. THE COMMITTEE MEETS MONTHLY AT THE HOSPITAL AND LED THE EFFORT TO GET A SMOKE FREE COMMUNITY ORDINANCE PASSED. THE GROUP IS NOW WORKING ON MAKING POSITIVE DIFFERENCES IN THE HEALTH OF OUR COMMUNITY IN SUCH TOPICS AS DIABETES, EXERCISE, NUTRITION AND GENERAL HEALTH. THE HOSPITAL PARTNERED WITH THE UNIVERSITY OF KENTUCKY COOPERATIVE EXTENSION SERVICE AND HOSTED A LOCAL FARMER'S MARKET ON THE HOSPITAL CAMPUS. TIME AND SOME ADVERTISING BUDGET WERE GIVEN TO PROMOTING THIS EFFORT TO SUPPORT LOCAL FARMERS AND TO MAKE FRESH VEGETABLES MORE READILY AVAILABLE TO THE COMMUNITY. THE HOSPITAL PROVIDED FREE MEETING SPACE TO SEVERAL GROUPS THROUGHOUT THE YEAR AND SEVERAL CLASSES WERE SPONSORED BY THE HOSPITAL THAT EDUCATED INTERESTED COMMUNITY RESIDENTS ON HEALTH & WELLNESS ISSUES. THEY INCLUDE: A. C.P.R. TO HEALTHCARE PROVIDERS AND TO THE COMMUNITY B. PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES C. COUNTYWIDE BABY SHOWER IN GRAYSON COUNTY - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT D. COMMUNITY-WIDE BABY SHOWER IN BRECKINRIDGE COUNTY - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT E. SPONSORS THE AMERICAN RED CROSS BLOOD MOBILE TWO OR THREE TIMES EACH YEAR F. PROVIDED HEALTH INFORMATION AT THE RELAY FOR LIFE G. PARTICIPATED IN UNITED WAY MEETNGS H. CPR CLASSES AT CROSSPOINT CHURCH IN LEITCHFIELD UPON REQUEST, THE HOSPITAL ALSO PARTICIPATES IN LOCAL EDUCATION BY PROVIDING HOSPITAL EMPLOYEES AS SPEAKERS FOR CLASSROOMS OR CIVIC ORGANIZATIONS SUCH AS THE FOLLOWING EXAMPLES: I. PARTICIPATED IN OPERATION PREPARATION J. ASSISTED IN PROVIDING TRANSLATION SERVICES K. PARTICIPATED IN WILKEY ELEMENTARY HEALTH FAIR AND CAREER DAY L. PARTICIPATED IN MID-PARK HEALTH FAIR M. PARTICIPATED IN PLASTIKON HEALTH FAIR N. PARTICIPATED IN HEALTH FAIR AT HARDINSBURG ELEMENTARY SCHOOL O. PARTICIPATED IN NUTRITION DAY AT CLARKSON ELEMENTARY SCHOOL P. PROVIDED SPEAKERS FOR MANY HEALTH FAIRS, SCHOOLS, AND COMMUNITY EVENTS Q. PARTICIPATED IN CANEYVILLE ELEMENTARY SCHOOL HEALTH FAIR IN ADDITION TO SERVING OUR LOCAL COMMUNITY NEEDS, TLRMC HAS ALSO TAKEN ON MEASURES TO IMPROVE AMERICA. BY PARTICIPATING IN THE CODE GREEN - RECYCLING PROJECT, TLRMC HOPES TO REDUCE WASTE AND IMPROVE THE ENVIRONMENT. TWIN LAKES REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS HAS PLEDGED TO BUY AMERICAN-MADE PRODUCTS WHEN WE CAN FIND A PRODUCT OF EQUAL OR GREATER QUALITY. TLRMC ENCOURAGES OTHER COMPANIES AND INDIVIDUALS TO DO THE SAME.
FORM 990, PAGE 6, PART VI, LINE 3	THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER OF THE HOSPITAL ARE EMPLOYED BY ALLIANT MANAGEMENT SERVICES AND ARE RESPONSIBLE FOR CONTROLLING MANAGEMENT DUTIES.
FORM 990, PAGE 6, PART VI, LINE 6	THE ORGANIZATION HAS STOCKHOLDERS. EACH SHARE OF STOCK IS VALUED AT 25. STOCKHOLDERS MUST BE AT LEAST 18 YEARS OLD AND A RESIDENT OF GRAYSON COUNTY, KENTUCKY.
FORM 990, PAGE 6, PART VI, LINE 7A	NINE MEMBERS OF THE BOARD OF DIRECTORS ARE ELECTED BY THE STOCKHOLDERS AND THE OTHER MEMBER IS THE PRESIDENT OF THE MEDICAL STAFF (WHOM IS VOTED ON BY THE MEDICAL STAFF).
FORM 990, PAGE 6, PART VI, LINE 11B	THE FORM 990 IS SUBMITTED TO THE GOVERNING BOARD FOR REVIEW AND APPROVAL BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE.
FORM 990, PAGE 6, PART VI, LINE 12C	CORPORATE COMPLIANCE REQUIRES EACH EMPLOYEE AND BOARD MEMBER TO UPDATE AND SIGN OFF ON A CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS.
FORM 990, PAGE 6, PART VI, LINE 15A	ALLIANT MANAGEMENT SERVICES, ACTING AS THE MANAGEMENT COMPANY, BRINGS COMPARABLE NATIONAL DATA TO THE BOARD OF DIRECTORS FOR THE BOARD TO DETERMINE WHAT COMPENSATION IS TO BE PAID.
FORM 990, PAGE 6, PART VI, LINE 15B	ALLIANT MANAGEMENT SERVICES, ACTING AS THE MANAGEMENT COMPANY, BRINGS COMPARABLE NATIONAL DATA TO THE BOARD OF DIRECTORS FOR THE BOARD TO DETERMINE WHAT COMPENSATION IS TO BE PAID.
FORM 990, PAGE 6, PART VI, LINE 19	GOVERNING DOCUMENTS ARE MADE AVAILABLE UPON REQUEST.
FORM 990, PART IX, LINE 24E	MEDICAL & SURGICAL 929,063 0 0 MATERIALS MANAGEMENT 886,297 0 0 SURGERY 780,417 0 0 PHYSICAL THERAPY 715,602 0 0 WOUND CARE 470,372 0 0 EMERGENCY ROOM 359,176 0 0 RADIOLOGY 314,504 0 0 NUCLEAR MEDICINE 147,049 0 0 PAIN MANAGEMENT 125,760 0 0 MRI 123,173 0 0 SLEEP CENTER 119,696 0 0 RESPIRATORY THERAPY 113,466 0 0 OBSTETRICS 81,715 0 0 ANESTHESIOLOGY 80,546 0 0 CT SCANS 71,836 0 0 INTENSIVE CARE 70,148 0 0 SPECIALTY CLINIC 23,601 0 0 INFUSION CENTER 19,201 0 0 CARDIAC 13,529 0 0 USE OF DONATED ITEMS 12,939 0 0 OCCUPATIONAL THERAPY 872 0 0 FITNESS CENTER 147 0 0
FORM 990, PART XI, LINE 9	VALUE OF DONATED ITEMS -12,939 DONATED SERVICES -69,274 OPERATING LOSS REPORTED UNDER ID 61-1269278 -3,926,115 DONATED SERVICES 69,274 USE OF DONATED ITEMS 12,939 TOTAL -3,926,115

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2015

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

2015

Open to Public Inspection

Name of the organization

GRAYSON COUNTY HOSPITAL FOUNDATION

Employer identification number

61-0523298

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" 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)TWIN LAKES MEDICAL FOUNDATION INC 910 WALLACE AVE LEITCHFIELD,KY42754 61-1269278	MEDICAL PR	KY	501C3	9	GCHF GRAYSON COUNTY HOSPITAL FOUNDATION		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2015

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) TWIN LAKES HOME HEALTH AGENCY LLC 901 S HUGH WALLIS ROAD LAFAYETTE,LA70508 27-1000828	HOME HEALT	LA	N/A	RELATED	-4,929	56,882		No			No	25.000 %
(2) TWIN LAKES REGIONAL PAIN MANAGEMENT 908 WALLACE AVE LEITCHFIELD,KY42754 47-2329929	PAIN MANAG	KY	N/A	RELATED	48,176	319,973		No			No	51.000 %

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) WTK HOLDINGS INC 910 WALLACE AVE LEITCHFIELD,KY42754 61-0608823	HOLDING CO	KY	GCHF GRAYSON COUNTY HOSPITAL FOUNDATION	C CORP	-311,416	1,727,598	100.000 %		No

Schedule R (Form 990) 2015

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

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

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

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

Yes

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

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

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

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

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

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

Yes

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

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

Yes

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

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

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

Yes

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

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

Yes

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

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) TWIN LAKES MEDICAL FOUNDATION INC	D	3,368,710	FAIR MARKET VALUE
(2) TWIN LAKES MEDICAL FOUNDATION INC	J	301,358	FAIR MARKET VALUE
(3) TWIN LAKES MEDICAL FOUNDATION INC	L	202,461	FAIR MARKET VALUE
(4) TWIN LAKES MEDICAL FOUNDATION INC	O	46,080	FAIR MARKET VALUE
(5) TWIN LAKES MEDICAL FOUNDATION INC	Q	3,228,035	FAIR MARKET VALUE
(6) TWIN LAKES MEDICAL FOUNDATION INC	S	19,609	FAIR MARKET VALUE

Schedule R (Form 990) 2015

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) 2015

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) 2015

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	50	12,939
9	Program service revenue (Part VIII, line 2g) .........	42,074,001	42,251,358
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	113,835	71,599
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,435,317	649,785
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	43,623,203	42,985,681
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	12,320,158	12,276,201
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	25,067,672	26,113,154
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	37,387,830	38,389,355
19	Revenue less expenses. Subtract line 18 from line 12.......	6,235,373	4,596,326
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	99,372,520	102,651,308
21	Total liabilities (Part X, line 26).............	17,644,458	16,326,920
22	Net assets or fund balances. Subtract line 21 from line 20.....	81,728,062	86,324,388

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 24,434,887 including grants of $ ) (Revenue $ 42,251,358 )
	TWIN LAKES REGIONAL MEDICAL CENTER PROVIDES QUALITY MEDICAL HEALTH CARE SERVICES TO PATIENTS REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR THE ABILITY TO PAY. ALTHOUGH REIMBURSEMENT FOR SERVICES RENDERED IS CRITICAL TO THE OPERATION AND FINANCIAL STABILITY OF TWIN LAKES REGIONAL MEDICAL CENTER, IT IS RECOGNIZED THAT NOT ALL INDIVIDUALS POSSESS THE ABILITY TO PURCHASE ESSENTIAL MEDICAL SERVICES. IN KEEPING WITH ITS COMMITMENT TO SERVE ALL MEMBERS OF THIS AREA, THE HOSPITAL PROVIDES FREE CARE TO THE MOST INDIGENT OF PATIENTS AND WRITES OFF PORTIONS OF BILLS TO OTHER PATIENTS WHO HAVE DEMONSTRATED THE INABILITY TO PAY FOR ALL HEALTH CARE SERVICES RECEIVED. ADDITIONAL CHARGES ARE WRITTEN OFF DUE TO ARRANGEMENTS WITH MEDICARE, MEDICAID, AND OTHER THIRD PARTIES. THE TOTAL UNREIMBURSED CHARGES FORGONE IN FISCAL YEAR 2016 DUE TO CONTRACTUAL AGREEMENTS WITH PAYERS AMOUNTED TO 89,190,839. ALSO, 696,857 WAS PAID AS A "PROVIDER TAX" TO THE COMMONWEALTH OF KENTUCKY TO HELP DEFRAY THE COSTS OF COVERING INDIGENT PATIENTS UNDER A SPECIAL STATE PROGRAM. WRITE-OFFS FROM PATIENTS "UNWILLING" TO PAY - I.E. BAD DEBTS - ACCOUNTED FOR 4,163,652. THE PRIMARY MISSION OF TWIN LAKES REGIONAL MEDICAL CENTER IS TO HEAL THE SICK, RELIEVE PAIN AND SUFFERING, AND IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE WE SERVE. TLRMC'S VISION IS TO BE RECOGNIZED BY THE PEOPLE WE SERVE AS THE PROVIDER OF CHOICE FOR THEIR HEALTH CARE NEEDS AND AS A LEADING FORCE FOR PROGRESSIVE CHANGE WITHIN OUR COMMUNITY. TO ENHANCE QUALITY, THE HOSPITAL ACTIVELY OPERATES A PERFORMANCE IMPROVEMENT PROGRAM WHICH HELPS IDENTIFY BETTER PATIENT CARE AS WELL AS EFFICIENCIES IN OPERATIONS. TO ENHANCE OUR COMMUNITY, TLRMC PROVES TO BE A DRIVING FORCE IN CHANGE BY EDUCATING THE COMMUNITY ON HEALTH & WELLNESS ISSUES AND BY RECOGNIZING COMMUNITY NEEDS AND WORKING TO FULFILL THOSE NEEDS. THE HOSPITAL CARED FOR 2,314 INPATIENTS AND 94,937 OUTPATIENTS. TO ASSIST THOSE PATIENTS WITH LIMITED RESOURCES, TLRMC ALSO OFFERS A PATIENT FINANCIAL ASSISTANCE PROGRAM. THERE ARE SEVERAL OPTIONS FOR PATIENTS WHO ARE UNINSURED OR UNDERINSURED, AND TLRMC'S PATIENT FINANCIAL SERVICES DEPARTMENT EDUCATES THE PATIENTS OF THE DIFFERENT PROGRAMS. BASED ON THE RESULTS OF OUR LATEST COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), TWIN LAKES REGIONAL MEDICAL CENTER CREATED THE POPULATION HEALTH COMMITTEE. THIS GROUP IS MADE UP OF HOSPITAL EMPLOYEES AND REPRESENTATIVES FROM THE LOCAL HEALTH DEPARTMENT, SCHOOL SYSTEM, LOCAL FACTORIES, EXTENSION SERVICE LEADERS, GOVERNMENT OFFICIALS AND OTHERS. THE COMMITTEE MEETS MONTHLY AT THE HOSPITAL AND LED THE EFFORT TO GET A SMOKE FREE COMMUNITY ORDINANCE PASSED. THE GROUP IS NOW WORKING ON MAKING POSITIVE DIFFERENCES IN THE HEALTH OF OUR COMMUNITY IN SUCH TOPICS AS DIABETES, EXERCISE, NUTRITION AND GENERAL HEALTH. THE HOSPITAL PARTNERED WITH THE UNIVERSITY OF KENTUCKY COOPERATIVE EXTENSION SERVICE AND HOSTED A LOCAL FARMER'S MARKET ON THE HOSPITAL CAMPUS. TIME AND SOME ADVERTISING BUDGET WERE GIVEN TO PROMOTING THIS EFFORT TO SUPPORT LOCAL FARMERS AND TO MAKE FRESH VEGETABLES MORE READILY AVAILABLE TO THE COMMUNITY. THE HOSPITAL PROVIDED FREE MEETING SPACE TO SEVERAL GROUPS THROUGHOUT THE YEAR AND SEVERAL CLASSES WERE SPONSORED BY THE HOSPITAL THAT EDUCATED INTERESTED COMMUNITY RESIDENTS ON HEALTH & WELLNESS ISSUES. THEY INCLUDE: A. C.P.R. TO HEALTHCARE PROVIDERS AND TO THE COMMUNITY B. PREPARED CHILDBIRTH AND BREAST FEEDING CLASSES C. COUNTYWIDE BABY SHOWER IN GRAYSON COUNTY - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT D. COMMUNITY-WIDE BABY SHOWER IN BRECKINRIDGE COUNTY - PROVIDES INFORMATION TO WOMEN WHO ARE PREGNANT OR WANT TO BECOME PREGNANT E. SPONSORS THE AMERICAN RED CROSS BLOOD MOBILE TWO OR THREE TIMES EACH YEAR F. PROVIDED HEALTH INFORMATION AT THE RELAY FOR LIFE G. PARTICIPATED IN UNITED WAY MEETNGS H. CPR CLASSES AT CROSSPOINT CHURCH IN LEITCHFIELD UPON REQUEST, THE HOSPITAL ALSO PARTICIPATES IN LOCAL EDUCATION BY PROVIDING HOSPITAL EMPLOYEES AS SPEAKERS FOR CLASSROOMS OR CIVIC ORGANIZATIONS SUCH AS THE FOLLOWING EXAMPLES: I. PARTICIPATED IN OPERATION PREPARATION J. ASSISTED IN PROVIDING TRANSLATION SERVICES K. PARTICIPATED IN WILKEY ELEMENTARY HEALTH FAIR AND CAREER DAY L. PARTICIPATED IN MID-PARK HEALTH FAIR M. PARTICIPATED IN PLASTIKON HEALTH FAIR N. PARTICIPATED IN HEALTH FAIR AT HARDINSBURG ELEMENTARY SCHOOL O. PARTICIPATED IN NUTRITION DAY AT CLARKSON ELEMENTARY SCHOOL P. PROVIDED SPEAKERS FOR MANY HEALTH FAIRS, SCHOOLS, AND COMMUNITY EVENTS Q. PARTICIPATED IN CANEYVILLE ELEMENTARY SCHOOL HEALTH FAIR IN ADDITION TO SERVING OUR LOCAL COMMUNITY NEEDS, TLRMC HAS ALSO TAKEN ON MEASURES TO IMPROVE AMERICA. BY PARTICIPATING IN THE CODE GREEN - RECYCLING PROJECT, TLRMC HOPES TO REDUCE WASTE AND IMPROVE THE ENVIRONMENT. TWIN LAKES REGIONAL MEDICAL CENTER'S BOARD OF DIRECTORS HAS PLEDGED TO BUY AMERICAN-MADE PRODUCTS WHEN WE CAN FIND A PRODUCT OF EQUAL OR GREATER QUALITY. TLRMC ENCOURAGES OTHER COMPANIES AND INDIVIDUALS TO DO THE SAME.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses24,434,887

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	642,677	44,268

		Business Code
2a	PATIENT SERVICES	42,050,670	42,050,670
b	CAFETERIA REVENUE	174,957	174,957
c	FITNESS CENTER & OTHER INCOME	25,731	25,731
d
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....		42,251,358

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE QUALITY MEDICAL HEALTHCARE TO THE GRAYSON COUNTY, KENTUCKY AREA.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	10
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	509
6	Total number of volunteers (estimate if necessary) .............	6	45
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	12,939

g	Noncash contributions included in lines 1a-1f:$ 12,939
h Total.Add lines 1a-1f.......		12,939

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			71,599			71,599
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		579,870
b	Less: rental expenses		329,911
c	Rental income or (loss)		249,959
d	Net rental income or (loss)......			249,959	249,959
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory
b	Less: cost or other basis and sales expenses
c	Gain or (loss)
d	Net gain or (loss).....
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	TAX REVENUE			604,155	604,155
b	MANAGEMENT FEES			202,461	202,461
c	SALE OF EQUIPMENT			-16,619	-16,619
d	All other revenue ....			-390,171	-390,171
e	Total. Add lines 11a–11d ......			399,826
12	Total revenue. See Instructions......			42,985,681	42,901,143		71,599

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	12,276,201	10,234,228	2,041,973
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)
12	Advertising and promotion ....
13	Office expenses .......
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........	468,245		468,245
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	2,992,377	2,647,655	344,722
23	Insurance ...
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	ADMINISTRATIVE & GENERAL	11,099,528		11,099,528
b	PHARMACY	2,768,388	2,768,388
c	LABORATORY	2,164,739	2,164,739
d	PROVISION FOR BAD DEBTS	1,160,768	1,160,768
e	All other expenses	5,459,109	5,459,109
25	Total functional expenses. Add lines 1 through 24e	38,389,355	24,434,887	13,954,468	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).

1	Cash–non-interest-bearing ........			19,992,475	1	22,244,841
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			6,093,303	4	6,075,532
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 ....			35,339,205	7	38,707,915
8	Inventories for sale or use ........			1,628,952	8	1,844,239
9	Prepaid expenses and deferred charges ......			507,531	9	453,324
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	69,006,832
b	Less: accumulated depreciation	10b	37,601,483	33,400,165	10c	31,405,349
11	Investments—publicly traded securities .			2,410,889	11	1,920,108
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........				15
16	Total assets. Add lines 1 through 15 (must equal line 34)...			99,372,520	16	102,651,308

17	Accounts payable and accrued expenses .....	4,053,060	17	3,667,604
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........	12,237,903	20	11,264,742
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	1,353,495	25	1,394,574
26	Total liabilities. Add lines 17 through 25..	17,644,458	26	16,326,920

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	81,728,062	27	86,324,388
28	Temporarily restricted net assets ...........		28
29	Permanently restricted net assets		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	81,728,062	33	86,324,388
34	Total liabilities and net assets/fund balances ........	99,372,520	34	102,651,308