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)	(F) Estimated amount of other compensation from the organization and related organizations
(1) DAVID BUCKLER...................................................................... DIRECTOR	1.0 ................. 2.0	X			0	0
(2) MICHAEL CALLAHAN...................................................................... DIRECTOR/PHYSICIAN	1.0 ................. 1.0	X			25,000	0
(3) CHRISTIAN CARAMIA MD...................................................................... DIRECTOR BEGINNING 11/2015	40.0 ................. 1.0	X			485,475	34,760
(4) RON CASKEY...................................................................... SECRETARY	1.0 ................. 1.0	X	X		0	0
(5) DAVID CRANDALL...................................................................... CHAIR	1.0 ................. 1.0	X	X		0	0
(6) ALANNA HUCK...................................................................... DIRECTOR	1.0 ................. 1.0	X			0	0
(7) JOHN LEETE...................................................................... DIRECTOR BEGINNING 10/2015	1.0 ................. 1.0	X			0	0
(8) JEANNE MIGLICIO...................................................................... DIRECTOR AT LARGE	1.0 ................. 1.0	X	X		0	0
(9) THOMAS SHAFFER...................................................................... TREASURER	1.0 ................. 1.0	X	X		0	0
(10) ROBERT SMITH...................................................................... DIRECTOR	1.0 ................. 1.0	X			0	0
(11) JASON TRONETTI MD...................................................................... DIRECTOR/PHYSICIAN	40.0 ................. 1.0	X			363,868	34,141
(12) CHARLES UPDEGRAFF...................................................................... VICE CHAIR	1.0 ................. 1.0	X	X		0	0
(13) CLIFFORD WOOD...................................................................... DIRECTOR	1.0 ................. 1.0	X			0	0
(14) KALLIOPI NESTOR...................................................................... DIRECTOR END 12/2015/PHYSICIAN	40.0 ................. 1.0	X			229,085	12,416
(15) EDWARD PITCHFORD...................................................................... PRESIDENT, CEO, & ASST SECRETA	48.0 ................. 2.0		X		387,892	64,500
(16) RONALD RAPP...................................................................... CONTROLLER	50.0 ................. 1.0		X		140,604	28,790
(17) CYNTHIA HARDESTY...................................................................... VICE PRESIDENT ENDING 12/2015	49.0 ................. 1.0			X	177,721	20,666

(A) Name and business address	(B) Description of services	(C) Compensation
HAMOTCOLE VENTURES, INC COUDERSPORT,PA16915	RENT	557,661
FOOT ANKLE INNOVATIONS, PC SMETHPORT,PA16749	PHYSICIAN SERVICES	494,158
ALLEGHANY HOSPITAL ASSOCIATES, PLLC OLEAN,NY14760	PHYSICIAN SERVICES	374,459
JAMES BARKE, MD SHINGLEHOUSE,PA16748	PHYSICIAN SERVICES	147,013
HALLSTROM CONSTRUCTION, INC DUBOIS,PA15801	CONSTRUCTION	5,126,942
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 9

- 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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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 CHARLES COLE MEMORIAL HOSPITAL

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 CHARLES COLE MEMORIAL HOSPITAL		Employer identification number 24-0802108

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 CHARLES COLE MEMORIAL HOSPITAL			Employer identification number 24-0802108
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 C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

Complete if the organization is described below. SchCMd Bullet

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

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

OMB No. 1545-0047

2015

Open to Public
Inspection

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

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

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

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

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

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

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

Name of the organization

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I-A

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

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

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

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

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2015

Page 2

Part II-A

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

A Check SchCMd Bullet

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

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

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

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

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2012	(b) 2013	(c) 2014	(d) 2015	(e) Total

2a	Lobbying nontaxable amount

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

c	Total lobbying expenditures

d	Grassroots nontaxable amount

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

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2015

Page 3

Part II-B

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

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

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

Yes

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

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

Yes

11,291

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

11,291

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Return Reference	Explanation
SCHEDULE C, PART II-B, LINE 1G	DIRECT CONTACT WITH LEGISLATORS: EDWARD PITCHFORD, CEO, ATTENDS MEETING WITH LEGISLATORS. THERE IS NO COST TO THE HOSPITAL ASSOCIATED WITH THESE MEETINGS.
SCHEDULE C, PART II-B, LINE 1I	OTHER LOBBYING ACTIVITIES: THE ORGANIZATION IS A MEMBER OF HAP, AHA, AND HCWP. $11,291 OF DUES ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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	5,605
d	Additions during the year ............................	1d	23,689
e	Distributions during the year ..........................	1e	25,114
f	Ending balance ................................	1f	4,180

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 ....	4,148,803	4,420,558	3,994,146	3,877,382	4,280,877
b	Contributions ...
c	Net investment earnings, gains, and losses	-42,451	-36,364	660,852	378,612	-106,295
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...	214,771	235,391	234,440	261,858	297,200
f	Administrative expenses ....
g	End of year balance ......	3,891,581	4,148,803	4,420,558	3,994,136	3,877,382

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

100.000 %

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)

Yes

(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 ...	1,135,847		1,135,847
b	Buildings	50,874,813	26,334,639	24,540,174
c	Leasehold improvements
d	Equipment ...	29,101,094	22,565,137	6,535,957
e	Other ...	1,841,632	1,465,648	375,984
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				32,587,962

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	0
DUE TO THIRD PARTY PAYERS	2,381,147
MALPRACTICE LIABILITY	1,305,474
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	3,686,621
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	83,422,659
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	272,962
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-3,696,627
e	Add lines 2a through 2d .....................			2e	-3,423,665
3	Subtract line 2e from line 1..................			3	86,846,324
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	96,536
c	Add lines 4a and 4b....................			4c	96,536
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	86,942,860

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	84,367,291
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	234,797
e	Add lines 2a through 2d....................			2e	234,797
3	Subtract line 2e from line 1...................			3	84,132,494
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	46,082
b	Other (Describe in Part XIII.) ............	4b	4,072,663
c	Add lines 4a and 4b.....................			4c	4,118,745
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	88,251,239

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, PART IV, LINE 1B	ESCROW ACCOUNTS: THE CORPORATION HAS AN ESCROW ACCOUNT FOR THEIR SKILLED NURSING FACILITY PATIENTS WHO REQUEST THE USE OF THE ACCOUNT.
SCHEDULE D, PART V, LINE 4	ENDOWMENT FUND: THE ENDOWMENT FUND WAS ESTABLISHED TO ALLOW THE HOSPITAL TO PROVIDE HEALTHCARE SERVICES TO POOR AND NEEDY PATIENTS.
SCHEDULE D, PART X, LINE 2	UNCERTAIN TAX POSITIONS: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS.
SCHEDULE D, PART XI, LINE 2D	OTHER REVENUE ON LINE 1, BUT NOT ON FORM 990, PART VII, LINE 12: $ (4,072,663) BAD DEBT EXPENSE 422,118 UNRESTRICTED NARR (46,082) INVESTMENT MANAGEMENT FEES ------------- $ (3,696,627)
SCHEDULE D, PART XI, LINE 4B	OTHER REVENUE ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1: $ (234,797) RENTAL EXPENSES 474,810 UNRESTRICTED CONTRIBUTIONS (326,352) GAAP/TAX DIFFERENCE DEFERRED OIL, GAS & MINERAL LEASE 226,154 TRNA CONTRIBUTIONS (828) TRNA INVESTMENT RETURN (42,451) PRNA INVESTMENT RETURN ------------- $ 96,536
SCHEDULE D, PART XII, LINE 2D	OTHER EXPENSES ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25: $ 234,797 RENTAL EXPENSES
SCHEDULE D, PART XII, LINE 4B	OTHER EXPENSES ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1: $ 4,072,663 BAD DEBT EXPENSE

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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? . . . . . .

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	283,155		283,155	0.340 %
b	Medicaid (from Worksheet 3, column a) . . . . .	17,871,563	12,237,048	5,634,515	6.690 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	18,154,718	12,237,048	5,917,670	7.030 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	173,092	21,606	151,486	0.180 %
f	Health professions education (from Worksheet 5) . . .	227,354		227,354	0.270 %
g	Subsidized health services (from Worksheet 6) . . . .	36,061,452	21,885,809	14,175,643	16.850 %
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	6,427		6,427	0.010 %
j	Total. Other Benefits . .	36,468,325	21,907,415	14,560,910	17.310 %
k	Total. Add lines 7d and 7j .	54,623,043	34,144,463	20,478,580	24.340 %

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.

		(c) Total community building expense	(e) Net community building expense
1	Physical improvements and housing
2	Economic development
3	Community support	7,194	7,194
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	3,275	3,275
7	Community health improvement advocacy	1,278	1,278
8	Workforce development	2,681	2,681
9	Other
10	Total	14,428	14,428

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. ......

4,072,663

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. ......

549,810

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).....

13,766,435

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

13,630,134

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

136,301

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 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	CHARLES COLE MEMORIAL HOSPITAL 1001 EAST 2ND STREET COUDERSPORT,PA16915 WWW.COLEMEMORIAL.ORG 031801	X	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)

	CHARLES COLE MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

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

Yes

Community Health Needs Assessment

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

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

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 15

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): HTTP://WWW.COLEMEMORIAL.ORG/ABOUT.ASPX

Other website (list url):

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

Other (describe in Section C)

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

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15

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

Yes

If "Yes" (list url): HTTP://WWW.COLEMEMORIAL.ORG/ABOUT.ASPX

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)

	CHARLES COLE MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

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 200.% and FPG family income limit for eligibility for discounted care of 400.%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

Yes

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

Yes

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

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

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

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

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

Other (describe in Section C)

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

Yes

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

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

SEE PART V, SECTION C

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

SEE PART V, SECTION C

A plain language summary of the FAP was widely available on a website (list url):
SEE PART V, SECTION C

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

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

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

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

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

Other (describe in Section C)

Billing and Collections

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	CHARLES COLE MEMORIAL HOSPITAL
Name of hospital facility or letter of facility reporting group

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?............

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
SCHEDULE H, PART V, SECTION B, LINE 5	COMMUNITY INPUT: COLE MEMORIAL USED A 6-STEP APPROACH TO COMPLETE THE NEEDS ASSESSMENT. INCLUDED IN THIS APPROACH WERE SEVERAL DATA ANALYSES, BASED ON SECONDARY SOURCE DATA AUGMENTED WITH COMMUNITY HEALTH SURVEY DATA. SINCE THE SERVICE AREA DOES NOT COMPRISE SOME OF THE ENTIRE COUNTIES WE SERVE, COLE MEMORIAL ASKED LOCAL RESIDENTS TO NOTE IF THEY PERCEIVED THE PROBLEMS, OR NEEDS IDENTIFIED BY SECONDARY SOURCES TO EXIST IN THEIR PORTION OF THE COUNTY THEY LIVE IN. DATA SOURCES USED INCLUDED SEVERAL WEBSITES TO ASSESS THE HEALTH NEEDS OF THE COUNTIES SERVED, ACCESS CURRENT POPULATION DATA, ASSESS CHARACTERISTICS OF CERTAIN HEALTH OBJECTIVES, ADDRESS THE PROBLEM OF ESCALATING HEALTH COSTS, AND CAPTURE DATA THAT CAN HELP UNDERSTAND HEALTH STATISTICS. TO OBTAIN DATA WITHIN THE COMMUNITIES SERVED BY COLE MEMORIAL, ALL COMMUNITY MEMBERS WERE INVITED TO COMPLETE A SURVEY, WHICH WOULD REMAIN ANONYMOUS. THE ADMINISTRATION OF AN INTERNET-BASED AND PAPER SURVEY WAS PROMOTED THROUGH ADVERTISEMENTS IN LOCAL NEWSPAPERS, BLOGS, AND TELEVISION AND WAS DISTRIBUTED TO LOCAL CIVIC AND HEALTH ORGANIZATIONS. IN ADDITION, WE CONDUCTED 3 SURVEYS; SURVEY WITHIN THE COMMUNITIES COLE SERVES FOR ANY COMMUNITY RESIDENT TO COMPLETE; KEY LEADERS OF THE REGION, AND OUR SERVICE PROVIDERS. RESPONDENTS REPLIED FROM AUGUST 3, 2015 THROUGH AUGUST 14, 2015. THE TERMS OF GAINING INPUT SPECIFIED EACH RESPONDENT REMAINED ANONYMOUS. THE HOSPITAL DID INCORPORATE COMMENTS ON THE 2013 CHNA, ALTHOUGH THE COMMENTS WERE NOT WRITTEN. THE FEEDBACK WAS SOLICITED THROUGH THE SURVEY AND INTERVIEW PROCESS. THE ADMINISTRATION OF AN INTERNET-BASED AND PAPER SURVEY WAS PROMOTED THROUGH ADVERTISEMENTS IN LOCAL NEWSPAPERS, BLOGS, AND TELEVISION AND WAS DISTRIBUTED TO LOCAL CIVIC AND HEALTH ORGANIZATIONS WITH A REQUEST FOR PARTICIPATION. PRELIMINARY CONCLUSIONS OF THE THREE SURVEY RESULTS WERE PRESENTED TO THE CHNA STEERING COMMITTEE, WHICH WERE ASKED TO VALIDATE PRIOR ASSESSMENTS AND TO ESTABLISH PRIORITY AMONG VARIOUS IDENTIFIED HEALTH NEEDS. MEMBERS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT STEERING COMMITTEE INCLUDE 40 PROFESSIONALS AND OVER 25 COMMUNITY ORGANIZATIONS SUCH AS: - COLE MEMORIAL - DICKINSON CENTER, INC. - OFFICE OF AGING - DRUG AND ALCOHOL SERVICES - DCNR - WIC - LOCAL AREA SCHOOL DISTRICTS - POTTER COUNTY LINK - MULTI-CARE CENTER - LAKEVIEW NURSING HOME - MCKEAN AND POTTER COUNTY DISTRICT OFFICE - EMERGENCY SERVICES - IU9 - A WAY OUT - LOCK HAVEN PA PROGRAM
SCHEDULE H, PART V, SECTION B, LINE 7D	CHNA AVAILABILITY: COLE MEMORIAL POSTED THE CHNA ON THE FACEBOOK PAGE.
SCHEDULE H, PART V, SECTION B, LINE 11	IMPLEMENTATION STRATEGY: THE HEALTH NEEDS THAT WERE ACKNOWLEDGED BY THE COMMUNITY HEALTH NEEDS ASSESSMENT HAVE BEEN INTEGRATED INTO THE DESIGN OF A THREE-YEAR IMPLEMENTATION PLAN. AFTER REVIEWING CURRENT COMMUNITY COLLABORATIONS AND PARTNERSHIPS, AND INTERNAL RESOURCES, THE STEERING COMMITTEE FORMED 3 COMMITTEES TO HELP IDENTIFY ITS EXISTING RESOURCES AND CREATE INNOVATIVE PROGRAMS. THE COMMITTEES WERE BROKEN UP INTO OBESITY/NUTRITION/PHYSICAL INACTIVITY, MENTAL HEALTH AND SUBSTANCE ABUSE. EACH OF THE THREE IDENTIFIED PRIORITIES WILL BE FACILITATED BY A KEY LEADER IN THE REGION. JESSICA ROHRER, COUDERSPORT AREA SCHOOL DISTRICT NURSE AND RICH NEEFE, COUDERSPORT AREA SCHOOL DISTRICT FOOD SERVICES DIRECTOR WILL OVERSEE THE OBESITY, PHYSICAL INACTIVITY, AND NUTRITION FOCUS GROUP, HEIDI EASTMAN, POTTER COUNTY OPERATIONS MANAGER FOR DICKINSON CENTER, INC. HEADS UP THE MENTAL HEALTH FOCUS GROUP AND COLLEEN WILBER, DRUGS AND ALCOHOL ADMINISTRATOR FOR POTTER COUNTY HUMAN SERVICES WILL MANAGE THE SUBSTANCE ABUSE FOCUS GROUP. OVER THE COURSE OF THE NEXT THREE YEARS, THESE THREE COMMITTEES WILL BE COMMITTED TO ENHANCING THE CULTURE OF HEALTH FOR OUR COMMUNITIES BY PROMOTING HEALTHY LIFESTYLE, IMPROVING ACCESS TO INTEGRATED, AND HOLISTIC BEHAVIORAL HEALTH CARE AND SUBSTANCE ABUSE SERVICES. THE STEERING COMMITTEE ALSO RECOGNIZED THE IMPORTANCE OF A COMMUNITY COLLABORATIVE AND WORKING TOGETHER IN MEETING THE NEEDS OF THE COMMUNITIES WE SERVE. IT'S JUST NOT THE WORK OF THE HOSPITAL BUT WITH COMMUNITY PARTNERS AND WE CAN'T DO THIS ALONE. WE DECIDED THAT WE WOULD LIKE TO FORM A COMMUNITY COLLABORATIVE CALLED THE NORTHERN TIER COMMUNITY HEALTH COLLABORATION. THE NORTHERN TIER COMMUNITY HEALTH COLLABORATIVE WILL DEVELOP A CARE COORDINATION NETWORK ACROSS BEHAVIORAL HEALTH, DRUG & ALCOHOL, AND PHYSICAL HEALTH PROVIDERS TO PRODUCE THE FOLLOWING OUTCOMES: A) CONDUCT A GAP ANALYSIS FOR MENTAL HEALTH AND DRUG & ALCOHOL SERVICES; B) DESIGN AN OPERATIONAL FRAMEWORK FOR A PATIENT-CENTERED PHYSICAL, BEHAVIORAL HEALTH AND DRUG & ALCOHOL SYSTEM; C) DEVELOP A NETWORK PLAN FOR PHYSICAL, BEHAVIORAL HEALTH AND DRUG & ALCOHOL SERVICES IMPROVEMENT (I.E., GOALS, STRATEGIES, OUTCOMES AND MEASURES FOR EVALUATION OF PROGRESS TOWARD NETWORK GOALS); D) ASSESS HEALTH LITERACY TRAINING NEEDS FOR NETWORK PARTNERS AND DEVELOP AN EDUCATIONAL PLAN FOR NETWORK PARTNERS. E) FORMALIZE AND APPROVE THE NORTHERN TIER COMMUNITY HEALTH COLLABORATIVE INFRASTRUCTURE F) DEVELOP A COMMUNICATION PLAN FOR DISSEMINATION OF BEHAVIORAL HEALTH AND D & A "ROADMAP" OF SERVICES THAT SPEAKS TO PROVIDERS AND USERS OF BEHAVIORAL HEALTH AND D & A SERVICES. PLEASE SEE THE CHNA REPORT AT HTTP://WWW.COLEMEMORIAL.ORG/ABOUT.ASPX FOR THE FULL IMPLEMENTATION STRATEGY
SCHEDULE H, PART V, LINE 13H	OTHER FACTORS USED IN ELIGIBILITY CRITERIA: CHARLES COLE MEMORIAL HOSPITAL ALSO USES THE FOLLOWING METHODS: -EMPLOYMENT STATUS ALONG WITH FUTURE EARNINGS POTENTIAL AND ACCESS IF IT IS SUFFICIENT TO MEET THE OBLIGATION WITHIN A REASONABLE PERIOD OF TIME -FAMILY SIZE AND CONFIGURATION -AMOUNT(S) AND FREQUENCY OF HOSPITAL AND OTHER HEALTHCARE/MODIFICATION BILLS IN RELATION TO ALL OTHER FACTORS.
SCHEDULE H, PART V, LINE 16A, 16B & 16C	POLICY PUBLICATION: HTTP://WWW.COLEMEMORIAL.ORG/PATIENTS-FINANCIAL.ASPX
SCHEDULE H, PART V, LINE 22D	MAXIMUM AMOUNTS CHARGED: COLE MEMORIAL WILL LIMIT THE AMOUNTS CHARGED TO INDIVIDUALS ELIGIBLE FOR FINANCIAL ASSISTANCE, FOR EMERGENCY AND MEDICALLY NECESSARY TREATMENT, TO THE AMOUNTS GENERALLY RECEIVED BY INDIVIDUALS WITH COMMERCIAL, MEDICARE AND MEDICAID INSURANCE COVERAGE. AMOUNTS GENERALLY BILLED IS CALCULATED USING THE LOOK-BACK METHOD DESCRIBED IN THE IRS AND TREASURY'S FINAL RULES ON THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA).

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?12
Name and address		Type of Facility (describe)
1	PORT ALLEGANY HEALTH CENTER 45 PINE STREET PORT ALLEGANY,PA16743	DENTAL PRACTICE, RURAL HEALTH CENTER, REHABILITATION LAB SERVICES, RADIOLOGY
2	SHINGLEHOUSE HEALTH CENTER 129 PURITAN STREET SHINGLEHOUSE,PA16748	RURAL HEALTH CENTER REHABILITATION LAB SERVICES, RADIOLOGY
3	ELDRED HEALTH CENTER 139 MAIN STREET ELDRED,PA16371	RURAL HEALTH CENTER LAB SERVICES
4	EMPORIUM HEALTH CENTER 288 SIZERVILLE ROAD EMPORIUM,PA15834	RURAL HEALTH CENTER REHABILITATION LAB SERVICES
5	GALETON HEALTH CENTER 30 RIVER STREET GALETON,PA16922	RURAL HEALTH CENTER LAB SERVICES
6	WESTFIELD RURAL HEALTH CLINIC 222 CHURCH STREET WESTFIELD,PA16950	RURAL HEALTH CENTER LAB SERVICES
7	SMETHPORT HEALTH CENTER 83 MARVIN STREET SMETHPORT,PA16749	RURAL HEALTH CENTER REHABILITATION LAB SERVICES
8	NORTHERN POTTER HEALTH CENTER 511 ACADEMY STREET ULYSSES,PA16948	RURAL HEALTH CENTER LAB SERVICES
9	CENTRAL POTTER HEALTH CENTER 46 ELK STREET COUDERSPORT,PA16915	RURAL HEALTH CENTER LAB SERVICES
10	HOME HEALTH & HOSPICE 269 ROUTE 6 COUDERSPORT,PA16915	HOME HEALTH OFFICES
11	DR VICTOR BROWN DMD 11 8TH STREET COUDERSPORT,PA16915	DENTAL PRACTICE
12	DR TOD TWICHELL DDS 438 EAST 2ND STREET COUDERSPORT,PA16915	DENTAL PRACTICE

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
SCHEDULE H, PART I, LINE 7, COLUMN F	PERCENT OF TOTAL EXPENSE: TO ARRIVE AT THE PERCENT OF TOTAL EXPENSES, THE DENOMINATOR WHICH EQUALS TOTAL OPERATING EXPENSES PER PART IX, LINE 25, OF THE FORM 990 WAS REDUCED BY BAD DEBT EXPENSE OF $4,072,663.
SCHEDULE H, PART I, LINE 7G	SUBSIDIZED HEALTH SERVICES: SEVERAL RURAL HEALTH CLINICS WERE INCLUDED IN THE COMPUTATION OF SUBSIDIZED HEALTH SERVICES ON LINE 7G AMOUNTING TO $9,256,912 NET COMMUNITY BENEFIT EXPENSE. COLE MEMORIAL PROVIDES PRIMARY CARE TO THE SURROUNDING COUNTIES AT THESE RURAL HEALTH CENTERS. THESE SERVICES ARE PROVIDED IN RURAL AREAS WHERE THERE WOULD BE A SHORTAGE OF QUALITY MEDICAL CARE WITHOUT THE SERVICES. COLE MEMORIAL CONTINUES TO PROVIDE THESE SERVICES AS A BENEFIT TO THE COMMUNITY DESPITE KNOWING THAT FINANCIAL SHORTFALLS WILL BE SUSTAINED.
SCHEDULE H, PART I, LINE 7	COSTING METHODOLOGY: THE COST TO CHARGE RATIO CALCULATED ON IRS WORKSHEET 2 WAS USED IN THE CALCULATION OF COST ON IRS WORKSHEETS 1, 3, AND 6.
SCHEDULE H, PART II	COMMUNITY BUILDING ACTIVITIES: THE COMMUNITY BUILDING ACTIVITIES ALLOWS COLE MEMORIAL TO PROMOTE AND IMPROVE COMMUNITY HEALTH AND WELL-BEING. AT COLE MEMORIAL, ONE OF OUR STRATEGIC PRIORITIES IS TO CREATE A CULTURE OF HEALTH AND BY DOING THIS, WE NEED TO HAVE COMMUNITY HEALTH IMPROVEMENT ADVOCACY, WORKFORCE DEVELOPMENT, AND COALITION BUILDING. SPEAKER BUREAUS, CAREER FAIRS, AND OUR COMMUNITY BENEFIT ADVISORS PLAY A KEY ROLE WITH HELPING US TO BUILD AND CREATE A CULTURE OF HEALTH.
SCHEDULE H, PART III, SECTION A, LINE 2	BAD DEBT EXPENSE: LINE 2 REPORTS THE BAD DEBT ATTRIBUTABLE TO PATIENT ACCOUNTS FROM THE AUDITED FINANCIAL STATEMENTS.
SCHEDULE H, PART III, SECTION A, LINE 3	BAD DEBT EXPENSE ATTRIBUTABLE TO FAP-ELIGIBLE PATIENTS: LINE 3 WAS DETERMINED BY MULTIPLYING THE BAD DEBT EXPENSE (LINE 2) BY THE PERCENT OF PERSONS BELOW THE POVERTY LEVEL BASED ON US CENSUS BUREAU DATA FOR 2010 - 2014.
SCHEDULE H, PART III, SECTION A, LINE 4	BAD DEBT EXPENSE FOOTNOTE: THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS, WHICH IS BASED UPON A REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. ACCOUNTS ARE CONSIDERED DELINQUENT AND SUBSEQUENTLY WRITTEN OFF AS BAD DEBTS BASED ON INDIVIDUAL CREDIT EVALUATION AND SPECIFIC CIRCUMSTANCES OF THE PATIENT OR THIRD-PARTY PAYER.
SCHEDULE H, PART III, SECTION B, LINE 8	COMMUNITY BENEFIT: MEDICARE DATA COMPUTED USING THE MEDICARE COST REPORT FILED WITH CMS WAS UTILIZED FOR THE COMPUTATIONS IN PART III, SECTION B. COLE MEMORIAL IS CLASSIFIED AS A CRITICAL ACCESS HOSPITAL. THIS CLASSIFICATION SHOWS THAT COLE MEMORIAL IS IN A MEDICALLY UNDERSERVED AREA AND AT A HEALTH PROFESSIONAL SHORTAGE AREA. THIS DEMONSTRATES THAT COLE MEMORIAL IS THE ONLY REASONABLE SOURCE OF HOSPITAL CARE AVAILABLE TO MEDICARE BENEFICIARIES IN OUR SERVICE AREA, AND LIKEWISE TREATS ALL BENEFICIARIES IN OUR SERVICE AREA THAT PRESENT THEMSELVES FOR CARE, DESPITE KNOWING WE WILL GENERALLY LOSE MONEY CARING FOR MEDICARE PATIENTS. ADDITIONALLY, SERVING PATIENTS WITH GOVERNMENT HEALTH BENEFITS, SUCH AS MEDICARE, IS A COMPONENT OF THE COMMUNITY BENEFIT STANDARD THAT TAX-EXEMPT HOSPITALS ARE HELD TO. THIS IMPLIES THAT SERVING MEDICARE PATIENTS IS A COMMUNITY BENEFIT AND THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY.
SCHEDULE H, PART III, SECTION C, LINE 9B	COLLECTION POLICY: EFFORTS ARE MADE TO IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR CHARITY CARE IN ACCORDANCE WITH THE HOSPITAL'S CHARITY CARE POLICY OR THE PHYSICIAN NETWORK SLIDING FEE SCALE PRIOR TO THE STATEMENT PROCESS WHEN POSSIBLE.
SCHEDULE H, PART VI, LINE 2	NEEDS ASSESSMENT: UNDERSTANDING THE HEALTH NEEDS OF THE COMMUNITY ALLOWS COLE MEMORIAL TO DESIGN AND IMPLEMENT COST-EFFECTIVE STRATEGIES THAT IMPROVE THE HEALTH STATUS OF THE POPULATIONS WE SERVE. A COMPREHENSIVE DATA-DRIVEN ASSESSMENT PROCESS CAN IDENTIFY PRIORITY HEALTH NEEDS AND ISSUES RELATED TO PREVENTION, DIAGNOSIS AND TREATMENT THROUGH QUANTITATIVE AND QUALITATIVE DATA. COLE MEMORIAL'S COMMUNITY HEALTH NEEDS ASSESSMENT FOCUSES ON THE 28 ZIP CODES THAT WE SERVE. TO HELP GUIDE THE PROCESS USED FOR THE ASSESSMENT, A CHNA STEERING COMMITTEE WAS CONVENED. THIS COMMITTEE'S ROLE WAS TO PROVIDE INPUT ON: (A) IDENTIFICATION OF EXISTING DATA SOURCES FOR THE STUDY; (B) CONTENT OF THE COMMUNITY ONLINE SURVEY QUESTIONNAIRE; (C)INTERPRETATION OF SURVEY FINDINGS; (D) REVIEW OF RECOMMENDATIONS, AND; (E)DATA DISSEMINATION AND A FOLLOW-UP PLAN. THE COMMITTEE WILL CONTINUE TO MEET QUARTERLY WITH THE FOCUS LEADERS THAT HAVE BEEN IDENTIFIED TO ENSURE PROGRESS IS BEING MADE UNDER EACH IDENTIFIED PRIORITY. THE COMMITTEE MET OVER A 9-MONTH PERIOD TO REVIEW, CONSIDER, AND PRIORITIZE SURVEY DATA AND SECONDARY DATA COLLECTED DURING THIS PROCESS. THE COMMITTEE WILL CONTINUE TO MEET QUARTERLY WITH THE FOCUS LEADERS THAT HAVE BEEN IDENTIFIED TO ENSURE PROGRESS IS BEING MADE UNDER EACH IDENTIFIED PRIORITY. IN ADDITION TO THE CHNA STEERING COMMITTEE, COLE MEMORIALS COMMUNITY BENEFIT ADVISORY COMMITTEES WHICH REPRESENT PUBLIC HEALTH, GOVERNMENT, FORMER AND PRESENT BOARD MEMBERS, FOUNDATIONS, PASTORS, SCHOOL NURSES, AND VARIOUS OTHER ORGANIZATIONS, PROVIDED CRITICAL INPUT INTO THE NEEDS ASSESSMENT, FROM INITIAL CONCEPT TO HOW THE DATA WOULD BE SHARED WITH COMMUNITIES IN OUR FALL AND SPRING MEETINGS IN 2015-2016. WE CONDUCTED 3 SURVEYS WITHIN THE COMMUNITIES COLE SERVES FOR COMPLETION BY ANY COMMUNITY RESIDENT, KEY LEADERS OF THE REGION, AND OUR SERVICE PROVIDERS. RESPONDENTS REPLIED FROM AUGUST 3, 2015 THROUGH AUGUST 14, 2015. THE TERMS OF GAINING INPUT SPECIFIED EACH RESPONDENT REMAINED ANONYMOUS. THE HOSPITAL DID INCORPORATE COMMENTS ON THE 2013 CHNA, ALTHOUGH THE COMMENTS WERE NOT WRITTEN. THE FEEDBACK WAS SOLICITED THROUGH THE SURVEY AND INTERVIEW PROCESS. THE ADMINISTRATION OF AN INTERNET-BASED AND PAPER SURVEY WAS PROMOTED THROUGH ADVERTISEMENTS IN LOCAL NEWSPAPERS, BLOGS, AND TELEVISION AND WAS DISTRIBUTED TO LOCAL CIVIC AND HEALTH ORGANIZATIONS WITH A REQUEST FOR PARTICIPATION. PRELIMINARY CONCLUSIONS OF THE THREE SURVEY RESULTS WERE PRESENTED TO THE CHNA STEERING COMMITTEE, WHICH WERE ASKED TO VALIDATE PRIOR ASSESSMENTS AND TO ESTABLISH PRIORITY AMONG VARIOUS IDENTIFIED HEALTH NEEDS. MEMBERS OF THE COMMUNITY HEALTH NEEDS ASSESSMENT STEERING COMMITTEE INCLUDE 40 PROFESSIONALS AND OVER 25 COMMUNITY ORGANIZATIONS. AFTER A COUPLE OF MONTHS ANALYZING THE PRECEDING DATA AND INFORMATION WE RECEIVED FROM THE SURVEYS AND SECONDARY DATA, WE PUT THE INFORMATION IN FRONT OF OUR BOARD OF DIRECTORS AND COMMUNITY BENEFIT ADVISORS DURING OUR ANNUAL MEETING ON OCTOBER 5, 2015. THEY WERE ASKED TO AGREE OR DISAGREE WITH OUR CURRENT SUMMARY CONCLUSIONS. THEY ALSO WERE AT LIBERTY TO AUGMENT POTENTIAL CONCLUSIONS WITH ADDITIONAL STATEMENTS. THE TOP HEALTH CONCERNS WERE OBESITY/PHYSICAL INACTIVITY/NUTRITION, MENTAL HEALTH, AND SUBSTANCE ABUSE. WE MADE OUR COMMUNITY HEALTH NEEDS ASSESSMENT WIDELY AVAILABLE VIA THE WEBSITE. WE ALSO HAVE PLACED HARD COPIES IN OUR ACCOUNTING DEPARTMENT AND COMMUNITY OUTREACH DEPARTMENT.
SCHEDULE H, PART VI, LINE 3	PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE: THE PATIENT FINANCIAL COUNSELOR CONTACTS SELF-PAY PATIENTS/GUARANTORS TO DISCUSS PAYMENT ARRANGEMENTS. IF THEY ARE UNABLE TO PAY, SHE EXPLAINS THE PROCESS OF APPLYING FOR CHARITY WHICH INCLUDES APPLYING FOR PA MEDICAL ASSISTANCE FIRST AND IF THEY ARE DENIED OR HAVE A PORTION TO PAY, THEN THEY CAN APPLY FOR CHARITY. THE CHARITY APPLICATION IS ON THE BACK OF OUR SELF-PAY STATEMENTS. ALSO, THE HOSPITAL-OWNED PHYSICIAN PRACTICES ARE AWARE OF THIS PROGRAM AND REFER PATIENTS/GUARANTORS TO THE PATIENT FINANCIAL COUNSELOR.
SCHEDULE H, PART VI, LINE 4	COMMUNITY INFORMATION: COLE MEMORIAL IS LOCATED IN COUDERSPORT, POTTER COUNTY, IN NORTH-CENTRAL PENNSYLVANIA. THE HOSPITAL SERVES 55,000 RESIDENTS IN ITS PRIMARY AND SECONDARY SERVICE AREAS, ENCOMPASSING CAMERON, MCKEAN, POTTER, AND TIOGA COUNTIES IN PENNSYLVANIA AND PORTIONS OF NEW YORK'S SOUTHERN TIER. ALL OF THE COUNTIES THAT WE SERVE ARE CONSIDERED RURAL AND MOUNTAINOUS. ACCORDING TO THE ROBERT WOODS JOHNSON FOUNDATION COUNTY HEALTH RANKINGS, OUT OF 67 COUNTIES IN PENNSYLVANIA WITH 67 BEING RANKED THE WORST, CAMERON IS RANKED 11, POTTER RANKED 29, TIOGA RANKED 30, AND MCKEAN COUNTY RANKED 52 IN OVERALL HEALTH OUTCOMES. THIS INCLUDES LENGTH OF LIFE AND QUALITY OF LIFE. WHEN IT CAME TO BEING OVERALL RANKED FOR HEALTH FACTORS WHICH INCLUDE HEALTH BEHAVIORS, CLINICAL CARE, SOCIAL AND ECONOMIC FACTORS, AND PHYSICAL ENVIRONMENT; TIOGA RANKED 31, CAMERON RANKED 34, MCKEAN RANKED 47, AND POTTER RANKED 63. THIS IS WHY CONDUCTING A CHNA IS EXTREMELY IMPORTANT.
SCHEDULE H, PART VI, LINE 5	PROMOTION OF COMMUNITY HEALTH: THE MISSION OF COLE MEMORIAL IS TO PROVIDE EXCELLENT HEALTH CARE SERVICES, RESPONDING TO THE CHANGING NEEDS OF THE COMMUNITIES WE SERVE. IT IS LARGELY DEPENDENT ON PROVIDING SERVICES AND CARE TO THOSE INDIVIDUALS WHO MAY NOT HAVE THE RESOURCES TO BE AWARE OF, ABLE TO PAY FOR, OR HAVE THE EDUCATION/KNOWLEDGE ABOUT CARE, PROGRAMS AND SERVICES THAT ARE AVAILABLE TO THEM. THROUGH VARIOUS ACTIVITIES, COLE MEMORIAL REACHES OUT TO OUR COMMUNITIES TO EDUCATE, IMPROVE HEALTH, PREVENT AND TREAT DISEASE AND SUPPORT INDIVIDUALS AND GROUPS. COLE MEMORIAL, IN COOPERATION WITH COMMUNITY-BASED GROUPS SUCH AS 4 ROTARIES AND OSWAYO VALLEY MEMORIAL LIBRARY, PROVIDES FIVE COMPREHENSIVE BLOOD ANALYSIS SCREENINGS ANNUALLY IN FIVE RURAL COMMUNITIES: GALETON, SMETHPORT, PORT ALLEGANY, SHINGLEHOUSE AND COUDERSPORT. CBA'S SCREEN OVER 30 OF THE MOST COMMON BLOOD TESTS THAT DETECT HEALTH ISSUES SUCH AS CORONARY HEART DISEASE, LIVER DISEASE, KIDNEY DISEASE, CANCER, THYROID DISEASE, DIABETES, ANEMIA, BONE DISEASE AND RESPIRATORY DISEASE. THESE SCREENINGS ARE PROVIDED AT A FRACTION OF THE COST OF HAVING THESE TESTS PERFORMED THROUGH A FAMILY PHYSICIAN. ALL PARTICIPANTS AND THEIR PRIMARY MEDICAL PROVIDER ARE SENT THE RESULTS AND PROVIDERS FOLLOW-UP WITH INDIVIDUALS WHOSE SCREENING RESULTS INDICATE ABNORMALITIES. FOR MANY INDIVIDUALS WHO ARE UNINSURED OR UNDERINSURED AND LIKELY WOULD NOT SEEK MEDICAL CARE UNTIL IT WAS EMERGENT, THESE EVENTS PROVIDE AN AVENUE TO MONITOR THEIR HEALTH AND DETECT POTENTIAL ISSUES BEFORE THEY BECOME EMERGENT. IN ADDITION, THE LOCAL CO-SPONSORS RECEIVE A PORTION OF THE PROCEEDS FROM THESE EVENTS AND UTILIZE THE FUNDS TO PROVIDE SCHOLARSHIPS AND SUPPORT TO LOCAL STUDENTS AND PROJECTS TO BENEFIT THE COMMUNITY. ALSO, IN CONJUNCTION WITH THE AREA AGENCY ON AGING, COLE MEMORIAL PROVIDES NO-COST EDUCATION TO COUNTY SENIOR CENTERS FOR A TOTAL OF 30+ SESSIONS. TOPICS INCLUDE IMMUNIZATIONS, COPD, ADVANCE DIRECTIVES, HEART DISEASE, DIET AND NUTRITION, INJURY PREVENTION, THE DIABETIC FOOT AND GOUT, COLE MEMORIAL SERVICES AND MANY MORE. FINALLY, AS AN ONGOING EFFORT TO PROVIDE FULL-SPECTRUM CANCER CARE TO INDIVIDUALS IN RURAL NORTHCENTRAL PENNSYLVANIA, THE PATTERSON CANCER CARE CENTER PHYSICIANS AND STAFF PROVIDED APPROXIMATELY 150 NO-COST CANCER SCREENINGS. SCREENINGS INCLUDED SCREENINGS FOR PROSTATE, COLORECTAL AND SKIN CANCER. SCREENINGS WERE PERFORMED BY ONCOLOGY PHYSICIANS WHO SPECIALIZE IN THE DETECTION, DIAGNOSIS AND TREATMENT OF CANCER. INDIVIDUALS PARTICIPATING IN THESE SCREENINGS WERE BOTH MALE AND FEMALE, ADULT AND SENIOR AND UNINSURED/UNDERINSURED. ALONG WITH MANY OTHER PROGRAMS SUCH AS SUPPORT GROUPS, SPEAKER'S BUREAU, WORKFORCE DEVELOPMENT, ECONOMIC SUPPORT, COMMUNITY LEADERSHIP, PARTNERSHIPS WITH LOCAL CIVIC, GOVERNMENT, SCHOOL DISTRICTS AND COMMUNITY GROUPS, COLE MEMORIAL CONTINUES EFFORTS TO ASSURE THAT HEALTHCARE, IN ALL FORMS, IS ACCESSIBLE AND AVAILABLE TO THOSE WHO MAY OTHERWISE GO WITHOUT. OTHER INFORMATION: COLE MEMORIAL PROVIDES THE COMMUNITY WITH SPACE FOR EVENTS, MEETINGS AND PROGRAMS SUCH AS SUPPORT GROUPS, ANNUAL EVENTS, TRAINING SESSIONS AND YOUTH SPORTS. COLE MEMORIAL'S EMPLOYEE GIVING CLUB, HEART OF COLE, HAS A DESIGNATED GROUP THAT FOCUSES ON COMMUNITY CONNECTIONS. COLE MEMORIAL STRIVES TO LIVE UP TO ITS NON-PROFIT MISSION EVERY DAY, PROVIDING EXCELLENT HEALTHCARE SERVICES TO OUR AREA AND LISTENING AND RESPONDING TO THE COMMUNITIES WE SERVE. IN AN EFFORT TO PLAN FOR THE UNIQUE NEEDS OF COMMUNITIES IN THE SERVICE AREA, FIVE COMMUNITY BENEFIT ADVISORY COMMITTEES WERE ESTABLISHED AS A MAJOR INITIATIVE TO DEEPEN AND STRENGTHEN ITS CONNECTION WITH THE COMMUNITY AND TO LINK COMMUNITY BENEFIT ACTIVITIES TO STRATEGIC AND OPERATIONAL PLANS. THE ROLE OF THE COMMITTEES IS TO IDENTIFY THE NEEDS AND CONCERNS OF THE COMMUNITY, ADVISE ABOUT THE BEST WAY TO PARTNER WITH THE COMMUNITY AND AID IN THE DEVELOPMENT OF MEANINGFUL COMMUNITY PROGRAMS.
SCHEDULE H, PART VI, LINE 6	AFFILIATED HEALTH CARE SYSTEM: THE AFFILIATED HEALTH CARE SYSTEM INCLUDES CHARLES COLE MEMORIAL HOSPITAL (COLE MEMORIAL), COLE CARE, INC., HENDORN, INC., AND COLE FOUNDATION. COLE MEMORIAL (THE "HOSPITAL") PRIMARILY EARNS REVENUES BY PROVIDING INPATIENT, OUTPATIENT AND EMERGENCY CARE SERVICES TO PATIENTS IN COUDERSPORT, PENNSYLVANIA. THE HOSPITAL ALSO OPERATES A HOME HEALTH AGENCY AND A NUMBER OF PHYSICIAN CLINICS IN THE SAME GEOGRAPHIC AREA. COLE CARE, INC., A WHOLLY OWNED SUBSIDIARY OF THE HOSPITAL, OPERATES A DURABLE MEDICAL EQUIPMENT COMPANY FOR THE SALE AND RENTAL OF EQUIPMENT. HENDORN, INC., D/B/A COLE MANOR (COLE MANOR), OF WHICH THE HOSPITAL IS THE SOLE CORPORATE MEMBER, OWNS AND OPERATES A 30-BED PERSONAL CARE RESIDENTIAL FACILITY. COLE FOUNDATION PROVIDES SUPPORT TO THESE ORGANIZATIONS THROUGH FUNDRAISING ACTIVITIES.

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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? .........

Yes

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

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

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

For persons listed 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 ............

Yes

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)
1CHRISTIAN CARAMIA MDDIRECTOR BEGINNING 11/2015	(i) (ii)	485,009 ------------- 0	0 ------------- 0	466 ------------- 0	6,625 ------------- 0	28,135 ------------- 0	520,235 ------------- 0	0 ------------- 0
2JASON TRONETTI MDDIRECTOR/PHYSICIAN	(i) (ii)	275,713 ------------- 0	87,879 ------------- 0	276 ------------- 0	6,625 ------------- 0	27,516 ------------- 0	398,009 ------------- 0	0 ------------- 0
3EDWARD PITCHFORDPRESIDENT, CEO, & ASST SECRETA	(i) (ii)	328,080 ------------- 0	33,408 ------------- 0	26,404 ------------- 0	37,625 ------------- 0	26,875 ------------- 0	452,392 ------------- 0	0 ------------- 0
4KALLIOPI NESTORDIRECTOR END 12/2015/PHYSICIAN	(i) (ii)	228,586 ------------- 0	0 ------------- 0	499 ------------- 0	5,750 ------------- 0	6,666 ------------- 0	241,501 ------------- 0	0 ------------- 0
5BRADLEY GIANNOTTIPHYSICIAN	(i) (ii)	966,449 ------------- 0	1,413 ------------- 0	1,380 ------------- 0	6,625 ------------- 0	20,060 ------------- 0	995,927 ------------- 0	0 ------------- 0
6PHONG NGUYENPHYSICIAN	(i) (ii)	477,187 ------------- 0	52,537 ------------- 0	493 ------------- 0	6,625 ------------- 0	16,909 ------------- 0	553,751 ------------- 0	0 ------------- 0
7SAKET PRASADPHYSICIAN	(i) (ii)	539,598 ------------- 0	41,965 ------------- 0	18,900 ------------- 0	6,625 ------------- 0	23,937 ------------- 0	631,025 ------------- 0	0 ------------- 0
8TERRANCE FOUSTPHYSICIAN	(i) (ii)	762,415 ------------- 0	17,555 ------------- 0	600 ------------- 0	6,625 ------------- 0	21,020 ------------- 0	808,215 ------------- 0	0 ------------- 0
9MAZEN FOUANYPHYSICIAN	(i) (ii)	389,150 ------------- 0	121,408 ------------- 0	317 ------------- 0	6,625 ------------- 0	26,803 ------------- 0	544,303 ------------- 0	0 ------------- 0
10CYNTHIA HARDESTYVICE PRESIDENT ENDING 12/2015	(i) (ii)	148,066 ------------- 0	9,350 ------------- 0	20,305 ------------- 0	4,386 ------------- 0	16,280 ------------- 0	198,387 ------------- 0	0 ------------- 0
11RONALD RAPPCONTROLLER	(i) (ii)	131,105 ------------- 0	9,234 ------------- 0	265 ------------- 0	3,617 ------------- 0	25,173 ------------- 0	169,394 ------------- 0	0 ------------- 0

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, PART I, LINE 4B

NONQUALIFIED RETIREMENT PLAN: THE ORGANIZATION CONTRIBUTED $31,000 TO A 457(F) PLAN FOR EDWARD PITCHFORD, CEO. THIS CONTRIBUTION IS NOT SUBSTANTIALLY VESTED UNTIL 12/31/17.

SCHEDULE J, PART I, LINE 7

NON-FIXED PAYMENTS: SOME OF THOSE LISTED IN FORM 990, PART VII RECEIVED PAYOUTS OF ACCRUED BONUSES AND ACCRUED ADDITIONAL BONUSES FOR PARTICIPATING IN THE EXECUTIVE TEAM INCENTIVE COMPENSATION PROGRAM. EACH PARTICIPANT HAD AN ESTABLISHED TARGET TOTAL COMPENSATION BASED ON INDUSTRY SURVEYS AND THE INCENTIVE PROGRAM COMPRISED APPROXIMATELY 10% OF THE TARGETED TOTAL COMPENSATION. THE BONUS WAS BASED ON OVERALL PERFORMANCE.

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
CHARLES COLE MEMORIAL HOSPITAL

Employer identification number
24-0802108

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	POTTER COUNTY HOSPITAL AUTHORITY	25-6691439		06-25-2014	9,800,000	OPER ROOM EXPANSION, FACIL UPGRADE		X		X		X
B	POTTER COUNTY HOSPITAL AUTHORITY	25-6691439		12-19-2013	20,575,000	REFUND BONDS/LOAN, PURCH CAP EQUIP		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	0		0
2 Amount of bonds legally defeased ..............	0		0
3 Total proceeds of issue ..................	9,800,000		20,575,000
4 Gross proceeds in reserve funds .............	300,000		700,000
5 Capitalized interest from proceeds .............	0		0
6 Proceeds in refunding escrows ...............	0		17,445,440
7 Issuance costs from proceeds ...............	41,073		127,545
8 Credit enhancement from proceeds .............	0		0
9 Working capital expenditures from proceeds .............	0		0
10 Capital expenditures from proceeds .............	8,873,549		2,302,015
11 Other spent proceeds .............	0		0
12 Other unspent proceeds .............	498,906		0
13 Year of substantial completion .............			2016
	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 ....	0 %		0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........
6 Total of lines 4 and 5 .............
7 Does the bond issue meet the private security or payment test? ...		X		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............		X		X
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, 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 ..........	0		0
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 ..........	0		0
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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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) EDMOND HARDESTY	HUSBAND OF C HARDESTY	99,908	EMPLOYEE OF HOSPITAL		No
(2) ADAM NESTOR	HUSBAND OF K. NESTOR	91,052	EMPLOYEE OF HOSPITAL		No
(3) VICTORIA COPP	SISTER OF J. MIGLICIO	36,502	EMPLOYEE OF HOSPITAL		No
(4) NANCY RUDOLPH	SISTER OF J. MIGLICIO	46,246	EMPLOYEE OF HOSPITAL		No

Part V

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

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2015

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE M
(Form 990)

Department of the Treasury

Internal Revenue Service

Noncash Contributions

Complete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image

Attach to Form 990.
Right pointing arrow large image

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Part I

Types of Property

	(a) Check if applicable	(b) Number of contributions or items contributed	(c) Noncash contribution amounts reported on Form 990, Part VIII, line 1g	(d) Method of determining noncash contribution amounts
1 Art—Works of art ....
2 Art—Historical treasures .
3 Art—Fractional interests ..
4 Books and publications ..
5 Clothing and household goods .......
6 Cars and other vehicles ..
7 Boats and planes ....
8 Intellectual property ...
9 Securities—Publicly traded .
10 Securities—Closely held stock .
11 Securities—Partnership, LLC, or trust interests ....
12 Securities—Miscellaneous ..
13 Qualified conservation contribution—Historic structures .....
14 Qualified conservation contribution—Other ...
15 Real estate—Residential .
16 Real estate—Commercial ..
17 Real estate—Other ...
18 Collectibles .....
19 Food inventory ...
20 Drugs and medical supplies .
21 Taxidermy ......
22 Historical artifacts ....
23 Scientific specimens ..
24 Archeological artifacts ...
25 Other ( COPIER )	X	1	9,973	VALUATION
26 Other ( FURN & EQUIP )	X	1	96,910	VALUATION
27 Other ( )
28 Other ( )

Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement

Yes

30a

During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that

it must hold for at least three years from the date of the initial contribution, and which is not required to be used

for exempt purposes for the entire holding period? ..................

30a

If "Yes," describe the arrangement in Part II.

Does the organization have a gift acceptance policy that requires the review of any non-standard contributions?

32a

Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash

contributions? ..........................

32a

If "Yes," describe in Part II.

If the organization did not report an amount in column (c) for a type of property for which column (a) is checked,

describe in Part II.

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

Cat. No. 51227J

Schedule M (Form 990) (2015)

Page 2

Part II

Supplemental Information. Provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.

Return Reference	Explanation
SCHEDULE M, PART I, COLUMN B	NUMBER OF CONTRIBUTIONS: THE AMOUNT REPORTED IN COLUMN B IS THE NUMBER OF CONTRIBUTORS.

Schedule M (Form 990) (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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

Return Reference	Explanation
FORM 990, PART I, LINE 1	ORGANIZATION'S MISSION: COLE MEMORIAL IS A FULL SERVICE, COMPREHENSIVE HEALTH SYSTEM, SERVING POTTER, MCKEAN, CAMERON, AND TIOGA COUNTIES IN RURAL, NORTH CENTRAL PA AND PORTIONS OF NEW YORK STATE AND IS THE ONLY HOSPITAL IN POTTER COUNTY (COUDERSPORT, PA). COLE MEMORIAL IS A CRITICAL ACCESS HOSPITAL PROVIDING PRIMARY, EMERGENCY, AND SPECIALTY CARE, AS WELL AS REHABILITATION AND WELLNESS SERVICES TO PATIENTS WITHIN A 50-MILE RADIUS. COLE MEMORIAL STRIVES TO LIVE UP TO ITS NON-PROFIT MISSION EVERY DAY, PROVIDING EXCELLENT HEALTHCARE SERVICES TO OUR AREA AND LISTENING AND RESPONDING TO THE COMMUNITIES WE SERVE. IN AN EFFORT TO PLAN FOR THE UNIQUE NEEDS OF COMMUNITIES IN THE SERVICE AREA, FIVE COMMUNITY BENEFIT ADVISORY COMMITTEES WERE ESTABLISHED AS A MAJOR INITIATIVE TO DEEPEN AND STRENGTHEN OUR CONNECTION WITH THE COMMUNITY AND TO LINK COMMUNITY BENEFIT ACTIVITIES TO STRATEGIC AND OPERATIONAL PLANS. THE ROLE OF THE COMMITTEES ARE TO IDENTIFY THE NEEDS AND CONCERNS OF THE COMMUNITY, ADVISE ABOUT THE BEST WAY TO PARTNER WITH THE COMMUNITY, AID IN THE DEVELOPMENT OF MEANINGFUL COMMUNITY PROGRAMS AND ACTIVITIES, AND PROMOTE IMPROVED COMMUNICATIONS BETWEEN THE HOSPITAL AND THE COMMUNITY. THE HOSPITAL PROVIDES DEDICATED ADMINISTRATIVE TIME TO PLANNING AND CONDUCTING FIVE CBAC MEETINGS IN THE COMMUNITIES WE SERVE THREE TIMES PER YEAR.
FORM 990, PART III, LINE 2	SIGNIFICANT PROGRAM SERVICES: DURING 2015, COLE MEMORIAL ADDED DENTAL AND OPTHAMOLOGY PRACTICES.
FORM 990, PART III, LINE 4	PROGRAM SERVICE ACCOMPLISHMENTS: LINE 4B ONE OUTLYING CENTER OFFERS IMAGING SERVICES, WHILE ALL RHCS PROVIDE LAB DRAWS SO PATIENTS DON'T HAVE TO DRIVE TO RECEIVE NECESSARY TESTING. IN ADDITION TO THE FAMILY AND INTERNAL MEDICINE SERVICES AT RHCS, PHYSICIAN PRACTICES ALSO PROVIDE SPECIALTY CARE INCLUDING PEDIATRICS, GASTROENTEROLOGY, ORTHOPEDICS, PHYSIATRY, SURGERY, PODIATRY, OBSTETRICS/GYNECOLOGY AND ONCOLOGY. LINE 4C IN ADDITION TO THE HOSPITAL'S ACUTE CARE FLOORS, COLE MEMORIAL CARES FOR PATIENTS IN ITS 44-BED SKILLED NURSING AND REHABILITATION UNIT WHICH REPORTED 14,000 DAYS LAST YEAR. A 10-BED INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT ADMITTED 20 PATIENTS LAST YEAR. LINE 4D THE ORGANIZATION ALSO OFFERS CARDIO-PULMONARY SERVICES, CLINICAL SERVICES, CLINICS, AND CORPORATE SERVICES.
FORM 990, PART VI, SECTION A, LINES 6 & 7A	MEMBERS: THE MEMBERS OF THE CORPORATION, THE CHARLES COLE MEMORIAL HOSPITAL, SHALL BE KNOWN AS COMMUNITY BENEFIT ADVISORS (ADVISORS), WHOSE FUNCTIONS AND QUALIFICATIONS SHALL INCLUDE THE FOLLOWING: (A) PROMOTE THE PROGRAMS, GOALS AND OBJECTIVES OF COLE MEMORIAL; (B) EDUCATE THEIR PUBLIC CONTACTS, BOTH ON HEALTH CARE ISSUES AND ON SERVICES AND PROGRAMS AVAILABLE THROUGH COLE MEMORIAL, AND SEEK THEIR SERVICES WHEN NECESSARY AND APPROPRIATE; (C) PROVIDE AN IMPORTANT LINK BETWEEN COLE MEMORIAL AND ITS AFFILIATES, THE OTHER INSTITUTIONS AND BUSINESSES WHICH THEY REPRESENT, AND THE COMMUNITIES SERVED BY THE HOSPITAL; (D) ATTEND MEETINGS, TO SHARE INFORMATION ON ACTIVITIES AND TO SUPPORT AND GUIDE COLE MEMORIAL; (E) PARTICIPATE IN FUNDRAISING EFFORTS TO BENEFIT PATIENT CARE PROGRAMS FOR COLE MEMORIAL; (F) BE A CITIZEN IN GOOD STANDING, AS DETERMINED BY THE EXECUTIVE COMMITTEE OF THE BOARD, IN A COMMUNITY SERVED BY COLE MEMORIAL; AND (G) BE BETWEEN THE AGES OF EIGHTEEN (18) AND EIGHTY (80) YEARS OLD. UPON AN ACTIVE ADVISOR ATTAINING THE AGE OF EIGHTY (80) YEARS, SAID ACTIVE ADVISOR'S SEAT SHALL BE DEEMED VACANT DUE TO RETIREMENT EFFECTIVE AS OF SEPTEMBER 30 FOLLOWING HIS/HER ATTAINING THE AGE OF EIGHTY YEARS. SUBSEQUENT TO ATTAINING THE AGE OF EIGHTY, AN ACTIVE ADVISOR WILL AUTOMATICALLY BECOME AN HONORARY ADVISOR. THE MEMBERS SHALL BE DIVIDED INTO TWO CLASSES: (A) ACTIVE ADVISORS (B) HONORARY ADVISORS UPON NOMINATION BY THE EXECUTIVE COMMITTEE PER SECTION 5.2.2.(E) OF THESE BYLAWS, ALL ADVISORS SHALL BE ELECTED BY A TWO THIRDS (2/3) VOTE OF THE MEMBERS PRESENT AND VOTING AT A DULY CALLED MEETING OF THE MEMBERS WHICH A QUORUM IS PRESENT. (A) AN ACTIVE ADVISOR OF COLE MEMORIAL SHALL BE A MEMBER FOR A TERM OF FIVE (5) YEARS AFTER HIS/HER ELECTION, OR UNTIL HIS/HER EARLIER RESIGNATION. THERE IS NO LIMIT ON THE NUMBER OF TERMS AN ADVISOR CAN SERVE. (B) AN HONORARY ADVISOR MAY BE ELECTED BY THE ACTIVE ADVISORS AND SHALL SERVE FOR LIFE, IN RECOGNITION OF MERITORIOUS OR FAITHFUL SERVICE TO COLE MEMORIAL OR IN RECOGNITION OF DISTINGUISHED ACHIEVEMENT. (C) EACH ADVISOR OWES A DUTY OF UNDIVIDED AND UNQUALIFIED LOYALTY TO THE ORGANIZATION. ADVISORS MAY NOT USE THEIR POSITIONS TO PROFIT PERSONALLY OR TO ASSIST OTHERS IN PROFITING IN ANY WAY AT THE EXPENSE OF THE ORGANIZATION. (D) ADVISORS SHALL AVOID ALL CONFLICTS OF INTEREST AND THE APPEARANCE OF ANY CONFLICT OF INTEREST. A CONFLICT OF INTEREST OCCURS IN ANY SITUATION IN WHICH ONE IS POTENTIALLY NOT ABLE TO REMAIN IMPARTIAL OR MAINTAIN OBJECTIVITY IN CHOOSING BETWEEN THE INTERESTS OF THE ORGANIZATION AND ONE'S PERSONAL INTERESTS OR THE INTERESTS OF THIRD PARTIES. TO AVOID THE APPEARANCE OF A CONFLICT OF INTEREST, AN ADVISOR SHALL NOT PARTICIPATE IN THE MAKING OF ANY DECISION OR RECOMMENDATION CONCERNING A MATTER WHICH MAY RESULT IN ANY BENEFIT OR FINANCIAL GAIN, EITHER DIRECTLY OR INDIRECTLY, TO THE ADVISOR OR A MEMBER OF HIS/HER IMMEDIATE FAMILY. IN ADDITION, FULL DISCLOSURE OF THE PERTINENT FACTS REGARDING THE POTENTIAL CONFLICT OF INTEREST SHOULD BE PROVIDED BY THE ADVISOR. (E) NO ADVISOR SHALL HAVE ANY VESTED RIGHT, INTEREST OR PRIVILEGE OF, IN, OR TO THE ASSETS, FUNCTIONS, AFFAIRS OR FRANCHISES OF THE CORPORATION OR ANY SUCH RIGHT, INTEREST OR PRIVILEGE WHICH MAY BE TRANSFERABLE OR INHERITABLE, OR WHICH SHALL CONTINUE IF HIS/HER MEMBERSHIP CEASES. NO ADVISOR SHALL BE AN EMPLOYEE OF THE HOSPITAL OR ANY OF ITS AFFILIATES. (F) ADVISORS SHALL INCLUDE REPRESENTATIVES FROM VARIOUS ECONOMIC, SOCIAL AND OCCUPATIONAL GROUPS BROADLY REPRESENTATIVE OF THE DEMOGRAPHIC CHARACTERISTICS OF THE COMMUNITIES SERVED BY COLE MEMORIAL, AND SHALL ALL HAVE AN INTEREST IN AND COMMITMENT TO FURTHER THE HEALTH AND WELL-BEING OF THE CITIZENS OF COLE MEMORIAL'S SERVICE AREA. (G) THE SECRETARY OF THE BOARD SHALL ACT AS LIAISON TO THE COMMUNITY BENEFIT ADVISORS. THE NUMBER OF ACTIVE ADVISORS SHALL NOT BE LESS THAN FIFTY (50) NOR MORE THAN ONE HUNDRED (100), EXCLUSIVE OF HONORARY ADVISORS. EVERY ACTIVE ADVISOR SHALL BE ENTITLED TO ONE (1) VOTE AT ANY MEETING OF THE ADVISORS IN WHICH A VOTE IS TAKEN FOR ANY ELECTION OR ON ANY MATTER OR TRANSACTION. IN THE CASE OF VOTING FOR THE ELECTION OF DIRECTORS, EACH ADVISOR MUST CAST ONE (1) VOTE FOR EACH POSITION TO BE FILLED OR THE BALLOT WILL BE VOID AS IT PERTAINS TO THE ELECTION OF DIRECTORS. VOTING FOR DIRECTORS SHALL BE BY WRITTEN BALLOT EITHER BY (1) FIRST CLASS MAIL, POSTMARKED NO LATER THAN TWENTY (20) DAYS PRIOR TO THE DATE SELECTED FOR THE ANNUAL MEETING OR (2) ELECTRONIC MEANS (E.G., SCANNED AND EMAILED OR FAXED) NO LATER THAN TWENTY (20) DAYS PRIOR TO THE DATE SELECTED FOR THE ANNUAL MEETING. EVERY ADVISOR SHALL BE ENTITLED IN RETURNING HIS/HER BALLOT FOR THE ANNUAL ELECTION OF DIRECTORS, TO DIRECT THAT HIS/HER VOTE BE WITHHELD FROM ONE (1) OR MORE OF THE CANDIDATES SUBMITTED BY THE NOMINATING COMMITTEE AND ANY SUCH ADVISOR MAY, ON HIS/HER BALLOT, MAY SET FORTH THE NAME OF ANY PERSON FOR WHOM HE/SHE WISHES TO RECORD HIS/HER VOTE FOR A DIRECTOR OF THE CORPORATION. RESULTS OF THE ELECTION PROCESS WILL BE ANNOUNCED AT THE ANNUAL MEETING OF THE ADVISORS. HONORARY ADVISORS SHALL RECEIVE NOTICES OF AND MAY ATTEND ALL MEETINGS OF THE ADVISORS BUT SHALL NOT BE ENTITLED TO VOTE ON ANY MATTER.
FORM 990, PART VI, SECTION B, LINE 11B	FORM 990 REVIEW PROCESS: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE 990 IS THEN REVIEWED BY THE ACCOUNTING DEPARTMENT AND THE CONTROLLER. IT IS THEN PRESENTED TO THE GOVERNANCE OVERSIGHT COMMITTEE FOR REVIEW. AFTER THE GOVERNANCE OVERSIGHT COMMITTEE HAS REVIEWED, A FULL COPY IS DISTRIBUTED TO THE BOARD OF DIRECTORS PRIOR TO THE CEO'S FINAL SIGNATURE. THE OVERSIGHT COMMITTEE WILL REPORT THEIR REVIEW OF FORM 990 TO THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 12C	MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY: MEMBERS OF THE BOARD OF DIRECTORS; BOARD COMMITTEES; MANAGEMENT EMPLOYEES; AND MEDICAL STAFF WITH ADMINISTRATIVE RESPONSIBILITIES ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY AND ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST STATEMENT. THE LEVELS AT WHICH ACTUAL CONFLICTS ARE REVIEWED ARE THE COMPLIANCE OFFICER AND GOVERNANCE OVERSIGHT COMMITTEE (GOC) OF THE BOARD OF DIRECTORS OR PRESIDENT AND CEO. RESTRICTIONS INCLUDE: A MEMBER OF THE BOARD/BOARD COMMITTEE MUST DISCLOSE THE EXISTENCE OF HIS/HER FINANCIAL INTEREST AFTER WHICH A DETERMINATION OF CONFLICT OF INTEREST WILL BE MADE. A VOTING MEMBER OF THE BOARD OF DIRECTORS OR A VOTING MEMBER OF ANY COMMITTEE WHOSE SCOPE OF RESPONSIBILITIES INCLUDES COMPENSATION, DIRECTLY OR INDIRECTLY, IS PRECLUDED FROM VOTING ON MATTERS PERTAINING TO THAT MEMBER'S COMPENSATION. A MANAGEMENT EMPLOYEE, OR A MEDICAL STAFF MEMBER WITH ADMINISTRATIVE RESPONSIBILITIES MUST DISCLOSE TO THE SENIOR LEADER THE EXISTENCE OF THE FINANCIAL INTEREST AND ALL RELATED MATERIAL FACTS. COLE'S CONTRACTING POLICY CONTAINS A PROVISION FOR DISCLOSURE OF A FINANCIAL INTEREST ON THE CONTRACT ROUTING FORM.
FORM 990, PART VI, SECTION B, LINE 15A	COMPENSATION DETERMINATION: A REVIEW WAS CONDUCTED IN 2015 FOR PRESIDENT AND CEO ED PITCHFORD BY 3C COMPENSATION CONSULTING CONSORTIUM, LLC, LOCATED IN PITTSBURGH, PA. THE BOARD APPROVED AN INCREASE AS RECOMMENDED BY THE GOVERNANCE OVERSIGHT COMMITTEE.
FORM 990, PART VI, SECTION C, LINE 19	DOCUMENT AVAILABILITY: THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS CAN BE VIEWED ONSITE THROUGH A WRITTEN REQUEST TO THE ORGANIZATION'S CORPORATE COMPLIANCE OFFICER. REQUESTS FOR FINANCIAL STATEMENTS AND 990'S ARE FORWARDED TO THE FINANCE / ACCOUNTING DEPARTMENT AND ARE OPEN FOR PUBLIC INSPECTION.
FORM 990, PART VII, SECTION A	BOARD MEMBER COMPENSATION: NO BOARD MEMBERS RECEIVE ANY COMPENSATION FOR THEIR DIRECTOR DUTIES. MICHAEL CALLAHAN IS COMPENSATED BY COLE MEMORIAL AS A PHYSICIAN. JASON TRONETTI IS COMPENSATED BY COLE MEMORIAL AS A PHYSICIAN. KALLIOPI NESTOR IS COMPENSATED BY COLE MEMORIAL AS A PHYSICIAN.
FORM 990, PART IX, LINE 11G	OTHER FEES FOR SERVICES: $ 11,626,914 PROFESSIONAL FEES 6,994,159 PURCHASED SERVICES 210,695 DIRECTOR FEES 37,256 CONTRACTED SERVICES ------------ $ 18,869,024
FORM 990, PART XI, LINE 9	OTHER CHANGES IN NET ASSETS: $ (3,007,862) AMORTIZATION OF NET LOSS 326,352 GAAP/TAX DIFFERENCE DEFERRED OIL & GAS MINERAL LEASE (31,940) TRANSFERS TO AFFILIATES ------------ $ (2,713,450)

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

CHARLES COLE MEMORIAL HOSPITAL

Employer identification number

24-0802108

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)HENDORN INC DBA COLE MANOR 1001 EAST SECOND STREET COUDERSPORT,PA16915 23-1972659	RESIDENT CARE	PA	501(C)(3)	11A I	COLE MEM	Yes
(2)HAMOTCOLE VENTURES INC 1001 EAST SECOND STREET COUDERSPORT,PA16915 27-3172100	REAL ESTATE	PA	501(C)(3)	11A I	NA		No
(3)COLE FOUNDATION 1001 EAST SECOND ST COUDERSPORT,PA16915 45-5417308	SUPPORT	PA	501(C)(3)	11A I	COLE MEM	Yes

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	(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 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

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) COLE CARE INC 1001 EAST 2ND STREET COUDERSPORT,PA16915 25-1497347	DURABLE MED EQUIP	PA	COLE MEMORIAL	C CORPORATION	11,755,093	1,715,438	100.000 %	Yes

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

Yes

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

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

Yes

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

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

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

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

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) COLE CARE INC	A/J	228,771	FMV
(2) COLE CARE INC	L	184,836	FMV
(3) HENDORN INC	L	50,580	FMV
(4) HENDORN INC	M	509,862	FMV
(5) COLE CARE INC	O	9,230,013	FMV
(6) COLE CARE INC	P	72,592	FMV
(7) HAMOTCOLE VENTURES INC	K	449,668	FMV

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:

1	Briefly describe the organization’s mission or most significant activities: COLE MEMORIAL PROVIDES EXCELLENT HEALTHCARE SERVICES, RESPONDING TO THE CHANGING NEEDS OF THE COMMUNITIES WE SERVE. SEE SCHEDULE O.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	13
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	9
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	683
6	Total number of volunteers (estimate if necessary) .............	6	53
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	54,181
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	52,931

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	458,524	701,074
9	Program service revenue (Part VIII, line 2g) .........	83,917,388	85,501,258
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	268,947	192,941
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,144,829	547,587
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	85,789,688	86,942,860
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	36,418,219	36,702,994
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	47,612,882	51,548,245
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	84,031,101	88,251,239
19	Revenue less expenses. Subtract line 18 from line 12.......	1,758,587	-1,308,379
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	74,430,860	72,220,492
21	Total liabilities (Part X, line 26).............	48,330,669	49,869,168
22	Net assets or fund balances. Subtract line 21 from line 20.....	26,100,191	22,351,324

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 20,520,462 including grants of $ ) (Revenue $ 41,204,807 )
	COLE MEMORIAL OFFERS OUTPATIENT SERVICES, EXCEEDING 364,000 TESTS/TREATMENTS ANNUALLY THROUGHOUT THE HOSPITAL'S FOUR-COUNTY AREA AND INCLUDING IMAGING, LAB, AND REHABILITATION SERVICES. OUTPATIENT SURGERIES EXCEED 4,300 ANNUALLY. THE PATTERSON CANCER CARE CENTER OFFERS FULL SERVICE RADIATION AND MEDICAL ONCOLOGY SERVICES AND HOUSES AN AMERICAN CANCER SOCIETY PATIENT RESOURCE CENTER ONSITE. THE CANCER CENTER IS HOME TO A VARIETY OF SUPPORT GROUPS, AS WELL AS FREQUENT FREE CANCER SCREENINGS FOR THE PUBLIC. COLE MEMORIAL'S HOME HEALTH AND HOSPICE SERVICES ASSIST PATIENTS THROUGHOUT THE REGION, WITH A GROWING NUMBER OF REFERRALS AND LOWER INFECTION RATES AMONG STATE AND NATIONAL AVERAGES.

4b	(Code: ) (Expenses $ 20,620,631 including grants of $ ) (Revenue $ 12,887,300 )
	COLE MEMORIAL PROVIDES PRIMARY CARE TO ITS SURROUNDING COMMUNITIES. THE HOSPITAL PROVIDES PRIMARY CARE TO THE SURROUNDING COMMUNITIES IN FOUR COUNTIES AT RURAL HEALTH CENTERS(RHCS), LOCATED IN COUDERSPORT, GALETON, ULYSSES, WESTFIELD, SHINGLEHOUSE, PORT ALLEGANY, ELDRED, SMETHPORT, AND EMPORIUM. COLLECTIVELY, 96,000 PATIENT VISITS WERE REPORTED LAST YEAR. FOUR OF THOSE LOCATIONS ALSO INCLUDE WELLNESS AND REHABILITATION CENTERS, MAKING IT MORE CONVENIENT FOR PATIENTS TO RECEIVE THE CARE THEY NEED CLOSE TO HOME. SEE SCHEDULE O FOR DETAIL.

4c	(Code: ) (Expenses $ 13,950,214 including grants of $ ) (Revenue $ 18,393,920 )
	COLE MEMORIAL OFFERS VARIOUS INPATIENT SERVICES. COLE MEMORIAL ADMITTED 1,550 ACUTE PATIENTS LAST YEAR (4,800 ACUTE CARE DAYS) TO INPATIENT SERVICES INCLUDING MEDICAL/SURGICAL, INTENSIVE CARE AND OBSTETRICS UNITS. COLE MEMORIAL'S 24-HOUR EMERGENCY DEPARTMENT ADMITTED 960 PATIENTS LAST YEAR AND SAW 10,000 VISITS LAST YEAR. THE HOSPITAL'S MATERNITY UNIT WELCOMED 140 BABIES INTO THE WORLD LAST YEAR AND ALSO SUPPORTS MOTHERS-TO-BE WITH REGULAR LAMAZE AND BREASTFEEDING SUPPORT PROGRAMS AND THE HEALTHY BEGINNINGS PLUS PROGRAM FOR LOW INCOME MOTHERS.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 21,977,545 including grants of $ ) (Revenue $ 13,015,231 )
4e	Total program service expenses77,068,852

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) BRADLEY GIANNOTTI........................................................................ PHYSICIAN	40.0 .......................0.0	X	969,242	0	26,685
(19) PHONG NGUYEN........................................................................ PHYSICIAN	40.0 .......................0.0	X	530,217	0	23,534
(20) SAKET PRASAD........................................................................ PHYSICIAN	40.0 .......................0.0	X	600,463	0	30,562
(21) TERRANCE FOUST........................................................................ PHYSICIAN	40.0 .......................1.0	X	780,570	0	27,645
(22) MAZEN FOUANY........................................................................ PHYSICIAN	40.0 .......................0.0	X	510,875	0	33,428

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	5,201,012	0	337,127

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	43,080
e	Government grants (contributions)		1e	186,090

f	All other contributions, gifts, grants, and similar amounts not included above		1f	471,904

g	Noncash contributions included in lines 1a-1f:$ 106,883
h Total.Add lines 1a-1f.......		701,074

			Business Code
2a	NET PATIENT SERVICE REVENUE	621990	79,173,243	79,173,243
b	PHARMACY	621990	5,337,753	5,337,753
c	CAFETERIA	722514	413,887	413,887
d	OTHER	621990	576,375	576,375
e
f	All other program service revenue.
g Total.Add lines 2a–2f.....			85,501,258

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			280,460			280,460
4 Income from investment of tax-exempt bond proceeds			0
5 Royalties...........			0
		(ii) Personal	(i) Real
6a	Gross rents		279,838
b	Less: rental expenses		234,797
c	Rental income or (loss)	0	45,041
d	Net rental income or (loss)......			45,041			45,041
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	18,880	18,681,007
b	Less: cost or other basis and sales expenses	8,496	18,778,910
c	Gain or (loss)	10,384	-97,903
d	Net gain or (loss).....			-87,519			-87,519
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..			0
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..			0
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..			0
Business Code			Miscellaneous Revenue
11a	GAIN ON INVESTMENT IN EQUITY INVESTEE		900099	427,175		54,181	372,994
b	INCOME FROM INVESTMENT IN SUBSIDIARIES		900099	75,371			75,371
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			502,546
12	Total revenue. See Instructions......			86,942,860	85,501,258	54,181	686,347

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	1,795,331	1,095,625	699,706
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	273,708	173,800	99,908
7	Other salaries and wages	26,733,551	22,679,577	4,053,974
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	716,871	430,747	286,124
9	Other employee benefits .......	5,216,905	4,600,120	616,785
10	Payroll taxes ...........	1,966,628	1,571,072	395,556
11	Fees for services (non-employees):
a	Management ......	1,143,825	1,143,825
b	Legal .........	107,156		107,156
c	Accounting ...........	125,418		125,418
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	46,082		46,082
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	18,869,024	17,538,716	1,330,308
12	Advertising and promotion ....	177,077	28,294	148,783
13	Office expenses .......	5,423,662	3,770,316	1,653,346
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	2,335,020	2,202,670	132,350
17	Travel ............	427,566	403,772	23,794
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .	0
19	Conferences, conventions, and meetings ....	341,424	208,079	133,345
20	Interest ...........	1,016,513	910,149	106,364
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization ..	3,444,826	3,084,372	360,454
23	Insurance ...	901,593	376,464	525,129
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	MEDICAL SUPPLIES & DRUGS	12,369,360	12,369,360
b	BAD DEBT	4,072,663	4,072,663
c	LICENSES, DUES, SUBSCRIPTIONS	688,852	409,231	279,621
d	RECRUITING & RETENTION	58,184		58,184
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	88,251,239	77,068,852	11,182,387	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 ........			2,953,182	1	1,156,856
2	Savings and temporary cash investments .........			5,749,729	2	1,644,184
3	Pledges and grants receivable, net ......			0	3	0
4	Accounts receivable, net .............			9,474,828	4	9,432,141
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net ....			0	7	0
8	Inventories for sale or use ........			1,107,387	8	1,107,657
9	Prepaid expenses and deferred charges ......			1,465,491	9	1,564,415
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	82,953,386
b	Less: accumulated depreciation	10b	50,365,424	30,793,590	10c	32,587,962
11	Investments—publicly traded securities .			16,677,848	11	17,289,887
12	Investments—other securities. See Part IV, line 11 .....			2,764,366	12	3,103,836
13	Investments—program-related. See Part IV, line 11 ..			1,014,080	13	1,180,728
14	Intangible assets ...............			0	14	164,165
15	Other assets. See Part IV, line 11 ...........			2,430,359	15	2,988,661
16	Total assets. Add lines 1 through 15 (must equal line 34)...			74,430,860	16	72,220,492

17	Accounts payable and accrued expenses .....	14,159,592	17	16,690,532
18	Grants payable ...	0	18	0
19	Deferred revenue .........	1,441,372	19	1,115,020
20	Tax-exempt bond liabilities .........	28,980,728	20	27,892,354
21	Escrow or custodial account liability. Complete Part IV of Schedule D	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	388,106	23	484,641
24	Unsecured notes and loans payable to unrelated third parties ..	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	3,360,871	25	3,686,621
26	Total liabilities. Add lines 17 through 25..	48,330,669	26	49,869,168

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	21,904,608	27	18,426,923
28	Temporarily restricted net assets ...........	46,780	28	32,820
29	Permanently restricted net assets	4,148,803	29	3,891,581
	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 ...........	26,100,191	33	22,351,324
34	Total liabilities and net assets/fund balances ........	74,430,860	34	72,220,492