TY 2015 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) TERRY FULWILER...................................................................... Chairperson	0.50 .................	X	X	0	0
(2) ELL LEE DDS...................................................................... Vice Chairperson	0.50 .................	X	X	0	0
(3) MARK MCMULLEN...................................................................... Secretary	0.50 .................	X	X	0	0
(4) NANCY ARMBRUST...................................................................... Board MEMBER	0.50 .................	X		0	0
(5) G CORT CONDON...................................................................... Board MEMBER	0.50 .................	X		0	0
(6) Daniel Gulling...................................................................... Board MeMBER	0.50 .................	X		0	0
(7) FRED SCHMIDT MD...................................................................... BOARD MEMBER	0.50 .................	X		0	0
(8) DANIEL ARIENS...................................................................... Board MEMBER	0.50 .................	X		0	0
(9) WILLIAM WITTMAN MD...................................................................... Board Member	40.00 .................	X		377,831	23,250
(10) LARRY BORGARD...................................................................... Board MEMBER	0.50 .................	X		0	0
(11) JOHN JONES...................................................................... Board MEMBER	0.50 .................	X		0	0
(12) SUSAN FINCO...................................................................... Board MEMBER	0.50 .................	X		0	0
(13) MICHAEL HADDAD...................................................................... BOARD MEMBER	0.50 .................	X		0	0
(14) LOREN FUGLESTAD MD - Termed...................................................................... Board Member/BMG physician	40.00 .................	X		316,520	33,047
(15) CHRISTINE VANDENHOUTEN...................................................................... BOARD MEMBER	0.50 .................	X		0	0
(16) JOHN DYKEMA...................................................................... Treasurer	0.50 .................	X	X	0	0
(17) ROBERT CLAUSEN...................................................................... BOARD MEMBER	0.50 .................	X		0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(18) GEORGE KERWIN........................................................................ Bellin CEO/Board Member	50.00 .......................	X	X		910,203	27,477
(19) Paul Casey MD........................................................................ Board Member/President Medical Staff	50.00 .......................	X			111,515	0
(20) Cynthia Lasecki MD........................................................................ Board Member/Former President Medical Staff	50.00 .......................	X			350,680	17,301
(21) Sabina Singh MD........................................................................ Board Member/President Bellin Medical Group	50.00 .......................	X			263,429	21,321
(22) Mark Ringwelski MD........................................................................ Board Member/FPresident Bellin Specialty Group	50.00 .......................	X			312,926	28,241
(23) Karl Schmidt........................................................................ Board Member	0.50 .......................	X			0	0
(24) Dennis Hogan - Termed........................................................................ Board Member	0.50 .......................	X			0	0
(25) JAMES DIETSCHE........................................................................ CFO	50.00 .......................		X		385,624	30,760
(26) PETER KNOX........................................................................ EXECUTIVE VP	50.00 .......................		X		376,989	34,275
(27) CHRISTINE WOLESKE........................................................................ EXECUTIVE VP	50.00 .......................		X		410,015	35,558
(28) CHRISTOPHER WOLFRAM MD........................................................................ Physician	40.00 .......................			X	939,518	26,211
(29) TIMOTHY TANKE MD........................................................................ Physician	40.00 .......................			X	886,258	30,839
(30) RICHARD TIMMONS MD........................................................................ PHYSICIAN	40.00 .......................			X	824,336	32,558
(31) Vijaya Munagala MD........................................................................ Physician	40.00 .......................			X	789,439	28,985
(32) Paul Hudson MD........................................................................ PHYSICIAN	40.00 .......................			X	856,152	34,228

(A) Name and business address	(B) Description of services	(C) Compensation
IEI General Contractors 1725 Midway Road De Pere,WI54115	Construction contractor services	6,039,255
BLR Further LLC 4841 Summer Avenue Memphis,TN38122	Advertising/marketing services	2,445,723
AmeriEBO LLC 1851 South Alverno Road Manitowoc,WI54220	Collections services	1,709,919
Miron Construction Co Inc PO Box 509 Neenah,WI54957	Construction contractor services	1,216,027
Bay Towel & Linen 2580 South Broadway Green Bay,WI54301	Linen services	1,190,559
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 64

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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 Bellin Memorial Hospital Inc

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	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 Bellin Memorial Hospital Inc		Employer identification number 39-0884478

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 Bellin Memorial Hospital Inc			Employer identification number 39-0884478
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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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

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

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

Yes

5,840

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

5,840

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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

Return Reference	Explanation
Part II-B, Line 1:	AHA and WHA Dues

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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

			(a) Donor advised funds	(b) Funds and other accounts

1	Total number at end of year ....
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ....

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ...........

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ............................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

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

Cat. No. 52283D

Schedule D (Form 990) 2015

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability?

Yes No

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

Part V

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

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

1a	Beginning of year balance ....	2,283,113	2,446,300	2,417,823	2,372,548	2,239,178
b	Contributions ...	319,500	101,050			86,124
c	Net investment earnings, gains, and losses	45,890	-255,551	35,966	48,841	68,097
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...	10,824	8,686	7,489	3,566	20,851
f	Administrative expenses ....
g	End of year balance ......	2,637,679	2,283,113	2,446,300	2,417,823	2,372,548

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

94.400 %

Temporarily restricted endowment SchDMd Bullet

5.600 %

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)

Yes

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

Yes

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 ...	7,483,827		7,483,827
b	Buildings	134,067,453	56,654,528	77,412,925
c	Leasehold improvements	2,404,457	1,757,006	647,451
d	Equipment ...	200,839,132	137,119,944	63,719,188
e	Other ...	22,511,544		22,511,544
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				171,774,935

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
Deferred compensation	8,880,480
Noncontrolling interest of consolidated affiliate	1,206,577
Capital lease obligations	9,407,798
Interest rate swap valuation	10,453,173
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	29,948,028
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	477,809,238
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	6,374,351
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	-9,853,897
e	Add lines 2a through 2d .....................			2e	-3,479,546
3	Subtract line 2e from line 1..................			3	481,288,784
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	-2,296,507
c	Add lines 4a and 4b....................			4c	-2,296,507
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	478,992,277

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	447,214,305
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	2,913,502
e	Add lines 2a through 2d....................			2e	2,913,502
3	Subtract line 2e from line 1...................			3	444,300,803
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b	7,097,554
c	Add lines 4a and 4b.....................			4c	7,097,554
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	451,398,357

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
Part V, Line 4:	ENDOWMENT FUNDS ARE INTENDED TO BE USED FOR HEALTH CARE SERVICES AND EMPLOYEE TRAINING AND DEVELOPMENT.
Part XI, Line 2d - Other Adjustments:	LOSS ON SWAP AGREEMENT -1,293,827. NON-CONTROLLING INTEREST -1,854,305. Provision for bad debts -6,705,765.
Part XI, Line 4b - Other Adjustments:	TRANSFER FROM FOUNDATION 554,562. HOSPITAL SUPPLIES 62,433. RENTAL EXPENSES -2,705,839. Loss from healthcare affiliates -207,663.
Part XII, Line 2d - Other Adjustments:	RENTAL EXPENSES 2,705,839. Loss from healthcare affiliates 207,663.
Part XII, Line 4b - Other Adjustments:	REALLOCATION OF SUPPLIES EXPENSE TO 990T 62,433. EXPENSES PAID FOR BY FOUNDATION TRANSFERS 329,356. Provision for bad debts 6,705,765.

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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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 22000.0000000000 %

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) . . .	2,251,326		2,251,326	0.510 %
b	Medicaid (from Worksheet 3, column a) . . . . .	53,192,139	27,705,329	25,486,810	5.730 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	55,443,465	27,705,329	27,738,136	6.240 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	4,277,046		4,277,046	0.960 %
f	Health professions education (from Worksheet 5) . . .	3,285,907		3,285,907	0.740 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	705,626		705,626	0.160 %
j	Total. Other Benefits . .	8,268,579		8,268,579	1.860 %
k	Total. Add lines 7d and 7j .	63,712,044	27,705,329	36,006,715	8.100 %

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	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other	722,593	722,593	0.160 %
10	Total	722,593	722,593	0.160 %

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. ......

2,649,862

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

127,704,014

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

192,605,440

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

-64,901,426

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 %	(e) Physicians' profit % or stock ownership %
11 Bellin Orthopedic Surgery Center LLC	orthopedic surgery center	55.000 %	45.000 %
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2015

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	Bellin Memorial Hospital 744 S Webster Ave Green Bay,WI54305 147	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)

	Bellin 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 14

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

Yes

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

Yes

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): www.bellin.org/patients_visitors/company-information/community-health

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 14

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

Yes

If "Yes" (list url): www.bellin.org/patients_visitors/company-information/community-health

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)

	Bellin 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 220.000000000000% and FPG family income limit for eligibility for discounted care of 400.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

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

Yes

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

Yes

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

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

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

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

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

Other (describe in Section C)

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

Yes

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

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

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

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

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

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

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

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

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

Other (describe in Section C)

Billing and Collections

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

Yes

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

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Schedule H (Form 990) 2015

Page 6

Part VFacility Information (continued)

	Bellin 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
Bellin Memorial Hospital	Part V, Section B, Line 5: THE BROWN COUNTY AND CITY OF DE PERE HEALTH DEPARTMENTS CONVENED A COMMUNITY HEALTH NEEDS ASSESSMENT STEERING COMMITTEE THAT INCLUDED REPRESENTATIVES OF BELLIN HEALTH, ST. MARYS ANDITS SISTER HOSPITAL ST. VINCENT, THE LOCAL UNITED WAY, AND REPRESENTATIVES OF THE REGIONAL OFFICE OF WISCONSINS DEPARTMENT OF HEALTH. THIS STEERING COMMITTEE WORKED TO IDENTIFY REPRESENTATIVES THAT COULD BROADLY REPRESENT THE COMMUNITY IN ACTUALLY CONDUCTING THE NEEDS ASSESSMENT AND SETTING PRIORITIES. THESE INDIVIDUALS WERE REFERRED TO AS COMMUNITY PARTNERS.LIST OF NAMES FOLLOWS:AGING & DISABILITY RESOURCE CENTER, SUNNY ARCHAMBAULTAURORA HEALTH SYSTEM, JULIE POMASLBAY AREA COMMUNITY COUNCIL, PAT FINDER-STONEBELLIN COLLEGE, KATHIE DEMUTHBELLIN HEALTH, JODY WILMETBELLIN HEALTH, LINDA ROETHLEBOYS & GIRLS CLUB, JOHN BENBERGBROWN COUNTY BOARD, MIKE FLECKBROWN COUNTY BOARD OF HEALTH (BOARD MEMBER), AUDREY MURPHYBROWN COUNTY COMMUNITY TREATMENT CENTER, MARY JOHNSONBROWN COUNTY COOPERATIVE EXTENSION, JUDY KNUDSENBROWN COUNTY HEALTH DEPARTMENT, JUDY FRIEDERICHS (DIRECTOR, BROWN COUNTYHEALTH DEPARTMENT) *BROWN COUNTY HUMAN SERVICES, KEVIN LUNOGBROWN COUNTY PLANNING, CHUCK LAMINEBROWN COUNTY UNITED WAY, STEPHANIE FOLEY#CENTER FOR CHILDHOOD SAFETY/ SAFE KIDS GREATER GREEN BAY, JUSTINE LODLCITY OF DE PERE BOARD OF HEALTH (BOARD MEMBER), PAT FINDER-STONE *CITY OF DE PERE HEALTH DEPARTMENT, MARY DORN, HEALTH DIRECTOR *DE PERE AREA CHAMBER OF COMMERCE, CHERYL DETRICKDIVISION OF PUBLIC HEALTH NORTHEAST REGIONAL OFFICE, REBECCA HOVARTER,REGIONAL PUBLIC HEALTH NURSING CONSULTANT *DIVISION OF PUBLIC HEALTH NORTHEAST REGIONAL OFFICE, LYNN HRABIK,EPIDEMIOLOGIST *FAMILY SERVICES-CRISIS CENTER, TANA KOSS #GREATER GREEN BAY COMMUNITY FOUNDATION, MARTHA AHRENDTGREATER GREEN BAY YMCA, SANDY ATKINSGREEN BAY CHAMBER OF COMMERCE, NAN NELSON, CCEHOMELESS POPULATION REPRESENTATIVE, SETH MOORE #N.E.W. COMMUNITY CLINIC, BONNIE KUHR #NWTC HEALTH SCIENCE, KAY TUPALA, DEANONEIDA TRIBE OF INDIANS, MICHELLE MYERS #PARISH NURSE, KATIE DYKES #BROWN COUNTY SHERIFF REPRESENTATION - CHIEFS GROUP, CAPT. RANDY SCHULTZPREVEA HEALTH, DR. ASHOK RAIST. MARYS HOSPITAL MEDICAL CENTER, HEIDI SELBERGST. VINCENT HOSPITAL, HEIDI SELBERGST. WILLEBROAD CATHOLIC PARISH, MARIA PLASCENCIASCHOOL REPRESENTATION - SUPERINTENDENTS GROUP, BARB NATELLETHE SALVATION ARMY, REBECCA LESPERANCE #UNITED HMONG AND ASIAN AMERICAN COMMUNITY CENTER, STARYOUNG THAO #UWGB-ENVIRONMENTAL SCIENCES, THOMAS ERDMANUW-GREEN BAY NURSING PROGRAM, CHRIS VANDENHOUTENWOMEN, INFANT AND CHILDREN (WIC), BONNIE KUHR # STEERING COMMITTEE MEMBER** PERSON WITH SPECIAL KNOWLEDGE OF PUBLIC HEALTH, INCLUDING PUBLIC HEALTHDEPARTMENT LEADERSHIP STAFF AND MEMBERS OF GOVERNANCE BODIES FOR PUBLICHEALTH DEPARTMENTS.# REPRESENTATIVES OF UNDERSERVED, LOW INCOME, MINORITY OR CHRONIC DISEASE
Bellin Memorial Hospital	Part V, Section B, Line 6a: St. Mary's and St. Vincent Hospitals (HSHS, Green Bay)
Bellin Memorial Hospital	Part V, Section B, Line 6b: BROWN COUNTY HEALTH DEPARTMENT, CITY OF DE PERE HEALTH DEPARTMENT, BROWN COUNTY UNITED WAY, AND WI DIVISION OF PUBLIC HEALTH NE REGIONAL OFFICE
Bellin Memorial Hospital	Part V, Section B, Line 11: The most recent CHNA identified community needs from 2015 through 2017. We are in the process of leading a community reassessment.The needs identified are: Oral Health, Alcohol and Other Drug Abuse, Mental Health and Physical Activity and Nutrition. Bellin representatives lead the Alcohol and Other Drug Abuse and Mental Health Community Action teams and is active on the other teams. A summary of how Bellin has been addressing the needs identified in the CHNA is as follows:Oral Health: Bellin sponsored a legislative breakfast to improve health care policy and coverage of Medicaid patients. We have standardized our ED protocols to be consistent with the other health care systems for patients with oral pain., along with conducting a oral health screening pilot with our OB patients. Bellin donates funds annually to the NEW Community Clinic which has been able to expand access for oral care for Medicaid and uninsured patients. Alcohol and Other Drug Misuse: The Alcohol and Drug Task Force has three key focus areas: Access to Care, Public Policy, and Public Awareness. This past year the group has partnered with the Mental Health Task Force in establishing a goal of four days to treatment for those who are in need of Alcohol and Drug treatment. The team has partnered with local agencies to understand barriers to access-including financial, transportation, and education. Interventions are being tested to remove barriers. Under public awareness there has been work done to provide education within the Green Bay Public schools in a presentation called "Wrecked at the Weidner". This presentation was a community effort to address impaired/inattentive driving due to alcohol and drug use and texting. Nearly 3,000 youth attended. Multiple media outlets covered the impact of binge drinking on the communitywith responses from our local representatives. Work also occurred around advancing education surrounding Opioid and Heroin use within the community. Public policy: Action has been made by local representatives towards passing the ordinance around Social Hosting. Work also being prioritized with local festivals around "evidenced based strategies to decrease alcohol misuse". Alcohol compliance checks also started back up in the city of Green Bay to address the sale of alcohol to minors.Physical Activity and Nutrition: Bellin sponsors on a Community team which has focused on increasing healthy food donations at local food pantry's. This team has met monthly from 2015 until present. This team has effectively improved the percent of healthy foods by 2% every year. The team has also worked on the ability for EBT dollars to be used at the local farmers market, the creation of the Food Drive 5 Toolkit, and a collaborative Food Drive with the Boys and Girls Scouts of America.Mental Health: Brown County Mental Health Task Force Goal: Brown County will increase access to mental health services for all populations in the county by identifying gaps and disparities and creating a common platform that mental health providers, partner agencies, and stakeholders can access 1. By December 31, 2017, with a goal of getting to 0 suicides, the number of annual suicides in Brown County will decrease from 35 to 302. By December 31, 2017, the average number of poor mental health days per 30 days, as reported by county residents, will decrease from 3.2 to 3.0OBJECTIVE #1: By December 31, 2017, the task force will create a document accessible to all stakeholders that identifies the current state of mental health care in Brown County, including all available resources and services provided, gaps and disparities in care, needed programs, and ratio of specific mental health providers to population. We have evaluated best practice screening tools that can be implemented across community and healthcare settings (help identify current state of mental health and needs) In partnership with the St. Norbert College Strategic Research Center, we have identified disparities in poor mental health days in Brown County and created initiatives to address these areas. (see below)OBJECTIVE #2: By December 31, 2017, the mental health task force will create a draft proposal for creating a community-wide "No Wrong Door" access platform for mental health treatment and connection between mental health providers. (The goal is to create the right access at the right time by having a comprehensive view and collaborative connections between all Brown County mental health service providers.) We have selected our virtual online vendor for community-wide access platform. We received a $1M grant in collaboration with Connections for Mental Wellness to reduce the number of poor mental health days by: o Improving accesso Improving community members' knowledge of mental health and mental wellnesso Creating mentally healthy workplaceso Building the workforce (psychiatrists and mental health therapists)
Bellin Memorial Hospital	Part V, Section B, Line 13b: A patient's liability is capped to 15% of annual income. A patient who receives any percentage of charity care based on their income, will not be responsible for more than 15% of their annual income.
Bellin Memorial Hospital	Part V, Section B, Line 22d: The hospital looked at the average amount collected for all payers (including medicare and medicaid). Average collection rate was 44%. Any patient receiving Financial Assistance, will not be responsible for more than 44% of charges.

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?48
Name and address		Type of Facility (describe)
1	2 - The Cancer Team of Bellin Health 1580 Commanche Ave Green Bay,WI54313	Hospital Based Site
2	3 - Cardiology Associates of Bellin Health 744 S Webster Ave Green Bay,WI54301	Hospital Based Site
3	4 - Family Medical Center Ashwaubenon 1630 Commanche Ave Green Bay,WI54313	Provider Clinic Site
4	5 - Bellin Health Cardiovascular & Thoracic Su 720 S Van Buren St Suite 303 Green Bay,WI54301	Provider Clinic Site
5	6 - Bellin Health Surgical Associates 720 S Van Buren St Suite 201 Green Bay,WI54301	Provider Clinic Site
6	7 - Gastroenterology Associates of Green Bay 725 S Webster Ave Green Bay,WI54301	Provider Clinic Site
7	8 - Family Medical Center De Pere East 555 Redbird Circle De Pere,WI54115	Provider Clinic Site
8	9 - Bellin Health Generations 704 S Webster Ave Suite 300 Green Bay,WI54301	Provider Clinic Site
9	10 - Family Medical Center Howard 2714 Riverview Green Bay,WI54313	Provider Clinic Site
10	11 - Family Medical Center Bellevue 3263 Eaton Rd Green Bay,WI543116830	Provider Clinic Site
11	12 - Family Medical Center De Pere West 1800 Lawrence Dr De Pere,WI54115	Provider Clinic Site
12	13 - Bellin Health Iron Mountain 440 Woodward Ave Iron Mountain,MI49801	Provider Clinic Site
13	14 - Neurology Consultants of Bellin Health 725 S Webster Ave Green Bay,WI54301	Provider Clinic Site
14	15 - Bellin Health Orthopedics 1630 Commanche Ave Green Bay,WI54313	Provider Clinic Site
15	16 - Bellin Health NorthReach Internal Medicine 3123 Shore Drive Suite 102 Marinette,WI54143	Provider Clinic Site
16	17 - Bellin Health Escanaba 610 S Lincoln Road ESCANABA,MI49829	Provider Clinic Site
17	18 - Family Medical Center Green Bay 704 S Webster Ave Green Bay,WI54301	Provider Clinic Site
18	19 - Bellin Health NorthReach Pediatrics 1106 Universtiy Drive Marinette,WI54143	Provider Clinic Site
19	20 - Bellin Health NorthReach Crivitz Medical C 218 S Hwy 141 Crivitz,WI54114	Provider Clinic Site
20	21 - Family Medical Center Kewaunee 575 - 4th Street Kewaunee,WI54216	Provider Clinic Site
21	22 - Bellin Health NorthReach FamilyCare Medica 3123 Shore Drive Marinette,WI54143	Provider Clinic Site
22	23 - Bellin Health Marinette Menominee Clinic 3200 Shore Drive Marinette,MI54143	Provider Clinic Site
23	24 - Family Medical Center Algoma 831 Parker Ave Algoma,WI54201	Provider Clinic Site
24	25 - Family Medical Center Brillion 964 W Ryan St Suite B Brillion,WI54110	Provider Clinic Site
25	26 - Bellin Health Oconto Falls 107 E Highland Dr Oconto Falls,WI54154	Provider Clinic Site
26	27 - Bellin Health Asthma & Allergy 519 S Monroe Avenue Green Bay,WI54301	Provider Clinic Site
27	28 - Bellin Health NorthReach OBGYN 3123 Shore Drive Suite 201 Marinette,WI54143	Provider Clinic Site
28	29 - Family Medical Center Denmark 595 County Road R Denmark,WI54208	Provider Clinic Site
29	30 - Bellin Health NorthReach Peshtigo Family M 441 French St Peshtigo,WI54143	Provider Clinic Site
30	31 - Family Medical Center Seymour 405 Commercial St Seymour,WI54165	Provider Clinic Site
31	32 - Bellin Health NorthReach Urgent Care 3200 Shore Drive Marinette,WI54143	Provider Clinic Site
32	33 - Family Medical Center Wrightstown 555 Quality Ct Wrightstown,WI54180	Provider Clinic Site
33	34 - Family Medical Center Luxemburg 140 B School Creek Trail Luxemburg,WI54217	Provider Clinic Site
34	35 - Family Medical Center Manitowoc 3415 Custer St Suite D Manitowoc,WI54221	Provider Clinic Site
35	36 - Bellin Health NorthReach Menominee Medical 1100 10th Street Menominee,MI49858	Provider Clinic Site
36	37 - Family Medical Center Pulaski 723 S Wisconsin St Pulaski,WI541620109	Provider Clinic Site
37	38 - Bellin Health NorthReach Daggett Medical C 106 S School Rd Daggett,MI49821	Provider Clinic Site
38	39 - Bellin Health NorthReach After Hours Marin 1106 Universtiy Drive Marinette,MI54143	Provider Clinic Site
39	40 - Bellin Health Asthma & Allergy - Neenah 119 E Bell St Suite B Neenah,WI54957	Provider Clinic Site
40	41 - BELLIN HEALTH FAST CARE ASHWAUBENON 301 BAY PARK SQUARE Green Bay,WI54304	Convenient Care Center
41	42 - BELLIN HEALTH FAST CARE EAST TOWNE MALL 2430 E MASON STREET Green Bay,WI54302	Convenient Care Center
42	43 - Bellin Health NorthReach Laboratory 3200 Shore Drive Marinette,WI54143	Provider Clinic Site
43	44 - Family Medical Center Bonduel 401 W Mill St Bonduel,WI54107	Provider Clinic Site
44	45 - Bellin Health Endocrinology 720 S Van Buren Ste 104 Green Bay,WI54301	Provider Clinic Site
45	46 - BELLIN HEALTH FAST CARE SUAMICO 2318 LINEVILLE ROAD Suamico,WI54173	Convenient Care Center
46	47 - Bellin Health NorthReach Fast Care Marinet 2741 Roosevelt Road Marinette,MI54143	Convenience Care Center
47	48 - Family Medical Center Suring 307 Manor Dr Suring,WI54174	Provider Clinic Site
48	49 - Family Medical Center Sturgeon Bay 311 N 3rd Ave Sturgeon Bay,WI43235	Provider Clinic Site

Schedule H (Form 990) 2015

Page 9

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
Part I, Line 6a:	BELLIN MEMORIAL HOSPITAL IN INCLUDED IN THE BELLIN HEALTH SYSTEMS, INC. COMMUNITY BENEFIT REPORT.
Part I, Line 7:	AMOUNTS ARE CALCULATED BASED ON COST TO CHARGE RATIOS AND AMOUNTS PER THE FINANCIAL STATEMENTS.
Part I, Ln 7 Col(f):	BAD DEBT EXPENSE OF $6,705,765 INCLUDED ON FORM 990, PART IX, LINE 25 WAS EXCLUDED FROM THE DENOMINATOR PER INSTRUCTIONS WHEN CALCULATING THE PERCENT TOTAL EXPENSES ON SCHEDULE H.
Part II, Community Building Activities:	COMMUNITY BUILDING ACTIVITIES FOCUS ON SOCIAL CONDITIONS THAT CONTRIBUTE TO HEALTH PROBLEMS, SUCH AS HOMELESSNESS, POVERTY, AND OTHER LIVING CONDITIONS AFFECTING THE QUALITY OF LIFE. THESE RANGE FROM DEVELOPING COMMUNITY LEADERS, DISASTER READINESS, AND SUPPORT OF LOCAL ECONOMIC DEVELOPMENT, TO HEALTH IMPROVEMENT ADVOCACY. BELLIN MEMORIAL HOSPITAL IS ACTIVE IN THE GREEN BAY PUBLIC SCHOOLS WITH OUR THRIVE PROGRAM THAT ASSISTS IN SETTING AND MEETING HEALTH AND WELLNESS GOALS FOR STUDENTS IN THIS SCHOOL SYSTEM. BELLIN ALSO HOLDS AN ANNUAL BELLIN RUN/WALK 10K EVENT EACH YEAR WITH OVER 18,000 PARTICIPANTS OF ALL AGES LEARNING FIRST HAnD THE VALUE OF EXERCISE IN DAILY LIFE.
Part III, Line 2:	THE BAD DEBT EXPENSE AT COST IS CALCULATED BASED ON THE COST TO CHARGE RATIOS
Part III, Line 3:	The hospital utilizes HFMA #15 therefore none of the bad debt would be deemed charity care.
Part III, Line 4:	The attached financial statements do not contain a specific bad debt expense footnote. However, the summary of significant accounting policies describes the provision for bad debt on pages 12 and 13 of the financial statements.For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for a portion of the bill), Bellin Health Systems records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowances for doubtful accounts.
Part III, Line 8:	THE AMOUNTS REPORTED FOR MEDICARE WERE CALCULATED USING A COST TO CHARGE RATIO. THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT FOR THE FOLLOWING REASONS. IRS REV RUL 69-545 WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS STATES THAT IF A HOSPITAL SERVICES PATIENTS WITH GOVERNMENT HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. IN ADDITION, FOR-PROFIT HOSPITALS HAVE CARVED OUT HIGH-MARGIN SERVICES (I.E. ONCOLOGY, ORTHO, ETC) LEAVING GENERAL ACUTE CARE HOSPITALS WITH LOWER-MARGIN MEDICARE SERVICES. THIS MEANS THAT THE SHORTFALL IS NOT NECESSARILY FROM INEFFICIENT OPERATIONS. MEDICARE CAN BE THE LARGEST PAYOR AND HOSPITALS HAVE NO ABILITY TO DENY COVERAGE. THIS, IN TURN, IS A PROMOTION OF ACCESS TO HEALTHCARE SERVICES (A COMMUNITY BENEFIT). ALSO, ELDERLY PATIENTS ARE OFTEN UNDERSERVED AND EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES.
Part III, Line 9b:	If a patient is known to qualify for charity care, the amount of charity care the patient receives is based on the patients income. We have a sliding scale that looks at your income as a % of the Federal Poverty Level. Income from 0-220% gets 100% charity care. Income 401% or more than the federal poverty level gets 0%. In between 220% and 400% is the sliding scale. Once qualified for charity care, this qualification is good for 6 months going forward.
Part VI, Line 2:	BELLIN MEMORIAL HOSPITAL HAS COMPLETED A COMMUNITY NEEDS ASSESSMENT AND IT IS POSTED ON BELLIN.ORG
Part VI, Line 3:	FINANCIAL COUNSELORS ADVISE PATIENTS OF ASSISTANCE PROGRAMS AS WELL AS SERVICE CALLED HRS ERASE IS USED TO REVIEW SELF PAY ACCOUNTS FOR POSSIBLE COVERAGE THROUGH GOVERNMENT PROGRAMS.
Part VI, Line 4:	BELLIN MEMORIAL HOSPITAL SERVES NORTHEAST WISCONSIN AND UPPER MICHIGAN. OUR CURRENT PAYOR SUPPLEMENTAL INFORMATION MIX IS 48.7% MEDICARE AND 9.8% MEDICAID. 12% OF THE POPULATION IS BELOW THE POVERTY LEVEL AND 13.5% OF THE POPULATION IS OVER AGE 65.
Part VI, Line 5:	A MAJORITY OF BELLIN MEMORIAL HOSPITALS GOVERNING BODY IS COMPRISED OF PERSON WHO RESIDE IN BELLIN MEMORIAL HOSPITAL'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEROF. IN ADDITION, BELLIN MEMORIAL HOSPITAL EXTENDS MEDICAL STAFF PRIVELEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR ALL OF ITS DEPARTMENTS. BELLIN MEMORIAL HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVEMENTS IN PATIENT CARE, EDUCATION AND FACILITIES.
Part VI, Line 6:	BELLIN HEALTH IS A COMMUNITY-OWNED NOT-FOR-PROFIT ORGANIZATION RESPONSIBLE FOR THE PHYSICAL AND EMOTIONAL HEALTH OF PEOPLE LIVING IN NORTHEAST WISCONSIN AND THE UPPER PENINSULA OF MICHIGAN. DIRECTLY, AND IN PARTNERSHIP WITH COMMUNITIES, EMPLOYERS, SCHOOLS, AND GOVERNMENT OFFICIALS, WE GUIDE INDIVIDUALS AND FAMILIES IN THEIR LIFELONG JOURNEY TOWARD OPTIMAL HEALTH. WE ARE COMMITTED TO PROVIDING SAFE, RELIABLE, COST-EFFECTIVE TOTAL HEALTH SOLUTIONS WITH RESPECT AND COMPASSION. OUR INNOVATIVE WORK WILL IMPACT HEALTHCARE DELIVERY IN OUR REGION AS WELL AS THROUGHOUT THE WORLD.
Part VI, Line 7, Reports Filed With States	WI

Schedule H (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990.
lBullet

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

OMB No. 1545-0047

2015

Open to Public
Inspection

Name of the organization
Bellin Memorial Hospital Inc

Employer identification number
39-0884478

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient

that received more than $5,000. Part II can be duplicated if additional space is needed.

(a) Name and address of organization or government	(b) EIN	(c) IRC section if applicable	(d) Amount of cash grant	(e) Amount of non-cash assistance	(f) Method of valuation (book, FMV, appraisal, other)	(g) Description of non-cash assistance	(h) Purpose of grant or assistance

(1) NEW Community Clinic 622 Bodart Street Green Bay,WI54301	39-1200636	501(c)3	100,000	Support Free Community Health Clinic
(2) GREEN BAY PUBLIC SCHOOLS PO BOX 23387 Green Bay,WI543053387	39-6002329	GOVT - PUBLIC SCHOOL	63,333	HEALTH & WELLNESS PROGRAM
(3) FESTIVAL FOODS TURKEY TROT 2250 W MASON ST GREEN BAY,WI54303	39-1814712		15,000	TURKET TROT RUN FOR CHARITY
(4) DOWNTOWN GREEN BAY INC 130 E WALNUT ST STE 501 GREEN BAY,WI54301	39-1858389	501(c)3	8,500	Winter Farmers Market
(5) KIWANIS SKI CLUB PO BOX 475 IRON MOUNTAIN,MI49801	38-3254313	501(c)3	25,000	DONATION
(6) UW OSHKOSH 842 ALGOMA BLVD OSHKOSH,WI54901	39-1805963	Govt- STATE AGENCY	60,000	SUPPORT ORGANIZATION'S ACTIVITIES
(7) NORTHEAST WISCONSIN TECHNICAL COLLEGE 2740 W MASON ST GREEN BAY,WI54307	39-1087141	GOVT- STATE AGENCY	21,000	HEALTH SCIENCE SIMULATION LAB
(8) AMERICAN FOUNDATION OF COUNSELING 130 E WALNUT ST 7TH FLOOR GREEN Bay,WI54301	39-1047205	501(c)3	8,000	ETHICS IN BUSINESS AWARDS AND MORE PROGRAM FOR MENTAL WELLNESS/TREATMENT INDIGENT POPULATION
(9) GREATER GREEN BAY COMMUNITY FOUNDATION 310 W WALNUT ST SUITE 350 GREEN Bay,WI54303	39-1699966	501(c)3	40,200	Green Bay Neighboorhood Leadership Council, Women's Fund of Green Bay
(10) UNITED WAY OF BROWN COUNTY 112 N ADAMS ST STE 201 GREEN BAY,WI54301	39-0806299	501(c)3	36,000	Donation
(11) ALGOMA SCHOOL DISTRICT 1715 DIVISION ST ALGOMA,WI54201	39-1032686	GOVT - PUBLIC SCHOOL	20,400	DONATION
(12) ASHWAUBENON EDUCATION FOUNDATION 320 N BROADWAY ST SUITE 260 GREEn Bay,WI54303	39-6000770	GOVT - PUBLIC SCHOOL	5,000	DONATION
(13) BRIAN LAVIOLETTE SCHOLARSHIP 1135 PLEASANT VALLEY DR ONEIDA,WI54155	39-1836591	501(c)3	5,500	BELLIN COLLEGE SCHOLARSHIP
(14) NEIGHBORHOOD HOUSING SERVICES OF GREEN BAY 437 S JACKSON ST GREEN BAY,WI54301	39-1402851	501(c)3	10,000	PROGRAM ASSISTANCE
(15) UNIVERSITY OF WISCONSIN - GREEN BAY FOUNDATION 2420 NICOLET DR GREEN BAY,WI54311	39-1805963	GOVT - PUBLIC SCHOOL	20,000	MARK REINKE, MD MEMORIAL SCHOLARSHIP
(16) BROWN COUNTY MEDICAL SOCIETY ALLIANCE 563 CARTER CT STE B KIMBERLY,WI54136	39-1516026	501(c)3	5,000	2015 DOCTORS IN RECITAL SPONSORSHIP
(17) BELLIN COLLEGE 3201 EATON RD GREEN BAY,WI54311	39-1620530	501(c)3	63,938	BUILD OUT LAB AND NURSING CAMPS
(18) UNITY HOSPICE 2366 OAK RIDGE CIRCLE DE PERE,WI54115	39-1750729	501(c)3	5,500	DONATION
(19) US VENTURE OPEN 425 BETTER WAY APPLETON,WI54915	39-1548450	501(c)3	25,000	DONATION

Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image

Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image

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

Cat. No. 50055P

Schedule I (Form 990) 2015

Page 2

Part III

Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.

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

(1)
(2)
(3)
(4)
(5)
(6)
(7)

Part IV

Supplemental Information. Provide the information required in Part I, line 2, Part III, column (b), and any other additional information.

Return Reference

Explanation

Part I, Line 2:

THE ORGANIZATION REQUIRES A COMPREHENSIVE REQUEST OF THE GRANTEE TO PROVIDE RATIONALE FOR THE REQUEST. REQUIRED INFORMATION TO BE PROVIDED BY THE GRANTEE INCLUDES, TAX-EXEMPT STATUS, IDENTIFICATION OF USE OF RESOURCES AND FOLLOW UP INFORMATION AS TO THE UTILIZATION OF THE RESOURCES. THE ORGANIZATION REVIEWS EACH GRANTEE REQUEST IN RELATIONSHIP TO THE MISSION OF THE ORGANIZATION AND COMMUNITY SUPPORT. ALL REQUESTS REQUIRE APPROVAL BY SENIOR LEADERSHIP OF THE ORGANIZATION.

Schedule I (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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

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

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

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

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

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

Any related organization?

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

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

The organization?

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2015

Page 2

Part II

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

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

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column(B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1WILLIAM WITTMAN MDBoard Member	(i) (ii)	231,823 ------------- 0	144,820 ------------- 0	1,188 ------------- 0	8,673 ------------- 0	14,577 ------------- 0	401,081 ------------- 0	0 ------------- 0
2LOREN FUGLESTAD MD - TermedBoard Member/BMG physician	(i) (ii)	195,487 ------------- 0	120,763 ------------- 0	270 ------------- 0	13,424 ------------- 0	19,623 ------------- 0	349,567 ------------- 0	0 ------------- 0
3GEORGE KERWINBellin CEO/Board Member	(i) (ii)	546,445 ------------- 0	348,100 ------------- 0	15,658 ------------- 0	10,400 ------------- 0	17,077 ------------- 0	937,680 ------------- 0	0 ------------- 0
4Cynthia Lasecki MDBoard Member/Former President Medica	(i) (ii)	184,632 ------------- 0	165,778 ------------- 0	270 ------------- 0	13,742 ------------- 0	3,559 ------------- 0	367,981 ------------- 0	0 ------------- 0
5Sabina Singh MDBoard Member/President Bellin Medica	(i) (ii)	184,631 ------------- 0	78,528 ------------- 0	270 ------------- 0	10,460 ------------- 0	10,861 ------------- 0	284,750 ------------- 0	0 ------------- 0
6Mark Ringwelski MDBoard Member/FPresident Bellin Speci	(i) (ii)	231,352 ------------- 0	80,800 ------------- 0	774 ------------- 0	10,010 ------------- 0	18,231 ------------- 0	341,167 ------------- 0	0 ------------- 0
7JAMES DIETSCHECFO	(i) (ii)	325,354 ------------- 0	60,000 ------------- 0	270 ------------- 0	10,079 ------------- 0	20,681 ------------- 0	416,384 ------------- 0	0 ------------- 0
8PETER KNOXEXECUTIVE VP	(i) (ii)	325,801 ------------- 0	50,000 ------------- 0	1,188 ------------- 0	17,698 ------------- 0	16,577 ------------- 0	411,264 ------------- 0	0 ------------- 0
9CHRISTINE WOLESKEEXECUTIVE VP	(i) (ii)	329,653 ------------- 0	79,948 ------------- 0	414 ------------- 0	16,752 ------------- 0	18,806 ------------- 0	445,573 ------------- 0	0 ------------- 0
10CHRISTOPHER WOLFRAM MDPhysician	(i) (ii)	552,922 ------------- 0	386,416 ------------- 0	180 ------------- 0	7,588 ------------- 0	18,623 ------------- 0	965,729 ------------- 0	0 ------------- 0
11TIMOTHY TANKE MDPhysician	(i) (ii)	552,221 ------------- 0	333,623 ------------- 0	414 ------------- 0	12,432 ------------- 0	18,407 ------------- 0	917,097 ------------- 0	0 ------------- 0
12RICHARD TIMMONS MDPHYSICIAN	(i) (ii)	555,930 ------------- 0	267,632 ------------- 0	774 ------------- 0	12,562 ------------- 0	19,996 ------------- 0	856,894 ------------- 0	0 ------------- 0
13Vijaya Munagala MDPhysician	(i) (ii)	514,087 ------------- 0	275,082 ------------- 0	270 ------------- 0	8,112 ------------- 0	20,873 ------------- 0	818,424 ------------- 0	0 ------------- 0
14Paul Hudson MDPHYSICIAN	(i) (ii)	681,661 ------------- 0	174,311 ------------- 0	180 ------------- 0	13,547 ------------- 0	20,681 ------------- 0	890,380 ------------- 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 (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
Bellin Memorial Hospital Inc

Employer identification number
39-0884478

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	WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY	39-1337855		11-23-2011	12,944,000	REFINANCING OF 2001 BONDS		X		X		X
B	Wisconsin Health and EDUCATIONAL FACILITIES AUTHORITY	39-1337855	97712DLH7	04-09-2015	44,994,006	Refund and legally defease		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	1,040,000		1,355,616
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	12,944,000		44,994,006
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	79,844		528,236
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............
11 Other spent proceeds .............			44,465,770
12 Other unspent proceeds .............
13 Year of substantial completion .............	2001		2009
	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?	X		X
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 ....	1.000 %		1.000 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %
6 Total of lines 4 and 5 .............	1.000 %		1.000 %
7 Does the bond issue meet the private security or payment test? ...		X	X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X

Part IV

Arbitrage

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

Schedule K (Form 990) 2015

Page 3

Part IV

Arbitrage (Continued)

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

Part V

Procedures To Undertake Corrective Action

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

Part VI

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

Return Reference	Explanation

Schedule K (Form 990) 2015

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

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

Attach to Form 990 or Form 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2015

Open to Public Inspection

Name of the organization

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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) Wisconsin Public Service Corp Constellation Energy Services & WE Energies	Board Member Larry Borgard is President & COO - Utilities at Integrys	3,226,053	Integrys Energy Group provides utility services to Bellin Memorial Hospital		No
(2) Associated Bank	Board Member Denis Hogan is Market President	205,229	Banking Services		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 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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

Return Reference	Explanation
Form 990, Part VI, Section A, line 6	The organization has one corporate member, Bellin Health Systems, Inc.
Form 990, Part VI, Section A, line 7a	The corporate member, Bellin Health Systems, Inc. has the power to appoint board members.
Form 990, Part VI, Section A, line 7b	The corporate member, Bellin Health Systems, Inc., has the power to approve major expenditures and long-term borrowings.
Form 990, Part VI, Section B, line 11	The Form 990 is reviewed in detail by senior administration and is presented to the Executive Committee in its entirety for a review of the document.
Form 990, Part VI, Section B, line 12c	Each year a conflict of interest request document is provided to each board member. All documents are provided back to administration and reviewed. All employees are required to review the conflict of interest policy as part of annual mandatory education. If there is a conflict of interest, the corporate compliance officer and corporate compliance committee which is a committee of the board of directors is notified. The corporate compliance officer and corporate compliance committee addresses the issue.
Form 990, Part VI, Section B, line 15	Compensation for the CEO and key executives are set by the executive committee of the Board supported by market data from surveys and an independent consultants report. The compensation is determined by members of the executive committee without conflict and is documented. CEO Compensation: CEO presents results of Performance Objectives to the Executive Committee in January of each year. The Chair applies a formula to the results and comes up with a recommendation. The Chair facilitates getting approval from other members of the Executive Committee. Senior Leaders: Compensation for those who report to the CEO is taken to the Executive Committee for discussion/approval.
Form 990, Part VI, Section C, line 19	THE ORGANIZATION BELIEVES THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION.
Form 990, Part XI, line 9:	CHANGE IN INTEREST IN FOUNDATION 797,887. INTEREST RATE SWAP AGREEMENT -1,293,827. NON-CONTROLLING INTEREST IN CONSOLIDATED AFFILIATE -1,854,305.
FORM 990, PART XI, LINE 2B-2C	BELLIN MEMORIAL HOSPITAL, INC. IS INCLUDED IN THE CONSOLIDATED AUDIT OF BELLIN HEALTH SYSTEMS, INC. THE BOARD OF DIRECTORS OF BELLIN HEALTH SYSTEMS, INC. ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT AUDITOR. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.

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

Bellin Memorial Hospital Inc

Employer identification number

39-0884478

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
(1) NORTHREACH HEALTHCARE LLC 3120 RIVERSIDE AVE GATE B BLDG 1 MARINETTE,WI54143 39-1999260	PRIMARY AND SPECIALTY PHYSICIAN CLINICS	WI	13,542,838	785,285	BELLIN MEMORIAL HOSPITAL

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)LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY,WI54305 39-1512903	SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL	WI	501(c)(3)	Line 11b, II	Bellin Health Systems Inc	Yes
(2)BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY,WI54311 39-1620530	NURSING COLLEGE	WI	501(c)(3)	Line 2	Bellin Health Systems Inc	Yes
(3)THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY,WI54305 39-1809171	FOUNDATION	WI	501(c)(3)	Line 7	Bellin Health Systems Inc	Yes
(4)BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY,WI54305 39-1657627	PPSYCHIATRIC HOSPITAL	WI	501(c)(3)	Line 3	Bellin Health Systems Inc	Yes
(5)OCONTO HOSPITAL & MEDICAL CENTER INC PO BOX 357 OCONTO,WI54153 06-1745397	HOSPITAL	WI	501(c)(3)	Line 3	BELLIN MEMORIAL HOSPITAL INC	Yes
(6)BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY,WI54305 39-1512904	SUPPORT OF HEALTHCARE ORGANIZATIONS	WI	501(c)(3)	Line 11b, II	N/A		No
(7)UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE,WI54115 39-1750729	HOSPICE, PALLIATIVE & BEREAVEMENT SERVICES	WI	501(c)(3)	Line 9	BELLIN MEMORIAL HOSPITAL INC	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	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) BELLIN ORTHOPEDIC SURGERY CENTER LLC 2223 LIME KILN RD GREEN BAY,WI54311 26-4677834	AMBULATORY ORTHOPEDIC SURGERY	WI	Bellin Memorial Hospital Inc	RELATED	2,277,170	566,118		No			No
(2) D1 SPORTS TRAINING OF GREEN BAY LLC SOUTH SPRINGS DRIVE FRANKLIN,TN37067 45-4848172	SPORTS TRAINING	TN	N/A

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(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) BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY,WI54301 39-1504766	DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS	WI	N/A	C				No
(2) BELLIN INVESTMENTS INC PO BOX 23400 GREEN BAY,WI54305 39-1564939	OTHER	WI	N/A	C				No

Schedule R (Form 990) 2015

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

Yes

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

Yes

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

Yes

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

Yes

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

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

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

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

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

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

Yes

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

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

Yes

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

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) OCONTO HOSPITAL & MEDICAL CENTER	D	12,249,995	ACTUAL
(2) OCONTO HOSPITAL & MEDICAL CENTER	O	657,118	ACTUAL
(3) OCONTO HOSPITAL & MEDICAL CENTER	M	1,233,599	ACTUAL
(4) OCONTO HOSPITAL & MEDICAL CENTER	Q	4,250,000	ACTUAL
(5) bellin college	B	63,938	ACTUAL
(6) Bellin Health Foundation	C	554,562	ActUAL
(7) Bellin Psychiatric Center	L	2,097,955	ActUAL
(8) Bellin psychiatric Center	D	3,060,492	ACTUAL
(9) bellin college	L	329,943	actual
(10) bellin college	N	350,014	aCTUAL
(11) bellin health Foundation	Q	560,294	aCTUAL
(12) bellin health Foundation	O	367,331	aCTUAL
(13) bellin health Foundation	S	1,345,000	aCTUAL

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: BELLIN MEMORIAL HOSPITAL, INC. (BMH) PROVIDES HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY AND IMPROVE THE HEALTH OF LOW-INCOME PATIENTS. CONSISTENT WITH THE MISSION OF BMH, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. IN ADDITION, BMH PROVIDES SERVICES INTENDED TO BENEFIT THE POOR AND UNDERSERVED, INCLUDING THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR ARE UNINSURED OR UNDERINSURED. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF THE BELLIN HEALTH BENEFITS PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN COST.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	22
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	15
5	Total number of individuals employed in calendar year 2015 (Part V, line 2a) ......	5	3,483
6	Total number of volunteers (estimate if necessary) .............	6	420
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	8,224,037
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-790,158

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,097,065	922,507
9	Program service revenue (Part VIII, line 2g) .........	449,192,956	472,729,864
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	5,978,466	1,277,875
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,911,513	4,062,031
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	460,180,000	478,992,277
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	1,225,882	607,321
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)	227,999,752	255,739,020
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)....	194,357,613	195,052,016
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	423,583,247	451,398,357
19	Revenue less expenses. Subtract line 18 from line 12.......	36,596,753	27,593,920
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	454,995,944	491,466,100
21	Total liabilities (Part X, line 26).............	140,678,606	145,530,736
22	Net assets or fund balances. Subtract line 21 from line 20.....	314,317,338	345,935,364

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 370,867,487 including grants of $ 606,348 ) (Revenue $ 453,799,453 )
	THE HOSPITAL PROVIDES ACUTE HOSPITAL CARE TO RESIDENTS OF NORTHEASTERN WISCONSIN. DURING FISCAL YEAR 2016 33,060 INPATIENT DAYS WERE PROVIDED (30,075 ADULTS AND PEDIATRICS), AS COMPARED TO 33,329 (30,590 ADULTS AND PEDIATRICS) IN FISCAL YEAR 2015. THE NUMBER OF OUTPATIENTS REGISTERED FOR 2016 AND 2015 WERE 241,774 AND 242,670, RESPECTIVELY. BELLIN MEMORIAL HOSPITAL ALSO PROVIDED 828,162 (AS COMPARED TO 745,126 IN 2015) PHYSICIAN CLINIC VISITS THROUGH BELLIN MEDICAL AND SPECIALTY GROUPS.

4b	(Code: ) (Expenses $ 16,149,096 including grants of $ 973 ) (Revenue $ 13,350,771 )
	Northreach Healthcare is a primary care organization with service lines of family practice, ob/gyn, pediatrics, and internal medicine. NorthReach provides service to Marinette county, Menominee county, and the surrounding areas.

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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses387,016,583

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	8,111,435	0	404,051

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	554,562
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	367,945

g	Noncash contributions included in lines 1a-1f:$
h Total.Add lines 1a-1f.......		922,507

		Business Code
2a	NET PATIENT SERVICE REVENUE	621500	464,766,967	457,173,783	7,593,184
b	CONTRACTED SERVICES	621110	3,078,643	3,078,643
c	MISCELLANEOUS	621110	2,631,757	2,631,757
d	CAFETERIA	621110	863,578			863,578
e	ACO INCENTIVE	621110	609,812	609,812
f	All other program service revenue.			779,107	91,255	630,853	56,999
g Total.Add lines 2a–2f.....			472,729,864

3 Investment income (including dividends, interest, and othersimilar amounts) ..........			2,082,486			2,082,486
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents	45,925	3,156,971
b	Less: rental expenses	45,925	2,659,914
c	Rental income or (loss)	0	497,057
d	Net rental income or (loss)......			497,057			497,057
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	334,915
b	Less: cost or other basis and sales expenses	293,056	846,470
c	Gain or (loss)	41,859	-846,470
d	Net gain or (loss).....			-804,611			-804,611
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	Income FROM HEALTHCARE AFFILIATES		900099	3,281,597	3,281,597
b	EHR INCENTIVE		621110	283,377	283,377
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			3,564,974
12	Total revenue. See Instructions......			478,992,277	467,150,224	8,224,037	2,695,509

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21	607,321	607,321
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	4,066,962	1,744,546	2,322,416
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....
7	Other salaries and wages	203,472,603	185,629,454	17,843,149
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	9,152,929	8,275,797	877,132
9	Other employee benefits .......	26,272,558	22,934,678	3,337,880
10	Payroll taxes ...........	12,773,968	11,442,936	1,331,032
11	Fees for services (non-employees):
a	Management ......	636,232	636,232
b	Legal .........	621,851		621,851
c	Accounting ...........	622,909		622,909
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	27,202,082	20,011,440	7,190,642
12	Advertising and promotion ....	7,630,896	43,351	7,587,545
13	Office expenses .......	4,960,659	2,057,032	2,903,627
14	Information technology ......	7,699,772	3,807,148	3,892,624
15	Royalties ..
16	Occupancy ...........	11,118,215	10,001,161	1,117,054
17	Travel ............	1,097,813	676,033	421,780
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	1,698,577	1,022,850	675,727
20	Interest ...........	3,838,662	402,263	3,436,399
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	18,461,552	13,410,094	5,051,458
23	Insurance ...	871,334	684,816	186,518
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	Supplies expense	77,151,680	76,602,961	548,719
b	Equipment Rent/Maint	11,726,994	10,084,183	1,642,811
c	Dues & subscriptions	10,051,961	8,515,251	1,536,710
d	Bad Debt expense	6,705,765	6,704,616	1,149
e	All other expenses	2,955,062	1,722,420	1,232,642
25	Total functional expenses. Add lines 1 through 24e	451,398,357	387,016,583	64,381,774	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 ........			15,994	1	17,432
2	Savings and temporary cash investments .........			90,773,641	2	80,772,767
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			48,389,694	4	48,985,833
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net ....			6,347,210	7	2,968,083
8	Inventories for sale or use ........			4,987,231	8	5,813,537
9	Prepaid expenses and deferred charges ......			6,774,092	9	5,826,209
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	367,306,413
b	Less: accumulated depreciation	10b	195,531,478	144,955,990	10c	171,774,935
11	Investments—publicly traded securities .			123,364,419	11	135,677,068
12	Investments—other securities. See Part IV, line 11 .....			13,839,345	12	17,958,742
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............			6,105,842	14	5,368,296
15	Other assets. See Part IV, line 11 ...........			9,442,486	15	16,303,198
16	Total assets. Add lines 1 through 15 (must equal line 34)...			454,995,944	16	491,466,100

17	Accounts payable and accrued expenses .....	38,980,842	17	47,700,716
18	Grants payable ...		18
19	Deferred revenue .........	320,036	19	230,863
20	Tax-exempt bond liabilities .........	72,367,813	20	67,651,129
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D	29,009,915	25	29,948,028
26	Total liabilities. Add lines 17 through 25..	140,678,606	26	145,530,736

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	310,758,298	27	341,994,662
28	Temporarily restricted net assets ...........	1,388,632	28	1,450,794
29	Permanently restricted net assets	2,170,408	29	2,489,908
	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 ...........	314,317,338	33	345,935,364
34	Total liabilities and net assets/fund balances ........	454,995,944	34	491,466,100