TY 2017 Form 990

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) JIM KIRSH...................................................................... CHAIR	1.00 ................. 0.00	X	X			0	0
(2) SUE SUTTER...................................................................... VICE CHAIR	1.00 ................. 0.00	X	X			0	0
(3) MARSHA BORLING...................................................................... SECRETARY	1.00 ................. 0.00	X	X			0	0
(4) DOUG MATHISON...................................................................... TREASURER	1.00 ................. 0.00	X	X			0	0
(5) KARLA CHASE...................................................................... PAST CHAIR	1.00 ................. 1.00	X	X			0	0
(6) SETH BARUDIN BOARD MEMBER...................................................................... CHIEF OF STAFF (THROUGH DEC 2017)	40.00 ................. 0.00	X				0	0
(7) WADE FLETCHER...................................................................... BOARD MEMBER	1.00 ................. 3.00	X				0	0
(8) TERRY O'CONNOR...................................................................... BOARD MEMBER	1.00 ................. 0.00	X				0	0
(9) FRANK PODOJIL...................................................................... BOARD MEMBER & CHIEF OF STAFF	40.00 ................. 0.00	X				0	0
(10) KIMBERLY JM MILLER...................................................................... PRESIDENT & CEO	40.00 ................. 3.00	X	X			657,464	43,427
(11) DAVID CORSO...................................................................... CHIEF OPERATIONS OFFICER	40.00 ................. 0.00		X			260,015	6,695
(12) MELANIE BRUINS...................................................................... CHIEF TALENT OFFICER	40.00 ................. 0.00		X			170,723	32,590
(13) JASON SMITH...................................................................... CHIEF MEDICAL OFFICER	40.00 ................. 0.00		X			348,540	37,157
(14) CAROLYN CATTON...................................................................... INTERIM CHIEF PATIENT CARE	40.00 ................. 0.00		X			249,716	7,927
(15) THOMAS GEHIN...................................................................... DIRECTOR OF PHARMACY	40.00 ................. 0.00			X		153,613	6,140
(16) JOSEPH PUCCINELLI...................................................................... ORTHOPEDIC SURGEON	40.00 ................. 0.00				X	660,394	62,683
(17) ROBERT SEIPEL...................................................................... ORTHOPEDIC SURGEON	40.00 ................. 0.00				X	642,275	60,900

(A) Name and business address	(B) Description of services	(C) Compensation
GREENFIELD REHABILITATION AGENCY 7517 W COLDSPRING ROAD GREENFIELD,WI53220	REHABILITATION SERVICES	717,344
HALL RENDER KILLIAN 39778 TREASURY CENTER CHICAGO,IL60691	LEGAL SERVICES	572,861
DAILY CARE HOSPITALISTS LLC PO BOX 11934 GREEN BAY,WI543071934	CONTRACT LABOR	490,633
SHALOM MEDICAL INC 977 GREEN RIDGE DRIVE DE PERE,WI54115	CONTRACT LABOR	437,885
COMPHEALTH ASSOCIATES INC PO BOX 972651 DALLAS,TX753972651	CONTRACT LABOR	363,866
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 12

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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 12, 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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

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 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

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) 2019

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2018 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2019. 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—2018. 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—2019. 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—2018. 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) 2019

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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) 2015	(b) 2016	(c) 2017	(d) 2018	(e) 2019	(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 2019 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2018 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2019 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2018 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2019. 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—2018. 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) 2019

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d 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 12a or 12b 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) 2019

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) 2019

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 (explain in Part VI). 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) 2019

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 2019 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-2019	(iii) Distributable Amount for 2019
1 Distributable amount for 2019 from Section C, line 6
2 Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2019:
a From 2014.......
b From 2015.......
c From 2016.......
d From 2017.......
e From 2018.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2019 distributable amount
i Carryover from 2014 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2019 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2019 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2019, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2019. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2020. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2015.....
b Excess from 2016.....
c Excess from 2017.....
d Excess from 2018.....
e Excess from 2019.....

Schedule A (Form 990 or 990-EZ) (2019)

Schedule A (Form 990 or 990-EZ) 2019

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) 2019

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.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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. Don't 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 isn't covered by the General Rule and/or the Special Rules doesn't 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 doesn't 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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019) Page 2

Name of organization BEAVER DAM COMMUNITY HOSPITALS INC

Part I Contributors	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
		$	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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 3

Name of organization BEAVER DAM COMMUNITY HOSPITALS INC		Employer identification number 39-1157876

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) (2019)

Schedule B (Form 990, 990-EZ, or 990-PF) (2019)

Page 4


Name of organization BEAVER DAM COMMUNITY HOSPITALS INC			Employer identification number 39-1157876
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) (2019)

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

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

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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 (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

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) 2019

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) 2016	(b) 2017	(c) 2018	(d) 2019	(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) 2019

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|No

(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

3,722

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

3,722

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:	BDCH PAYS ANNUAL MEMBERSHIP FEES TO WISCONSIN HOSPITAL ASSOCIATION (WHA), A PORTION OF WHICH WAS USED BY WHA FOR LOBBYING ON BEHALF OF ITS MEMBERS.

Schedule C (Form 990 or 990EZ) 2019

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.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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 7/25/06, 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 FASB 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 FASB 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 FASB 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) 2019

Page 2

Part III

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

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

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No


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

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

Yes No

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

Part V

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

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

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

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

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

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

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

1a	Land .....	4,003,014		4,003,014
b	Buildings ....	115,501,809	52,115,596	63,386,213
c	Leasehold improvements	1,172,848	572,769	600,079
d	Equipment ....	62,575,825	50,462,478	12,113,347
e	Other .....	2,431,607		2,431,607
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				82,534,260

Schedule D (Form 990) 2019

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
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
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

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
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
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	7,688,425
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) 2019

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
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1..................		3
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
c	Add lines 4a and 4b....................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

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
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
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3
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
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

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 IV, LINE 2B:

RESIDENT TRUST FUNDS ARE FUNDS THAT ARE THE RESIDENTS' THAT ARE DEPOSITED IN A SEPARATE BANK ACCOUNT. THESE FUNDS ARE TRACKED SEPARATELY FROM BDCH'S FUNDS AND BELONG TO THE RESIDENTS. SECURITY DEPOSITS ARE DEPOSITS PAID TO BDCH UPON ENTERING INTO A RENTAL AGREEMENT FOR CBRF RESIDENTS AND ARE DUE BACK TO THE TENANTS UPON TERMINATION OF THEIR RENTAL AGREEMENT.

PART X, LINE 2:

ALL OF THE ENTITIES WITHIN THE CORPORATION ARE NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE, EXCEPT BDMCB2 AND DHE. BDMCB2 AND DHE ARE LIMITED LIABILITY COMPANIES AND ARE NOT DIRECTLY SUBJECT TO TAXATION. THEY HAVE ELECTED TO BE TREATED AS DISREGARDED ENTITIES FOR FEDERAL INCOME TAX PURPOSES. INCOME AND LOSSES OF THE COMPANIES ARE PASSED THROUGH TO AND REPORTED FOR INCOME TAX PURPOSES BY THE CORPORATION. THE CORPORATION FOLLOWS THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION GUIDANCE ON INCOME TAXES, ACCOUNTING FOR UNCERTAINTIES IN INCOME TAXES, WHICH ADDRESSES THE DETERMINATION OF WHETHER TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED IN THE FINANCIAL STATEMENTS. UNDER THIS GUIDANCE, THE CORPORATION MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. UNRELATED BUSINESS TAXABLE INCOME IS REPORTED ON FORM 990T, AS APPROPRIATE. THE BENEFITS RECOGNIZED IN THE FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES ALSO ADDRESSES DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES ON INCOME TAXES, AND ACCOUNTING IN INTERIM PERIODS. AT JUNE 30, 2018 AND 2017, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS LIABILITIES.

Schedule D (Form 990) 2019

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

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

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) . . .	1,071,345		1,071,345	0.980 %
b	Medicaid (from Worksheet 3, column a) . . . . .	13,391,620	7,589,701	5,801,919	5.280 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	14,462,965	7,589,701	6,873,264	6.260 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	1,891,030		1,891,030	1.720 %
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	12,213		12,213	0.010 %
j	Total. Other Benefits . .	1,903,243		1,903,243	1.730 %
k	Total. Add lines 7d and 7j .	16,366,208	7,589,701	8,776,507	7.990 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2019

Schedule H (Form 990) 2019

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

4,748,062

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. ......

389,592

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).....

14,410,739

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

18,515,076

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

-4,104,337

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

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

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

Schedule H (Form 990) 2019

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?1Name, 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	BEAVER DAM COMMUNITY HOSPITAL 707 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 WWW.BDCH.COM 199	X	X	X

Schedule H (Form 990) 2019

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)

	BEAVER DAM COMMUNITY 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

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

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

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

Yes

6 a

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

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

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

Yes

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

Hospital facility’s website (list url): WWW.BDCH.COM/COMMUNITY-HEALTH-NEEDS

Other website (list url):

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

Other (describe in Section C)

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

Yes

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

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

Yes

If "Yes" (list url): WWW.BDCH.COM/COMMUNITY-HEALTH-NEEDS

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) 2019

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	BEAVER DAM COMMUNITY 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 150.000000000000%
and FPG family income limit for eligibility for discounted care of 0.000000000000%

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)

Was widely publicized 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):

WWW.BDCH.COM/FINANCIAL-ASSISTANCE

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

WWW.BDCH.COM/FINANCIAL-ASSISTANCE

A plain language summary of the FAP was widely available on a website (list url):
WWW.BDCH.COM/FINANCIAL-ASSISTANCE

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)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

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

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2019

Page 6

Part VFacility Information (continued)

Billing and Collections

	BEAVER DAM COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

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 nonpayment?..................................

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

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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

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

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

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):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

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)

Schedule H (Form 990) 2019

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	BEAVER DAM COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

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 a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

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) 2019

Page 8

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, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 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
BEAVER DAM COMMUNITY HOSPITAL	PART V, SECTION B, LINE 5: BDCH GATHERED QUALITATIVE INFORMATION AND PERSPECTIVES ON COMMUNITY HEALTH NEEDS THROUGH ONE-ON-ONE AND SMALL GROUP INTERVIEWS WITH KEY COMMUNITY STAKEHOLDERS. REFER TO PAGES 11 AND 12 OF THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT, AVAILABLE ON OUR WEBSITE, FOR A COMPLETE LIST OF COMMUNITY PARTICIPANTS. IN ADDITION, A COMMUNITY FORUM WAS HELD SPECIFICALLY TO REQUEST INPUT FROM THE HISPANIC COMMUNITY MEMBERS WITH LIMITED ENGLISH PROFICIENCY. APPROXIMATELY 24 HISPANIC INDIVIDUALS PARTICIPATED IN THIS COMMUNITY FORUM.
BEAVER DAM COMMUNITY HOSPITAL	PART V, SECTION B, LINE 7D: IN ADDITION TO POSTING THE CHNA REPORT ON OUR WEBSITE, WE HAVE COMMUNICATED THE RESULTS OF THE SURVEY QUITE WIDELY. THIS INCLUDES AN ARTICLE IN THE 2016 ANNUAL REPORT, WHICH WENT TO 50,000 HOUSEHOLDS. IN ADDITION, THE CHNA IS OFTEN DISCUSSED IN PRESENTATIONS THE HOSPITAL PARTICIPATES IN, SUCH AS CHAMBER OF COMMERCE AND OTHER LOCAL CIVIC AND COMMUNITY ORGANIZATION EVENTS.
BEAVER DAM COMMUNITY HOSPITAL	PART V, SECTION B, LINE 11: BECAUSE OF LIMITED RESOURCES, BDCH CANNOT RESPOND EFFECTIVELY TO EVERY IDENTIFIED HEALTH NEED. AS SUCH, BDCH HAS ELECTED TO TAKE A HOLISTIC APPROACH BY ENGAGING WITH HEALTHWAYS, INC. TO CREATE A BLUE ZONES DESIGNATED AREA ENCOMPASSING DODGE COUNTY. IT IS THROUGH THIS PARTNERSHIP THAT WE HAVE ADDRESSED NUTRITIONAL AND PHYSICAL ACTIVITY BARRIERS AND SUBSTANCE ABUSE CONCERNS IN FY18. THERE ARE NOW SEVERAL RESTAURANTS AND WORKPLACES WITHIN DODGE COUNTY THAT ARE "BLUE ZONES CERTIFIED", MEANING THESE BUSINESSES HAVE PROVEN TO PROVIDE HEALTHY OPTIONS TO THEIR CUSTOMERS (THROUGH HEALTHY MENU OPTIONS) AND EMPLOYEES (THROUGH CREATION OF WALKING MOAIS OR OTHER HEALTH-RELATED ACTIVITIES). IN ADDITION, THE BLUE ZONES PROJECT HELD SEVERAL COMMUNITY-SPECIFIC ENGAGEMENT EVENTS THROUGHOUT THE YEAR, FOCUSING ON THE ENVIRONMENT, FOOD, ALCOHOL AND TOBACCO.ANOTHER EXAMPLE OF HOW BDCH IS PROMOTING THE HEALTH OF THE COMMUNITY IS THROUGH ITS ENGAGEMENT WITH HEALTHWAYS, INC. TO CREATE A BLUE ZONES DESIGNATED AREA THAT ENCOMPASSES DODGE COUNTY. THROUGH THIS PARTNERSHIP WITH HEALTHWAYS, INC. WE ADDRESS AND PROMOTE HEALTHY LIFESTYLES THROUGH NUTRITIONAL AND PHYSICAL ACTIVITY AS WELL AS FOCUS ON SUBSTANCE ABUSE CONCERNS. BUSINESSES AND COMMUNITIES PARTNER TOGETHER WITH BDCH TO PROVIDE HEALTHY OPTIONS AND LIFESTYLES FOR THEIR CUSTOMERS, EMPLOYEES AND CITIZENS. ALL OF THE BLUE ZONES PROGRAMS ARE OFFERED TO THE COMMUNITY FREE OF CHARGE. WE WORK WITH THE COUNTY AND CITY MUNICIPALITIES, FAITH-BASED ORGANIZATIONS, GROCERY STORES, AND SCHOOLS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COUNTY RESIDENTS.

Schedule H (Form 990) 2019

Page 9

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?16
Name and address		Type of Facility (describe)
1	1 - HILLSIDE MANOR 803 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916	SKILLED NURSING FACILITY
2	2 - REMEMBRANCE HOME 1810 NORTH SPRING STREET BEAVER DAM,WI53916	DEMENTIA-SPECIFIC COMMUNITY-BASED RESIDENTIAL FACILITY
3	3 - EAGLES WINGS 408 STONE STREET BEAVER DAM,WI53916	COMMUNITY-BASED RESIDENTIAL FACILITY
4	4 - BEAVER DAM REFERENCE LAB 707 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916	REFERENCE LAB
5	5 - BEAVER DAM ORTHOPEDIC CLINIC 705 SOUTH UNIVERSITY AVENUE STE 150 BEAVER DAM,WI53916	PHYSICIAN CLINIC
6	6 - COLUMBUS MEDICAL CLINIC 1580 WEST JAMES STREET COLUMBUS,WI53925	PHYSICIAN CLINIC
7	7 - WAUPUN MEDICAL CLINIC 180 GATEWAY DRIVE WAUPUN,WI53963	PHYSICIAN CLINIC
8	8 - HORICON MEDICAL CLINIC 610 WASHINGTON STREET HORICON,WI53032	PHYSICIAN CLINIC
9	9 - SURGICAL SPECIALISTS 705 SOUTH UNIVERSITY AVENUE STE 350 BEAVER DAM,WI53916	GENERAL SURGERY CLINIC
10	10 - JUNEAU MEDICAL CLINIC 420 WEST NORTH STREET JUNEAU,WI53039	PHYSICIAN CLINIC
11	11 - SLEEP LAB 919 UNIVERSITY AVENUE BEAVER DAM,WI53916	SLEEP LAB
12	12 - HILLSIDE HOMECARE AND HOSPICE 709 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916	HOME HEALTH AGENCY
13	13 - UROLOGY CLINIC 130 WARREN STREET BEAVER DAM,WI53916	PHYSICIAN CLINIC
14	14 - BEAVER DAM MEDICAL CLINIC 130 WARREN STREET BEAVER DAM,WI53916	PHYSICIAN CLINIC
15	15 - BDCH CHIROPRACTIC 211 CORPORATE DRIVE H BEAVER DAM,WI53916	CHIROPRACTIC CLINIC
16	16 - PODIATRY CILNIC 705 SOUTH UNIVERSITY AVENUE STE 150 BEAVER DAM,WI53916	PHYSICIAN CLINIC

Schedule H (Form 990) 2019

Page 10

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
PART I, LINE 3C:	BEAVER DAM COMMUNITY HOSPITAL ("BDCH") GRANTS FINANCIAL ASSISTANCE IF THEY (A) RECEIVE EMERGENCY MEDICAL CARE OR MEDICALLY NECESSARY CARE, (B) SUBMIT A COMPLETE COMMUNITY CARE APPLICATION INCLUDING REQUIRED SUPPORTING DOCUMENTS AND (C) HAVE HOUSEHOLD INCOME LESS THAN 150% OF FEDERAL POVERTY GUIDELINES. BDCH MAY ALSO GIVE FINANCIAL ASSISTANCE BASED ON A PROPENSITY-TO-PAY FORMULA THAT IS PROVIDED AND RUN BY A THIRD-PARTY VENDOR.
PART I, LINE 6A:	IN ADDITION TO ITS COMMUNITY BENEFITS REPORT WHICH IT PREPARES, BDCH PREPARES AN ANNUAL REPORT EACH YEAR THAT IS DISTRIBUTED TO MEMBERS OF THE COMMUNITIES THAT WE SERVE. WITHIN THE ANNUAL REPORT IS A SECTION REGARDING COMMUNITY BENEFITS.
PART I, LINE 7:	CHARITY CARE IS DETERMINED BY UTILIZING THE TOTAL AMOUNT FROM THE PATIENT BILLING SYSTEM THAT IS WRITTEN OFF USING THE CHARITY CARE ALLOWANCE CHARGE CODES FROM THE CHARGEMASTER. THIS AMOUNT TIES TO THE NUMBER THAT IS REPORTED IN THE AUDITED FINANCIAL STATEMENTS FOR THE FISCAL YEAR ENDED 6/30/18. THE TOTAL CHARITY CARE AMOUNT REPORTED ON LINE 7A COLUMN (C) IS REDUCED TO COST BY APPLYING BDCH'S COST TO CHARGE RATES AS CALCULATED ON IRS SCHEDULE H, WORKSHEET 2.
PART I, LINE 7G:	BDCH DOES NOT HAVE SUFFICIENT INFORMATION AT THIS TIME TO DETERMINE IF SUBSIDIZED SERVICES EXIST BASED ON THE DEFINITION AND CALCULATIONS REQUIRED BY THE IRS AND IS WORKING TO PROVIDE SUCH INFORMATION.
PART I, LN 7 COL(F):	THE AMOUNT OF BAD DEBT EXPENSES THAT WAS EXCLUDED FROM THE CALCULATION TO DETERMINE THE NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSES WAS $4,748,062.
PART III, LINE 2:	THE AMOUNT OF BAD DEBT EXPENSE REPORTED ON LINE 2 IS THE AMOUNT OF PATIENT RECEIVABLE THAT WAS DEEMED UNCOLLECTIBLE DURING FY2018. BDCH BELIEVES THAT ITS CHARITY CARE AND RELATED COMMUNITY BENEFIT IS UNDERESTIMATED DUE TO PATIENTS THAT MAY POTENTIALLY QUALIFY FOR CHARITY CARE BUT CHOOSE NOT TO APPLY FOR IT. IN ADDITION, THERE IS ADDITIONAL BAD DEBT EXPENSE DUE TO CHARITY CARE APPLICATIONS THAT ARE MISSING INFORMATION AND ARE THEREFORE INCOMPLETE. BAD DEBT IN FY2018 WAS $4,748,062.
PART III, LINE 3:	TO CALCULATE THE CHARITY-ELIGIBLE COST OF ACCOUNTS WRITTEN OFF AS BAD DEBT EXPENSE ON LINE 3, THE PERCENT OF POPULATION BELOW POVERTY LEVEL WAS DETERMINED FROM U.S. CENSUS BUREAU INFORMATION. THIS PERCENTAGE WAS MULTIPLIED BY THE COST OF THE AMOUNT WRITTEN OFF TO BAD DEBT, WHICH PRODUCED THE AMOUNT OF CHARGES WRITTEN OFF TO BAD DEBT THAT COULD BE ASSUMED TO BE CHARITY-ELIGIBLE.
PART III, LINE 4:	SEE THE "PATIENT ACCOUNTS RECEIVABLE" DISCLOSURE IN NOTE 2 (PAGE 8) OF THE ATTACHED AUDITED CONSOLIDATED FINANCIAL STATEMENTS.
PART III, LINE 8:	THE ALLOWABLE MEDICARE COST ON PART III, LINE 6 IS DETERMINED USING THE FY 2018 FILED MEDICARE COST REPORT. THE REIMBURSEMENT FROM MEDICARE IS DEDUCTED FROM THE ESTIMATED COST TO DETERMINE THE ESTIMATED SHORTFALL FROM THE MEDICARE PROGRAM. BDCH RECOGNIZES THAT THE ESTIMATED SHORTFALL IS ACTUALLY GREATER THAN WHAT IS INCLUDED IN PART III, LINE 7 DUE TO THE NON-ALLOWABLE COSTS PER THE MEDICARE COST REPORT. THIS SHORTFALL OF $4,104,337 IS NOT CLASSIFIED AS COMMUNITY BENEFIT. HOWEVER, BDCH BELIEVES IT IS AN IMPORTANT CONTRIBUTION MADE BY THE HOSPITAL TO SUPPORT ITS MISSION OF DELIVERING EXCELLENCE ACROSS A CONTINUUM OF SERVICES, EVEN IF WE ARE NOT COMPENSATED FULLY FOR DOING SO. IN ADDITION, MANY OF THESE PATIENTS WOULD QUALIFY FOR MEDICAID AS SEVERAL PATIENTS CARRY IT AS A SECONDARY PLAN, SO THEREFORE, IF THE MEDICARE PROGRAM DID NOT EXIST, MEDICAID WOULD BE THE PRIMARY INSURANCE FOR MANY PATIENTS, WHICH IS CONSIDERED TO BE COMMUNITY BENEFIT.
PART III, LINE 9B:	BDCH MAKES EVERY EFFORT TO DETERMINE WHETHER A PATIENT IS ELIGIBLE FOR CHARITY CARE OR OTHER FINANCIAL ASSISTANCE. AS DESCRIBED IN PART VI, QUESTION 3, BDCH HAS PROCESSES IN PLACE TO INFORM PATIENTS OF OUR CHARITY CARE POLICY AND TO PROVIDE THEM WITH INFORMATION IN APPLYING FOR OTHER THIRD-PARTY OR GOVERNMENT REIMBURSEMENT. IF THE PATIENT'S INCOME LEVEL QUALIFIES THEM FOR CHARITY CARE, THE FULL AMOUNT OF THEIR ACCOUNT BALANCE IS WRITTEN OFF AS CHARITY CARE. IF THE PATIENT DOES NOT AUTOMATICALLY QUALIFY FOR CHARITY CARE, THEY CAN PROVIDE ADDITIONAL INCOME INFORMATION TO DETERMINE IF THEY QUALIFY FOR FULL CHARITY CARE WRITE-OFFS. IF THE PATIENT DOES NOT QUALIFY FOR CHARITY CARE, THEN THE PATIENT IS RESPONSIBLE FOR THE REMAINING BALANCE. THE PATIENT HAS THE OPTION TO MAKE INSTALLMENT PAYMENTS WITH NO INTEREST. IN THE EVENT THAT THE PATIENT DEFAULTS ON THEIR INSTALLMENT PAYMENTS OR DOES NOT COOPERATE WITH BDCH'S COLLECTION EFFORTS, THE ACCOUNT WILL BE SENT TO A COLLECTION AGENCY.
PART VI, LINE 2:	BDCH HAS RESPONDED TO THE CHNA IN A HOLISTIC MANNER BY ENGAGING WITH HEALTHWAYS, INC. TO CREATE A BLUE ZONES AREA ENCOMPASSING DODGE COUNTY. BLUE ZONES MEASURES WELL-BEING USING THE GALLUP WELL-BEING INDEX. GALLUP SURVEYS DODGE COUNTY ON AN ANNUAL BASIS AND REPORTS THE DATA OF DODGE COUNTY AS COMPARED TO WISCONSIN AND A NATIONAL AGGREGATE. THEY LOOK AT SOCIAL, COMMUNITY, PHYSICAL, FINANCIAL, AND PURPOSE WELL-BEING. AS PART OF THE SURVEY, THEY DO ASK ABOUT SOME HEALTH METRICS LIKE SMOKING, OBESITY, HYPERTENSION, ETC.
PART VI, LINE 3:	AT BDCH, WE COMMUNICATE OUR COMMUNITY CARE POLICY UPON REGISTRATION TO SELF-PAY PATIENTS FOR INPATIENT CARE, AT WHICH TIME PATIENTS MAY BE QUALIFIED FOR COMMUNITY CARE IMMEDIATELY. FOR OUR OUTPATIENT SELF-PAY PATIENTS, WE INCLUDE CONTACT INFORMATION IN OUR LETTERS AND STATEMENTS, ENCOURAGING THE PATIENTS TO CONTACT US IF THEY DO NOT HAVE THE MEANS TO PAY THEIR MEDICAL EXPENSES. WHEN CONTACTED, WE ASK QUESTIONS TO DETERMINE IF THE PATIENT MAY QUALIFY. IF SO, WE MAIL OUT A PACKET FOR COMPLETION.
PART VI, LINE 4:	BEAVER DAM COMMUNITY HOSPITALS, INC. SERVES THE GREATER DODGE AND COLUMBIA COUNTY REGION. THE HOME SERVICES PROGRAM ALSO TRAVELS TO OUR PATIENTS IN THEIR HOMES UP TO 30 MILES AWAY. THE POPULATION OF THE AREA WE SERVE IS APPROXIMATELY 125,000 PEOPLE. DEMOGRAPHICALLY, ABOUT 20% OF THE POPULATION IS UNDER THE AGE 18, ABOUT 63% IS AGED 18 - 64 AND ABOUT 17% IS AGE 65 AND OLDER. OUR HOSPITAL SERVES PATIENTS OF ALL AGES. ALTHOUGH THE POPULATION IS PRIMARILY CAUCASIAN, THERE IS A GROWING HISPANIC POPULATION. MULTIPLE LANGUAGES ARE SPOKEN IN THE AREA, AND THEREFORE INTERPRETATION SERVICES ARE PROVIDED FOR ALL PATIENTS.
PART VI, LINE 5:	BDCH HAS A LONG HISTORY OF SERVING THE COMMUNITY OF BEAVER DAM AND THE SURROUNDING REGION. BDCH HAS CONTINUALLY GROWN SERVICES TO RESPOND TO THE NEEDS OF PATIENTS WE SERVE ACROSS THE REGION IN CARRYING OUT ITS MISSION OF PROVIDING EXCELLENCE ACROSS THE CONTINUUM. BDCH OFFERS SEVERAL HEALTH AND COMMUNITY PROGRAMS AT NO OR LOW COST SUCH AS HEALTH AND SAFETY FAIRS, LACTATION CONSULTATION SERVICES, SUPPORT GROUPS, HEALTH SCREENINGS, MEMORY CARE CLINIC, WELLNESS CLASSES, MEALS ON WHEELS, JOINT REPLACEMENT SEMINARS, FOOT CLINIC, PACEMAKER CLINIC, AND SELF-REQUESTED, WALK-IN LAB TESTING, AMONG OTHERS.BDCH HAS AN OPEN MEDICAL STAFF, A BOARD COMPRISED OF COMMUNITY MEMBERS, AND USES ITS SURPLUS FUNDS TO REINVEST IN TECHNOLOGY AND PROGRAM SERVICES TO BETTER SERVE ITS PATIENTS. BDCH SUPPORTS CHURCH HEALTH SERVICES, A LOCAL ORGANIZATION COMMITTED TO PROVIDING HEALTH SERVICES TO LOW-INCOME PATIENTS WITHOUT INSURANCE. BDCH PARTICIPATES AS A DROP-OFF SITE FOR SHARPS AND IN THE WISCONSIN HOSPITAL EMERGENCY PREPAREDNESS PLAN WHOSE PURPOSE IS TO MEET A COMMUNITY NEED BY BRINGING ORGANIZATIONS TOGETHER IN THE EVENT OF AN EMERGENCY IN A COLLABORATIVE AND ORGANIZED MANNER. BDCH'S LEADERSHIP STAFF PARTICIPATES IN MANY LOCAL ORGANIZATIONS THROUGHOUT THE REGION.ANOTHER EXAMPLE OF HOW BDCH IS PROMOTING THE HEALTH OF THE COMMUNITY IS THROUGH ITS ENGAGEMENT WITH HEALTHWAYS, INC. TO CREATE A BLUE ZONES DESIGNATED AREA THAT ENCOMPASSES DODGE COUNTY. THROUGH THIS PARTNERSHIP WITH HEALTHWAYS, INC. WE ADDRESS AND PROMOTE HEALTHY LIFESTYLES THOUGH NUTRITIONAL AND PHYSICAL ACTIVITY AS WELL AS FOCUS ON SUBSTANCE ABUSE CONCERNS. BUSINESSES AND COMMUNITIES PARTNER TOGETHER WITH BDCH TO PROVIDE HEALTHY OPTIONS AND LIFESTYLES FOR THEIR CUSTOMERS, EMPLOYEES AND CITIZENS. ALL OF THE BLUE ZONES PROGRAMS ARE OFFERED TO THE COMMUNITY FREE OF CHARGE. WE WORK WITH THE COUNTY AND CITY MUNICIPALITIES, FAITH-BASED ORGANIZATIONS, GROCERY STORES, AND SCHOOLS TO IMPROVE THE HEALTH AND WELL-BEING OF OUR COUNTY RESIDENTS.
PART VI, LINE 6:	BDCH IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM.
PART VI, LINE 7, REPORTS FILED WITH STATES	WI

Schedule H (Form 990) 2019

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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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number
39-1157876

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 noncash assistance	(h) Purpose of grant or assistance
(1) BEAVER DAM COMMUNITY HOSPITALS FOUNDATION INC 707 S UNIVERSITY AVE BEAVER DAM,WI53916	39-1499140	501(C)(3)	69,000				SUPPORT FOR HILLSIDE MANOR BEAUTY SHOP, HOSPICE HOME, HILLSIDE HOSPICE AND LIFELINE.

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) 2019

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 noncash assistance	(e) Method of valuation (book, FMV, appraisal, other)	(f) Description of noncash assistance

(1) EMPLOYEE TUITION REIMBURSEMENT	24	59,525
(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 GRANTS GIVEN TO OUTSIDE ORGANIZATIONS WERE GIVEN TO A RELATED ENTITY. FUNDS TRANSFERRED ARE MONITORED THROUGH THE INTERNAL FINANCIAL REPORTING PROCESS AS BOTH ENTITIES ARE UNDER COMMON MANAGEMENT. THE GRANTS GIVEN TO INDIVIDUALS WERE RELATED TO BDCH'S EMPLOYEE TUITION REIMBURSEMENT PROGRAM. THIS PROGRAM PROVIDES ELIGIBLE EMPLOYEES WITH THE OPPORTUNITY TO OBTAIN, MAINTAIN, OR IMPROVE JOB-RELATED OR CAREER-RELATED OBJECTIVES THROUGH PARTICIPATION IN ACADEMIC COURSES AT ACCREDITED COLLEGES AND UNIVERSITIES. THIS PROGRAM IS MONITORED BY HUMAN RESOURCES AND IN ORDER TO RECEIVE THIS BENEFIT, EMPLOYEES MUST GET COURSE APPROVAL PRIOR TO ENROLLMENT, SUCCESSFULLY COMPLETE EACH COURSE WITH A MINIMUM OF A "C" FOR UNDERGRADUATE COURSES OR "B" FOR GRADUATE COURSES, AND SUBMIT A COPY OF AN ITEMIZED RECEIPT WITHIN ONE MONTH FOLLOWING THE END OF CLASS.

Schedule I (Form 990) 2019

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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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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 on 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 on Line 1a? ..

Yes

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

Yes

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 nonfixed
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) 2019

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)
1KIMBERLY JM MILLER PRESIDENT & CEO	(i) (ii)	492,371 ------------- 0	54,075 ------------- 0	111,018 ------------- 0	10,800 ------------- 0	32,627 ------------- 0	700,891 ------------- 0	0 ------------- 0
2DAVID CORSO CHIEF OPERATIONS OFFICER	(i) (ii)	174,692 ------------- 0	33,936 ------------- 0	51,387 ------------- 0	6,695 ------------- 0	0 ------------- 0	266,710 ------------- 0	0 ------------- 0
3MELANIE BRUINS CHIEF TALENT OFFICER	(i) (ii)	126,952 ------------- 0	24,170 ------------- 0	19,601 ------------- 0	5,616 ------------- 0	26,974 ------------- 0	203,313 ------------- 0	0 ------------- 0
4JASON SMITH CHIEF MEDICAL OFFICER	(i) (ii)	288,820 ------------- 0	20,300 ------------- 0	39,420 ------------- 0	10,800 ------------- 0	26,357 ------------- 0	385,697 ------------- 0	0 ------------- 0
5CAROLYN CATTON INTERIM CHIEF PATIENT CARE	(i) (ii)	190,324 ------------- 0	0 ------------- 0	59,392 ------------- 0	7,927 ------------- 0	0 ------------- 0	257,643 ------------- 0	0 ------------- 0
6THOMAS GEHIN DIRECTOR OF PHARMACY	(i) (ii)	153,504 ------------- 0	0 ------------- 0	109 ------------- 0	6,140 ------------- 0	0 ------------- 0	159,753 ------------- 0	0 ------------- 0
7JOSEPH PUCCINELLI ORTHOPEDIC SURGEON	(i) (ii)	658,588 ------------- 0	0 ------------- 0	1,806 ------------- 0	31,486 ------------- 0	31,197 ------------- 0	723,077 ------------- 0	0 ------------- 0
8ROBERT SEIPEL ORTHOPEDIC SURGEON	(i) (ii)	641,269 ------------- 0	0 ------------- 0	1,006 ------------- 0	27,016 ------------- 0	33,884 ------------- 0	703,175 ------------- 0	0 ------------- 0
9PAUL PALMER SURGEON	(i) (ii)	456,656 ------------- 0	0 ------------- 0	656 ------------- 0	28,800 ------------- 0	32,356 ------------- 0	518,468 ------------- 0	0 ------------- 0
10JANIE ORRINGTON-MYERS SURGEON	(i) (ii)	392,589 ------------- 0	0 ------------- 0	648 ------------- 0	10,800 ------------- 0	23,849 ------------- 0	427,886 ------------- 0	0 ------------- 0
11ANNE DEGREVE HOSPITALIST	(i) (ii)	247,469 ------------- 0	28,250 ------------- 0	394 ------------- 0	16,910 ------------- 0	31,136 ------------- 0	324,159 ------------- 0	0 ------------- 0
12DONALD ANDERSON FORMER DIRECTOR OF PHARMACY	(i) (ii)	126,581 ------------- 0	0 ------------- 0	737 ------------- 0	5,339 ------------- 0	24,585 ------------- 0	157,242 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2019

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation
PART I, LINE 1A	BDCH PROVIDED BDCH-OWNED HOUSING TO THE INTERIM CHIEF PATIENT CARE OFFICER, WHO WAS A TEMPORARY EMPLOYEE. THIS WAS INCLUDED IN HER TAXABLE W-2 COMPENSATION.
PART I, LINE 1B	BDCH OCCASIONALLY PROVIDES HOUSING OR A HOUSING ALLOWANCE TO TEMPORARY EMPLOYEES. DETERMINATIONS ARE MADE BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. WHEN THIS BENEFIT IS PROVIDED TO A TEMPORARY EMPLOYEE, BDCH FOLLOWS IRS GUIDELINES IN RECORDING AND REPORTING THE BENEFIT.
PART I, LINE 6	THE BDCH BOARD OF DIRECTORS APPROVED AN INCENTIVE PLAN FOR THE CHIEF EXECUTIVE OFFICER THAT IS RELATED TO THE FINANCIAL PERFORMANCE, QUALITY, PATIENT SATISFACTION, EMPLOYEE TURNOVER, ORGANIZATIONAL GROWTH AND INDIVIDUAL PERSONAL GOALS. THE INCENTIVE MATRIX WAS APPROVED BY THE BOARD EXECUTIVE COMPENSATION COMMITTEE. EACH YEAR THE INCENTIVE COMPENSATION MEASURES ARE CALCULATED AFTER COMPLETION OF THE EXTERNAL AUDIT AND PRESENTED TO THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE WHICH IS COMPRISED OF FIVE INDEPENDENT BOARD MEMBERS FOR APPROVAL. THE EXECUTIVE TEAM INCENTIVE PLAN IS THEN DEVELOPED BASED ON THE CEO'S PLAN AND DIRECTION OF BOARD APPROVED GOALS.

Schedule J (Form 990) 2019

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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 Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization
BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number
39-1157876

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 & EDUCATION FACILITIES AUTHORITY	39-1337855		05-09-2012	25,745,000	REFINANCE 2004A CALLABLE, 2004B, & 1998 BONDS		X		X		X
B	WISCONSIN HEALTH & EDUCATION FACILITIES AUTHORITY	39-1337855	97712DBW5	06-25-2013	42,864,560	REFINANCE 2004A BONDS		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	7,515,000		5,195,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	25,745,000		42,864,560
4 Gross proceeds in reserve funds .............			4,352,086
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	312,355		646,395
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............			8,491,772
11 Other spent proceeds .............	25,645,000
12 Other unspent proceeds .............
13 Year of substantial completion .............	2006		2006
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2018, a current refunding issue)? ........
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2018, an advance refunding issue)? ........
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) 2019

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 ....	0.030 %		0.010 %
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 .........	0.100 %		0.190 %
6 Total of lines 4 and 5 .............	0.130 %		0.200 %
7 Does the bond issue meet the private security or payment test? ...		X		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X

Part Ⅳ

Arbitrage

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

Schedule K (Form 990) 2019

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
DATE REBATE COMPUTATION PERFORMED	ISSUER NAME: WISCONSIN HEALTH & EDUCATION FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 08/15/2017

Schedule K (Form 990) 2019

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2019

Open to Public
Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

Return Reference	Explanation
FORM 990, PART III, LINE 2	BDCH ADDED PODIATRY SERVICES DURING THE FISCAL YEAR ENDED JUNE 30, 2018.
FORM 990, PART III, LINE 3	BDCH CLOSED ITS UROLOGY CLINIC DURING THE FISCAL YEAR ENDED JUNE 30, 2018.
FORM 990, PART VI, SECTION A, LINE 1	THE MEMBERSHIP OF THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE CHAIRPERSON OF THE BOARD, THE SECRETARY, THE TREASURER, AND THE VICE CHAIRPERSON OF THE BOARD AND SUCH MEMBERS OF THE BOARD OF DIRECTORS AS MAY BE APPOINTED BY THE BOARD OF DIRECTORS. THE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF BDCH DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS MAY OVERRULE ANY ACTION PREVIOUSLY TAKEN BY THE EXECUTIVE COMMITTEE.
FORM 990, PART VI, SECTION A, LINE 7A	ONE MEMBER OF THE BOARD OF DIRECTORS SHALL BE A PHYSICIAN ELECTED BY THE MEDICAL STAFF OF BDCH.
FORM 990, PART VI, SECTION B, LINE 11B	THE HOSPITAL'S CONTROLLER PERFORMS A THOROUGH REVIEW OF THE RETURN AND REVIEWS IT WITH BDCH'S CEO BEFORE PRESENTING IT TO THE EXECUTIVE COMPENSATION COMMITTEE WHICH IS COMPRISED OF FIVE INDEPENDENT BOARD MEMBERS (CHAIRMAN, VICE-CHAIR, CHAIR OF THE FINANCE COMMITTEE, CHAIR OF THE QUALITY COMMITTEE, AND ONE OTHER BOARD MEMBER) FOR REVIEW, DISCUSSION, AND QUESTIONS.
FORM 990, PART VI, SECTION B, LINE 12C	EACH DIRECTOR, OFFICER AND COMMITTEE MEMBER, AS A CONDITION TO SERVING THE CORPORATION IN HIS OR HER RESPECTIVE ROLE AND ANNUALLY THEREAFTER, SIGNS A STATEMENT AGREEING TO BE BOUND BY THE TERMS OF THE CONFLICT OF INTEREST POLICY. ANY DIRECTOR, OFFICER OR COMMITTEE MEMBER HAVING A FINANCIAL INTEREST OR OTHER INTEREST IN A CONTRACT, MATTER OR OTHER TRANSACTION PRESENTED TO THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF FOR AUTHORIZATION, APPROVAL, OR RATIFICATION SHALL MAKE A PROMPT, FULL AND FRANK DISCLOSURE OF SUCH PERSON'S INTEREST TO THE BOARD OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. SUCH DISCLOSURE SHALL INCLUDE ANY RELEVANT AND MATERIAL FACTS, KNOWN TO SUCH PERSON, ABOUT THE CONTRACT, MATTER OR TRANSACTION WHICH MIGHT REASONABLY BE CONSTRUED TO BE ADVERSE TO THE CORPORATION'S INTEREST. AFTER THE POTENTIALLY CONFLICTED INDIVIDUAL HAS LEFT THE ROOM, THE BOARD OR COMMITTEE TO WHICH SUCH DISCLOSURE IS MADE SHALL THEREUPON DETERMINE, BY MAJORITY VOTE, WHETHER THE DISCLOSURE SHOWS THAT A CONFLICT OF INTEREST EXISTS OR CAN REASONABLY BE CONSTRUED TO EXIST. IF A CONFLICT IS DEEMED TO EXIST, SUCH PERSON SHALL BE INVITED BACK TO PRESENT ANY FACTUAL INFORMATION HE OR SHE DEEMS APPROPRIATE OR TO RESPOND TO QUESTIONS IF SUCH IS REQUESTED OF OTHERS PRESENT. THE INDIVIDUAL SHALL THEN AGAIN LEAVE THE ROOM AND NOT VOTE ON, NOR USE PERSONAL INFLUENCE ON, OR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION TO OR RESPOND TO QUESTIONS AS DESCRIBED ABOVE) IN THE DISCUSSIONS AND DELIBERATIONS WITH RESPECT TO SUCH CONTRACT, MATTER OR TRANSACTION. SUCH PERSON MAY BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM AT ANY MEETING WHERE THE CONTRACT, MATTER OR TRANSACTION IS UNDER DISCUSSION OR IS BEING VOTED UPON. THE MINUTES OF THE MEETING SHALL REFLECT THE DISCLOSURE MADE, THE VOTE AND, WHERE APPLICABLE, THE ABSTENTION FROM VOTING AND PARTICIPATION, AND WHETHER A QUORUM WAS PRESENT.
FORM 990, PART VI, SECTION B, LINE 15A	THE DETERMINATION OF THE CEO'S COMPENSATION IS IMPLEMENTED, REVIEWED, AND MONITORED BY THE BOARD OF DIRECTORS' EXECUTIVE COMPENSATION COMMITTEE. THIS COMMITTEE IS COMPRISED OF FIVE INDEPENDENT BOARD MEMBERS AND IS ASSISTED BY AN OUTSIDE NATIONALLY RECOGNIZED CONSULTING FIRM DEALING WITH HOSPITAL EXECUTIVE COMPENSATION AND BENEFITS. SALARIES AND BENEFITS FOR THE CEO ARE EVALUATED BY THE EXECUTIVE COMPENSATION COMMITTEE ON AN ANNUAL BASIS AND COMPARED TO THE NATIONAL EXECUTIVE COMPENSATION BENCHMARKS FOR HOSPITAL EXECUTIVES. THE DETERMINATION OF THE CFO'S, OTHER OFFICERS', AND KEY EMPLOYEES' COMPENSATION IS IMPLEMENTED, REVIEWED, AND MONITORED BY THE CEO BASED ON NATIONAL EXECUTIVE COMPENSATION BENCHMARKS. THIS IS DONE ANNUALLY.
FORM 990, PART VI, SECTION C, LINE 19	BDCH DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. BDCH DOES HOWEVER MAKE ITS FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC USING SEVERAL METHODS. FIRST, AN ANNUAL REPORT IS DISTRIBUTED TO THE COMMUNITY USING THE CURRENT MAILING ADDRESSES IN OUR SERVICE AREA. IN ADDITION, SINCE WE HAVE TAX-EXEMPT BONDS, WE REPORT OUR FINANCIAL STATEMENTS THROUGH THE MUNICIPAL SECURITIES RULEMAKING BOARD'S ELECTRONIC MUNICIPAL MARKET ACCESS (EMMA).
FORM 990, PART IX, LINE 11G	OTHER FEES: PROGRAM SERVICE EXPENSES 7,867,573. MANAGEMENT AND GENERAL EXPENSES 3,757,422. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,624,995.
FORM 990, PART XI, LINE 9:	PENSION-RELATED CHANGES 2,970,087. CHANGE IN BENEFICIAL INTEREST IN BDCH FOUNDATION 203,927.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2019

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2019

Open to Public Inspection

Name of the organization

BEAVER DAM COMMUNITY HOSPITALS INC

Employer identification number

39-1157876

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) DODGE HEALTH ENTERPRISES LLC 715 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 39-1538653	REFERENCE LAB	WI	622,647	1,240,639	BEAVER DAM COMMUNITY HOSPITALS
(2) DELMAN DEVELOPMENT LLC 707 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 27-2375085	REAL ESTATE	WI	65,865	1,256,119	BEAVER DAM COMMUNITY HOSPITALS
(3) BEAVER DAM MEDICAL BUILDING 2 LLC 705 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 39-1157876	BUILDING MANAGEMENT	WI	554,068	17,538,819	BEAVER DAM COMMUNITY HOSPITALS
(4) WELL LIFE HOME MEDICAL EQUIPMENT AND SUPPLIES LLC 707 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 81-2463679	DURABLE MEDICAL EQUIPMENT	WI	0	0	BEAVER DAM COMMUNITY HOSPITALS

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)BEAVER DAM COMMUNITY HOSPITALS FOUNDATION INC 707 SOUTH UNIVERSITY AVENUE BEAVER DAM,WI53916 39-1499140	TO RAISE & DIRECT FUNDS FOR HEALTHCARE AND WELLNESS	WI	501(C)(3)	LINE 10	BEAVER DAM COMMUNITY HOSPITALS	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2019

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(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

Schedule R (Form 990) 2019

Page 3

Part V

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

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

Yes

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

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

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

Yes

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

Yes

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

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

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

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

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

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

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

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

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) BEAVER DAM COMMUNITY HOSPITALS FOUNDATION	B	69,000	BOOK VALUE
(2) BEAVER DAM COMMUNITY HOSPITALS FOUNDATION	C	259,802	BOOK VALUE

Schedule R (Form 990) 2019

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) 2019

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) 2019

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: DELIVER EXCELLENCE ACROSS A CONTINUUM OF SERVICES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	9
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	7
5	Total number of individuals employed in calendar year 2019 (Part V, line 2a) ......	5	987
6	Total number of volunteers (estimate if necessary) .............	6	297
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	4,151,586
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,203,247	292,661
9	Program service revenue (Part VIII, line 2g) .........	100,249,264	104,712,694
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	3,411,863	4,739,991
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	3,917,054	3,780,470
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	108,781,428	113,525,816
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	153,065	128,525
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)	52,740,885	53,204,053
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)....	58,186,589	56,489,500
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	111,080,539	109,822,078
19	Revenue less expenses. Subtract line 18 from line 12.......	-2,299,111	3,703,738
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	179,813,601	180,456,848
21	Total liabilities (Part X, line 26).............	87,879,190	83,047,420
22	Net assets or fund balances. Subtract line 21 from line 20.....	91,934,411	97,409,428

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 66,302,844 including grants of $ 128,525 ) (Revenue $ 72,840,426 )
	THE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT SERVICES TO ITS PATIENTS. IN THE FISCAL YEAR ENDED 6/30/2018, THERE WERE 4,188 INPATIENT DAYS, 1,545 ADMISSIONS, 273 BIRTHS, 561 NURSERY DAYS, AND 90,745 OUTPATIENT VISITS. THERE ARE MEDICAL/SURGICAL, TELEMETRY, INTENSIVE CARE, OBSTETRICS, AND NURSERY UNITS ON THE INPATIENT FLOORS. THERE IS AN EMERGENCY ROOM, URGENT CARE, SURGERY CENTER, REHABILITATION CENTER, PAIN CLINIC, OUTPATIENT MEDICAL ONCOLOGY CLINIC, MEDICAL IMAGING, PHARMACY DEPARTMENT AND A WOUND CENTER. THESE SERVICES ALL GENERATE NET PATIENT REVENUE.

4b	(Code: ) (Expenses $ 5,489,108 including grants of $ 0 ) (Revenue $ 8,548,214 )
	HILLSIDE MANOR IS A 115 BED NURSING HOME CERTIFIED BY MEDICARE/MEDICAID THAT OFFERS SKILLED NURSING, COMPREHENSIVE REHABILITATION, AND AN EXTENSIVE ACTIVITIES PROGRAM. TOTAL PATIENT DAYS FOR THE FISCAL YEAR ENDED 6/30/2018 WERE 35,491.

4c	(Code: ) (Expenses $ 4,246,001 including grants of $ 0 ) (Revenue $ 5,792,268 )
	THE HOMECARE PROGRAM INCLUDES HOME HEALTH AND HOSPICE SERVICES. HOME HEALTH OFFERS SKILLED NURSING, PERSONAL CARE, AND REHABILITATION TO PATIENTS IN THEIR OWN HOME. THERE WERE 13,661 HOMECARE VISITS FOR THE FISCAL YEAR ENDED 6/30/2018. THE HOSPICE PROGRAM PROVIDES SUPPORT TO PATIENTS WHO ARE TERMINALLY ILL. THE HOSPICE PROGRAM HAD 20,850 TOTAL DAYS FOR THE FISCAL YEAR ENDED 6/30/2018.

	(Code: ) (Expenses $ 7,864,883 including grants of $ 0 ) (Revenue $ 19,153,846 )
	OTHER PROGRAMS INCLUDE PHYSICIAN CLINICS, OCCUPATIONAL HEALTH, DAYCARE PROGRAM, ASSISTED LIVING PROGRAM, REFERENCE LABORATORY, HOMEMAKER PROGRAM, AND SPORTS FITNESS FACILITY.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 7,864,883 including grants of $ 0 ) (Revenue $ 19,153,846 )
4e	Total program service expenses83,902,836

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)			(D) Reportable compensation from the organization (W-2/1099-MISC)	(E) Reportable compensation from related organizations (W-2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(18) PAUL PALMER........................................................................ SURGEON	40.00 .......................0.00	X		457,312	0	61,156
(19) JANIE ORRINGTON-MYERS........................................................................ SURGEON	40.00 .......................0.00	X		393,237	0	34,649
(20) ANNE DEGREVE........................................................................ HOSPITALIST	40.00 .......................0.00	X		276,113	0	48,046
(21) DONALD ANDERSON........................................................................ FORMER DIRECTOR OF PHARMACY	40.00 .......................0.00		X	127,318	0	29,924

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	4,396,720	0	431,294

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	259,802
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	32,859

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		292,661

		Business Code
2a	NET PATIENT REVENUES	621300	99,554,635	99,054,927	499,708
b	PHARMACY REVENUES	621990	2,187,228		2,187,228
c	ASSISTED CARE PROGRAM	623990	2,155,249	2,155,249
d	OCC HEALTH PROGRAM	621990	520,484	520,484
e	OTHER	713940	171,601	171,601
f	All other program service revenue.		123,497	657	122,840
g	Total. Add lines 2a–2f .....		104,712,694

3 Investment income (including dividends, interest, and othersimilar amounts) ......			1,672,355			1,672,355
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		2,257,144	6a
b	Less: rental expenses		1,870,241	6b
c	Rental income or (loss)		386,903	6c
d	Net rental income or (loss).......			386,903		216,557	170,346
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	4,000	67,798,690	7a
b	Less: cost or other basis and sales expenses	377,521	64,357,533	7b
c	Gain or (loss)	-373,521	3,441,157	7c
d	Net gain or (loss).........			3,067,636			3,067,636
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a	7,372
b	Less: direct expenses ...		8b	7,324
c	Net income or (loss) from fundraising events..			48			48
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	DAYCARE REVENUE		624410	1,251,611	151,547	1,100,064
b	MISCELLANEOUS INCOME		900099	954,616	954,616
c	FOOD SERVICE		722320	621,018			621,018
d	All other revenue ....			566,274	515,897	25,189	25,188
e	Total. Add lines 11a–11d ......			3,393,519
12	Total revenue. See instructions.....			113,525,816	103,524,978	4,151,586	5,556,591

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	69,000	69,000
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........	59,525	59,525
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	2,183,462		2,183,462
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........	130,739		130,739
7	Other salaries and wages........	38,204,029	32,061,101	6,142,928
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,872,096	1,535,534	336,562
9	Other employee benefits .......	8,124,109	6,621,673	1,502,436
10	Payroll taxes ...........	2,689,618	2,142,865	546,753
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	748,283	112,377	635,906
c	Accounting ...........	97,903		97,903
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	260,855		260,855
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	11,624,995	7,867,573	3,757,422
12	Advertising and promotion ....	320,631		320,631
13	Office expenses .......	2,651,341	1,813,538	837,803
14	Information technology ......	4,652,168	3,514,887	1,137,281
15	Royalties ..
16	Occupancy ...........	1,717,910	1,266,910	451,000
17	Travel ............	268,393	221,550	46,843
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	149,159	78,074	71,085
20	Interest ...........	2,507,787	2,069,998	437,789
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	8,567,318	6,244,196	2,323,122
23	Insurance ...	352,417	302,453	49,964
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MED. SUPPLIES & DRUGS	13,246,110	13,214,893	31,217
b	BAD DEBT EXPENSE	4,748,062	4,748,062
c	ASSESSMENT/USER FEES	2,298,609	269,180	2,029,429
d	BLUE ZONE	1,853,525		1,853,525
e	All other expenses	424,034	-310,553	734,587
25	Total functional expenses. Add lines 1 through 24e	109,822,078	83,902,836	25,919,242	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 ........			28,625	1	40,389
2	Savings and temporary cash investments .........			7,145,269	2	8,365,148
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			12,041,905	4	13,226,771
5	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			2,268,530	8	2,457,598
9	Prepaid expenses and deferred charges ......			1,645,321	9	1,756,078
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	185,685,103
b	Less: accumulated depreciation	10b	103,150,843	88,397,077	10c	82,534,260
11	Investments—publicly traded securities .			65,735,286	11	69,418,695
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			2,551,588	15	2,657,909
16	Total assets. Add lines 1 through 15 (must equal line 33)...			179,813,601	16	180,456,848

17	Accounts payable and accrued expenses .....	9,488,027	17	10,289,903
18	Grants payable ...		18
19	Deferred revenue .........	102,369	19	72,408
20	Tax-exempt bond liabilities .........	57,391,081	20	55,218,644
21	Escrow or custodial account liability. Complete Part IV of Schedule D	279,809	21	261,040
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..	10,285,000	23	9,517,000
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	10,332,904	25	7,688,425
26	Total liabilities. Add lines 17 through 25..	87,879,190	26	83,047,420

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........		27
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	91,934,411	32	97,409,428
33	Total liabilities and net assets/fund balances ........	179,813,601	33	180,456,848