Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
BIGFORK VALLEY HOSPITAL |
411242647 | 3 | Yes | 17,060 | 0 | |
| (B)
COMMUNITY MEMORIAL HOSPITAL |
410743546 | 3 | Yes | 25,805 | 0 | |
| (C)
COOK HOSPITAL |
410964895 | 3 | Yes | 14,138 | 0 | |
| (D)
NORTH SHORE HEALTH |
411647880 | 3 | Yes | 13,558 | 0 | |
| (E)
FAIRVIEW RANGE |
411293970 | 3 | Yes | 42,039 | 0 | |
| (F)
LAKE VIEW MEMORIAL HOSPITAL |
410786046 | 3 | Yes | 14,696 | 0 | |
| (G)
MERCY HOSPITAL |
410859808 | 3 | Yes | 19,954 | 0 | |
| (H)
RAINY LAKE MEDICAL CENTER |
410726171 | 3 | Yes | 17,131 | 0 | |
| (I)
ST LUKE'S HOSPITAL OF DULUTH |
410714079 | 3 | Yes | 137,980 | 0 | |
| (J)
GRAND ITASCA CLINIC AND HOSPITAL |
411865874 | 3 | Yes | 34,812 | 0 | |
| (K)
ELY-BLOOMENSON COMMUNITY HOSPITAL |
410808719 | 3 | Yes | 4,208 | 0 | |
|
Total 11
|
341,381 | 0 | ||||
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. | ||||||
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 | ||||||
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.) | ||||||
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.).. | ||||||
| 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 | ||||
| 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..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART IV, LINE 5A: | THE BOARD MADE THE DECISION TO ADD NEW MEMBERS AS AUTHORIZED BY THE ORGANIZATION'S BYLAWS. THE BOARD APPROVED THIS ADDITION IN OCTOBER 2019. ELY-BLOOMENSON COMMUNITY HOSPITAL (41-0808719) SIGNED THE MEMBERSHIP AGREEMENT EFFECTIVE OCTOBER 15, 2019. |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 1 | THE CHAIR, VICE-CHAIR, SECRETARY AND TREASURER, AS WELL AS ONE OTHER DIRECTOR, SERVE AS THE EXECUTIVE COMMITTEE. THE EXECUTIVE DIRECTOR IS A NON-VOTING PARTICIPANT. THE EXECUTIVE COMMITTEE MAKES STRATEGIC DECISION RECOMMENDATIONS AND REVIEWS AND APPROVES CONTRACTS ON BEHALF OF THE BOARD. |
| FORM 990, PART VI, SECTION A, LINE 2 | CASSANDRA BEARDSLEY AND KEVIN NOKELS - BUSINESS RELATIONSHIP |
| FORM 990, PART VI, SECTION A, LINE 3 | CASSANDRA BEARDSLEY, EXECUTIVE DIRECTOR OF WILDERNESS HEALTH, IS AN EMPLOYEE OF ST. LUKE'S HOSPITAL OF DULUTH. DURING 2018, IT WAS ESTIMATED THAT 75% OF HER TIME WAS SPENT SERVING WILDERNESS HEALTH. THEREFORE, WILDERNESS HEALTH PAID ST. LUKE'S HOSPITAL ASSOCIATION THIS PORTION OF HER SALARY AND BENEFITS. |
| FORM 990, PART VI, SECTION A, LINE 6 | THIS CORPORATION SHALL HAVE MEMBERS. THE ONLY ENTITIES THAT WILL BE ELIGIBLE TO SERVE AS MEMBERS ARE 501(C)(3) ORGANIZATIONS OR GOVERNMENTAL UNITS THAT PROVIDE HOSPITAL, MEDICAL, HEALTHCARE OR OTHER RELATED SERVICES IN NORTHEASTERN MINNESOTA AND NORTHWESTERN WISCONSIN. THERE SHALL BE TWO CLASSES OF MEMBERS: (A) CHARTER MEMBERS; AND (B) NON-CHARTER MEMBERS. THE CHARTER MEMBERS ARE: BIGFORK VALLEY HOSPITAL, COMMUNITY MEMORIAL HOSPITAL, COOK HOSPITAL, COOK COUNTY HOSPITAL, FAIRVIEW RANGE, LAKEVIEW HOSPITAL, MERCY HOSPITAL, RAINY LAKE MEDICAL CENTER, AND ST. LUKE'S HOSPITAL. THE NON CHARTER MEMBERS ARE GRAND ITASCA AND ELY. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE BOARD OF DIRECTORS IS MADE UP OF THE CHIEF EXECUTIVE OFFICERS (CEO) OF THE CHARTER MEMBERS AND ARE CLASSIFIED AS CHARTER DIRECTORS. A CHARTER DIRECTOR SHALL SERVE AS LONG AS THE DIRECTOR HOLDS THE OFFICE OR POSITION OF CEO OF THE CHARTER MEMBER. IN LIEU OF THE CEO REPRESENTING THE CHARTER MEMBER ON THE BOARD OF DIRECTORS OF THE CORPORATION, THE CEO MAY APPOINT A MEMBER OF THE CHARTER MEMBER'S SENIOR MANAGEMENT TEAM TO REPRESENT THE CHARTER MEMBER AS A CHARTER DIRECTOR ON THE CORPORATION'S BOARD. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE FOLLOWING ACTIONS OF THE BOARD OF DIRECTORS REQUIRE THE APPROVAL OF TWO-THIRDS OF THE CHARTER MEMBERS: (A) APPROVAL OF CHANGES TO THE ARTICLES OF INCORPORATION AND ANY CHANGES TO THE BYLAWS AFFECTING THE PURPOSES OF THE ORGANIZATION OR ANY RIGHTS OR OBLIGATIONS OF MEMBERS; (B) APPROVAL OF ANY REQUEST OR PROPOSAL FOR ADDITIONAL CAPITAL CONTRIBUTIONS (NOT INCLUDING ANNUAL MEMBERSHIP DUES); (C) ESTABLISHING AND MODIFYING THE NUMBER OF DIRECTORS ON THE BOARD; AND (D) APPROVAL OF ANY ACTION FOR WHICH APPROVAL BY THE MEMBERS IS REQUIRED UNDER THE NONPROFIT ACT. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE COMPLETE FORM 990 WAS REVIEWED IN DETAIL BY THE CHIEF EXECUTIVE OFFICER FOR ACCURACY. UPON APPROVAL BY THE CEO, A COPY OF THE FORM 990 WITH THE BOARD MEMBERS' COMPENSATION REDACTED WAS SHARED ELECTRONICALLY WITH THE FULL BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A BOARD COMMITTEE (AND ALL WILDERNESS HEALTH EMPLOYEES) SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: A. HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, B. HAS READ AND UNDERSTANDS THE POLICY, C. HAS AGREED TO COMPLY WITH THE POLICY, AND D. UNDERSTANDS WILDERNESS HEALTH IS A CHARITABLE ORGANIZATION AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. A POTENTIAL CONFLICT OF INTEREST ARISES WHENEVER WILDERNESS HEALTH IS CONSIDERING A POTENTIAL TRANSACTION OR RELATIONSHIP, DIRECT OR INDIRECT, WITH ANY INTERESTED PERSON AND FROM WHICH THE INTERESTED PERSON MAY DERIVE OR RECEIVE A MATERIAL FINANCIAL BENEFIT AS A CONSEQUENCE OF THE POTENTIAL INTEREST, TRANSACTION OR RELATIONSHIP. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON WITH A FINANCIAL INTEREST SHALL DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THEIR SUPERVISOR, IF ANY EMPLOYEE, AND TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH BOARD OF DIRECTORS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT, AS TO ANY OTHER INTERESTED PERSON. DISCLOSURES SHALL BE MADE ON AN ANNUAL, ROUTINE BASIS AND IMMEDIATELY IN THE EVENT THAT A FINANCIAL INTEREST ARISES THAT MAY CREATE A POTENTIAL CONFLICT OF INTEREST PRIOR TO THE ANNUAL DISCLOSURE. ANY MEMBER OF THE BOARD OF DIRECTORS, OR A BOARD COMMITTEE, OR A WILDERNESS HEALTH EMPLOYEE WITH A FINANCIAL INTEREST SHALL NOT INFLUENCE OR PARTICIPATE IN ANY DECISION OR ON ANY MATTER INVOLVING THE PROPOSED FINANCIAL INTEREST. ANY MEMBER OF THE BOARD OF DIRECTORS OR BOARD COMMITTEE THAT HAS A CONFLICT OF INTEREST ON ANY MATTER TO BE CONSIDERED BY THE BOARD OF DIRECTORS OR ANY COMMITTEE OF THE BOARD SHALL NOT VOTE ON SUCH MATTER. AFTER THE INTERESTED PERSON DISCLOSES THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AN INTERESTED PERSON MAY MAKE A PRESENTATION AT A MEETING OF THE BOARD OF DIRECTORS OR BOARD COMMITTEE PRIOR TO EXCUSING THEMSELVES FROM A MEETING. AFTER THE PRESENTATION, THE INTERESTED PERSON SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT INVOLVING THE POSSIBLE CONFLICT OF INTEREST. THE CHAIRPERSON OF THE BOARD OF DIRECTORS OR BOARD COMMITTEE MAY, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT THAT PRESENTS THE POTENTIAL CONFLICT. AFTER EXERCISING DUE DILIGENCE, THE BOARD OF DIRECTORS OR BOARD COMMITTEE SHALL DETERMINE WHETHER WILDERNESS HEALTH CAN OBTAIN, WITH REASONABLE EFFORTS, A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A CONFLICT OF INTEREST, THE BOARD OF DIRECTORS OR BOARD COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED MEMBERS OF THE BOARD OR COMMITTEE OF THE BOARD WHETHER THE TRANSACTION OR ARRANGEMENT IS IN WILDERNESS HEALTH'S BEST INTEREST, FOR ITS OWN BENEFIT, AND WHETHER IT IS FAIR AND REASONABLE. IN CONFORMITY WITH THE ABOVE DETERMINATION, THE BOARD OF DIRECTORS OR A BOARD COMMITTEE SHALL MAKE ITS DECISION AS TO WHETHER TO ENTER INTO THE PROPOSED TRANSACTION OR ARRANGEMENT. |
| FORM 990, PART VI, SECTION B, LINE 15 | INTEGRATED HEALTHCARE STRATEGIES (IHS), AN INDEPENDENT HEALTHCARE MANAGEMENT CONSULTING FIRM, CONDUCTED A REVIEW OF THE CEO'S TOTAL COMPENSATION RELATIVE TO CEO'S IN OTHER HEALTHCARE ORGANIZATIONS OF COMPARABLE SIZE AND SCOPE. THE BOARD OF DIRECTORS USED THIS INFORMATION TO ESTABLISH AN APPROPRIATE LEVEL OF COMPENSATION AS DOCUMENTED IN THE REPORT FROM IHS AND BOARD MEETING MINUTES. |
| FORM 990, PART VI, SECTION C, LINE 19 | WILDERNESS HEALTH'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. |
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| Software Version: |