TY 2020 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) MICHAEL PACKNETT...................................................................... DIRECTOR/PH PRESIDENT & CEO	0.00 ................. 40.00	X	X			0	2,048,421	1,656,853
(2) LISA BOOTH...................................................................... DIRECTOR/PH PHYSICIAN	0.00 ................. 40.00	X				5,978	429,950	46,305
(3) RHONDA SHARP...................................................................... DIRECTOR/PH PHYSICIAN	15.00 ................. 25.00	X				126,732	242,727	35,986
(4) JORDI DISLER...................................................................... DIRECTOR/LGHOS PRESIDENT	40.00 ................. 0.00	X	X			279,137	0	85,831
(5) JAMIN YODER...................................................................... DIRECTOR/PH PHYSICIAN	0.00 ................. 40.00	X				17,619	243,170	47,349
(6) GREGORY MIELKE...................................................................... DIRECTOR-PARTIAL YR/PH PHYSICIAN	0.00 ................. 6.00	X				1,834	66,490	5,890
(7) SHERRYL RHINESMITH...................................................................... DIRECTOR/CHAIR	1.00 ................. 1.00	X	X			6,500	3,849	0
(8) STEVEN CHRISTNER...................................................................... DIRECTOR	1.00 ................. 0.00	X				4,750	0	0
(9) MARK LEU...................................................................... DIRECTOR	1.00 ................. 0.00	X				4,750	0	0
(10) MICHAEL MELLINGER...................................................................... DIRECTOR	1.00 ................. 1.00	X				3,750	1,000	0
(11) BETH THORNBURG...................................................................... DIRECTOR	1.00 ................. 0.00	X				4,750	0	0
(12) JOE URBANSKI...................................................................... DIRECTOR	1.00 ................. 0.00	X				4,750	0	0
(13) ROBERT BOND...................................................................... DIRECTOR/VICE CHAIR	1.00 ................. 0.00	X	X			4,500	0	0
(14) PAUL YODER...................................................................... DIRECTOR/SECRETARY/TREASURER	1.00 ................. 0.00	X	X			4,500	0	0
(15) JEANNE' WICKENS...................................................................... PH CHIEF FINANCIAL OFFICER	0.00 ................. 40.00		X			0	1,084,552	339,895
(16) TODD KLINEDINST...................................................................... LGHOS VP PATIENT CARE	40.00 ................. 0.00			X		155,955	0	3,177
(17) BRENDA ARMENTROUT...................................................................... LGHOS MGR PHARMACY	40.00 ................. 0.00				X	195,081	0	32,242

(A) Name and business address	(B) Description of services	(C) Compensation
PROFESSIONAL EMERGENCY PHYSICIANS INC PO BOX 12949 FORT WAYNE,IN46866	PHYSICIANS	1,980,777
PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE,IN46845	LABORATORY SERVICES	1,070,767
CLINICAL COLLEAGUES INC PO BOX 824246 PHILADELPHIA,PA19182	ANESTHESIOLOGISTS	909,937
NORTHEAST INTERNAL MEDICINE ASSOC INC 2500 N DETROIT STREET LAGRANGE,IN46761	HOSPITALISTS	448,838
AVANT HEALTHCARE PROFESSIONALS LLC 1211 SEMORAN BLVD SUITE 227 CASSELBERRY,FL32707	NURSES	178,697
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 6

- 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

2020

Open to Public
Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

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) 2020

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) 2016	(b) 2017	(c) 2018	(d) 2019	(e) 2020	(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) 2016	(b) 2017	(c) 2018	(d) 2019	(e) 2020	(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 5 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 2020 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2019 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2020. 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—2019. 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—2020. 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—2019. 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) 2020

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) 2016	(b) 2017	(c) 2018	(d) 2019	(e) 2020	(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) 2016	(b) 2017	(c) 2018	(d) 2019	(e) 2020	(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 5 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 2020 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2019 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2020 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2019 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2020. 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—2019. 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) 2020

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, 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 lines 3b and 3c 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 box 12a or 12b in Part I, answer lines 4b and 4c 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 lines 5b and 5c 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) 2020

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 lines 11b and 11c below, the governing body of a supported organization?

11a

A family member of a person described in 11a above?

11b

A 35% controlled entity of a person described in line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the officers, 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 line 2 above, 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 lines 2a and 2b 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 line 2a, above 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 lines 3a and 3b 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?If "Yes" or "No", 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) 2020

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 0.015 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 0.035	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) 2020

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	1
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity	2
3 Administrative expenses paid to accomplish exempt purposes of supported organizations	3
4 Amounts paid to acquire exempt-use assets	4
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI)	5
6 Other distributions (describe in Part VI). See instructions	6
7Total annual distributions. Add lines 1 through 6.	7
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions	8
9 Distributable amount for 2020 from Section C, line 6	9
10 Line 8 amount divided by Line 9 amount	10

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2020	(iii) Distributable Amount for 2020
1 Distributable amount for 2020 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 2020:
a From 2015.......
b From 2016.......
c From 2017.......
d From 2018.......
e From 2019.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2020 distributable amount
i Carryover from 2015 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2020 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2020 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2020, 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 2020. 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 2021. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2016.....
b Excess from 2017.....
c Excess from 2018.....
d Excess from 2019.....
e Excess from 2020.....

Schedule A (Form 990 or 990-EZ) (2020)

Schedule A (Form 990 or 990-EZ) 2020

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) 2020

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

2020

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

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) (2020)

Schedule B (Form 990, 990-EZ, or 990-PF) (2020) Page 2

Name of organization COMMUNITY HOSPITAL OF LAGRANGE COUNTY 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
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2020)

Schedule B (Form 990, 990-EZ, or 990-PF) (2020)

Page 3

Name of organization COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC		Employer identification number 20-2401676

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) (2020)

Schedule B (Form 990, 990-EZ, or 990-PF) (2020)

Page 4


Name of organization COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC			Employer identification number 20-2401676
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) (2020)

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

2020

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

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

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) 2020

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) 2017	(b) 2018	(c) 2019	(d) 2020	(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) 2020

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

3,706

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

3,706

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:	REPRESENTS THE PORTION OF THE DUES PAID TO INDIANA HOSPITAL AND HEALTH ASSOCIATION, AMERICAN HOSPITAL ASSOCIATION, NATIONAL RURAL HEALTH ASSOCIATION AND VARIOUS PROFESSIONAL ASSOCIATIONS USED FOR LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2020

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

2020

Open to Public Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

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) 2020

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 .....	320,702		320,702
b	Buildings ....	13,566,857	4,909,442	8,657,415
c	Leasehold improvements	29,098	29,098	0
d	Equipment ....	18,187,005	13,979,552	4,207,453
e	Other .....	2,116,923	1,333,360	783,563
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				13,969,133

Schedule D (Form 990) 2020

Page 3

Part VII

Investments - Other 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

Investments - Program 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
(1)DUE TO/FROM INTERUNIT				1,865,632
(2)RIGHT OF USE ASSETS				54,620
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,920,252

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
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,166,397
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) 2020

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 X, LINE 2:

PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTS TEXT OF THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES THE LIABILITY FOR UNCERTAIN TAX POSITIONS UNDER FIN 48 (ASC 740): INCOME TAXES: THE INTERNAL REVENUE SERVICE HAS DETERMINED THAT THE CORPORATION AND CERTAIN AFFILIATED ENTITIES ARE TAX-EXEMPT ORGANIZATIONS AS DEFINED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. CERTAIN SUBSIDIARIES OF THE CORPORATION ARE TAXABLE ENTITIES, THE TAX EXPENSE AND LIABILITIES OF WHICH ARE NOT MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES EACH FILE A FORM 990 (RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX) ANNUALLY. WHEN THESE RETURNS ARE FILED, IT IS HIGHLY CERTAIN THAT SOME POSITIONS TAKEN WOULD BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, WHILE OTHERS ARE SUBJECT TO UNCERTAINTY ABOUT THE MERITS OF THE POSITION TAKEN OR THE AMOUNT OF THE POSITION THAT WOULD ULTIMATELY BE SUSTAINED. EXAMPLES OF TAX POSITIONS COMMON TO HEALTH SYSTEMS INCLUDE SUCH MATTERS AS THE TAX-EXEMPT STATUS OF EACH ENTITY, THE CONTINUED TAX-EXEMPT STATUS OF BONDS, THE NATURE, CHARACTERIZATION AND TAXABILITY OF JOINT VENTURE INCOME, AND VARIOUS POSITIONS RELATING TO POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (REPORTED ON FORM 990T). AS OF DECEMBER 31, 2020 AND 2019, THERE ARE NO UNRECOGNIZED TAX BENEFITS RESULTING FROM UNCERTAIN TAX POSITIONS. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UP TO THREE YEARS FROM THE EXTENDED DUE DATE OF EACH RETURN. FORMS 990 AND 990T FILED BY THE CORPORATION AND ITS TAX-EXEMPT AFFILIATED ENTITIES ARE GENERALLY NO LONGER SUBJECT TO EXAMINATION FOR THE YEAR 2016 AND PRIOR.

Schedule D (Form 990) 2020

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

2020

Open to Public Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other %

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(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) . . .	750,077	0	750,077	2.190 %
b	Medicaid (from Worksheet 3, column a) . . . . .	3,657,698	967,168	2,690,530	7.860 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .	3,445,384	1,391,140	2,054,244	6.000 %
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	7,853,159	2,358,308	5,494,851	16.050 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	80,894	0	80,894	0.240 %
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) . . . .	25,488	0	25,488	0.070 %
j	Total. Other Benefits . .	106,382		106,382	0.310 %
k	Total. Add lines 7d and 7j .	7,959,541	2,358,308	5,601,233	16.360 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2020

Schedule H (Form 990) 2020

Page

Part II

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

		(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	2,500	0	2,500	0.010 %
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	2,500		2,500	0.010 %

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. ......

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. ......

14,298

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).....

6,735,314

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

6,741,864

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

-6,550

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) 2020

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	COMMUNITY HOSPITAL OF LAGRANGE COUNTY 207 N TOWNLINE RD LAGRANGE,IN46761 WWW.PARKVIEW.COM 14-005085-1	X	X	X	X

Schedule H (Form 990) 2020

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)

	COMMUNITY HOSPITAL OF LAGRANGE COUNTY
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 19

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

Yes

6 a

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

Yes

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

Yes

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

Yes

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

Hospital facility’s website (list url): HTTPS://WWW.PARKVIEW.COM/LOCALHEALTHNEEDS

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 19

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

Yes

If "Yes" (list url): HTTPS://WWW.PARKVIEW.COM/LOCALHEALTHNEEDS

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) 2020

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	COMMUNITY HOSPITAL OF LAGRANGE COUNTY
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.000000000000%
and FPG family income limit for eligibility for discounted care of 250.000000000000%

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):

HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE

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

HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE

A plain language summary of the FAP was widely available on a website (list url):
HTTPS://WWW.PARKVIEW.COM/PATIENTS-VISITORS/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) 2020

Page 6

Part VFacility Information (continued)

Billing and Collections

	COMMUNITY HOSPITAL OF LAGRANGE COUNTY
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) 2020

Page 7

Part VFacility Information (continued)

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

	COMMUNITY HOSPITAL OF LAGRANGE COUNTY
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) 2020

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
COMMUNITY HOSPITAL OF LAGRANGE COUNTY	PART V, SECTION B, LINE 5: DESCRIBE HOW THE HOSPITAL FACILITY TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE COMMUNITY, AND IDENTIFY THE PERSONS THE HOSPITAL FACILITY CONSULTED:PARKVIEW HEALTH SYSTEM, INC. INCLUDING COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., CONDUCTED ITS LAST COMMUNITY HEALTH NEEDS ASSESSMENT IN 2019. OVER THE COURSE OF ADMINISTERING THIS COMMUNITY HEALTH NEEDS ASSESSMENT, THE INDIANA PARTNERSHIP FOR HEALTH COMMUNITIES (IN-PHC) RESEARCH TEAM WORKED TO ENSURE THAT THE NEEDS OF THE MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS WERE TAKEN INTO ACCOUNT.THE INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (IN-PHC) IS A COLLABORATION BETWEEN THE POLIS CENTER AT IUPUI (POLIS) AND THE INDIANA UNIVERSITY RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH (FSPH). FORMED WITH SUPPORT FROM THE INDIANA CLINICAL AND TRANSLATIONAL SCIENCES INSTITUTE (I-CTSI), ITS MISSION IS TO HELP BUILD THE CAPACITY OF HOSPITALS, LOCAL HEALTH DEPARTMENTS, AND COMMUNITY-BASED ORGANIZATIONS TO IMPROVE THE HEALTH OF INDIANA COMMUNITIES. IN-PHC DOES THIS BY TRANSLATING KNOWLEDGE GENERATED BY THE ACADEMY AND BY COMMUNITIES INTO IMPROVED AND SUSTAINABLE PROCESSES FOR UNDERSTANDING AND EFFECTING COMMUNITY HEALTH. THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT USED THREE SOURCES OF PRIMARY DATA: 1) A PHONE SURVEY OF THE COMMUNITY CONDUCTED ON BEHALF OF PARKVIEW LAGRANGE HOSPITAL BY THE IN-PHC COMPLETED IN MARCH 2019; 2) AN ONLINE SURVEY DEVELOPED BY THE IN-PHC AND DISTRIBUTED BY THE HOSPITAL TO AREA PROVIDERS INCLUDING PUBLIC HEALTH OFFICIALS, OTHER HEALTHCARE PROFESSIONALS AND VARIOUS SOCIAL SERVICE ORGANIZATIONS THAT SPECIALIZE IN AIDING VULNERABLE POPULATIONS COMPLETED IN JUNE 2019; AND 3) A WRITTEN SURVEY, FOR THE AMISH COMMUNITY IN LAGRANGE COUNTY, WAS DISTRIBUTED THROUGH COMMUNITY LEADERS, AND WAS COMPLETED IN THE SUMMER OF 2019.THE PARKVIEW HEALTH COMMUNITY DASHBOARD DEVELOPED BY HEALTHY COMMUNITIES INSTITUTE WAS USED AS A PRIMARY SOURCE OF SECONDARY DATA. THIS DASHBOARD INCLUDES DATA FROM THE INDIANA HOSPITAL ASSOCIATION AS WELL AS THE INDIANA STATE DEPARTMENT OF HEALTH, NATIONAL CANCER INSTITUTE, CENTERS FOR DISEASE CONTROL AND PREVENTION, CENTERS FOR MEDICAID AND MEDICARE SERVICES, THE NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD AND TB PREVENTION, INSTITUTE FOR HEALTH METRICS AND EVALUATION, COUNTY HEALTH RANKINGS WEBSITE, US CENSUS BUREAU, US DEPARTMENT OF AGRICULTURE, AND OTHER SOURCES. ADDITIONAL STATE AND NATIONAL SECONDARY DATA SOURCES WERE ACCESSED BY THE CHNA TEAM FOR MORE RECENT AND GEOGRAPHICALLY SPECIFIC INFORMATION, INCLUDING THE FOLLOWING:- AMERICAN COMMUNITY SURVEY: THE AMERICAN COMMUNITY SURVEY (ACS) HELPS LOCAL OFFICIALS, COMMUNITY LEADERS, AND BUSINESSES UNDERSTAND THE CHANGES TAKING PLACE IN THEIR COMMUNITIES. IT IS THE PREMIER SOURCE FOR DETAILED POPULATION AND HOUSING INFORMATION ABOUT OUR NATION.- ANNIE E. CASEY FOUNDATION: THE ANNIE E. CASEY FOUNDATION IS A PRIVATE PHILANTHROPIC ORGANIZATION THAT WORKS TO BUILD A BRIGHTER FUTURE FOR DISADVANTAGED CHILDREN IN THE UNITED STATES. THE KIDS COUNT DATA BOOK OFFERS A NATIONAL LOOK AT THE WELL-BEING OF AMERICA'S CHILDREN AND FAMILIES BY EXPLORING HOW STATES ARE PERFORMING ON KEY DATA INDICATORS. - CENTER FOR DISEASE CONTROL AND PREVENTION: AS A FEDERALLY FUNDED AGENCY, CDC SERVES AS A GREAT RESOURCE FOR MORTALITY AND MORBIDITY DATA FOR ALL THE INFECTIOUS AND CHRONIC DISEASES AND OTHER CONDITIONS.- COUNTY HEALTH RANKINGS: A ROBERT WOOD JOHNSON FOUNDATION PROGRAM IMPLEMENTED BY THE UNIVERSITY OF WISCONSIN POPULATION HEALTH INSTITUTE THAT RELEASES NEW ESTIMATES ANNUALLY MEASURING HEALTH ACROSS ALL US COUNTIES. THESE DATA ARE COMPILED FROM A VARIETY OF PROVIDERS AND TYPICALLY COMBINES DATA ACROSS MULTIPLE YEARS TO RELEASE ESTIMATES FOR AREAS WITH SMALL POPULATIONS, SUCH AS RURAL COUNTIES.- CENTERS FOR MEDICARE & MEDICAID SERVICES: THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) PROVIDES HEALTH COVERAGE TO MORE THAN 100 MILLION PEOPLE THROUGH MEDICARE, MEDICAID, AND THE CHILDREN'S HEALTH INSURANCE PROGRAM, AND THE HEALTH INSURANCE MARKETPLACE. THE CMS SEEKS TO STRENGTHEN AND MODERNIZE THE NATION'S HEALTH CARE SYSTEM TO PROVIDE ACCESS TO HIGH QUALITY CARE AND IMPROVED HEALTH AT LOWER COSTS.- FEEDING AMERICA: A NONPROFIT ORGANIZATION WORKING TO FEED AMERICA'S HUNGRY THROUGH FOOD BANKS. DATA ARE COMPILED FROM THE CURRENT POPULATION SURVEY, AMERICAN COMMUNITY SURVEY, AND BUREAU OF LABOR STATISTICS TO PRODUCE FOOD-INSECURITY REPORTS.- INDIANA INDICATORS: A FREE DATA RESOURCE PROVIDING CURRENT INDIANA HEALTH-RELATED DATA AT THE STATE AND COUNTY LEVELS AND DEVELOPED BY THE INDIANA STATE DEPARTMENT OF HEALTH, INDIANA HOSPITAL ASSOCIATION, AND INDIANA BUSINESS RESEARCH CENTER.- INDIANA STATE DEPARTMENT OF HEALTH (ISDH): THE ISDH'S ANNUAL NATALITY REPORT INCLUDES INFORMATION ON LIVE BIRTHS IN INDIANA AS WELL AS A MORTALITY REPORT COMPILING INFORMATION ON THE DEATHS OF INDIANA RESIDENTS.- NATIONAL CANCER INSTITUTE: THE NATIONAL CANCER INSTITUTE (NCI) IS THE FEDERAL GOVERNMENT'S PRINCIPAL AGENCY FOR CANCER RESEARCH AND TRAINING. NCI MAINTAIN LARGE REGISTRIES OF INFORMATION ABOUT PEOPLE DIAGNOSED WITH CANCER TO HELP IDENTIFY IMPORTANT ISSUES THAT AFFECT CANCER PATIENTS AND SURVIVORS.- NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD, AND TB PREVENTION: THE NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD, AND TB PREVENTION IS ONE OF THE LARGER CENTERS AT CDC AND A FEDERAL SOURCE OF DATA ABOUT SEXUALLY TRANSMITTED INFECTIONS AND DISEASES.- THE NATIONAL ENVIRONMENTAL PUBLIC HEALTH TRACKING NETWORK: THE TRACKING NETWORK BRINGS TOGETHER HEALTH DATA AND ENVIRONMENT DATA FROM NATIONAL, STATE, AND CITY SOURCES AND PROVIDES SUPPORTING INFORMATION TO MAKE THE DATA EASIER TO UNDERSTAND. - US CENSUS BUREAU: A LEADING SOURCE OF DATA ON THE PEOPLE AND ECONOMY OF THE US.- 2018 INDIANA ASSOCIATION OF ADULT DAY SERVICES (IAADS) SURVEY: THE 5TH ANNUAL INDIANA ADULT DAY CENTER SURVEY WAS CONDUCTED DURING THE SUMMER OF 2018 BY THE MEMBER RELATIONS COMMITTEE OF THE IAADS BOARD OF DIRECTORS. FOR THE FIRST TIME, CENTERS WERE GIVEN THE OPTION TO COMPLETE THE SURVEY ONLINE AS WELL AS BY TELEPHONE. SEVENTY-SEVEN PERCENT OF THOSE RESPONDING USED THE ONLINE OPTION. RESULTS WERE TABULATED BASED ON INDIVIDUAL SURVEY DATA.FOLLOWING THE PRIMARY DATA COLLECTION THAT WAS CONDUCTED FOR THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT, INPUT WAS GATHERED FROM THE COMMUNITY MEMBERS WHO SIT ON THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BOARD OF DIRECTORS AT THEIR SEPTEMBER 2019 MEETING. BASED ON THIS REVIEW AND INPUT, THREE PRIORITIES WERE RECOMMENDED FOR ADDITIONAL EMPHASIS, WHICH ARE: 1) MENTAL HEALTH/SUBSTANCE USE DISORDER, 2) OBESITY, 3) MATERNAL/INFANT/CHILD HEALTH - WITH SPECIFIC FOCUS ON CHILD HEALTH.THIS INFORMATION WAS THEN PRESENTED AT A COMMUNITY MEETING ON NOVEMBER 4, 2019 THAT WAS OPEN TO THE PUBLIC. REPRESENTATIVES FROM THE FOLLOWING ORGANIZATIONS WERE PRESENT: YMCA, LAGRANGE COUNTY COMMUNITY FOUNDATION, BRIGHTPOINT, COMMUNITY HEALTH CLINIC, COMMUNITY DENTAL CLINIC, PLAIN CHURCH GROUP MINISTRY LLC, LAGRANGE COUNTY SHERIFF'S DEPARTMENT, PURDUE EXTENSION, TOPEKA PHARMACY, LAGRANGE COUNTY HEALTH COALITION, LAGRANGE COUNTY HEALTH DEPARTMENT, LAGRANGE COUNTY COMMISSIONER, LAGRANGE COUNTY ECONOMIC DEVELOPMENT AND TC ENERGY. AT THIS COMMUNITY MEETING, A SUMMARY PRESENTATION OF THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT WAS GIVEN AND THE THREE PRIORITIES OUTLINED ABOVE WERE SHARED. THOSE PRESENT WERE ASKED TO CONSIDER BECOMING INVOLVED IN COLLABORATIVE GROUPS THAT WERE FORMED, ONE FOR EACH OF THE HEALTH PRIORITIES IDENTIFIED.IN 2020, COLLABORATIVE GROUPS, INCLUDING THE COMMUNITY STAKEHOLDERS IDENTIFIED ABOVE, FOR EACH OF THE THREE HEALTH PRIORITIES MET REGULARLY TO REVIEW ADDITIONAL DATA SOURCES, DEVELOP AN IMPLEMENTATION STRATEGY, AND BEGIN TO DEVELOP TACTICS TO ROLL OUT AND MEASURE UNTIL THE NEXT COMMUNITY HEALTH NEEDS ASSESSMENT IS CONDUCTED IN 2022.
COMMUNITY HOSPITAL OF LAGRANGE COUNTY	PART V, SECTION B, LINE 6A: THE HOSPITAL FACILITY'S CHNA WAS CONDUCTED WITH THE FOLLOWING HOSPITAL FACILITIES:PARKVIEW HOSPITAL, INC. (EIN 35-0868085); COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (EIN 35-2087092); HUNTINGTON MEMORIAL HOSPITAL, INC. (EIN 35-1970706); WHITLEY MEMORIAL HOSPITAL, INC. (EIN 35-1967665); PARKVIEW WABASH HOSPITAL, INC. (EIN 47-1753440) AND ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH, LLC (EIN 26-0143823).
COMMUNITY HOSPITAL OF LAGRANGE COUNTY	PART V, SECTION B, LINE 6B: THE HOSPITAL FACILITY'S CHNA WAS ALSO CONDUCTED WITH THE FOLLOWING ORGANIZATIONS OTHER THAN HOSPITAL FACILITIES:PARKVIEW HEALTH SYSTEM, INC.(EIN 35-1972384); INDIANA PARTNERSHIP FOR HEALTHY COMMUNITIES (A PARTNERSHIP BETWEEN THE INDIANA UNIVERSITY RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH AND THE POLIS CENTER AT IUPUI) AND CONDUENT HEALTHY COMMUNITIES INSTITUTE.
COMMUNITY HOSPITAL OF LAGRANGE COUNTY	PART V, SECTION B, LINE 11: DESCRIBE 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:SIGNIFICANT HEALTH NEEDS BEING ADDRESSED:MENTAL HEALTH:A COLLABORATIVE GROUP WAS FORMED IN 2019 TO BRING KEY STAKEHOLDERS FROM THE LAGRANGE COUNTY COMMUNITY TOGETHER TO ADDRESS MENTAL HEALTH/SUBSTANCE USE DISORDER. THIS WAS IDENTIFIED AS THE TOP NEED IN OUR REGION BASED ON RESULTS FROM THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT, MEASURING THE PERCENT OF THE POPULATION WITH FREQUENT MENTAL DISTRESS. IN 2020, THE COLLABORATIVE GROUP MEETING FREQUENCY AND EFFORTS WERE IMPACTED BY COVID-19, HOWEVER, THE MENTAL HEALTH/SUBSTANCE USE COLLABORATIVE MADE PROGRESS IN THE FOLLOWING AREA:-UTILIZED SHIP FUNDING TO ACQUIRE DRUG DISPOSAL BAGS THAT CAN SAFELY BE USED TO DEACTIVATE PILLS, LIQUID OR PATCHES AND HELP TO REDUCE THE LIKELIHOOD OF PRESCRIPTION DRUG ABUSE. THESE BAGS WERE PLACED THROUGHOUT LAGRANGE COUNTY IN KEY LOCATIONS, SOME OF WHICH ARE: LAGRANGE COUNTY HEALTH DEPARTMENT, HOSPITAL EMERGENCY ROOM, COUNTY PHYSICIAN OFFICES, AND LAGRANGE COUNTY COUNCIL ON AGING.-UTILIZED SHIP FUNDING TO HAVE THREE INDIVIDUALS TRAINED SO THEY CAN TEACH THE QPR GATEKEEPER SUICIDE PREVENTION CURRICULUM. WITH ASSISTANCE FROM PARKVIEW BEHAVIORAL HEALTH INSTITUTE, AN EVIDENCE-BASED SUICIDE PREVENTION STRATEGY KNOWN AS QUESTION, PERSUADE AND REFER (QPR) IS OFFERED AS A FREE TRAINING PROGRAM TO EQUIP PARTICIPANTS TO RECOGNIZE THE WARNING SIGNS OF SUICIDE AND HOW TO TAKE STEPS TO INTERVENE. SINCE BEING IMPLEMENTED IN 2017, OVER 934 PEOPLE HAVE RECEIVED THIS EDUCATION, WITH 82 PEOPLE BEING TRAINED IN 2020. THE GOAL OF THIS PROGRAM IS TO REDUCE THE NUMBER OF SUICIDE COMPLETIONS IN LAGRANGE COUNTY. THE LIFEBRIDGE SENIOR INTENSIVE OUTPATIENT PROGRAM IS A SPECIALTY MENTAL/BEHAVIORAL PROGRAM DESIGNED TO MEET THE NEEDS OF OLDER ADULTS FOCUSING ON PROVIDING INTENSIVE INDIVIDUAL, FAMILY AND/OR GROUP SERVICES. SINCE ITS INCEPTION IN 2014 AT COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., THE PROGRAM HAS PROVIDED OVER 13,000 HOURS OF DIRECT COUNSELING SERVICES TO INDIVIDUALS IN LAGRANGE, STEUBEN AND NOBLE COUNTIES, WITH 2,360 HOURS BEING PROVIDED TO 39 PATIENTS IN 2020. IN ADDITION, EACH OF THE INDIVIDUALS ENROLLED IN THE LIFEBRIDGE PROGRAM ATTEND MONTHLY APPOINTMENTS WITH MEDICAL DIRECTOR/PSYCHIATRIST FOR MEDICATION MANAGEMENT AND TREATMENT PLANNING. AT EACH VISIT, INDIVIDUALS ARE SCREENED BY NURSING STAFF FOR VITALS, MEDICATION RECONCILIATION AND ANY MEDICAL CONCERNS ARE IMMEDIATELY COMMUNICATED TO THE INDIVIDUAL'S PRIMARY CARE PHYSICIAN. FAMILY AND SIGNIFICANT OTHERS ARE ENCOURAGED TO PARTICIPATE IN THE TREATMENT PROCESS. LIFEBRIDGE PROVIDES A COHESIVE TREATMENT TEAM TO INCREASE INDIVIDUAL'S MENTAL HEALTH AND PHYSICAL WELL-BEING.OBESITY: A COLLABORATIVE GROUP WAS FORMED IN 2019 TO BRING KEY STAKEHOLDERS FROM THE LAGRANGE COUNTY COMMUNITY TOGETHER TO ADDRESS OBESITY. THIS WAS IDENTIFIED AS A TOP NEED IN OUR COUNTY BASED ON RESULTS FROM THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT. THIS GROUP WILL BE WORKING ON PROVIDING PUBLIC EDUCATION ON WHY IT IS IMPORTANT TO BE HEALTHY, INCREASING ACCESS TO FITNESS IN LAGRANGE COUNTY, AND PARTNERING WITH LAGRANGE COUNTY RESTAURANTS TO INCREASE HEALTHY FOOD OPTIONS BEING OFFERED. THE GOAL OF THIS COLLABORATIVE GROUP IS TO SEE A REDUCTION IN THE NUMBER OF OBESE AND OVERWEIGHT INDIVIDUALS IN THE COUNTY. IN 2020, THE COLLABORATIVE GROUP MEETING FREQUENCY AND EFFORTS WERE IMPACTED BY COVID-19, HOWEVER, THE OBESITY COLLABORATIVE MADE PROGRESS IN THE FOLLOWING AREA:-LAGRANGE COUNTY COMMUNITY MEMBERS WERE ENCOURAGED TO PARTICIPATE IN THE GREAT APPLE CRUNCH FOR THE MONTH OF OCTOBER 2020 BY TAKING PHOTOS OF THEMSELVES BITING INTO AN APPLE AND POSTING IT ON SOCIAL MEDIA. THE INTENT WAS TO RAISE AWARENESS TO THE HEALTH BENEFITS OF MAKING HEALTHIER FOOD CHOICES. THE HOSPITAL DELIVERED 6 BASKETS OF APPLES TO COUNTY BUSINESSES ALONG WITH A HEALTHY RECIPE. BECAUSE WE HAVE A SIGNIFICANT PLAIN CHURCH/AMISH POPULATION IN LAGRANGE COUNTY, A CHALLENGE WAS PUT OUT TO AMISH SCHOOLS TO SUBMIT AN ORIGINAL RECIPE OR ESSAY ON THE APPLE. STUDENTS IN GRADES K - 8 SUBMITTED 79 ENTRIES. SIX RANDOM WINNERS WERE SELECTED TO RECEIVE WELLNESS BUNDLES FOR THEIR SCHOOL CLASSROOM. THE HOSPITAL IMPLEMENTED A FOOD PHARMACY PROGRAM IN 2018 TO REDUCE THE NEGATIVE EFFECTS (HEALTH AND ECONOMIC) OF OBESITY, AND RELATED CHRONIC DISEASES, SUCH AS DIABETES, THROUGH EDUCATION AND HEALTHY EATING PRACTICES. PATIENTS MUST BE REFERRED BY THEIR DOCTOR, HAVE TYPE 2 DIABETES, AND A BMI>30 TO PARTICIPATE. THIS FREE 6-MONTH PROGRAM BRINGS CLASS PARTICIPANTS TOGETHER MONTHLY TO LEARN HOW TO EAT AND SHOP HEALTHIER, COOK HEALTHIER, MANAGE MEDICATION, AND MORE. SINCE STARTING, PARTICIPANTS HAVE SEEN AN AVERAGE IMPROVEMENT IN A1C LEVELS OF 1.7, AND AN AVERAGE WEIGHT REDUCTION OF 5.2 LBS., AND IMPROVEMENTS IN CHOLESTEROL AND BLOOD PRESSURE MEASUREMENTS. IN 2020, 10 PARTICIPANTS WERE ENROLLED IN THE PROGRAM. PARTICIPANTS WERE ABLE TO COMPLETE THREE SESSIONS BEFORE THE PROGRAM WAS SUSPENDED THE REMAINDER OF 2020 DUE TO COVID-19. THE HOSPITAL PARTNERS WITH THE COLE CENTER FAMILY YMCA TO INCREASE PHYSICAL ACTIVITY BY OFFERING GROUP EXERCISE CLASSES IN LAGRANGE COUNTY. IN 2020, APPROXIMATELY 300 PEOPLE PARTICIPATED IN THESE CLASSES. (THIS IS WAY DOWN FROM THE PRIOR YEAR DUE TO THE COVID-19 PANDEMIC.) THESE GROUP CLASSES ALSO OFFER A CLOSE-KNIT COMMUNITY TO PARTICIPANTS AS THEY DEVELOP FRIENDSHIPS THROUGH REGULAR ATTENDANCE, WHICH POSITIVELY IMPACTS THEIR MENTAL HEALTH AND WELL-BEING.MATERNAL/INFANT/CHILD HEALTH:A COLLABORATIVE GROUP WAS FORMED IN 2019 TO BRING KEY STAKEHOLDERS FROM THE LAGRANGE COUNTY COMMUNITY TOGETHER TO ADDRESS MATERNAL/INFANT/CHILD HEALTH. BASED ON RESULTS FROM THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT, CHILD HEALTH WAS IDENTIFIED AS A TOP NEED IN LAGRANGE COUNTY, EMPHASIZING CHILD ABUSE & NEGLECT AND CHILDCARE. THE GOAL OF THIS COLLABORATIVE GROUP IS TO SEE AN INCREASE IN THE NUMBER OF REFERRALS FOR PARENTAL SUPPORT, WHICH SHOULD RESULT IN A REDUCTION OF CASES OF CHILD ABUSE & NEGLECT, AND TO INCREASE THE NUMBER OF CERTIFIED CHILDCARE PROVIDERS IN LAGRANGE COUNTY. IN 2020, THE COLLABORATIVE GROUP MEETING FREQUENCY AND EFFORTS WERE IMPACTED BY COVID-19. THE HOSPITAL PROVIDES FREE SUPPORT AND GUIDANCE TO PREGNANT AND NEW MOTHERS REGARDLESS OF WHETHER OR NOT THEY DELIVER AT THE HOSPITAL. IN 2020, THE FOLLOWING SERVICES WERE PROVIDED: BIRTH PLANNING:-18 IN HOSPITAL = 36 HOURS = STAFFING COST OF $1,512.00 (36 PEOPLE SERVED)-7 HOME VISITS = 21 HOURS = STAFFING COST OF $882.00 AND MILEAGE COST OF $72.22 (14 PEOPLE SERVED)-BREASTFEEDING CLASS: 4 CLASSES HELD PRIOR TO COVID-19 = 10HRS = $420 STAFF COST (8 PEOPLE SERVED)-BREASTFEEDING, INPATIENT: 99 PATIENTS = APPROXIMATELY 212 HOURS-BREASTFEEDING, OUTPATIENT: 50 PATIENTS = APPROXIMATELY 150 HOURS-PRE-NATAL CLASS: 7 CLASSES FOR THE YEAR = 56 HOURS (34 PEOPLE SERVED TOTAL; 12 WERE NEW EDEN PATIENTS)-SAFE SLEEP CLASS: 6 CLASSES = 18 HOURS = (15 PEOPLE SERVED)OTHER HEALTH NEEDS NOT BEING ADDRESSED:-AGING - AGING AND IN-HOME SERVICES OF NORTHEAST INDIANA (AIHS) SERVES OLDER ADULTS, PERSONS WITH DISABILITIES AND THEIR CAREGIVERS IN NINE COUNTIES IN NORTHEAST INDIANA. THIS NOT-FOR-PROFIT, COMMUNITY-BASED ORGANIZATION IS A FEDERAL AND STATE DESIGNATED AREA AGENCY ON AGING AND AN AGING AND DISABILITY RESOURCE CENTER WHICH PROVIDES A STREAMLINED ACCESS TO INFORMATION, CARE OPTIONS, SHORT-TERM CASE MANAGEMENT AND BENEFITS ENROLLMENT ACROSS A SPECTRUM OF LONG-TERM CARE SERVICES. THROUGH THE CARE TRANSITIONS PROGRAM, AIHS PARTNERS WITH PARKVIEW HEALTH TO REDUCE MEDICARE READMISSIONS. IN ADDITION, THE AGENCY SERVES AS THE INITIAL COORDINATOR AND FISCAL AGENT FOR HONORING CHOICES INDIANA, WHICH IS AN INITIATIVE COMMITTED TO PROMOTING AND SUSTAINING ADVANCE CARE PLANNING (ACP) ACROSS THE STATE TO ENSURE INDIVIDUALS' FUTURE HEALTH CARE PREFERENCES ARE DISCUSSED, DOCUMENTED, AND HONORED. THROUGH HONORING CHOICES, PARKVIEW AND AIHS WORK TOGETHER TO TRAIN ACP FACILITATORS, PROMOTE BEST PRACTICE AND INCREASE PUBLIC AWARENESS ABOUT THE VALUE OF DISCUSSING HEALTH CARE DECISION MAKING IN ADVANCE OF MEDICAL CRISIS.-CARDIOVASCULAR DISEASE & DIABETES - WHILE WE ARE NOT ADDRESSING THIS NEED SPECIFICALLY, WE WILL BE ADDRESSING OBESITY. MANY OF OUR OUTREACH INITIATIVES TO ADDRESS OR PREVENT OBESITY WILL IMPACT BOTH THESE AREAS IN THAT INTERVENTIONS ARE SIMILAR FOR THESE HEALTH ISSUES.-TOBACCO USE - THE HOSPITAL IS A TOBACCO FREE CAMPUS AND OFFERS FREE CLASSES QUARTERLY TO COMMUNITY MEMBERS. THIS IS A 7-WEEK, 8-SESSION CLASS SERIES THAT PROVIDES SUPPORT AND EDUCATION TO HELP PEOPLE GET TOBACCO FREE. THE HOSPITAL ALSO THESE CLASSES WERE OFFERED VIRTUALLY IN 2020 DUE TO THE COVID-19 PANDEMIC.
PART V, SECTION B, LINE 3E:	THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AND IDENTIFIED THROUGH THE CHNA.

Schedule H (Form 990) 2020

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?2
Name and address		Type of Facility (describe)
1	1 - PARKVIEW LAGRANGE EMS - CENTRAL 0982 N 00 EW LAGRANGE,IN46761	AMBULANCE SERVICE
2	2 - PARKVIEW LAGRANGE EMS - WEST 8175 W US 20 SHIPSHEWANA,IN46565	AMBULANCE SERVICE
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2020

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:	EQUITY IN A HOME OTHER THAN THE PATIENT OR GUARANTOR'S PRIMARY RESIDENCE.
PART I, LINE 6A:	THE RELATED ENTITIES OF PARKVIEW HEALTH SYSTEM, INC. (EIN 35-1972384); PARKVIEW HOSPITAL, INC. (EIN 35-0868085); COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. (EIN 20-2401676); COMMUNITY HOSPITAL OF NOBLE COUNTY, INC. (EIN 35-2087092); HUNTINGTON MEMORIAL HOSPITAL, INC. (EIN 35-1970706); WHITLEY MEMORIAL HOSPITAL, INC. (EIN 35-1967665) AND PARKVIEW WABASH HOSPITAL, INC. (EIN 47-1753440) PREPARED A COMBINED REPORT TO THE COMMUNITY DETAILING COMMUNITY BENEFIT PROGRAMS AND SERVICES.
PART I, LINE 7:	PART I, LINE 7ATHE FINANCIAL ASSISTANCE COST REPORTED ON LINE 7A IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE FINANCIAL ASSISTANCE CHARGES FOREGONE ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF SERVICES RENDERED.PART I, LINE 7BCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICAID, MEDICAID MANAGED CARE, AND OUT-OF-STATE MEDICAID PATIENTS WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICAID PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICAID, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED MEDICAID COST REPORTED ON LINE 7B IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE MEDICAID CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF MEDICAID SERVICES RENDERED. THEN, THE COST OF MEDICAID SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR MEDICAID PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7CCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEANS-TESTED PATIENTS FROM THE HEALTHY INDIANA PLAN (HIP) WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEANS-TESTED PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING HIP, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. THE UNREIMBURSED HIP COST REPORTED ON LINE 7C IS CALCULATED UNDER THE COST TO CHARGE RATIO METHODOLOGY. UNDER THIS METHOD, THE HIP CHARGES ARE MULTIPLIED BY THE RATIO OF COST TO CHARGES TO DETERMINE THE COST OF HIP SERVICES RENDERED. THEN, THE COST OF HIP SERVICES RENDERED IS DEDUCTED FROM THE REIMBURSEMENT RECEIVED FOR HIP PATIENTS TO ARRIVE AT A GAIN/(LOSS) RELATIVE TO THESE PATIENTS.PART I, LINE 7EAMOUNTS PRESENTED ARE BASED ON ACTUAL SPEND FOR THOSE SERVICES AND BENEFITS PROVIDED DEEMED TO IMPROVE THE HEALTH OF THE COMMUNITIES IN WHICH WE SERVE AND CONFORM WITH THE MISSION OF OUR EXEMPT PURPOSE.PART I, LINE 7IIN KEEPING WITH OUR MISSION AND COMMITMENT TO THE COMMUNITIES IN WHICH WE SERVE, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUES ITS TRADITION OF CONTRIBUTING TO NUMEROUS ORGANIZATIONS ON BOTH AN AS-NEEDED BASIS AND NEGOTIATED BASIS. AMOUNTS PRESENTED REPRESENT ACTUAL SPEND TO ORGANIZATIONS THROUGHOUT OUR COMMUNITIES.
PART I, LN 7 COL(F):	PERCENT OF TOTAL EXPENSECOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. EXCLUDED $3,542,492 OF PH CLINICAL SUPPORT EXPENSE.
PART II, COMMUNITY BUILDING ACTIVITIES:	DESCRIBE HOW THE ORGANIZATION'S COMMUNITY BUILDING ACTIVITIES, AS REPORTED, PROMOTES THE HEALTH OF THE COMMUNITIES THE ORGANIZATION SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES SUPPORT FOR LOCAL ECONOMIC DEVELOPMENT PROGRAMS. THESE EFFORTS ARE ALIGNED WITH THE HEALTH SYSTEM'S STRATEGIC INVOLVEMENT IN THE NORTHEAST INDIANA REGIONAL PARTNERSHIP'S VISION 2020, AN INITIATIVE DESIGNED TO TRANSFORM NORTHEAST INDIANA INTO A TOP GLOBAL COMPETITOR BY FOCUSING ON A COMMON MISSION TO DEVELOP, ATTRACT AND RETAIN TALENT. VISION 2020'S PRIORITIES ARE TIED TO EDUCATION/WORKFORCE, BUSINESS CLIMATE, ENTREPRENEURSHIP, INFRASTRUCTURE, AND QUALITY OF LIFE FOR THE ELEVEN-COUNTY REGION IN NORTHEAST INDIANA. PROMOTION OF ECONOMIC DEVELOPMENT IN LAGRANGE COUNTY IS A PART OF A COLLECTIVE PLAN TO IMPROVE THE QUALITY OF LIFE AND ULTIMATELY THE OVERALL HEALTH AND WELL-BEING OF THE COMMUNITY.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. SUPPORTS ECONOMIC DEVELOPMENT IN THE COUNTY THROUGH THE FOLLOWING INITIATIVES:- LAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION - FINANCIAL SPONSOR FOR EDC INFRASTRUCTURE, HOUSING DEVELOPMENT, QUALITY OF LIFE/GROWTH IN COUNTY- LAGRANGE COUNTY CLOTHES AND FOOD BASKET - SUPPORTING FOOD PANTRY - LAGRANGE COUNTY CONVENTION & VISITORS BUREAU - SHARE THE ROAD EDUCATION INCLUDED IN AMISH BACKROADS VISITOR GUIDE- ACTIVE REPRESENTATION BY COMMUNITY HOSPITAL OF LAGRANGE COUNTY LEADERSHIP ON THE BOARDS OF NEARLY THIRTY COMMUNITY NON-PROFIT AND CIVIC AGENCIES IN LAGRANGE COUNTY AND THE SURROUNDING AREA, INCLUDING:AMERICAN MEDICAL TECHNOLOGIST INDIANA STATE BOARD MEMBERCOMMUNITY IMPROVEMENT LEAGUE OF STROH - TRUSTEE FORMED COMMITTEELAGRANGE COUNTY COUNCIL ON AGING - BOARD MEMBERLAGRANGE COUNTY CORONER'S OFFICE - DEPUTY CORONERDRUG FREE LAGRANGE COUNTY TASKFORCE - MEMBERHABITAT FOR HUMANITY - BOARD OF DIRECTORS MEMBERHOWE VOLUNTEER FIRE DEPARTMENT - FIRE CHIEF AND VOLUNTEER FIRE FIGHTERIMPACT - HEATH OCCUPATIONS EDUCATION ADVISORY COMMITTEEINSTRUCTOR FOR ONLINE BUSINESS CLASSESJUNIOR ACHIEVEMENT OF LAGRANGE COUNTY - BOARD MEMBER, VOLUNTEER LAGRANGE COUNTY COMMISSIONERLAGRANGE COUNTY EARLY CHILDHOOD DEVELOPMENT COALITIONLAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION BOARD OF DIRECTORSLAGRANGE COUNTY HEALTH DEPARTMENT - BOARD MEMBERLAGRANGE COUNTY HOUSING PROJECT STEERING COMMITTEELAGRANGE COUNTY JUDICIAL COMMITTEE MEMBERLAGRANGE COUNTY PARK BOARD MEMBERLAGRANGE COUNTY REGIONAL UTILITY DISTRICTLAGRANGE COUNTY TRAILS - COMMITTEE MEMBERLAGRANGE/NOBLE JOINT DRAINAGE BOARDFREE MASONS MERIDIAN SUN LODGE #76 - MEMBERNORTHEAST INDIANA SOLID WASTE DISTRICT BOARDPARKVIEW LAGRANGE HOSPITAL ADOPT-A-HIGHWAY PROGRAMPERSONNEL ADVISORY COMMITTEEPURDUE EXTENSION OFFICE IN LAGRANGE COUNTY - WELLNESS COMMITTEE MEMBERQPR INSTRUCTORS - EIGHT MEMBERS IF HOSPITAL LEADERSHIPREMC MEMBER ADVISORY COMMITTEESURVIVING LOSS BY SUICIDE - FOUNDER AND SUPPORTER OF LAGRANGE COUNTY SUICIDE SUPPORT GROUPUNITED FUND BOARD - MEMBERYOUTH FOR CHRIST SUPPORTER IN ALLEN AND LAGRANGE COUNTIES, LAGRANGE COUNTY PROGRAM FACILITATOR
PART III, LINE 2:	FOR FINANCIAL STATEMENT PURPOSES, THE ORGANIZATION HAS ADOPTED ACCOUNTING STANDARDS UPDATE NO. 2014-09 (TOPIC 606). IMPLICIT PRICE CONCESSIONS INCLUDES BAD DEBTS. THEREFORE, BAD DEBTS ARE INCLUDED IN NET PATIENT REVENUE IN ACCORDANCE WITH HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT NO. 15 AND BAD DEBT EXPENSE IS NOT SEPARATELY REPORTED AS AN EXPENSE. THE AMOUNT REPORTED ON PART III, LINE 3 IS THE ESTIMATED COST OF BAD DEBT ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER PARKVIEW HEALTH SYSTEM'S FINANCIAL ASSISTANCE POLICY ON A GROSS BASIS.
PART III, LINE 3:	COSTING METHODOLOGY USED:UNCOLLECTIBLE PATIENT ACCOUNTS ARE CHARGED AGAINST THE PROVISION FOR BAD DEBT IN ACCORDANCE WITH THE POLICIES OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HOWEVER, DURING THE COLLECTION PROCESS THERE IS A CONTINUOUS EFFORT TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THEREFORE, ONCE AN UNCOLLECTIBLE ACCOUNT HAS BEEN CHARGED OFF AND IT IS DETERMINED THROUGH THE COLLECTION PROCESS THAT THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, THE UNCOLLECTIBLE ACCOUNT IS RECLASSIFIED TO CHARITY CARE AND ALL COLLECTION EFFORTS CEASE. PATIENTS ARE ELIGIBLE TO APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME, INCLUDING PATIENTS WHOSE ACCOUNTS HAVE BEEN PLACED IN A BAD DEBT AGENCY. THE AMOUNT REFLECTED ON LINE 3 WAS CALCULATED BY TOTALING THE ACCOUNTS PREVIOUSLY WRITTEN OFF TO BAD DEBT AND PLACED WITH A COLLECTION AGENCY, BUT SUBSEQUENTLY RECLASSIFIED AS CHARITY CARE DURING THE TAX YEAR. THE ACCOUNTS WERE RECLASSIFIED AS CHARITY CARE DUE TO THE FACT THAT PATIENTS APPLIED FOR, AND WERE APPROVED FOR, FINANCIAL ASSISTANCE AFTER THE ACCOUNTS WERE PLACED WITH A BAD DEBT AGENCY.
PART III, LINE 4:	BAD DEBT EXPENSE - PARKVIEW HEALTH SYSTEM, INC. AND SUBSIDIARIES - NOTES TO THE CONSOLIDATED FINANCIAL STATEMENTSTEXT 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:PAGES 13 AND 24 - 27 OF ATTACHED FINANCIAL STATEMENTS.
PART III, LINE 8:	COMMUNITY BENEFIT & METHODOLOGY FOR DETERMINING MEDICARE COSTSSUBSTANTIAL SHORTFALLS TYPICALLY ARISE FROM PAYMENTS THAT ARE LESS THAN THE COST TO PROVIDE THE CARE OR SERVICES AND DO NOT INCLUDE ANY AMOUNTS RELATING TO INEFFICIENT OR POOR MANAGEMENT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ACCEPTS ALL MEDICARE PATIENTS, AS REFLECTED ON THE YEAR-END MEDICARE COST REPORT, WITH THE KNOWLEDGE THAT THERE MAY BE SHORTFALLS. INTERNAL REVENUE SERVICE (IRS) REVENUE RULING 69-545 IMPLIES THAT TREATING MEDICARE PATIENTS IS A COMMUNITY BENEFIT. IRS REVENUE RULING 69-545, WHICH ESTABLISHED THE COMMUNITY BENEFIT STANDARD FOR NONPROFIT HOSPITALS, STATES THAT IF A HOSPITAL SERVES PATIENTS WITH GOVERNMENTAL HEALTH BENEFITS, INCLUDING MEDICARE, THEN THIS IS AN INDICATION THAT THE HOSPITAL OPERATES TO PROMOTE THE HEALTH OF THE COMMUNITY. HOWEVER, MEDICARE PAYMENTS REPRESENT A PROXY OF COST CALLED THE "UPPER PAYMENT LIMIT." IT HAS HISTORICALLY BEEN ASSUMED THAT UPPER PAYMENT LIMIT PAYMENTS DO NOT GENERATE A SHORTFALL. AS A RESULT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. HAS TAKEN THE POSITION NOT TO INCLUDE THE MEDICARE SHORTFALLS OR SURPLUSES AS PART OF COMMUNITY BENEFIT. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. RECOGNIZES THAT THE SHORTFALL OR SURPLUS FROM MEDICARE DOES NOT INCLUDE THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS. AS SUCH, THE TOTAL SHORTFALL OR SURPLUS OF MEDICARE IS UNDERSTATED DUE TO THE COSTS AND REVENUES ASSOCIATED WITH MEDICARE ADVANTAGE PATIENTS NOT BEING INCLUDED IN THE COMMUNITY BENEFIT DETERMINATION.
PART III, LINE 9B:	IF THE PATIENT CANNOT PAY IN FULL, THE OPTION OF A LOW INTEREST LOAN IS AVAILABLE WITH THE SAME DISCOUNT OFFERED FOR CASH PAYMENTS AS LONG AS THE LOAN IS ARRANGED WITHIN 30 DAYS OF THE FIRST GUARANTOR STATEMENT. IF THE PATIENT DEFAULTS ON THE LOAN, THE DISCOUNT WILL BE REVERSED AND THE PATIENT'S ACCOUNT WILL BE PLACED IN A COLLECTION AGENCY.INTEREST-FREE PAYMENTS WITH PAY-OUT NOT TO EXCEED THIRTY-SIX (36) MONTHS ARE AVAILABLE. THE MINIMUM MONTHLY PAYMENT IS $25.FINANCIAL ASSISTANCE MAY BE AVAILABLE FOR THOSE PATIENTS WHO CANNOT PAY THEIR BILL. THOSE OPTIONS ARE GOVERNMENTAL ASSISTANCE OR FREE CARE THROUGH THE HOSPITAL FINANCIAL ASSISTANCE PROGRAM. THE HEALTH SYSTEM FINANCIAL ASSISTANCE POLICY IS AVAILABLE ON PARKVIEW.COM OR BY VISITING ANY HOSPITAL CASHIER OFFICE OR BY CALLING PATIENT ACCOUNTING AT 260.266.6700 OR TOLL FREE 855.814.0012. A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE ANYTIME DURING THE APPLICATION PERIOD. FAILURE TO MAKE ARRANGEMENTS AS LISTED ABOVE OR FAILURE TO APPLY FOR AND RECEIVE APPROVAL UNDER THE FINANCIAL ASSISTANCE POLICY MAY RESULT IN THE ACCOUNT BEING PLACED IN A COLLECTION AGENCY DUE TO NON-PAYMENT. THE COLLECTION AGENCY MAY REPORT THE ACCOUNT TO ONE OR ALL THREE CREDIT REPORTING AGENCIES WHICH MAY ULTIMATELY ADVERSELY AFFECT THE PATIENT'S CREDIT SCORE. ADDITIONALLY, THE COLLECTION AGENCY MAY SUE AND OBTAIN A JUDGMENT AGAINST THE PATIENT FOR NON-PAYMENT. THESE ACTIONS WILL NOT OCCUR UNTIL 120 DAYS AFTER THE PATIENT IS SENT THEIR FIRST FOLLOW-UP STATEMENT INDICATING THE AMOUNT THEY OWE.A PATIENT MAY APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME DURING THE APPLICATION PERIOD, EVEN THOUGH THEY HAVE BEEN PLACED WITH A COLLECTION AGENCY. IF THE PATIENT WAS SENT THEIR FIRST NOTICE ON THE ACCOUNT FOR WHICH THEY ARE APPLYING FOR FREE CARE BETWEEN 120 DAYS AND THE END OF THE APPLICATION PERIOD, THE ACTIONS ABOVE WILL BE SUSPENDED UNTIL THE FREE CARE APPLICATION ELIGIBILITY IS DETERMINED.
PART VI, LINE 2:	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.IN ADDITION TO COMPLETING A COMMUNITY HEALTH NEEDS ASSESSMENT ON A TRIENNIAL BASIS, PARKVIEW HEALTH SYSTEM, INC., INCLUDING COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH PRIMARY AND SECONDARY DATA ANALYSIS, WORKING WITH THE ORGANIZATION'S COMMUNITY PARTNERS, AND ITS FRONTLINE STAFF.- DATA COLLECTION FROM COMMUNITY HEALTH WORKERS- HCI SECONDARY DATA- MEETING WITH COMMUNITY PARTNERS- OBSERVATIONS FROM FRONTLINE STAFF WORKING WITH VULNERABLE POPULATIONS- REVIEW OF CHNA CONDUCTED BY LOCAL ORGANIZATIONSHOSPITAL REPRESENTATIVES MAINTAIN ONGOING RELATIONSHIPS THROUGHOUT THE COMMUNITY AND MEET REGULARLY WITH ORGANIZATIONS THAT SHARE THE MISSION OF IMPROVING THE HEALTH AND INSPIRING THE WELL-BEING OF THE COMMUNITY WE SERVE.
PART VI, LINE 3:	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.SIGNAGE AND BROCHURES ARE POSTED AND AVAILABLE AT ALL HOSPITAL POINTS OF REGISTRATION AND IN THE EMERGENCY DEPARTMENT. PATIENTS ARE OFFERED PLAIN LANGUAGE SUMMARIES OF THE FINANCIAL ASSISTANCE POLICY DURING THE REGISTRATION PROCESS AND IN EACH FOLLOW UP STATEMENT SENT TO THE PATIENT. PATIENT STATEMENTS WILL INDICATE HOW A PATIENT CAN OBTAIN FINANCIAL ASSISTANCE APPLICATIONS AND WHO THEY CAN CONTACT FOR ASSISTANCE.
PART VI, LINE 4:	DESCRIBE THE COMMUNITY THE ORGANIZATION SERVES, TAKING INTO ACCOUNT THE GEOGRAPHIC AREA AND DEMOGRAPHIC CONSTITUENTS IT SERVES.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., PRIMARILY SERVES THE LAGRANGE COUNTY COMMUNITIES OF LAGRANGE, TOPEKA, SHIPSHEWANA, WOLCOTTVILLE, AND HOWE, INDIANA. AS THE ONLY HOSPITAL IN THIS COUNTY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., ALSO SERVES, TO A LIMITED EXTENT, SURROUNDING COMMUNITIES IN THE EASTERN PORTION OF ELKHART COUNTY, INDIANA, THE WESTERN PORTION OF STEUBEN COUNTY, INDIANA, AND SOME OF THE SOUTHERN PORTIONS OF CASS, ST. JOSEPH, AND BRANCH COUNTIES IN MICHIGAN.IN APRIL 2020, THE POPULATION OF LAGRANGE COUNTY WAS APPROXIMATELY 39,614. ACCORDING TO STATS.INDIANA.EDU AND THE U.S. CENSUS BUREAU, 95.6% OF THE RESIDENTS ARE CAUCASIAN (NON-HISPANIC) AND 4.4% ARE HISPANIC. THE MEDIAN INCOME IN LAGRANGE COUNTY IS $64,498. THE COVID-19 PANDEMIC CREATED AN UNANTICIPATED SPIKE IN THE UNEMPLOYMENT RATE IN MAY OF 2020 UP TO 10.2%. THE PERCENTAGE OF THE POPULATION LIVING IN POVERTY DECREASED SLIGHTLY TO 7.5%. ACCORDING TO THE LAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION, PLAIN CHURCH RESIDENTS, INCLUDING MEMBERS OF THE AMISH COMMUNITY, MAKE UP APPROXIMATELY 45% OF THE TOTAL POPULATION OF LAGRANGE COUNTY. FOR THE MEMBERS OF THESE FAITH-BASED COMMUNITIES, TRAVEL IS BY HORSE AND BUGGY OR BICYCLE; COMMUNICATIONS ARE PRIMARILY FACE-TO-FACE OR THROUGH THE USE OF MULTI-FAMILY CENTRALIZED PARTY LINE TELEPHONE BOOTHS.
PART VI, LINE 5:	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.).THE MAJORITY OF THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA. THE HOSPITAL ALSO EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. PEOPLE THROUGHOUT THE COMMUNITY CAN COUNT ON COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. TO BE STANDING BY WITH EMERGENCY CARE 24 HOURS A DAY, 365 DAYS A YEAR. THE EMERGENCY DEPARTMENT IS STAFFED WITH BOARD-CERTIFIED PHYSICIANS AND A NURSING STAFF THAT IS TRAINED AND CERTIFIED IN EMERGENCY CARE. FURTHERMORE, NO PATIENT IS EVER DENIED TREATMENT, REGARDLESS OF THEIR ABILITY TO PAY.COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, EDUCATION AND OUTREACH PROGRAMS, FREE AND DISCOUNTED CARE, VOLUNTEERISM AND MUCH MORE. THE FOLLOWING ARE SOME OF THE WAYS COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS REACHING OUT TO MAKE OUR NEIGHBORHOODS AND COMMUNITIES HEALTHIER:THE COMMUNITY HEALTH IMPROVEMENT COMMITTEE (CHIC) OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A PROGRAM THAT PROVIDES GRANT SUPPORT FOR COMMUNITY HEALTH INITIATIVES DELIVERED BY NOT-FOR-PROFIT COMMUNITY ORGANIZATIONS THAT SHARE THE HOSPITAL'S MISSION TO ENCOURAGE HEALTHIER LIFESTYLES AMONG THE CITIZENS OF LAGRANGE COUNTY AND PROVIDE SERVICES THAT ARE NOT AVAILABLE THROUGH THE HOSPITAL. FUNDS ARE AWARDED BASED ON THE TOP NEEDS THAT WERE IDENTIFIED FOR LAGRANGE COUNTY THROUGH THE MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT. THE FOLLOWING CHIC INITIATIVES WERE SUPPORTED THROUGH HEALTH PARTNERS WHO ALIGN WITH THE TOP COMMUNITY HEALTH NEEDS IDENTIFIED FOR LAGRANGE COUNTY AND NORTHEAST INDIANA. FUNDED PROGRAMS PROVIDING SUPPORT TO LAGRANGE COUNTY PATIENTS IN 2020 INCLUDED:-LAGRANGE COUNTY COUNCIL ON AGING (COA) - SUPPORT WAS PROVIDED TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S SERVICES TO SENIORS, INCLUDING TRANSPORTATION TO ACCESS HEALTHCARE AND WELL-BEING RESOURCES SUCH AS ACCESS TO FOOD AND EXERCISE, AND HOMEMAKER SERVICES THAT HELP REDUCE THE RISK OF A FALL OR OTHER INJURY. -BRIGHTPOINT - SUPPORT WAS PROVIDED TO ASSIST WITH OBTAINING HEALTHCARE COVERAGE FOR CHILDREN AND THEIR FAMILIES. -CANCER SERVICES OF NORTHEAST INDIANA - SUPPORT WAS PROVIDED TO ASSIST PATIENTS WITH HEALTHCARE SUPPLIES NOT COVERED BY INSURANCE, FOR EDUCATION RELATED TO WELLNESS AND HEALTHY LIFESTYLE PRACTICES.-WESTVIEW SCHOOL CORPORATION - SUPPORT WAS PROVIDED TO ASSIST WITH THE OBTAINING MEDICAL SUPPLIES TO PUT TOGETHER SAFETY BAGS FOR CLASSROOMS TO HELP WITH FIRST AID AND STOP THE BLEED INITIATIVE.-TOWN OF LAGRANGE - SUPPORT WAS PROVIDED TO ASSIST WITH PLAYGROUND & SPLASH PAD PROJECT THAT PROVIDES A SAFE PLACE FOR YOUTH AND PEOPLE OF ALL AGES TO BE ACTIVE AND HAVE A SENSE OF COMMUNITY WITH EACH OTHER.-LAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION - SUPPORT WAS PROVIDED TO ASSIST WITH EFFORTS AROUND ACCESS TO HOUSING AND INCREASING CAPACITY FOR CERTIFIED EARLY LEARNING PROGRAMS.-RESPECTTEAM - SUPPORT WAS PROVIDED TO BRING EDUCATION AND PROGRAMMING ON MENTAL HEALTH/SUBSTANCE USE, AND WELLNESS TO STUDENTS AT PRAIRIE HEIGHTS SCHOOLS GRADES 6-12.-LAGRANGE COUNTY SHERIFF'S DEPARTMENT - SUPPORT WAS PROVIDED TO PUT TOGETHER SUPPLIES FOR ACTIVE SHOOTER BAGS.-LAGRANGE COUNTY HEALTH COALITION - SUPPORT WAS PROVIDED FOR THE CLEAN THE RIVER HEALTH CHALLENGE.-LIFEBRIDGE PROGRAM - SUPPORT WAS PROVIDED FOR EDUCATION ON 'ASSISTING INDIVIDUALS IN CRISIS AND GROUP CRISIS', AND THEN TO SIT FOR THE CISM (CRISES INCIDENT STRESS MANAGEMENT) CERTIFICATION EXAM.PATIENT & FAMILY ADVISORY COUNCIL (PFAC): IN 2020, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. CONTINUED ITS PARTNERSHIP WITH PATIENTS AND PATIENT FAMILY MEMBERS THROUGH THE HOSPITAL'S PFAC. THE PFAC MEMBERS PROVIDED FEEDBACK ABOUT PROCESSES AND COMMUNICATION OPPORTUNITIES THAT WOULD IMPROVE QUALITY AND THE PATIENT EXPERIENCE. AREAS IMPACTED BY THE PFAC'S INVOLVEMENT DURING 2020 WERE:-PROVIDING INPUT AND FEEDBACK REGARDING THE HOSPITAL'S VISITOR RESTRICTION PROCESS AND COMMUNICATION AS A RESULT OF THE COVID-19 PANDEMIC. -PROVIDING INPUT AND FEEDBACK ON HOW MANDATORY MASKING IS VIEWED FROM THE PLAIN CHURCH/AMISH PERSPECTIVE AND THE GENERAL POPULATION, AND HOW IT IMPACTS THE COMMUNICATION PROCESS BETWEEN CAREGIVERS, PATIENTS & FAMILY/SUPPORT MEMBERS.
PART VI, LINE 6:	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.PARKVIEW HEALTH SYSTEM, INC. (PARKVIEW), A HEALTHCARE SYSTEM SERVING NORTHEAST INDIANA AND NORTHWEST OHIO THROUGH OUR HOSPITALS AND PHYSICIAN CLINICS, INCLUDES THE NOT-FOR-PROFIT HOSPITALS OF PARKVIEW HOSPITAL, INC.; COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.; COMMUNITY HOSPITAL OF NOBLE COUNTY, INC.; PARKVIEW WABASH HOSPITAL, INC.; WHITLEY MEMORIAL HOSPITAL, INC.; HUNTINGTON MEMORIAL HOSPITAL, INC.; DEKALB MEMORIAL HOSPITAL, INC.; AS WELL AS 60 PERCENT OWNERSHIP IN THE JOINT VENTURE OF ORTHOPEDIC HOSPITAL AT PARKVIEW NORTH, LLC. PARKVIEW CONTRIBUTES TO THE SUCCESS OF THE REGION BY EFFECTIVELY MANAGING ITS FACILITIES, EFFICIENTLY PROVIDING, AND DELIVERING ITS SERVICES, AND SUPPORTING LOCAL BUSINESSES AND ACTIVITIES. PARKVIEW SEEKS TO CREATE ALIGNMENT OPPORTUNITIES TO DELIVER COMPREHENSIVE HIGH-QUALITY CARE THAT BENEFIT PATIENTS, PHYSICIANS, CO-WORKERS, AND COMMUNITIES. EACH HOSPITAL ENTITY ENGAGES IN COMMUNITY OUTREACH CUSTOMIZED TO MEET THE UNIQUE NEEDS OF THEIR RESPECTIVE COMMUNITIES. AFFILIATE HOSPITALS WORK TOGETHER AND SHARE PROGRAMMING AND MESSAGING WHERE COMMON COMMUNITY HEALTH ISSUES ARE IDENTIFIED. AS A COLLECTIVE GROUP, ALL AFFILIATE HOSPITALS HAVE CAREFULLY CHOSEN TO FOCUS ON THE HEALTH PRIORITY OF OBESITY AND THE PROMOTION OF A HEALTHY LIFESTYLE. THIS INCLUDES EDUCATION ON GOOD NUTRITION, CONSUMPTION AND ACCESS TO HEALTHY FOODS, AND AN ACTIVE LIFESTYLE. THE ABOVE FOCUS WAS SELECTED FROM A LIST OF HEALTH ISSUES THAT RESIDE IN THE SEVEN-COUNTY AREA. IN 2020, PARKVIEW HEALTH WORKED DILIGENTLY IN THE REGION TO ASSURE SAFE, COMPASSIONATE, AND APPROPRIATE CARE THROUGHOUT THE COMMUNITIES RELATED TO THE COVID-19 PANDEMIC. THE HEALTH SYSTEM AND ITS AFFILIATED HOSPITALS WERE IDENTIFIED AS A TRUSTED SOURCE OF INFORMATION, CARE, AND COMMITMENT TO EXCELLENCE. THIS INCLUDED THE EFFICIENT, EFFECTIVE, AND MOST UPDATED CARE OF CORONAVIRUS PATIENTS AS WELL AS AN ONGOING TRUSTED SOURCE OF RESEARCH-BASED EDUCATION AND COMMUNICATION. PARKVIEW HEALTH AND ITS COMMUNITY HOSPITALS WERE INTIMATELY INVOLVED IN LOCALLY PROMOTING SOCIAL DISTANCING, SAFE MASKING PRACTICES, LOCAL TESTING FOR THE VIRUS, AND ASSISTING WITH VACCINATION DISTRIBUTION. PARKVIEW PRIDES ITSELF IN NOT ONLY OFFERING THE HIGHEST LEVEL OF CARE TO ITS PATIENTS, BUT ALSO IN PROVIDING AN EXCELLENT WORKPLACE FOR ITS PHYSICIANS, NURSES, AND STAFF. PARKVIEW'S MISSION AND VISION IS: AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, PARKVIEW HEALTH IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING BY 1) TAILORING A PERSONALIZED HEALTH JOURNEY TO ACHIEVE YOUR UNIQUE GOALS, 2) DEMONSTRATING WORLD-CLASS TEAMWORK AS WE PARTNER WITH YOU ALONG THAT JOURNEY 3) PROVIDING THE EXCELLENCE, INNOVATION, AND VALUE YOU SEEK IN TERMS OF CONVENIENCE, COMPASSION, SERVICE, COST, AND QUALITY 4) "EXCELLENT CARE, EVERY PERSON, EVERY DAY". PARKVIEW BELIEVES THAT THE COMMUNITIES IT SERVES SHOULD ALL HAVE THE PEACE OF MIND THAT COMES WITH ACCESS TO COMPASSIONATE, HIGH-QUALITY HEALTHCARE, REGARDLESS OF WHETHER THE CARE IS DELIVERED IN A RURAL OR URBAN SETTING.
PART VI, LINE 7, REPORTS FILED WITH STATES	IN
PART VI, LINE 7:	A COPY OF FORM 990, SCHEDULE H IS FILED WITH THE INDIANA STATE DEPARTMENT OF HEALTH.

Schedule H (Form 990) 2020

Additional Data

Software ID:
Software Version:

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

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

2020

Open to Public
Inspection

Name of the organization
COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number
20-2401676

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) PARKVIEW LAGRANGE HOSPITAL FOUNDATION INC 207 N TOWNLINE ROAD LAGRANGE,IN46761	83-3347115	501(C)(3)	379,191				TRANSFER OF EXISTING DONATIONS/FUND BALANCES HELD BY THE HOSPITAL AS PARKVIEW LAGRANGE HOSPITAL FOUNDATION, INC. IS NOW A SEPARATE 501(C)(3) ORGANIZATION AND IS A TYPE I SUPPORTING ORGANIZATION TO COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.
(2) LAGRANGE COUNTY COUNCIL ON AGING INC PO BOX 107 LAGRANGE,IN46761	23-7455893	501(C)(3)	10,000				TRANSPORT PROGRAM AND ASSIST INDIVIDUALS TO REMAIN INDEPENDENT IN THEIR HOMES

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) 2020

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)
(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:	COMMUNITY HEALTH IMPROVEMENT FUNDING PARTNER ORGANIZATIONS ARE REQUIRED TO SUBMIT AN ANNUAL PROGRESS REPORT RELATED TO PROGRAM FUNDING. PARTNER ORGANIZATIONS ARE REQUIRED TO RE-APPLY FOR FUNDING ON AN ANNUAL BASIS.

Schedule I (Form 990) 2020

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Graphic Arrow

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Graphic Arrow

Attach to Form 990.
Graphic Arrow

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

OMB No. 1545-0047

2020

Open to Public Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

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 .....

Yes

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? .........

Yes

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

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2020

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)
1MICHAEL PACKNETT DIRECTOR/PH PRESIDENT & CEO	(i) (ii)	0 ------------- 1,193,402	0 ------------- 487,482	0 ------------- 367,537	0 ------------- 1,624,548	0 ------------- 32,305	0 ------------- 3,705,274	0 ------------- 319,527
2JEANNE' WICKENS PH CHIEF FINANCIAL OFFICER	(i) (ii)	0 ------------- 750,792	0 ------------- 262,181	0 ------------- 71,579	0 ------------- 309,952	0 ------------- 29,943	0 ------------- 1,424,447	0 ------------- 49,457
3LISA BOOTH DIRECTOR/PH PHYSICIAN	(i) (ii)	5,978 ------------- 369,291	0 ------------- 52,768	0 ------------- 7,891	430 ------------- 30,920	205 ------------- 14,750	6,613 ------------- 475,620	0 ------------- 0
4RHONDA SHARP DIRECTOR/PH PHYSICIAN	(i) (ii)	124,300 ------------- 186,450	0 ------------- 52,629	2,432 ------------- 3,648	10,754 ------------- 20,596	1,590 ------------- 3,046	139,076 ------------- 266,369	0 ------------- 0
5JORDI DISLER DIRECTOR/LGHOS PRESIDENT	(i) (ii)	207,358 ------------- 0	57,045 ------------- 0	14,734 ------------- 0	61,378 ------------- 0	24,453 ------------- 0	364,968 ------------- 0	13,216 ------------- 0
6JAMIN YODER DIRECTOR/PH PHYSICIAN	(i) (ii)	17,619 ------------- 193,929	0 ------------- 44,813	0 ------------- 4,428	1,073 ------------- 14,809	2,126 ------------- 29,341	20,818 ------------- 287,320	0 ------------- 0
7BRENDA ARMENTROUT LGHOS MGR PHARMACY	(i) (ii)	170,211 ------------- 0	21,060 ------------- 0	3,810 ------------- 0	21,171 ------------- 0	11,071 ------------- 0	227,323 ------------- 0	0 ------------- 0
8ROBERT BLOOMFIELD LGHOS MGR SUPPORT SERVICE	(i) (ii)	120,482 ------------- 0	15,649 ------------- 0	1,591 ------------- 0	15,490 ------------- 0	21,312 ------------- 0	174,524 ------------- 0	0 ------------- 0
9TREVOR FRY LGHOS MGR ER	(i) (ii)	112,495 ------------- 0	14,048 ------------- 0	371 ------------- 0	14,455 ------------- 0	23,552 ------------- 0	164,921 ------------- 0	0 ------------- 0
10TODD KLINEDINST LGHOS VP PATIENT CARE	(i) (ii)	153,818 ------------- 0	1,000 ------------- 0	1,137 ------------- 0	495 ------------- 0	2,682 ------------- 0	159,132 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2020

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	TAX INDEMNIFICATION AND GROSS-UP PAYMENTS - TAX ON TAXABLE GIFT: TREVOR FRY $13
PART I, LINE 3	RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF COMMUNITY HOSPITAL LAGRANGE COUNTY, INC.'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC. INDEPENDENT COMPENSATION CONSULTANT FORM 990 OF OTHER ORGANIZATIONS COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE OF RELATED ORGANIZATION PARKVIEW HEALTH SYSTEM, INC.
PART I, LINE 4B	SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS THE FOLLOWING INDIVIDUALS PARTICIPATE IN SUPPLEMENTAL NONQUALIFIED DEFERRED COMPENSATION PLANS. BENEFITS EARNED UNDER THE PLANS WILL FUND THE EMPLOYEES' EVENTUAL RETIREMENT BENEFIT. THESE BENEFITS ARE PROVIDED IN EXCHANGE FOR THE EMPLOYEES' YEARS OF SERVICE TO THE ORGANIZATION AND THE AMOUNT OF THE BENEFITS MAY VARY FROM YEAR TO YEAR. THE FOLLOWING INDIVIDUALS VESTED IN A PORTION OF THEIR DEFERRED COMPENSATION PLANS, WHICH IS TREATED AS TAXABLE INCOME TO THE INDIVIDUALS AT THE TIME OF VESTING. THESE AMOUNTS ARE REPORTED IN SCHEDULE J, PART II, COLUMN (B)(III): JORDI DISLER $13,216; MICHAEL PACKNETT $319,527; JEANNE' WICKENS $49,457 AMOUNTS LISTED ABOVE THAT HAVE BEEN REPORTED AS DEFERRED COMPENSATION ON PRIOR FORM 990 WILL ALSO BE REFLECTED IN SCHEDULE J, PART II, COLUMN (F). FOR EXAMPLE, THE AMOUNT OF $319,527 REPORTED AS REQUIRED FOR MR. PACKNETT WAS A RESULT OF THE VESTING OF SUCH AMOUNT UNDER THE TERMS OF THE RESPECTIVE PLANS. HOWEVER, THESE AMOUNTS WERE PREVIOUSLY REPORTED IN MR. PACKNETT'S DEFERRED COMPENSATION OVER MORE THAN 10 YEARS AS THE AMOUNTS WERE DEFERRED UNDER THE PLANS. AS SUCH, THE AMOUNT REPORTED IN SCHEDULE J, PART II, COLUMN (F) IS AN INDICATION OF AMOUNTS THAT HAVE BEEN REPORTED TWICE, ONCE AS A DEFERRAL AND ONCE AS VESTED. THE FOLLOWING INDIVIDUALS HAVE AN AMOUNT INCLUDED IN SCHEDULE J, PART II, COLUMN (C) FOR AN AMOUNT EARNED BUT NOT YET VESTED UNDER ONE OF PARKVIEW'S DEFERRED COMPENSATION PLANS. THE AMOUNTS ARE AT RISK AND WILL NOT BE PAID UNLESS AND UNTIL EACH EMPLOYEE HAS PROVIDED SUBSTANTIAL FUTURE SERVICES TO THE ORGANIZATION. BENEFITS UNDER THE PLANS VEST AT THE TIME SET FORTH IN THE PLAN DOCUMENTS AND ARE FORFEITED IF THE EMPLOYEES TERMINATE EMPLOYMENT BEFORE SATISFYING THOSE PLAN CONDITIONS. DEFERRALS REPORTED IN SCHEDULE J, PART II, COLUMN (C) INCLUDE: JORDI DISLER $33,140; MICHAEL PACKNETT $1,598,898; JEANNE' WICKENS $290,002
PART I, LINE 7	MANAGEMENT INCENTIVE COMPENSATION PLAN (MICP) AND PHYSICIAN AND PROVIDER INCENTIVE COMPENSATION PLAN (PICP) ARE ANNUAL INCENTIVE PROGRAMS. SYSTEM GOALS ARE APPROVED BY THE BOARD. AT CONCLUSION OF THE PLAN YEAR, RESULTS ARE SHARED WITH THE BOARD AND THE EXECUTIVE COMMITTEE OF THE BOARD APPROVES FINAL PAYMENT.

Schedule J (Form 990) 2020

Additional Data

Software ID:
Software Version:

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

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

2020

Open to Public
Inspection

Name of the organization
COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number
20-2401676

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	INDIANA HEALTH AND EDUCATIONAL FACILITY FINANCING AUTHORITY	35-1611409	45479RCF2	03-15-2007	24,930,000	SEE PART VI		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	9,695,000
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	25,930,446
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............	1,074,006
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	208,535
8 Credit enhancement from proceeds .............	154,519
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............	24,493,386
11 Other spent proceeds .............
12 Other unspent proceeds .............
13 Year of substantial completion .............	2008
	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 2019, a current refunding issue)? ........		X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2019, an advance refunding issue)? ........		X
16 Has the final allocation of proceeds been made? ..........	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X

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

Cat. No. 50193E

Schedule K (Form 990) 2020

Page 2

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
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............	X
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............	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
c Are there any research agreements that may result in private business use of bond-financed property? .............		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 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %
6 Total of lines 4 and 5 .............	0 %
7 Does the bond issue meet the private security or payment test? ...		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
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

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
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X
b Exception to rebate? ........		X
c No rebate due? .........	X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....	X

Schedule K (Form 990) 2020

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		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
7 Has the organization established written procedures to monitor the requirements of section 148? ...	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

Part Ⅵ

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

Return Reference	Explanation
SCHEDULE K, PART I, COLUMN F, LINE A:	CONSTRUCTION OF NEW HOSPITAL FACILITY FOR COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IN LAGRANGE, INDIANA
SCHEDULE K, PART II, COLUMN A, LINE 3:	THIS AMOUNT INCLUDES INTEREST OF $1,000,446. EARNED ON PROJECT, COST OF ISSUANCE AND CAPITALIZED INTEREST FUNDS.
SCHEDULE K, PART III, COLUMN A, LINES 4-6:	AS PART OF OUR EFFORTS TO MONITOR AND ENSURE THAT THERE IS NO PRIVATE USE AT OUR BOND FINANCED FACILITIES, WE CONTRIBUTE EQUITY TO FINANCE A PORTION OF OUR NEW MONEY PROJECTS.
SCHEDULE K, PART III, COLUMN A, LINE 7:	BECAUSE PARKVIEW MONITORS THE PRIVATE BUSINESS USE PERCENTAGE FOR EACH BOND ISSUE, TO ENSURE THAT THE PRIVATE BUSINESS USE LIMIT IS NOT EXCEEDED, PARKVIEW DOES NOT CALCULATE THE AMOUNT OF PRIVATE PAYMENTS.
SCHEDULE K, PART IV, COLUMN A, LINE 2C:	REBATE COMPUTATION PERFORMED ON APRIL 13, 2010.

Schedule K (Form 990) 2020

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

2020

Open to Public
Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

Return Reference	Explanation
FORM 990, PART V, LINES 1A AND 2A:	PARKVIEW HEALTH SYSTEM, INC. (PH), EIN 35-1972384, IS THE COMMON PAYING AGENT FOR THE FILING ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., EIN 20-2401676. THEREFORE, ALL APPLICABLE IRS TAX FILINGS, INCLUDING FORMS 1099, 1096, W-2 AND W-3 ARE REPORTED AND FILED BY PH. THE TOTAL NUMBER REPORTED IN BOX 3 OF FORM 1096 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2020 WAS 738. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, PH, FOR THE YEAR ENDED DECEMBER 31, 2020 WAS 15,150. FOR PURPOSES OF COMPLETING FORM 990, PART V, LINE 1A AND 2A, THE NUMBER REPORTED FOR THE COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WAS 35 AND 217 RESPECTIVELY.
FORM 990, PART VI, SECTION A, LINE 1	THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE OFFICERS OF THE BOARD, THE PRESIDENT OF THE CORPORATION, THE PRESIDENT/CHIEF EXECUTIVE OFFICER OF THE CORPORATE MEMBER OR HIS/HER DESIGNEE, THE CURRENT PRESIDENT OF THE MEDICAL STAFF AND SUCH OTHER PERSONS AS IDENTIFIED BY THE CHAIR OF THE BOARD, EACH OF WHOM SHALL BE ENTITLED TO VOTE. IN NO EVENT SHALL THE MEMBERS OF THE EXECUTIVE COMMITTEE EXCEED EIGHT (8) PEOPLE. THE EXECUTIVE COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION IN ANY MATTER WHEN THE BOARD IS NOT IN SESSION, REPORTING TO THE BOARD FOR ITS RATIFICATION OF ITS ACTION. THE CHAIR OF THE BOARD SHALL SERVE AS CHAIR OF THE EXECUTIVE COMMITTEE. MEETINGS OF THE EXECUTIVE COMMITTEE MAY BE CALLED BY THE CHAIR OR BY THREE (3) MEMBERS.
FORM 990, PART VI, SECTION A, LINE 2	DIRECTORS JORDI DISLER AND JOE URBANSKI HAVE A BUSINESS RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 6	THE ORGANIZATION IS ORGANIZED AS A NOT-FOR-PROFIT CORPORATION. PURSUANT TO THE ORGANIZATION'S GOVERNING DOCUMENTS, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384 IS THE SOLE MEMBER OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. WITH CERTAIN RESERVED POWERS.
FORM 990, PART VI, SECTION A, LINE 7A	THE CORPORATE MEMBER, PARKVIEW HEALTH SYSTEM, INC. EIN 35-1972384, SHALL HAVE THE FOLLOWING RESERVED POWERS: (I) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD SUBJECT TO THE COMPOSITION REQUIREMENTS REGARDING COMMUNITY AND PHYSICIAN REPRESENTATION SET FORTH IN ARTICLE V, SECTION 2; (II) APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE CHAIR AND VICE CHAIR OF THE BOARD AND THE PRESIDENT OF THE CORPORATION; (III) APPROVE AND/OR REQUIRE THE ADOPTION OF AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (IV) APPROVE AND/OR REQUIRE THE ESTABLISHMENT, ACQUISITION, DIVESTITURE, DISSOLUTION, CLOSURE, MERGER, CONSOLIDATION, CHANGE IN CORPORATE MEMBERSHIP, AFFILIATION OR CORPORATE REORGANIZATION OF THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (V) APPROVE AND ADOPT THE STRATEGIC PLAN AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (VI) APPROVE AND/OR REQUIRE THE INCURRENCE OF ANY DEBT, INCLUDING THE ISSUANCE OF ANY BONDS, PROPOSED BY THE CORPORATION OR ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VII) APPROVE AND/OR REQUIRE THE APPROVAL OF CONTRACTS OR LOANS OBLIGATING THE CORPORATION TO EXPEND OR REPAY AN AMOUNT IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (VIII) APPROVE AND/OR REQUIRE THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, TRANSFER, ENCUMBRANCE OR OTHER DISPOSITION OF PROPERTY AND ASSETS OF THE CORPORATION IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; (IX) APPROVE AND ADOPT THE CAPITAL BUDGET, OPERATING BUDGET, FINANCIAL PLANS AND ANY AMENDMENTS THERETO FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (X) APPROVE AND/OR REQUIRE THE ADOPTION OF A MANAGED CARE POLICY FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION, INCLUDING NETWORK PARTICIPATION, PARTICIPATION IN ANY MANAGED CARE AGREEMENT AND PARTICIPATION IN ANY OTHER HEALTH CARE SERVICE ARRANGEMENTS; (XI) APPOINT AND REMOVE AUDITORS, ATTORNEYS AND OTHER PROFESSIONAL ADVISORS FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XII) DEVELOP, APPROVE AND/OR REQUIRE THE ADOPTION OF MEDICAL STAFF QUALITY ASSURANCE STANDARDS, UTILIZATION REVIEW STANDARDS, CRITERIA, POLICIES AND PROCEDURES FOR THE CORPORATION AND ANY SUBSIDIARY OR AFFILIATE OF THE CORPORATION; (XIII) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION TO CHANGE THE CORPORATION FROM A GENERAL, ACUTE CARE COMMUNITY HOSPITAL OR TO CLOSE THE CORPORATION'S CURRENT LOCATION; (XIV) APPROVE EACH ANNUAL LIST OF PROPOSED DONORS AND AMOUNTS OF DONATIONS OR GRANTS NOT INCLUDED IN THE ANNUAL BUDGET, AND MAKE PROPOSALS TO DEVIATE THEREFROM THROUGHOUT EACH YEAR IN EXCESS OF LIMITS SPECIFIED IN THE POLICY OF THE CORPORATE MEMBER; AND (XV) APPROVE AND/OR REQUIRE THE ADOPTION OF ANY ACTION THAT IS INCONSISTENT WITH THE POLICY OF THE CORPORATE MEMBER.
FORM 990, PART VI, SECTION A, LINE 7B	SEE SCHEDULE O EXPLANATION FOR FORM 990, PART VI, SECTION A, LINE 7A
FORM 990, PART VI, SECTION B, LINE 11B	PURSUANT TO PARKVIEW HEALTH SYSTEM INC.'S BYLAWS, THE SYSTEM AUDIT COMMITTEE MAY ACT ON BEHALF OF THE CORPORATION TO PROVIDE REVIEW OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS' FORM 990 FILINGS. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A SUBSIDIARY CORPORATION OF PARKVIEW HEALTH SYSTEM, INC. AN ELECTRONIC COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES) WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY, PRIOR TO FILING WITH THE IRS. ON OCTOBER 27, 2021, THE SYSTEM AUDIT COMMITTEE REVIEWED THE FORM 990 AS ULTIMATELY FILED WITH THE IRS. THIS REVIEW INCLUDED A PRESENTATION BY THE ORGANIZATION'S TAX PREPARER TO HIGHLIGHT THE SIGNIFICANT AREAS ON THE FORM 990 AND SUPPLEMENTAL SCHEDULES.
FORM 990, PART VI, SECTION B, LINE 12C	AS DESCRIBED IN ARTICLE IX SECTION 6, OF THE PARKVIEW HEALTH SYSTEM, INC. (PH) BYLAWS, PH ADOPTED PH'S COMPLIANCE POLICY FOR THE ORGANIZATION AND ITS NOT-FOR-PROFIT RELATED ORGANIZATIONS (AND AS LIKEWISE NOTED IN THEIR BYLAWS) WHEN ADDRESSING CONFLICTS OR POTENTIAL CONFLICTS OF INTEREST. THIS COMPLIANCE POLICY (COMPLIANCE POLICY #14) REQUIRES THAT EACH BOARD MEMBER, BOARD COMMITTEE MEMBER, AND KEY MANAGEMENT PERSONNEL MUST ANNUALLY COMPLETE A CONFLICT OF INTEREST FORM. THIS INFORMATION IS PROVIDED TO THE CHAIRMAN OF THE BOARD (FOR BOARD AND BOARD COMMITTEE MEMBERS) AND TO SENIOR MANAGEMENT (FOR KEY MANAGEMENT PERSONNEL). IN ADDITION, AS TO THE CONDUCT OF BOARD MEETINGS, THE FOLLOWING PROCESS IS FOLLOWED: "WHENEVER A PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE IS CONSIDERING A TRANSACTION OR ARRANGEMENT WITH AN ORGANIZATION, ENTITY OR INDIVIDUAL IN WHICH A PERSON COVERED BY THIS POLICY HAS A FINANCIAL OR CONFLICTING INTEREST, THE FOLLOWING SHALL OCCUR: 1. THE INTERESTED PERSON MUST DISCLOSE THE FINANCIAL OR CONFLICTING INTEREST AND ALL MATERIAL FACTS TO THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE; 2. THE INTERESTED PERSON WITH THAT FINANCIAL OR CONFLICTING INTEREST MAY MAKE A PRESENTATION AT THE BOARD OR BOARD COMMITTEE MEETING REGARDING THE TRANSACTION OR ARRANGEMENT HOWEVER, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT RESULTS IN THE FINANCIAL OR CONFLICTING INTEREST; AND 3. THE PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE MUST APPROVE THE TRANSACTION OR ARRANGEMENT BY A MAJORITY VOTE OF THE BOARD MEMBERS PRESENT AT A MEETING THAT HAS A QUORUM, NOT INCLUDING THE VOTE OF THE INTERESTED PERSON. THE INTERESTED PERSON MAY NOT VOTE ON THE MATTER. A. UPON THE REQUEST OF PH OR PH AFFILIATE BOARD OR BOARD COMMITTEE, THE MATTER MAY BE DELEGATED TO THE PH COMPLIANCE COMMITTEE FOR EVALUATION, RECOMMENDATION AND/OR DETERMINATION. 4. WHENEVER A FINANCIAL OR CONFLICTING INTEREST IS ADDRESSED BY A PH OR PH AFFILIATE BOARD, NOTICE SHALL BE GIVEN TO THE PH COMPLIANCE OFFICER / GENERAL COUNSEL."
FORM 990, PART VI, SECTION B, LINE 15	LINES 15A AND 15B ARE ANSWERED NO IN ACCORDANCE WITH THE IRS INSTRUCTIONS. TO THE EXTENT THAT THE ORGANIZATION HAS VICE PRESIDENT OR ABOVE, THE COMPENSATION COMMITTEE OF RELATED ORGANIZATION, PARKVIEW HEALTH SYSTEM, INC., DETERMINES THE COMPENSATION OF THE CEO, OFFICERS, AND KEY EMPLOYEES.
FORM 990, PART VI, SECTION C, LINE 19	COPIES OF THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.
FORM 990, PART IX, LINE 11G	OTHER: PROGRAM SERVICE EXPENSES 703,342. MANAGEMENT AND GENERAL EXPENSES 26,905. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 730,247. MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,030,023. MANAGEMENT AND GENERAL EXPENSES 404,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,434,023. LAB SERVICES: PROGRAM SERVICE EXPENSES 1,070,767. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,070,767. COLLECTION EXPENSE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 237,794. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 237,794. TEMPORARY HELP: PROGRAM SERVICE EXPENSES 178,421. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 178,421.
FORM 990, PART IX, LINES 5-10:	PARKVIEW HEALTH SYSTEM, INC., EIN 35-1972384, SERVES AS THE COMMON PAYING AGENT FOR ALL TAX-EXEMPT ORGANIZATIONS OF THE SYSTEM. SALARIES AND WAGES OF EMPLOYEES WORKING FOR THESE ORGANIZATIONS ARE CHARGED DIRECTLY TO THE ORGANIZATIONS IN WHICH THEY WORK. THE ACTUAL EXPENSES FOR PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS ARE REFLECTED ON THE BOOKS OF PARKVIEW HEALTH SYSTEM, INC. FOR FINANCIAL REPORTING PURPOSES. TO ACCOUNT FOR BENEFIT COSTS ON THE BOOKS OF THE OTHER TAX EXEMPT ORGANIZATIONS, AN ALLOCATION METHODOLOGY IS UTILIZED TO CHARGE THESE ORGANIZATIONS WITH AN ESTIMATE OF THE OVERALL COSTS, REFERRED TO AS A "BENEFIT ALLOCATION" FROM PARKVIEW HEALTH SYSTEM, INC. THE ALLOCATION DOES NOT DISTINGUISH BETWEEN THE COSTS OF THE VARIOUS COMPONENTS (I.E. PAYROLL TAXES, EMPLOYEE BENEFITS, AND PENSION PLAN CONTRIBUTIONS). THEREFORE, FOR PURPOSES OF THE FORM 990, PART IX, THE TOTAL BENEFIT ALLOCATION FOR THE EMPLOYEES' SALARIES AND WAGES REPORTED ON LINE 7 IS REFLECTED ON LINE 9 AND NOT ALLOCATED BETWEEN LINES 8 OR 10. FOR PURPOSES OF THE FORM 990, PART IX, LINES 5 AND 6 REFLECT COMPENSATION AND BENEFIT AMOUNTS REPORTED IN PART VII.
FORM 990, PART XI, LINE 9:	ASSET TRANSFERS/ADJUSTMENTS 2,968.

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2020

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

2020

Open to Public Inspection

Name of the organization

COMMUNITY HOSPITAL OF LAGRANGE COUNTY
INC

Employer identification number

20-2401676

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)PARKVIEW HEALTH SYSTEM INC 1450 PRODUCTION RD FORT WAYNE,IN46808 35-1972384	HEALTH CARE	IN	501(C)(3)	LINE 12C, III-FI	N/A		No
(2)PARKVIEW LAGRANGE HOSPITAL FOUNDATION INC 207 N TOWNLINE ROAD LAGRANGE,IN46761 83-3347115	FUND MGMT	IN	501(C)(3)	LINE 12A, I	COMMUNITY HOSPITAL OF LAGRANGE COUNTY INC	Yes
(3)COMMUNITY HOSPITAL OF NOBLE COUNTY FOUNDATION INC 401 SAWYER ROAD KENDALLVILLE,IN46755 35-2089183	FUND MGMT	IN	501(C)(3)	LINE 12A, I	COMMUNITY HOSPITAL OF NOBLE COUNTY INC		No
(4)COMMUNITY HOSPITAL OF NOBLE COUNTY INC 401 SAWYER ROAD KENDALLVILLE,IN46755 35-2087092	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(5)DEKALB MEMORIAL HOSPITAL INC 1316 EAST SEVENTH STREET AUBURN,IN46706 35-1064295	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(6)HUNTINGTON MEMORIAL HOSPITAL INC 2001 STULTS ROAD HUNTINGTON,IN46750 35-1970706	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(7)MIDWEST COMMUNITY HEALTH ASSOCIATES INC 442 W HIGH STREET BRYAN,OH43506 34-1045870	PHYSICIANS	OH	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(8)PARK CENTER HOLDINGS INC 909 EAST STATE BLVD FORT WAYNE,IN46805 84-3684074	TO SUPPORT PARK CENTER, INC.	IN	501(C)(3)	LINE 12D, III-O	PARKVIEW HEALTH SYSTEM INC		No
(9)PARK CENTER INC 909 EAST STATE BLVD FORT WAYNE,IN46805 35-1135451	COMPREHENSIVE MENTAL HEALTH CENTER	IN	501(C)(3)	LINE 10	PARKVIEW HEALTH SYSTEM INC		No
(10)PARKVIEW DEKALB HOSPITAL FOUNDATION INC 1316 EAST SEVENTH STREET AUBURN,IN46706 35-6047817	FUND MGMT	IN	501(C)(3)	LINE 12A, I	DEKALB MEMORIAL HOSPITAL INC		No
(11)PARKVIEW FOUNDATION INC 3844 NEW VISION DR FORT WAYNE,IN46845 23-7220589	FUND MGMT	IN	501(C)(3)	LINE 12A, I	PARKVIEW HOSPITAL INC		No
(12)PARKVIEW HOSPITAL INC 11109 PARKVIEW PLAZA DRIVE FORT WAYNE,IN46845 35-0868085	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(13)PARKVIEW HUNTINGTON HOSPITAL FOUNDATION INC 2001 STULTS ROAD HUNTINGTON,IN46750 32-0012095	FUND MGMT	IN	501(C)(3)	LINE 12A, I	HUNTINGTON MEMORIAL HOSPITAL INC		No
(14)PARKVIEW OCCUPATIONAL HEALTH CENTERS INC 1450 PRODUCTION RD FORT WAYNE,IN46808 35-2064353	OCCUPATIONAL HEALTH	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(15)PARKVIEW WABASH HOSPITAL FOUNDATION INC 10 JOHN KISSINGER DRIVE WABASH,IN46992 35-1921445	FUND MGMT	IN	501(C)(3)	LINE 12A, I	PARKVIEW WABASH HOSPITAL INC		No
(16)PARKVIEW WABASH HOSPITAL INC 10 JOHN KISSINGER DRIVE WABASH,IN46992 47-1753440	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No
(17)WHITLEY MEMORIAL HOSPITAL FOUNDATION INC 1260 E STATE ROAD 205 COLUMBIA CITY,IN46725 31-1190239	FUND MGMT	IN	501(C)(3)	LINE 12A, I	WHITLEY MEMORIAL HOSPITAL INC		No
(18)WHITLEY MEMORIAL HOSPITAL INC 1260 E STATE ROAD 205 COLUMBIA CITY,IN46725 35-1967665	HOSPITAL CARE	IN	501(C)(3)	LINE 3	PARKVIEW HEALTH SYSTEM INC		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2020

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership
(1) ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC 1450 PRODUCTION RD FORT WAYNE,IN46808 26-0143823	ORTHO HOSPITAL	IN	N/A	N/A				No			No
(2) MANAGED CARE SERVICES LLC 1450 PRODUCTION RD FORT WAYNE,IN46808 35-1996535	HEALTH PLAN ADMIN	IN	N/A	N/A				No			No

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	Yes	No
(1) PARKVIEW PROFESSIONAL PROGRAMS INC 1450 PRODUCTION RD FORT WAYNE,IN46808 35-1668888	REFERENCE LAB	IN	N/A	C					No
(2) MIDWEST COMMUNITY HEALTH ASSOCIATES INC 442 W HIGH STREET BRYAN,OH43506 34-1045870	PHYSICIANS	OH	N/A	C					No
(3) WOODLAND PLAZA MEDICAL PARK CONDO ASSOC INC 202 W BERRY ST SUITE 800 FORT WAYNE,IN46802 35-2058340	CONDO MANAGEMENT	IN	N/A	C					No

Schedule R (Form 990) 2020

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) .......................

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) PARKVIEW LAGRANGE HOSPITAL FOUNDATION INC	B	379,191	PART VII SUPPLEMENTAL
(2) PARKVIEW LAGRANGE HOSPITAL FOUNDATION INC	M	70,498	PART VII SUPPLEMENTAL

Schedule R (Form 990) 2020

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?		(k) Percentage ownership
(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	(k) Percentage ownership

Schedule R (Form 990) 2020

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

Return Reference	Explanation
SCHEDULE R, PART V, LINE 2, COLUMN (C):	THE AMOUNTS REPORTED AS TRANSACTIONS WITH RELATED ORGANIZATIONS ARE CONSISTENT WITH THE AMOUNTS REPORTED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS UNDER THE GENERALLY ACCEPTED ACCOUNTING STANDARDS DEPENDING ON THE TYPE OF TRANSACTION INVOLVED.

Schedule R (Form 990) 2020

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	90,002	5,951,611
9	Program service revenue (Part VIII, line 2g) .........	41,474,607	33,966,116
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-303	79
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	240,763	139,986
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	41,805,069	40,057,792
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	41,997	408,134
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)	13,597,016	13,950,902
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 70,498
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	27,073,319	23,423,047
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	40,712,332	37,782,083
19	Revenue less expenses. Subtract line 18 from line 12.......	1,092,737	2,275,709
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	26,101,988	26,635,293
21	Total liabilities (Part X, line 26).............	21,563,217	19,817,845
22	Net assets or fund balances. Subtract line 21 from line 20.....	4,538,771	6,817,448

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 30,126,693 including grants of $ 408,134 ) (Revenue $ 33,966,116 )
	AS A COMMUNITY-OWNED, NOT FOR PROFIT ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS DEDICATED TO IMPROVING THE HEALTH AND INSPIRING THE WELL-BEING IN THE COMMUNITIES WE SERVE. COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. GIVES BACK TO THE COMMUNITY IN THE FORM OF IMPROVED FACILITIES, FREE AND DISCOUNTED CARE, EDUCATION AND OUTREACH PROGRAMS, VOLUNTEERISM AND MUCH MORE. USING INFORMATION FROM THE TRIANNUAL COMMUNITY HEALTH NEEDS ASSESSMENT, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. ALIGNS ITS OUTREACH PROGRAMS TO PRIORITIZE AND ADDRESS THE COMMUNITY'S NEEDS. SOME EXAMPLES INCLUDE: (SEE SCHEDULE O FOR CONTINUATION)-FINANCIAL ASSISTANCE-PRIMARY HEALTH CARE / ACCESS -HEALTH SCREENING AND PREVENTION-DISEASE MANAGEMENT-CONTRIBUTIONS TOWARD AND PARTICIPATION IN ECONOMIC DEVELOPMENT ACTIVITIESCOMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS A 25-BED CRITICAL ACCESS FACILITY THAT PROVIDES ACUTE-CARE SERVICES TO THE PEOPLE OF LAGRANGE COUNTY AND THE SURROUNDING AREA. THE VISION OF HOSPITAL LEADERSHIP HAS CONTINUED TO FOCUS ON EXPANDING ACCESS TO HEALTHCARE SERVICES AND HELPING TO IMPROVE THE HEALTH STATUS OF THOSE WHO LIVE AND WORK IN THE COMMUNITIES IT SERVES. AMONG THE SERVICES PROVIDED AT THE HOSPITAL ARE:-EMERGENCY CARE-INPATIENT MEDICAL/SURGICAL CARE-AMBULATORY AND INPATIENT SURGERY-ENDOSCOPY-ORTHOPEDIC SURGERY-INTENSIVE OUTPATIENT BEHAVIORAL HEALTH PROGRAM FOR SENIORS-OBSTETRICS/GYNECOLOGY SERVICES-OUTPATIENT AND INPATIENT REHABILITATION; OUTPATIENT CARDIAC REHABILITATION-ADVANCED, DIGITAL DIAGNOSTIC IMAGING-CARDIAC REHABTHE 17,300 SQUARE FOOT MEDICAL OFFICE PLAZA ADJACENT TO THE HOSPITAL HAS ALLOWED FOR EXPANSION OF FULL-TIME AND VISITING MEDICAL SPECIALISTS, MAKING THESE SERVICES AVAILABLE LOCALLY. ON-SITE MEDICAL SERVICES INCLUDE:-ONCOLOGY AND HEMATOLOGY -CARDIOLOGY-COLON AND RECTAL SURGERY-GENERAL SURGERY-GYNECOLOGY-INFERTILITY-OBSTETRICS-OPHTHALMOLOGY-ORTHOPEDIC SURGERY-PODIATRY-PULMONOLOGY-UROLOGYFINANCIAL ASSISTANCE:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC.'S MISSION INCLUDES CARING FOR PATIENTS WHO DO NOT HAVE THE MEANS TO MEET THEIR FINANCIAL OBLIGATIONS. THE HOSPITAL PLACES ITS PRIORITY ON PROVIDING THE NECESSARY CARE FOR EACH PATIENT, NOT ON THE PATIENT'S FINANCIAL ABILITY TO PAY FOR THEIR MEDICAL EXPENSES.PRIMARY HEALTH CARE / ACCESS:COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES CLINICAL STAFF AND SUPPORT TO TARGETED POPULATIONS WITHIN LAGRANGE COUNTY, INCLUDING:-A FULL TIME PLAIN CHURCH COORDINATOR WHO SERVES AS A RESOURCE FOR AMISH, MENNONITE AND OTHER PLAIN CHURCH MEMBERS TO ADDRESS QUESTIONS RELATED TO HEALTHCARE SERVICES AVAILABLE WITHIN THE PARKVIEW HEALTH SYSTEM, DETERMINING THE APPROXIMATE COST OF A PROCEDURE, SCHEDULING OF A DIAGNOSTIC TEST, OR A BILLING QUESTION. THE PLAIN CHURCH COORDINATOR ASSISTS INDIVIDUALS AND FAMILIES BY OBTAINING AN ANSWER TO THE QUESTIONS THIS COMMUNITY HAS RELATED TO SEEKING HEALTHCARE FROM PARKVIEW.-A PARTNERSHIP WITH THE LAGRANGE COUNTY COUNCIL ON AGING (COA) TO ASSIST WITH OPERATIONAL SUPPORT FOR THE COA'S TRANSPORTATION SERVICES TO ALL RESIDENTS OF LAGRANGE COUNTY. THEIR TRIPS PROVIDE RESIDENTS WITH ACCESS TO MEDICAL CARE, MENTAL HEALTH SERVICES, WELL-BEING ACTIVITIES, SUCH AS GROCERIES, NUTRITION, AND SOCIAL SERVICES. IN ADDITION TO TRANSPORTATION, THE COA PROVIDES HOMEMAKER SERVICES, A FOOD PANTRY AND MUCH MORE IN THEIR EFFORTS TO HELP SENIORS IN LAGRANGE COUNTY REMAIN INDEPENDENT IN THE HOMES OF THEIR CHOICE FOR AS LONG AS POSSIBLE. THE HOMEMAKER SERVICES HELP WITH DAY-TO-DAY TASKS THAT, IN MANY CASES, COULD PUT THE SENIOR AT RISK OF A FALL OR OTHER INJURY HAD THEY NOT RECEIVED ADDITIONAL SUPPORT IN THESE AREAS.HEALTH SCREENING, PREVENTION, AND DISEASE MANAGEMENT: COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES FREE AND LOW-COST SERVICES, HEALTH SCREENINGS AND EDUCATION TO DIVERSE POPULATIONS IN OUR SERVICE AREA. THESE INCLUDE: -COMMUNITY CHECK-UP DAYS. HISTORICALLY, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS ABLE TO PROVIDE LOCAL HEALTH FAIRS TO BRING FREE AND LOW-COST SCREENINGS TO THE COMMUNITY AND IMPROVING ACCESS TO THESE SERVICES, WHICH TYPICALLY INCLUDE LOW-COST BLOOD TESTS, HEARING SCREENINGS, BALANCE ASSESSMENTS AND MORE. HOWEVER, 2020 CHALLENGED THESE ENDEAVORS WITH COVID PANDEMIC SHUTDOWNS AND SOCIAL DISTANCING GUIDELINES. THE HOSPITAL WAS ABLE TO HOLD ONE SOCIALLY DISTANCED CHECK-UP DAY EVENT TO PROVIDE REDUCED-COST BLOOD TESTS TO THE COMMUNITY SERVING 49 PEOPLE. -VOUCHERS REDEEMABLE FOR NINE MONTHS OF PRENATAL VITAMINS. THESE ARE MADE AVAILABLE TO WOMEN THROUGH THE HOSPITAL BIRTH PLANNER, LAGRANGE COUNTY PRIMARY CARE PHYSICIANS AND OBSTETRICIANS, THE LAGRANGE COUNTY HEALTH DEPARTMENT, AND WIC. VOUCHERS ARE REDEEMABLE AT LOCAL PHARMACIES WHO THEN SUBMIT THEM TO THE HOSPITAL FOR REIMBURSEMENT THROUGH COMMUNITY HEALTH IMPROVEMENT FUNDS.-DIABETES SUPPORT GROUP - HISTORICALLY, THIS MONTHLY GROUP IS TAUGHT BY A DIABETES EDUCATOR/PHARMACIST AND IS FREE AND OPEN TO ANY WHOSE LIVES ARE AFFECTED BY DIABETES. THE GROUP OFFERS EDUCATIONAL PROGRAMS ON MEDICATION MANAGEMENT, NUTRITION, NEUROPATHY, ETC., IN ADDITION TO OPEN DIALOGUE ABOUT ANY ISSUES SPECIFIC TO MEMBERS OF THE GROUP. IN 2020, DUE TO THE COVID-19 PANDEMIC, THE DIABETES SUPPORT GROUP MEETINGS WERE SUSPENDED. -SURVIVING LOSS BY SUICIDE SUPPORT GROUP - HISTORICALLY, THIS GROUP MEETS MONTHLY TO PROVIDE A SUPPORT NETWORK WITH A COMPASSIONATE, HEALING ENVIRONMENT FOR ADULTS WHOSE LIVES HAVE BEEN AFFECTED BY THE LOSS OF A LOVED ONE DUE TO SUICIDE. IN 2020, DUE TO THE COVID-19 PANDEMIC, THE SURVIVING LOSS BY SUICIDE SUPPORT GROUP MEETINGS WERE SUSPENDED. -QPR TRAINING IS OFFERED MONTHLY TO CO-WORKERS OF COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. AND TO LAGRANGE COUNTY COMMUNITY MEMBERS. THIS SUICIDE PREVENTION TRAINING PREPARES ATTENDEES TO IDENTIFY WARNING SIGNS AND INTERVENE IN HOPES OF PREVENTING SUICIDE COMPLETION. IN 2020, DUE TO THE COVID-19 PANDEMIC, THESE TRAININGS WERE HELD VIRTUALLY. THE HOSPITAL WAS ABLE TO PROVIDE TRAINING TO 82 PEOPLE. ECONOMIC DEVELOPMENT:ECONOMIC DEVELOPMENT CORPORATION - COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. PROVIDES FUNDING TO THE LAGRANGE COUNTY ECONOMIC DEVELOPMENT CORPORATION (EDC) TO SUPPORT THEIR EFFORTS IN DEVELOPING BUSINESS RETENTION AND EXPANSION, BUSINESS ATTRACTION, ENTREPRENEURIAL DEVELOPMENT AND IMPROVING OVERALL QUALITY OF LIFE. THE EDC CONTRIBUTES TO FURTHERING ACCESS IN OUR COUNTY BY INVESTING IN AREAS THAT CONTRIBUTE TO A THRIVING COMMUNITY, SUCH AS HOUSING AND AIDING BUSINESSES IN IDENTIFYING BUILDING SITES. THE EDC ALSO INVESTS IN AREAS THAT IMPACT OBESITY AND MATERNAL/INFANT/CHILD HEALTH BY SUPPORTING THE LAUNCH LAGRANGE STUDENT ENTREPRENEURIAL COMPETITION AND LAGRANGE COUNTY TRAILS.IN ADDITION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC. IS PART OF THE LAGRANGE COUNTY EARLY LEARNING COALITION. LAGRANGE COUNTY IS CONSIDERED A CHILDCARE DESERT BECAUSE THERE ARE NOT ENOUGH CERTIFIED CHILDCARE PROVIDERS BASED ON OUR COUNTY'S POPULATION. REPRESENTATIVES FROM THE HOSPITAL COLLABORATE WITH KEY STAKEHOLDERS AND HR REPRESENTATIVES FROM COUNTY BUSINESSES TO WORK TOGETHER TOWARDS INCREASING THE NUMBER OF CERTIFIED CHILDCARE PROVIDERS FOR LAGRANGE COUNTY.

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












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












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses30,126,693

(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) ROBERT BLOOMFIELD........................................................................ LGHOS MGR SUPPORT SERVICE	40.00 .......................0.00	X	137,722	0	36,802
(19) TREVOR FRY........................................................................ LGHOS MGR ER	40.00 .......................0.00	X	126,914	0	38,007
(20) EMILY PLANT........................................................................ LGHOS MGR IP	40.00 .......................0.00	X	118,828	0	29,179
(21) BRUCE CONEY........................................................................ LGHOS MGR EMS	40.00 .......................0.00	X	117,923	0	23,995

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,321,973	4,120,159	2,381,511

1	Briefly describe the organization’s mission or most significant activities: AS A COMMUNITY OWNED, NOT-FOR-PROFIT ORGANIZATION, COMMUNITY HOSPITAL OF LAGRANGE COUNTY, INC., AN AFFILIATE OF PARKVIEW HEALTH SYSTEM, INC., IS DEDICATED TO IMPROVING YOUR HEALTH AND INSPIRING YOUR WELL-BEING.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	13
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	8
5	Total number of individuals employed in calendar year 2020 (Part V, line 2a) ......	5	217
6	Total number of volunteers (estimate if necessary) .............	6	15
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 39 .........	7b	0

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	36,622
e	Government grants (contributions)		1e	5,914,989

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

g	Noncash contributions included in lines 1a - 1f:$		1g	6,346

h Total. Add lines 1a-1f.......		5,951,611

		Business Code
2a	NET PATIENT SERVICE	622000	33,506,477	33,506,477
b	EMS SUBSIDY	621910	349,000	349,000
c	INTERUNIT RENT	531120	50,078	50,078
d	PHARMACY	446110	34,767	34,767
e	SPEECH THERAPY	621300	17,418	17,418
f	All other program service revenue.		8,376	8,376
g	Total. Add lines 2a–2f .....		33,966,116

3 Investment income (including dividends, interest, and othersimilar amounts) ......			79			79
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		17,624	6a
b	Less: rental expenses		49,047	6b
c	Rental income or (loss)		-31,423	6c
d	Net rental income or (loss).......			-31,423			-31,423
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory			7a
b	Less: cost or other basis and sales expenses			7b
c	Gain or (loss)			7c
d	Net gain or (loss).........
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
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	CAFETERIA REVENUE		722210	151,571			151,571
b	GIFT SHOP REVENUE		453220	19,838			19,838
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			171,409
12	Total revenue. See instructions.....			40,057,792	33,966,116	0	140,065

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....	408,134	408,134
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
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 ...........	730,849		730,849
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........	9,807,077	9,807,077
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......	3,412,976	3,412,976
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	5,651,252	4,982,553	668,699
12	Advertising and promotion ....
13	Office expenses .......	809,992	757,606	52,386
14	Information technology ......	415	415
15	Royalties ..
16	Occupancy ...........	581,645	572,129	9,516
17	Travel ............	15,712	13,396	2,316
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	10,563	9,213	1,350
20	Interest ...........	189,748	189,748
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	1,720,264	1,697,826	22,438
23	Insurance ...	93,312	93,312
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	CORP SERVICE ALLOCATION	6,068,221		6,068,221
b	PH CLINICAL SUPPORT	3,542,492	3,542,492
c	MEDICAL SUPPLIES	2,455,762	2,455,762
d	HOSPITAL ASSESSMENT FEE	2,165,606	2,165,606
e	All other expenses	118,063	18,448	29,117	70,498
25	Total functional expenses. Add lines 1 through 24e	37,782,083	30,126,693	7,584,892	70,498
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 ........			1,675	1	1,876
2	Savings and temporary cash investments .........			178,479	2	0
3	Pledges and grants receivable, net ......			7,104	3	0
4	Accounts receivable, net .............			5,484,350	4	5,300,146
5	Loans and other receivables from 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 ............			369,606	8	378,717
9	Prepaid expenses and deferred charges ......			-6,033	9	53,928
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	34,220,585
b	Less: accumulated depreciation	10b	20,251,452	15,009,587	10c	13,969,133
11	Investments—publicly traded securities .				11
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............			5,011,241	14	5,011,241
15	Other assets. See Part IV, line 11 ...........			45,979	15	1,920,252
16	Total assets. Add lines 1 through 15 (must equal line 33)...			26,101,988	16	26,635,293

17	Accounts payable and accrued expenses .....	1,483,479	17	1,539,679
18	Grants payable ...		18
19	Deferred revenue .........		19	1,986,028
20	Tax-exempt bond liabilities .........	16,092,367	20	15,125,741
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
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 ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	3,987,371	25	1,166,397
26	Total liabilities. Add lines 17 through 25..	21,563,217	26	19,817,845

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	4,538,771	27	6,817,448
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 ...........	4,538,771	32	6,817,448
33	Total liabilities and net assets/fund balances ........	26,101,988	33	26,635,293