Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
FAIRMONT REGIONAL MEDICAL CENTER |
352507149 | 7 | Yes | 14,479 | 0 | |
|
Total 1
|
14,479 | 0 | ||||
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. | ||||||
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 | ||||||
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.) | ||||||
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.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | 0 | 0 | ||
| 2 | Recoveries of prior-year distributions | 2 | 0 | 0 | ||
| 3 | Other gross income (see instructions) | 3 | 132,925 | 814 | ||
| 4 | Add lines 1 through 3 | 4 | 132,925 | 814 | ||
| 5 | Depreciation and depletion | 5 | 86 | 68 | ||
| 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 | 66,553 | 0 | ||
| 7 | Other expenses (see instructions) | 7 | 111,832 | 38,315 | ||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | -45,546 | -37,569 | ||
| 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 | 0 | 0 | ||
| b | Average monthly cash balances | 1b | 18,896 | 12,150 | ||
| c | Fair market value of other non-exempt-use assets | 1c | 0 | 0 | ||
| d | Total (add lines 1a, 1b, and 1c) | 1d | 18,896 | 12,150 | ||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): 0 |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | 0 | 0 | ||
| 3 | Subtract line 2 from line 1d | 3 | 18,896 | 12,150 | ||
| 4 | Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). | 4 | 283 | 182 | ||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | 18,613 | 11,968 | ||
| 6 | Multiply line 5 by 0.035 | 6 | 651 | 419 | ||
| 7 | Recoveries of prior-year distributions | 7 | 0 | 0 | ||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | 651 | 419 | ||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | -45,546 | |||
| 2 | Enter 85% of line 1 | 2 | -38,714 | |||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | 651 | |||
| 4 | Enter greater of line 2 or line 3 | 4 | 651 | |||
| 5 | Income tax imposed in prior year | 5 | 0 | |||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | 651 | |||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | 25,514 |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | 0 |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | 0 |
| 4 Amounts paid to acquire exempt-use assets | 4 | 0 |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | 0 |
| 6 Other distributions (describe in Part VI). See instructions | 6 | 0 |
| 7Total annual distributions. Add lines 1 through 6. | 7 | 25,514 |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | 25,514 |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | 651 |
| 10 Line 8 amount divided by Line 9 amount | 10 | 10000.0000000000 % |
| 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 | 651 | |||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
18,275 | |||
| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015.......0 | ||||
| b From 2016.......0 | ||||
| c From 2017.......0 | ||||
| d From 2018.......0 | ||||
| e From 2019.......0 | ||||
| fTotal of lines 3a through e | 0 | |||
| g Applied to underdistributions of prior years | 0 | |||
| h Applied to 2020 distributable amount | 0 | |||
|
i
Carryover from 2015 not applied (see instructions) |
0 | |||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | 0 | |||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ 25,514 | ||||
| a Applied to underdistributions of prior years | 18,275 | |||
| b Applied to 2020 distributable amount | 651 | |||
| c Remainder. Subtract lines 4a and 4b from line 4. | 6,588 | |||
|
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. |
0 | |||
|
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. |
0 | |||
|
7 Excess distributions carryover to 2021. Add lines 3j and 4c. |
6,588 | |||
| 8 Breakdown of line 7: | ||||
| a Excess from 2016.....0 | ||||
| b Excess from 2017.....0 | ||||
| c Excess from 2018.....0 | ||||
| d Excess from 2019.....0 | ||||
| e Excess from 2020.....6,588 | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART IV, SECTION D, LINE 2: | THE HOSPITAL MAY APPOINT A DIRECTOR OF VOLUNTEER SERVICES (DVS) WHO SHALL FUNCTION AS THE LIASION BETWEEN THE HOSPITAL AND THE ASSOCIATION. THE ASSOCIATION SHALL WORK WITH SUCH DVS WHO WILL AID AND ASSIST THE ASSOCIATION, ITS MEMBERS, AND OFFICERS BY PROVIDING PROGRAM PLANNING AND SUPPORT, OVERSIGHT OF TRAINING, ANY REGULATORY REQUIREMENTS COMPLIANCE AND DOCUMENTATION OF SUCH, AND OTHER DUTIES AS APPROPRIATE TO CARRY OUT THE PURPOSE OF THE ASSOCIATION. TRADITIONALLY, THE DVS SERVES AS AN EX-OFFICIO MEMBER OF THE BOARD OF DIRECTORS AND THE EXECUTIVE COMMITTEE. |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME | DESCRIPTION: INTEREST INC. AMOUNT: 1. |
| FORM 990-EZ, PART I, LINE 7 - SALES OF INVENTORY | INCOME: GROSS RECEIPTS: 450. RETURNS AND ALLOWANCES: 0. LESS COST OF GOODS SOLD: 0. GROSS PROFIT: 450. COST OF GOODS SOLD: INVENTORY AT BEGINNING OF YEAR: 785. MERCHANDISE PURCHASED: 0. COST OF LABOR: 0. MATERIALS AND SUPPLIES: 0. OTHER COSTS: -785. INVENTORY AT END OF YEAR: 0. COST OF GOODS SOLD: 0. |
| FORM 990-EZ, PART I, LINE 7B - OTHER COSTS | DESCRIPTION: OTHER COGS. AMOUNT: -785. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: FAIRMONT GENERAL HOSPITAL. GRANTEE ADDRESS: 1325 LOCUST AVENUE FAIRMONT, WV 26554. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 14,479. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: GARRETT OATES. PROPERTY DESCRIPTION: CASH SCHOLARSHIP. AMOUNT GIVEN: 2,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: FAIRMONT STATE UNIVERSITY FOUNDATION. GRANTEE ADDRESS: 1300 LOCUST AVENUE FAIRMONT, WV 26554. PROPERTY DESCRIPTION: CASH SCHOLARSHIP. AMOUNT GIVEN: 2,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: MADISON BOYLES. PROPERTY DESCRIPTION: CASH SCHOLARSHIP. AMOUNT GIVEN: 2,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: BELLVIEW HOSPICE. PROPERTY DESCRIPTION: DONATION OF INVENTORY. AMOUNT GIVEN: 785. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: RYAN VOLKER. PROPERTY DESCRIPTION: CASH SCHOLARSHIP. AMOUNT GIVEN: 1,000. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: BARRACKVILLE ELEM/MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: FAIRVIEW MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: MANNINGTON MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: MONONGAH MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: RIVESVILLE ELEM/MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: WEST FAIRMONT MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: EAST FAIRMONT MIDDLE SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 250. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: EAST FAIRMONT HIGH SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: FAIRMONT SENIOR HIGH SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 500. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: . GRANTEE NAME: NORTH MARION HIGH SCHOOL. PROPERTY DESCRIPTION: DONATION. AMOUNT GIVEN: 500. TOTAL INCLUDED ON FORM 990-EZ, LINE 10: 25,514. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: BANK CHARGE AND CREDIT CARD LATE FEE. AMOUNT: 53. DESCRIPTION: ASSOC. OFFICE EXP.. AMOUNT: 6,772. DESCRIPTION: LEASE. AMOUNT: 50. DESCRIPTION: TAXES. AMOUNT: 9. DESCRIPTION: UNCOLLECTIBLE ACCOUNTS. AMOUNT: 510. TOTAL TO FORM 990-EZ, LINE 16: 7,394. |
| FORM 990-EZ, PART II, LINE 24 - OTHER ASSETS | DESCRIPTION: ACCOUNTS RECEIVABLE. BEG. OF YEAR AMOUNT: 590. END OF YEAR AMOUNT: 0. DESCRIPTION: INVENTORIES FOR SALE OR USE. BEG. OF YEAR AMOUNT: 785. END OF YEAR AMOUNT: 0. DESCRIPTION: OTHER DEPRECIABLE ASSETS. BEG. OF YEAR AMOUNT: 415. END OF YEAR AMOUNT: 0. |
| FORM 990-EZ, PART II, LINE 26 - OTHER LIABILITIES | DESCRIPTION: SALES TAX PAYABLE. BEG. OF YEAR AMOUNT: 757. END OF YEAR AMOUNT: 0. |
| Software ID: | |
| Software Version: |