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)
ANDERSON HOSPITAL |
370662561 | 3 | Yes | 0 | 0 | |
| (B)
COMMUNITY HOSPITAL OF STAUNTON |
370624255 | 3 | Yes | 0 | 0 | |
|
Total 2
|
0 | 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 | ||||
| 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 | ||||
| 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..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SCHEDULE A, PART IV, SECTION D, LINE 3 | ANDERSON HOSPITAL AND COMMUNITY HOSPITAL OF STAUNTON HAVE A SIGNIFICANT VOICE IN DIRECTING THE USE OF THE CORPORATION'S INCOME AND ASSETS BY VIRTUE OF HAVING A MANDATORY PRESENCE ON THE CORPORATION'S BOARD OF TRUSTEES. PURSUANT TO THE CORPORATION'S BYLAWS, AT LEAST THREE TRUSTEES MUST BE MEMBERS OF THE BOARD OF TRUSTEES OF ANDERSON HOSPITAL AND AT LEAST ONE TRUSTEE MUST BE A MEMBER OF THE BOARD OF TRUSTEES OF COMMUNITY HOSPITAL OF STAUNTON. IN ADDITION, THE PRESIDENT AND CEO OF ANDERSON HOSPITAL, THE VICE-PRESIDENT OF FINANCE AND CFO OF ANDERSON HOSPITAL, AND THE ADMINISTRATIVE DIRECTOR OF PROCESS & CLINICAL IMPROVEMENT OF ANDERSON HOSPITAL SERVE AS OFFICERS OF THE CORPORATION. THE CLOSE GOVERNANCE AND OPERATING CONNECTIONS BETWEEN THE HOSPITALS AND THE CORPORATION ENSURE THAT THE SUPPORTED ORGANIZATIONS HAVE A SIGNIFICANT VOICE IN DIRECTING THE USE OF THE CORPORATION'S INCOME AND ASSETS. |
| SCHEDULE A, PART IV, SECTION E, LINE 3A | ANDERSON HEALTHCARE IS THE SOLE MEMBER OF ANDERSON HOSPITAL AND COMMUNITY HOSPITAL OF STAUNTON. AS THE SOLE MEMBER, IT HAS THE POWER TO APPOINT THE TRUSTEES OF EACH HOSPITAL'S GOVERNING BODY. |
| SCHEDULE A, PART IV, SECTION E, LINE 3B | ANDERSON HEALTHCARE APPOINTS THE MEMBERS OF THE GOVERNING BODIES OF THE SUPPORTED ORGANIZATIONS. AT LEAST THREE TRUSTEES OF ANDERSON HEALTHCARE MUST ALSO BE TRUSTEES OF ANDERSON HOSPITAL AND AT LEAST ONE TRUSTEE OF ANDERSON HEALTHCARE MUST ALSO BE A TRUSTEE OF COMMUNITY HOSPITAL OF STAUNTON. OFFICERS OF ANDERSON HOSPITAL ALSO SERVE AS OFFICERS OF ANDERSON HEALTHCARE. THE CLOSE GOVERNANCE AND OPERATING CONNECTIONS ENSURE THAT ANDERSON HEALTHCARE EXERCISES A SUBSTANTIAL DEGREE OF DIRECTION OVER THE POLICIES, PROGRAMS AND ACTIVITIES OF THE SUPPORTED ORGANIZATIONS. |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS REVIEWED BY THE CEO, CFO, AND CONTROLLER. INFORMATION FOR THE RETURN IS GATHERED BY THE HOSPITAL'S FINANCE DEPARTMENT AND GIVEN TO AN INDEPENDENT AUDITOR FOR FILING PREPARATION. A COPY OF THE FORM 990 IS MADE AVAILABLE TO THE BOARD OF TRUSTEES. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE COMPLIANCE OFFICER REVIEWS AND MONITORS THE POLICY ANNUALLY. PERSONS COVERED UNDER THE POLICY INCLUDE TRUSTEES/DIRECTORS/MANAGERS, OFFICERS AND COMMITTEE MEMBERS OF THE ANDERSON ENTITIES; DEPARTMENT DIRECTORS, ADMINISTRATIVE DIRECTORS, ASSISTANT DIRECTORS, MEMBERS OF SENIOR MANAGEMENT AND MEDICAL STAFF LEADERS OF ANDERSON, MEDICAL STAFF MEMBERS AND NON-MANAGEMENT STAFF. CONFLICTS ARE REVIEWED, IDENTIFIED AND MAINTAINED BY THE COMPLIANCE OFFICER. EXPLANATION OF ANY RESTRICTIONS IMPOSED ON PERSONS WITH A CONFLICT: THE COVERED INDIVIDUAL PROMPTLY AND FULLY DISCLOSES THE EXISTENCE OF ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AT THE FOLLOWING TIMES: A. WHEN THE COVERED INDIVIDUAL FIRST BECOMES A COVERED INDIVIDUAL AND AT EVERY ANNUAL MEETING OF THE ANDERSON ENTITY THEREAFTER THROUGH THE SUBMISSION OF A CONFLICT DISCLOSURE STATEMENT AFFIRMING THAT THE COVERED INDIVIDUAL (I) RECEIVED A COPY OF THIS POLICY, (II) READ AND UNDERSTOOD THIS POLICY, AND (III) AGREES TO COMPLY WITH THIS POLICY; B. UPON ANY CHANGES IN CIRCUMSTANCES WHICH GIVE RISE TO AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST; AND C. WHEN THE COVERED INDIVIDUAL HAS AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST WITH RESPECT TO A TRANSACTION OR ARRANGEMENT BEING CONSIDERED AT A BOARD OR COMMITTEE MEETING. FOR MANAGERS AND MEDICAL STAFF LEADERS: THE COVERED INDIVIDUAL PROMPTLY AND FULLY DISCLOSES THE EXISTENCE OF ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST TO THE COMPLIANCE OFFICER AT THE FOLLOWING TIMES: A. WHEN THE COVERED INDIVIDUAL FIRST BECOMES A COVERED INDIVIDUAL AND ANNUALLY THEREAFTER THROUGH THE SUBMISSION OF A CONFLICT DISCLOSURE STATEMENT AFFIRMING THAT THE COVERED INDIVIDUAL (I) RECEIVED A COPY OF THIS POLICY, (II) READ AND UNDERSTOOD THIS POLICY, AND (III) AGREES TO COMPLY WITH THIS POLICY; AND B. UPON ANY CHANGES IN CIRCUMSTANCES WHICH GIVE RISE TO AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST; C. WHEN A COVERED INDIVIDUAL HAS AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST WITH RESPECT TO A TRANSACTION OR ARRANGEMENT BEING CONSIDERED ON BEHALF OF ANDERSON AND THE COVERED INDIVIDUAL IS IN A POSITION TO INFLUENCE THE OUTCOME OF THE CONSIDERATION. DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST MADE AT THE MEETING AT WHICH THE TRANSACTION OR ARRANGEMENT IS BEING CONSIDERED SHALL BE MADE TO ALL INDIVIDUALS PRESENT AT THE MEETING. FOR OTHER MEDICAL STAFF MEMBERS: DISCLOSURE OCCURS AT APPOINTMENT AND REAPPOINTMENT UNLESS THEY ARE BOARD MEMBERS - THESE PHYSICIANS FOLLOW THE BOARD OF TRUSTEE REQUIREMENTS. EMPLOYEES NOT IN MANAGEMENT POSITIONS: AT TIME OF HIRE AND AT EACH ANNUAL EMPLOYEE EVALUATION. |
| FORM 990, PART VI, SECTION B, LINE 15A | REVIEW OF CEO OR TOP MANAGEMENT OFFICIAL COMPENSATION: THE CEO SALARY AND BONUS STRUCTURE IS DETERMINED ON AN ANNUAL BASIS BY THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF TRUSTEES, AND APPROVED BY THE FULL BOARD BASED ON AN EVALUATION DONE BY THE COMMITTEE. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS OR FUND BALANCES: TRANSFER FROM RELATED ORGANIZATIONS: $21,598,227 NET ASSETS TRANSFERRED IN FROM RELATED ORGANIZATIONS: $20,734,592 ------------ TOTAL $42,332,819 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:ADMINISTRATIVE SERVICES TOTAL FEES:875084 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:PHYSICIAN SERVICES TOTAL FEES:10800346 |
| FORM 990 PART IX LINE 11G | DESCRIPTION:OTHER MEDICAL SERVICES TOTAL FEES:14037 |
| Software ID: | |
| Software Version: |