TY 2021 Form 990

- TIN:

SCHEDULE A
(Form 990)

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.
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Attach to Form 990 or Form 990-EZ.
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Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

WAHIAWA HOSPITAL ASSOCIATION INC

Employer identification number

99-0073529

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).)

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 33 1/3% 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 33 1/3% 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 on 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 ...............................1

Provide the following information about the supported organization(s).

(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)
(i) Name of supported organization	(ii) EIN		Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(A) WAHIAWA GENERAL HOSPITAL	990268925	3	Yes		0	0

Total 1					0	0

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

Cat. No. 11285F

Schedule A (Form 990) 2021

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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 2021 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2020 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2021. 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—2020. 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—2021. 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—2020. 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) 2021

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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 on 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 2021 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2020 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2021 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2020 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2021. 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—2020. 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) 2021

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.

Yes

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.

Yes

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) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).

Yes

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 on 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 on 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) 2021

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

11a

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

11b

A 35% controlled entity of a person described on 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).

Yes

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 on 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) 2021

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) 2021

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 2021 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-2021	(iii) Distributable Amount for 2021
1 Distributable amount for 2021 from Section C, line 6
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2021:
a From 2016.......
b From 2017.......
c From 2018.......
d From 2019.......
e From 2020.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2021 distributable amount
i Carryover from 2016 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2021 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2021 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2021, 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 2021. 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 2022. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2017.....
b Excess from 2018.....
c Excess from 2019.....
d Excess from 2020.....
e Excess from 2021.....

Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021

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
FORM 990, SCHEDULE A, PART IV, SECTION A, LINE 6	WAHIAWA HOSPITAL ASSOCIATION ("WHA") IS A 501(C)(3) NON PROFIT CORPORATION, WHICH OWNS CERTAIN REAL PROPERTY AND WHICH SUPPORTS WAHIAWA GENERAL HOSPITAL ("WGH"). WGH IS A NONPROFIT 53-BED ACUTE CARE HOSPITAL AND 107-BED LONG-TERM CARE FACILITY LOCATED IN CENTRAL OAHU. THE HOSPITAL IS THE PRIMARY SOURCE OF ACUTE CARE HOSPITAL SERVICES FOR THE CIVILIAN RESIDENTS OF ITS SERVICE AREA, WHICH EXTENDS FROM CENTRAL OAHU TO THE NORTH SHORE, WHERE IT RUNS FROM KA'ENA POINT TO WAIMEA BAY. WGH IS A SMALL, RURAL HOSPITAL IN THE FRINGE AREA OF A COMPETITIVE METROPOLITAN AREA. WGH FACES MANY CHALLENGES TO ITS CONTINUING ABILITY TO PROVIDE TOP QUALITY MEDICAL CARE TO RESIDENTS OF ITS SERVICE AREA, INCLUDING DIFFICULTIES IN ATTRACTING AND RETAINING PHYSICIANS AND SUPPORT PERSONNEL TO STAFF THE HOSPITAL. RANDALL M. SUZUKA, M.D. IS A LICENSED PRIMARY CARE PHYSICIAN IN HAWAII AND PRESIDENT OF HALEIWA FAMILY CLINIC, INC. ("HALEIWA CLINIC"). AT CERTAIN TIMES, DR. SUZUKA HAS SERVED ON THE BOARD OF WGH AND /OR WHA. HALEIWA CLINIC IS A HAWAII PROFESSIONAL CORPORATION THAT OPERATES TWO PHYSICIAN CLINICS ON OAHU. ONE PHYSICIAN CLINIC IS LOCATED IN MILILANI, HAWAII. HALEIWA CLINIC SUBLEASED THE MILILANI CLINIC SITE FROM WHA. HALEIWA CLINIC HAS SUBLET THE MILILANI OFFICE SPACE FROM WHA SINCE 2004. IN RECOGNITION OF FINANCIAL DIFFICULTIES FACED BY HALEIWA CLINIC, WHA DEFERRED PAYMENTS OF RENT DUE. OVER THE YEARS, THE CLINIC ACCRUED AN OUTSTANDING BALANCE FOR PAST-DUE RENT. THUS, THE FACTS HERE COULD BE INTERPRETED AS WHA, IN EFFECT, LOANING MONEY TO HALEIWA CLINIC. HOWEVER, THE INTENT OF WHA AT ALL TIMES WAS SIMPLY TO ASSURE THE AVAILABILITY OF MUCH NEEDED PRIMARY CARE SERVICES FOR RESIDENTS OF WGH'S SERVICE AREA. CORRECTIVE ACTION TAKEN IN AUGUST 2017, WHA'S SUBLEASE WITH HALEIWA CLINIC WAS TERMINATED, AND HALEIWA CLINIC SIGNED A PROMISSORY NOTE, PURSUANT TO WHICH THE HALEIWA CLINIC AGREED TO REPAY THE BALANCE OF THE OUTSTANDING RENT OVER A FIVE-YEAR-TERM WITH INTEREST AT THE RATE OF 5% PER YEAR ON THE OUTSTANDING BALANCE. THE INTEREST RATE WAS 1-1/2 POINTS OVER THE PRIME RATE AS REPORTED BY THE WALL STREET JOURNAL AT THE DATE OF EXECUTION OF THE NOTE. DR. RANDALL SUZUKA, THE PRESIDENT OF HALEIWA CLINIC, PERSONALLY GUARANTEED THE NOTE. HALEIWA CLINIC CONTINUED TO EXPERIENCE FINANCIAL DIFFICULTY, AND AS OF MAY 2019 WAS NOT CURRENT ON PAYMENTS UNDER THE 2017 NOTE. WHA WAS STILL CONCERNED ABOUT THE AVAILABILITY OF PRIMARY CARE FOR RESIDENTS OF THE AREA, AND THEREFORE WORKED WITH HALEIWA CLINIC TO RESTRUCTURE THE NOTE. A LOAN MODIFICATION AGREEMENT WAS SIGNED, WITH AN EFFECTIVE DATE OF JUNE 1, 2019. THE PRINCIPAL AMOUNT DUE WAS NOT REDUCED, BUT THE TIMING OF PAYMENTS WAS ADJUSTED. DR. SUZUKA'S PERSONAL GUARANTY REMAINED IN PLACE. AS OF JUNE 30, 2022, HALEIWA CLINIC HAD NOT MADE ALL OF THE MONTHLY PAYMENTS THAT HAD BECOME DUE IN THE FISCAL YEAR ENDING JUNE 30, 2022. HOWEVER, THE REMAINING PRINCIPAL, INTEREST, AND PENALTIES WERE PAID BY JANUARY 2023.

Return Reference

Explanation

FORM 990, SCHEDULE A, PART IV, SECTION A, LINE 6

WAHIAWA HOSPITAL ASSOCIATION ("WHA") IS A 501(C)(3) NON PROFIT CORPORATION, WHICH OWNS CERTAIN REAL PROPERTY AND WHICH SUPPORTS WAHIAWA GENERAL HOSPITAL ("WGH"). WGH IS A NONPROFIT 53-BED ACUTE CARE HOSPITAL AND 107-BED LONG-TERM CARE FACILITY LOCATED IN CENTRAL OAHU. THE HOSPITAL IS THE PRIMARY SOURCE OF ACUTE CARE HOSPITAL SERVICES FOR THE CIVILIAN RESIDENTS OF ITS SERVICE AREA, WHICH EXTENDS FROM CENTRAL OAHU TO THE NORTH SHORE, WHERE IT RUNS FROM KA'ENA POINT TO WAIMEA BAY. WGH IS A SMALL, RURAL HOSPITAL IN THE FRINGE AREA OF A COMPETITIVE METROPOLITAN AREA. WGH FACES MANY CHALLENGES TO ITS CONTINUING ABILITY TO PROVIDE TOP QUALITY MEDICAL CARE TO RESIDENTS OF ITS SERVICE AREA, INCLUDING DIFFICULTIES IN ATTRACTING AND RETAINING PHYSICIANS AND SUPPORT PERSONNEL TO STAFF THE HOSPITAL. RANDALL M. SUZUKA, M.D. IS A LICENSED PRIMARY CARE PHYSICIAN IN HAWAII AND PRESIDENT OF HALEIWA FAMILY CLINIC, INC. ("HALEIWA CLINIC"). AT CERTAIN TIMES, DR. SUZUKA HAS SERVED ON THE BOARD OF WGH AND /OR WHA. HALEIWA CLINIC IS A HAWAII PROFESSIONAL CORPORATION THAT OPERATES TWO PHYSICIAN CLINICS ON OAHU. ONE PHYSICIAN CLINIC IS LOCATED IN MILILANI, HAWAII. HALEIWA CLINIC SUBLEASED THE MILILANI CLINIC SITE FROM WHA. HALEIWA CLINIC HAS SUBLET THE MILILANI OFFICE SPACE FROM WHA SINCE 2004. IN RECOGNITION OF FINANCIAL DIFFICULTIES FACED BY HALEIWA CLINIC, WHA DEFERRED PAYMENTS OF RENT DUE. OVER THE YEARS, THE CLINIC ACCRUED AN OUTSTANDING BALANCE FOR PAST-DUE RENT. THUS, THE FACTS HERE COULD BE INTERPRETED AS WHA, IN EFFECT, LOANING MONEY TO HALEIWA CLINIC. HOWEVER, THE INTENT OF WHA AT ALL TIMES WAS SIMPLY TO ASSURE THE AVAILABILITY OF MUCH NEEDED PRIMARY CARE SERVICES FOR RESIDENTS OF WGH'S SERVICE AREA. CORRECTIVE ACTION TAKEN IN AUGUST 2017, WHA'S SUBLEASE WITH HALEIWA CLINIC WAS TERMINATED, AND HALEIWA CLINIC SIGNED A PROMISSORY NOTE, PURSUANT TO WHICH THE HALEIWA CLINIC AGREED TO REPAY THE BALANCE OF THE OUTSTANDING RENT OVER A FIVE-YEAR-TERM WITH INTEREST AT THE RATE OF 5% PER YEAR ON THE OUTSTANDING BALANCE. THE INTEREST RATE WAS 1-1/2 POINTS OVER THE PRIME RATE AS REPORTED BY THE WALL STREET JOURNAL AT THE DATE OF EXECUTION OF THE NOTE. DR. RANDALL SUZUKA, THE PRESIDENT OF HALEIWA CLINIC, PERSONALLY GUARANTEED THE NOTE. HALEIWA CLINIC CONTINUED TO EXPERIENCE FINANCIAL DIFFICULTY, AND AS OF MAY 2019 WAS NOT CURRENT ON PAYMENTS UNDER THE 2017 NOTE. WHA WAS STILL CONCERNED ABOUT THE AVAILABILITY OF PRIMARY CARE FOR RESIDENTS OF THE AREA, AND THEREFORE WORKED WITH HALEIWA CLINIC TO RESTRUCTURE THE NOTE. A LOAN MODIFICATION AGREEMENT WAS SIGNED, WITH AN EFFECTIVE DATE OF JUNE 1, 2019. THE PRINCIPAL AMOUNT DUE WAS NOT REDUCED, BUT THE TIMING OF PAYMENTS WAS ADJUSTED. DR. SUZUKA'S PERSONAL GUARANTY REMAINED IN PLACE. AS OF JUNE 30, 2022, HALEIWA CLINIC HAD NOT MADE ALL OF THE MONTHLY PAYMENTS THAT HAD BECOME DUE IN THE FISCAL YEAR ENDING JUNE 30, 2022. HOWEVER, THE REMAINING PRINCIPAL, INTEREST, AND PENALTIES WERE PAID BY JANUARY 2023.

Schedule A (Form 990) 2021

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

2021

Open to Public Inspection

Name of the organization

WAHIAWA HOSPITAL ASSOCIATION INC

Employer identification number

99-0073529

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) 2021

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 .....	1,358,431		1,358,431
b	Buildings ....	13,757,418	13,755,032	2,386
c	Leasehold improvements	249,567	246,975	2,592
d	Equipment ....	5,199,001	5,198,899	102
e	Other .....
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				1,363,511

Schedule D (Form 990) 2021

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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
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)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)
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) 2021

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

Schedule D (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ.
MediumBullet

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

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

WAHIAWA HOSPITAL ASSOCIATION INC

Employer identification number

99-0073529

Part I

Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(b) Relationship between disqualified person and organization	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person		(c) Description of transaction	Yes	No
(1) HALEIWA FAMILY CLINIC INC	35% CONTROLLED ENTITY OF RANDALL M. SUZUKA, FORMER CHAIRMAN	SEE PART V	Yes

Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e) Original principal amount	(f) Balance due	(g) In default?		(h) Approved by board or committee?		(i) Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e) Original principal amount	(f) Balance due	Yes	No	Yes	No	Yes	No
(1) HALEIWA FAMILY CLINIC INC	35% CONTROLLED ENTITY OF RANDALL M. SUZUKA, FORMER CHAIRMAN	SEE PART V		X	533,001	255,216		No	Yes		Yes





Total ............... $						255,216

Part III

Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

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

Cat. No. 50056A

Schedule L (Form 990) 2021

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) HALEIWA FAMILY CLINIC INC	35% CONTROLLED ENTITY OF RANDALL M. SUZUKA, FORMER CHAIRMAN	255,216	SEE PART V		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference

Explanation

FORM 990 SCHEDULE L, PARTS I, II, AND IV

WAHIAWA HOSPITAL ASSOCIATION ("WHA") IS A 501(C)(3) NON PROFITCORPORATION, WHICH OWNS CERTAIN REAL PROPERTY AND WHICH SUPPORTS WAHIAWA GENERAL HOSPITAL ("WGH"). WGH IS A NONPROFIT 53-BED ACUTE CAREHOSPITAL AND 107-BED LONG-TERM CARE FACILITY LOCATED IN CENTRAL OAHU.THE HOSPITAL IS THE PRIMARY SOURCE OF ACUTE CARE HOSPITAL SERVICES FOR THE CIVILIAN RESIDENTS OF ITS SERVICE AREA, WHICH EXTENDS FROM CENTRALOAHU TO THE NORTH SHORE, WHERE IT RUNS FROM KA'ENA POINT TO WAIMEA BAY.WGH IS A SMALL, RURAL HOSPITAL IN THE FRINGE AREA OF A COMPETITIVE METROPOLITAN AREA. WGH FACES MANY CHALLENGES TO ITS CONTINUING ABILITYTO PROVIDE TOP QUALITY MEDICAL CARE TO RESIDENTS OF ITS SERVICE AREA,INCLUDING DIFFICULTIES IN ATTRACTING AND RETAINING PHYSICIANS AND SUPPORT PERSONNEL TO STAFF THE HOSPITAL.RANDALL M. SUZUKA, M.D. IS A LICENSED PRIMARY CARE PHYSICIAN IN HAWAIIAND PRESIDENT OF HALEIWA FAMILY CLINIC, INC. ("HALEIWA CLINIC"). ATCERTAIN TIMES, DR. SUZUKA HAS SERVED ON THE BOARD OF WGH AND /OR WHA.HALEIWA CLINIC IS A HAWAII PROFESSIONAL CORPORATION THAT OPERATES TWO PHYSICIAN CLINICS ON OAHU. ONE PHYSICIAN CLINIC IS LOCATED IN MILILANI, HAWAII. HALEIWA CLINIC SUBLEASED THE MILILANI CLINIC SITE FROM WHA.HALEIWA CLINIC HAS SUBLET THE MILILANI OFFICE SPACE FROM WHA SINCE2004. IN RECOGNITION OF FINANCIAL DIFFICULTIES FACED BY HALEIWACLINIC, WHA DEFERRED PAYMENTS OF RENT DUE. OVER THE YEARS, THE CLINICACCRUED AN OUTSTANDING BALANCE FOR PAST-DUE RENT. THUS, THE FACTS HERECOULD BE INTERPRETED AS WHA, IN EFFECT, LOANING MONEY TO HALEIWACLINIC. HOWEVER, THE INTENT OF WHA AT ALL TIMES WAS SIMPLY TO ASSURETHE AVAILABILITY OF MUCH NEEDED PRIMARY CARE SERVICES FOR RESIDENTS OF WGH'S SERVICE AREA.CORRECTIVE ACTION TAKEN IN AUGUST 2017, WHA'S SUBLEASE WITH HALEIWA CLINIC WAS TERMINATED, AND HALEIWA CLINIC SIGNED A PROMISSORY NOTE, PURSUANT TO WHICH THE HALEIWA CLINIC AGREED TO REPAY THE BALANCE OF THE OUTSTANDING RENT OVER A FIVE-YEAR-TERM WITH INTEREST AT THE RATE OF 5% PER YEAR ON THE OUTSTANDING BALANCE. THE INTEREST RATE WAS 1-1/2 POINTS OVER THE PRIME RATE AS REPORTED BY THE WALL STREET JOURNAL AT THE DATE OF EXECUTION OF THE NOTE. DR. RANDALL SUZUKA, THE PRESIDENT OF HALEIWA CLINIC, PERSONALLY GUARANTEED THE NOTE.HALEIWA CLINIC CONTINUED TO EXPERIENCE FINANCIAL DIFFICULTY, AND AS OF MAY 2019 WAS NOT CURRENT ON PAYMENTS UNDER THE 2017 NOTE. WHA WAS STILL CONCERNED ABOUT THE AVAILABILITY OF PRIMARY CARE FOR RESIDENTS OF THE AREA, AND THEREFORE WORKED WITH HALEIWA CLINIC TO RESTRUCTURE THE NOTE. A LOAN MODIFICATION AGREEMENT WAS SIGNED, WITH AN EFFECTIVE DATE OF JUNE 1, 2019. THE PRINCIPAL AMOUNT DUE WAS NOT REDUCED, BUT THE TIMING OF PAYMENTS WAS ADJUSTED. DR. SUZUKA'S PERSONAL GUARANTY REMAINED IN PLACE. AS OF JUNE 30, 2022, HALEIWA CLINIC HAD NOT MADE ALL OF THE MONTHLY PAYMENTS THAT HAD BECOME DUE IN THE FISCAL YEAR ENDING JUNE 30, 2022. HOWEVER, THE REMAINING PRINCIPAL, INTEREST, AND PENALTIES WERE PAID BY JANUARY 2023.

Schedule L (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990)

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

2021

Open to Public
Inspection

Name of the organization

WAHIAWA HOSPITAL ASSOCIATION INC

Employer identification number

99-0073529

Return Reference	Explanation
FORM 990, PART IV, LINE 12B AND PART XII, LINE 2B	SIMILAR TO PRIOR YEARS, THE ORGANIZATION'S FINANCIAL STATEMENTS WILL BE INCLUDED IN CONSOLIDATED FINANCIAL STATEMENTS THAT ARE AUDITED BY AN INDEPENDENT ACCOUNTANT. HOWEVER, THE AUDIT HAS NOT BEEN COMPLETED AT THE TIME OF FILING.
FORM 990, PART VI, SECTION A, LINE 6	MEMBERS AND RIGHTS ANY PERSON OR CORPORATION, ASSOCIATION, PARTNERSHIP, LIMITED LIABILITY COMPANY OR OTHER ENTITY WHO MAKES WRITTEN APPLICATION FOR MEMBERSHIP IN THE CORPORATION AND MAKES A CONTRIBUTION OF $50 MAY BE ELECTED BY THE BOARD OF DIRECTORS TO MEMBERSHIP IN THE CORPORATION. EACH MEMBER SHALL BE QUALIFIED TO VOTE ON ANY ISSUE THAT MAY PROPERLY COME BEFORE ANY MEETING. A MAJORITY OF THE MEMBERS OF THE BOARD OF DIRECTORS SHALL SERVE CONCURRENTLY AS DIRECTORS OF WAHIAWA GENERAL HOSPITAL.
FORM 990, PART VI, SECTION B, LINE 11B	DESCR THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 - THE FORM 990 WILL BE PRESENTED TO AND REVIEWED BY THE BOARD BEFORE THE RETURN IS FILED WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C	DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST - THE CONFLICT OF INTEREST POLICY AND RELATED REQUIREMENTS ARE INCLUDED AS PART OF THE BYLAWS ADOPTED IN NOVEMBER 2008. THE CONFLICT OF INTEREST POLICY ("COI") REQUIRES EACH DIRECTOR, OFFICER, AND MEMBER OF COMMITTEE WITH BOARD DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON: 1) RECEIVED A COPY OF THE COI POLICY, 2) READ AND UNDERSTANDS THE POLICY, 3) AGREED TO COMPLY WITH THE POLICY, AND 4) UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX EXEMPT PURPOSES. THE INTERESTED PERSON MAY MAKE A PRESENTATION TO THE BOARD OF DIRECTORS. THEN HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND VOTE ON, THE TRANSACTION INVOLVING THE POSSIBLE COI. AFTER EXERCISING DUE DILIGENCE, THE BOARD OF DIRECTORS SHALL DETERMINE WHETHER THE ORGANIZATION CAN OBTAIN WITH REASONABLE EFFORT A MORE ADVANTAGEOUS TRANSACTION FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A COI. IF A MORE ADVANTAGEOUS TRANSACTION IS NOT REASONABLY POSSIBLE UNDER CIRCUMSTANCES NOT PRODUCING A COI, THE DISINTERESTED DIRECTORS SHALL DETERMINE BY MAJORITY VOTE WHETHER THE TRANSACTION IS IN THE ORGANIZATION'S BEST INTEREST. IF THE BOARD OF DIRECTORS HAS REASONABLE CAUSE TO BELIEVE THAT A POTENTIAL INTERESTED PERSON HAS VIOLATED THE CONFLICTS OF INTEREST POLICY, IT SHALL INFORM THE POTENTIAL INTERESTED PERSON FOR SUCH BELIEF AND PROVIDE AN OPPORTUNITY TO EXPLAIN THE ALLEGED VIOLATION. AFTER HEARING THE POTENTIAL INTERESTED PERSON'S RESPONSE, THE BOARD OF DIRECTORS MAY TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION, IF NECESSARY. THE MINUTES OF THE BOARD OF DIRECTORS SHALL INCLUDE THE NAMES OF THE INTERESTED INDIVIDUALS, THE POSSIBLE COI AND THE ACTION TAKEN. THE MINUTES SHOULD INCLUDE THE NAMES OF THE INDIVIDUALS PRESENT FOR DISCUSSIONS AND VOTES RELATING TO THE COI. THERE WERE NO INSTANCES OF A CONFLICT OF INTEREST IN THIS REPORTING PERIOD BY ANY BOARD MEMBER.
FORM 990, PART VI, SECTION C, LINE 19	AVAIL OF GOV DOCS, CONFLICT OF INTEREST POLICY, & FIN STMTS TO GEN PUBLIC - THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.
FORM 990, PART VI, SECTION B, LINE 13 & LINE 14:	ADOPTION OF POLICIES AS OF JUNE 30, 2022, THE POLICIES IDENTIFIED IN PART VI, QUESTIONS 13 AND 14 WERE NOT FORMALLY ADOPTED BY THE ORGANIZATION. ALTHOUGH THE POLICIES HAVE NOT BEEN FORMALLY ADOPTED, THE ORGANIZATION HAS BEEN FOLLOWING THEM. THE WRITTEN POLICIES ARE CURRENTLY IN THE PROCESS OF BEING DEVELOPED BY THE ORGANIZATION'S BOARD. CURRENTLY THE ASSOCIATION DOES NOT HAVE ANY EMPLOYEES AND CONSISTS OF THE ASSOCIATION MEMBERS AND THE BOARD OF DIRECTORS ONLY.
FORM 990 - GOOD FAITH STATEMENT	THE ORGANIZATION HAS MADE ITS BEST EFFORTS TO COMPLY WITH TAX LAWS BASED UPON THE INFORMATION AVAILABLE AT THE TIME OF FILING. AT THE TIME OF FILING, THE AUDIT OF THE ORGANIZATION'S FINANCIAL STATEMENTS HAS NOT BEEN COMPLETED. RATHER THAN FILE A DELINQUENT TAX RETURN, THE ORGANIZATION AND TAX PROFESSIONALS MADE THEIR BEST EFFORTS TO DETERMINE THE PROPER TAX TREATMENT AND REPORTING OF VARIOUS ITEMS BASED ON THE ORGANIZATION'S UNAUDITED FINANCIALS. THE ORGANIZATION WILL AMEND THIS RETURN IF UPON COMPLETION OF THE AUDIT IT'S DETERMINED THAT THE INFORMATION REPORTED ON THIS RETURN IS MATERIALLY INCORRECT OR INACCURATE.

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

Cat. No. 51056K

Schedule O (Form 990) 2021

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

2021

Open to Public Inspection

Name of the organization

WAHIAWA HOSPITAL ASSOCIATION INC

Employer identification number

99-0073529

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)WAHIAWA HOSPITAL FOUNDATION 128 LEHUA STREET WAHIAWA,HI96786 30-0206692	FUNDRAISING	HI	501(C)(3)	LINE 12A, I	WAHIAWA GENERAL HOSPITAL	Yes
(2)WAHIAWA GENERAL HOSPITAL 128 LEHUA STREET WAHIAWA,HI96786 99-0269825	HEALTHCARE SVCS	HI	501(C)(3)	LINE 3	WAHIAWA HOSPITAL ASSOCIATION INC	Yes
(3)WAHIAWA GENERAL HOSPITAL AUXILIARY 128 LEHUA STREET WAHIAWA,HI96786 99-6009028	HEALTHCARE SVCS	HI	501(C)(3)	LINE 10	N/A		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2021

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(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

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) WAHIAWA HOSPITAL SERVICES CORPORATION 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(2) PACIFIC ADOLESCENT CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(3) PACIFIC HEALTH CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(4) WAHIAWA-PACIFIC HEALTH CENTER 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(5) PACIFIC HEALTH COMMUNITY INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(6) WAHIAWA-CENTRAL OAHU HEALTH CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(7) PACIFIC WOMEN'S CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(8) PACIFIC WELLNESS CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(9) PACIFIC BIOTECH INSTITUTE INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(10) PACIFIC SPORTS MEDICINE & RESEARCH CTR 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(11) PACIFIC SAGING CENTER INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(12) PACIFIC COMMUNITY HEALTH & WELNESS 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes
(13) PACIFIC CARDIAC INSTITUTE INC 128 LEHUA STREET WAHIAWA,HI96786	INACTIVE	HI	WHA	C			100.000 %	Yes

Schedule R (Form 990) 2021

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

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

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

Yes

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

Yes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) WAHIAWA GENERAL HOSPITAL	D	244,928	FMV

Schedule R (Form 990) 2021

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) 2021

Page 5

Part VII

Supplemental Information

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

Return Reference	Explanation

Schedule R (Form 990) 2021

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO SUPPORT, PROMOTE, AND MAINTAIN WAHIAWA GENERAL HOSPITAL NOT-FOR-PROFIT CORPORATION. TO OPERATE EXCLUSIVELY FOR HOSPITAL, CHARITABLE, EDUCATIONAL, AND SCIENTIFIC PURPOSES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	10
5	Total number of individuals employed in calendar year 2021 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	0
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	0	420
9	Program service revenue (Part VIII, line 2g) .........	62,917	86,826
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	16,018	13,894
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,533,854	0
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	1,612,789	101,140
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
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)	0	0
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	91,232	127,533
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	91,232	127,533
19	Revenue less expenses. Subtract line 18 from line 12.......	1,521,557	-26,393
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	2,731,618	3,657,866
21	Total liabilities (Part X, line 26).............	53,392	26,318
22	Net assets or fund balances. Subtract line 21 from line 20.....	2,678,226	3,631,548

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 32,131 including grants of $ ) (Revenue $ 86,826 )
	TO PROVIDE SUPPORT FOR NOT-FOR-PROFIT HOSPITAL SUBSIDIARY, WAHIAWA GENERAL HOSPITAL. 1) TO PERFORM CHARITABLE OR BENEVOLENT WORK INCLUDING HOSPITALS, SKILLED NURSING AND OTHER HEALTHCARE FACILITIES. 2) TO PERFORM STRATEGIC OR DEVELOPMENT PLANNING FOR THE HEALTHCARE SYSTEM.

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 expenses32,131

(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)		(D) Reportable compensation from the organization (W-2/1099-MISC/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(1) DAVID SEEHOLZER...................................................................... CHAIRMAN	1.23 ................. 0.35	X	X	0	0	0
(2) JOHN KAMPFER...................................................................... DIRECTOR	0.74 ................. 0.63	X		0	0	0
(3) NORBERTO BAYSA MD...................................................................... DIRECTOR	0.26 ................. 0.32	X		0	0	0
(4) R KALANI FRONDA...................................................................... VICE CHAIR	0.58 ................. 0.29	X	X	0	0	0
(5) BISHOP MICHAEL HENDERSON...................................................................... TREASURER	0.29 ................. 0.32	X	X	0	0	0
(6) JEFFREY ALAMEIDA...................................................................... DIRECTOR	0.77 ................. 0.32	X		0	0	0
(7) CRAIG THOMAS MD...................................................................... DIRECTOR	0.90 ................. 0.32	X		0	0	0
(8) ROBERT BUNDA...................................................................... DIRECTOR	0.53 ................. 0.46	X		0	0	0
(9) STACIE SASAGAWA...................................................................... SECRETARY	0.63 ................. 0.00	X	X	0	0	0
(10) GORDON KANEMARU DDS...................................................................... DIRECTOR	0.55 ................. 0.00	X		0	0	0
(11) BRIAN CUNNINGHAM...................................................................... CEO	1.00 ................. 41.00		X	0	0	0

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

(A) Name and business address	(B) Description of services	(C) Compensation





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 0

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	420

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

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

h Total. Add lines 1a-1f.......		420

		Business Code
2a	RENTAL INCOME RELATED	531120	86,826	86,826
b
c
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		86,826

3 Investment income (including dividends, interest, and othersimilar amounts) ......			13,894			13,894
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents			6a
b	Less: rental expenses			6b
c	Rental income or (loss)			6c
d	Net rental income or (loss).......
		(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
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......
12	Total revenue. See instructions.....			101,140	86,826	0	13,894

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
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 ...........
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........
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......
10	Payroll taxes ...........
11	Fees for services (non-employees):
a	Management ......	46,619		46,619
b	Legal .........	18,783		18,783
c	Accounting ...........	30,000		30,000
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)
12	Advertising and promotion ....
13	Office expenses .......
14	Information technology ......
15	Royalties ..
16	Occupancy ...........
17	Travel ............
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	6,990	6,990
23	Insurance ...
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	PROPERTY TAX	19,371	19,371
b	GENERAL EXCISE TAX & LI	5,268	5,268
c	OTHER EXPENSE	502	502
d
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	127,533	32,131	95,402	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			81,126	1	77,943
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			982,365	4	1,959,826
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 .......
				296,257	5	255,216
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 ............				8
9	Prepaid expenses and deferred charges ......				9
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	20,564,417
b	Less: accumulated depreciation	10b	19,200,906	1,370,500	10c	1,363,511
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 ...............				14
15	Other assets. See Part IV, line 11 ...........			1,370	15	1,370
16	Total assets. Add lines 1 through 15 (must equal line 33)...			2,731,618	16	3,657,866

17	Accounts payable and accrued expenses .....	27,077	17	26,318
18	Grants payable ...		18
19	Deferred revenue .........		19
20	Tax-exempt bond liabilities .........		20
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	26,315	25	0
26	Total liabilities. Add lines 17 through 25..	53,392	26	26,318

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	2,678,226	27	3,631,548
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 ...........	2,678,226	32	3,631,548
33	Total liabilities and net assets/fund balances ........	2,731,618	33	3,657,866