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 | |||||
|
Total |
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Calendar year
(or fiscal year beginning in)
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(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. | ||||||
Calendar year
(or fiscal year beginning in)
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(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 | ||||||
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.) | ||||||
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.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 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) |
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| 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): |
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| 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 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. |
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| 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) |
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| 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. |
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|
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. |
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|
7 Excess distributions carryover to 2022. Add lines 3j and 4c. |
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| 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..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 1A | THIS COMMITTEE SHALL CONSIST OF THE CHAIRPERSON, VICE CHAIRPERSON, THREE (3) OTHER VOTING MEMBERS OF THE BOARD, AND THE CEO AND CHIEF OF THE MEDICAL STAFF IN EX-OFFICIO, NON-VOTING CAPACITY. DURING THE INTERVALS BETWEEN MEETINGS OF THE BOARD, THE EXECUTIVE COMMITTEE MAY ACT IN THE NAME, AND WITH THE FULL POWER, OF THE BOARD PROVIDED THAT ANY SUCH ACTION SHALL NOT CONFLICT WITH THE POLICIES OF THE BOARD OF TRUSTEES AND BE OCCASIONED BY AN EMERGENT SITUATION IN WHICH AN EMERGENCY MEETING CANNOT BE HELD. ANY ACTION TAKEN BY THE EXECUTIVE COMMITTEE SHALL SET FORTH THE REASON ACTION WAS REQUIRED TO BE TAKEN PRIOR TO THE NEXT SCHEDULED MEETING OF THE BOARD AND WHY AN EMERGENCY MEETING WAS NOT CALLED. THIS COMMITTEE MAY REQUEST THE CHAIRPERSON TO CALL A SPECIAL MEETING OF THE BOARD OF TRUSTEES WHEN A SITUATION DICTATES. THIS COMMITTEE SHALL MEET AS NECESSARY AND SHALL REPORT TO THE BOARD AS A WHOLE. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE HOSPITAL HAS A DUAL CERTIFICATION IN THAT IT IS A POLITICAL SUB-DIVISION OF GRANT COUNTY. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE GRANT COUNTY COMMISSION APPOINTS MEMBERS TO THE BOARD WHO RESIDE IN GRANT COUNTY. THE HOSPITAL IS A POLITICAL SUB-DIVISION OR COMPONENT UNIT OF GRANT COUNTY (COUNTY HOSPITAL). |
| FORM 990, PART VI, SECTION B, LINE 11B | THE TAX RETURN WILL BE REVIEWED BY MANAGEMENT AND IS GIVEN TO EVERY BOARD MEMBER OF THE BOARD AFTER THE RETURN IS FILED. |
| FORM 990, PART VI, SECTION B, LINE 12C | TRUSTEES AND ADMINISTRATION OFFICIALS SHALL BE REQUIRED TO COMPLETE A WRITTEN CONFLICT OF INTEREST STATEMENT ANNUALLY WHICH SHALL DISCLOSE THE EXTENT OF FINANCIAL DEALINGS WITH THE ORGANIZATION BY ALL BUSINESSES OR OTHER ORGANIZATIONS IN WHICH THEY, OR MEMBERS OF THEIR IMMEDIATE FAMILIES, HAVE A BENEFICIAL INTEREST. A BENEFICIAL INTEREST WITH AN ORGANIZATION WILL BE CONSIDERED TO EXIST WHEN A TRUSTEE OR ADMINISTRATION OFFICIAL OR A MEMBER OF HIS/HER IMMEDIATE FAMILY IS AN OFFICER, DIRECTOR, TRUSTEE, PARTNER, EMPLOYEE OR AGENT OF THE ORGANIZATION, OR OWNS FIVE PERCENT OF THE VOTING STOCK OR CONTROLLING INTEREST IN THAT ORGANIZATION, OR HAS ANY OTHER SUBSTANTIAL INTEREST OR DEALINGS WITH THE ORGANIZATION. AT SUCH TIME, IF ANY MATTER SHOULD COME BEFORE THE BOARD OF TRUSTEES IN SUCH A WAY AS TO GIVE THE RISE TO A CONFLICT OF INTEREST, THE AFFECTED MEMBER OF THE BOARD SHALL MAKE KNOWN THE POTENTIAL CONFLICT AND IF ADVISABLE, WITHDRAW FROM THE MEETING FOR SO LONG AS THE MATTER SHALL CONTINUE UNDER DISCUSSION. SHOULD THE MATTER BE BROUGHT TO VOTE, THE AFFECTED MEMBER SHALL NOT VOTE, NOR BE COUNTED IN ESTABLISHING A QUORUM FOR THE VOTE ON THAT MATTER. PROCEEDINGS RELATED TO THE CONFLICT OF INTEREST MATTERS BEFORE THE BOARD OF TRUSTEES SHALL BE DOCUMENTED IN THE MINUTES OF THAT MEETING. EVERY JANUARY, THE CEO AND CHAIRMAN ENSURE THE CONFLICT OF INTEREST FORMS ARE COMPLETED. THEY REVIEW THE FORMS TO IDENTIFY ANY INSTANCES THEY CAN FORESEE AND DISCUSS THEM WITH THE BOARD. |
| FORM 990, PART VI, SECTION B, LINE 15A | EVERY YEAR A SURVEY IS CONDUCTED THROUGH THE STATE ON AVERAGE SALARIES FOR THE CEO OF THE ORGANIZATION. THIS ENSURES THE HOSPITAL IS PAYING NO MORE THAN FAIR MARKET VALUE FOR THE CEO COMPENSATION. THE COMPENSATION AVERAGES ARE GIVEN TO THE BOARD OF TRUSTEES AND THEY HAVE FINAL SAY ON THE ACTUAL COMPENSATION FOR THE CEO OF THE HOSPITAL |
| FORM 990, PART VI, SECTION C, LINE 18 | THE TAX RETURN IS SUBMITTED TO THE WEST VIRGINIA HEALTHCARE AUTHORITY UNDER THE STATE OF WEST VIRGINIA'S FINANCIAL DISCLOSURE STATUTE. |
| FORM 990, PART VI, SECTION C, LINE 19 | IT IS REQUIRED BY WEST VIRGINIA LAW THAT ALL HOSPITALS FILE AUDITED FINANCIAL STATEMENTS, MEDICARE/MEDICAID COST REPORTS, CHARGEMASTER AND SIGNED COPY OF WORKSHEET 12 OF THE UNIFORM REPORT N TO THE WEST VIRGINIA HEALTH CARE AUTHORITY. INFORMATION SUBMITTED TO THE WEST VIRGINIA HEALTH CARE AUTHORITY MAY BE OBTAINED UNDER THE FREEDOM OF INFORMATION ACT. THE GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY WILL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,940,568. MANAGEMENT AND GENERAL EXPENSES 512,932. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,453,500. MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 1,586,866. MANAGEMENT AND GENERAL EXPENSES 419,441. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,006,307. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,858,399. MANAGEMENT AND GENERAL EXPENSES 491,213. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,349,612. OTHER FEES: PROGRAM SERVICE EXPENSES 1,801,582. MANAGEMENT AND GENERAL EXPENSES 60,658. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,862,240. |
| FORM 990, PART XII, LINE 2C | THE ORGANIZATION'S BOARD OF DIRECTORS ASSUME RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE PROCESS IS CONSISTENT WITH PRIOR YEARS AND HAS NOT CHANGED. |
| Software ID: | |
| Software Version: |