TY 2022 Form 990

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)
(1) Timothy P Shafer MD...................................................................... Trustee/Physician	40.00 ................. 0.00	X			245,819	32,883
(2) Al Claussen III...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(3) Lucas Farrell...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(4) Thomas Kalchthaler...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(5) Karren Meyer...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(6) Terry Pollio...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(7) Rachel Stettler...................................................................... Trustee	1.00 ................. 1.00	X			0	0
(8) Sarah Vangel...................................................................... Trustee	1.00 ................. 0.00	X			0	0
(9) Martha Dale...................................................................... President	1.00 ................. 0.00	X	X		0	0
(10) Edward Druke...................................................................... Vice President	1.00 ................. 0.00	X	X		0	0
(11) Barry Emerson...................................................................... Treasurer	1.00 ................. 0.00	X	X		0	0
(12) Sheila Scheuerman...................................................................... Secretary	1.00 ................. 1.00	X	X		0	0
(13) Douglas DiVello...................................................................... CEO	40.00 ................. 1.00		X		324,346	48,804
(14) Stephen A Brown...................................................................... CFO	44.10 ................. 1.00		X		304,861	34,105
(15) George Terwilliger MD...................................................................... Physician	40.00 ................. 0.00			X	290,966	33,462
(16) Philip Schafer PA-C...................................................................... Physician Assistant	43.13 ................. 0.00			X	239,720	31,615
(17) Jeremy Morrison MD...................................................................... Physician	36.51 ................. 0.00			X	217,330	43,398

(A) Name and business address	(B) Description of services	(C) Compensation
Cerner Corporation PO Box 959156 St Louis,MO63195	Hardware/Software Support	467,038
Triage LLC PO Box 773328 Chicago,IL60677	Staffing Services	375,010
Trusted Health Inc PO Box 7775 San Francisco,CA94120	Staffing Services	350,693
Lavallee Brensinger Architects 155 Dow Street 400 Manchester,NH03101	Architectural Services	245,289
First Choice Comm Services Inc 49 Marlboro Road Brattleboro,VT05301	Communication Services	209,720
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 11

- 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.
right arrow

Attach to Form 990 or Form 990-EZ.
right arrow

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

OMB No. 1545-0047

2022

Open to Public
Inspection

Name of the organization

Carlos G Otis Health Care Center

Employer identification number

03-0177161

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 ...............................

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

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990) 2022

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) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(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) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(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 2022 (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—2022. 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—2021. 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—2022. 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—2021. 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) 2022

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) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(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) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(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 2022 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2021 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2022 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2021 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests-2022. 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—2021. 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) 2022

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

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).

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) 2022

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).

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) 2022

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) 2022

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 2022 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-2022	(iii) Distributable Amount for 2022
1 Distributable amount for 2022 from Section C, line 6
2 Underdistributions, if any, for years prior to 2022 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2022:
a From 2017.......
b From 2018.......
c From 2019.......
d From 2020.......
e From 2021.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2022 distributable amount
i Carryover from 2017 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2022 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2022 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2022, 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 2022. 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 2023. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2018.....
b Excess from 2019.....
c Excess from 2020.....
d Excess from 2021.....
e Excess from 2022.....

Schedule A (Form 990) (2022)

Schedule A (Form 990) 2022

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990) 2022

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

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

OMB No. 1545-0047

2022

Name of the organization

Carlos G Otis Health Care Center

Employer identification number

03-0177161

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

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

Cat. No. 30613XSchedule B (Form 990) (2022)

Schedule B (Form 990) (2022) Page 2

Name of organization Carlos G Otis Health Care Center

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990) (2022)

Schedule B (Form 990) (2022)

Page 3

Name of organization Carlos G Otis Health Care Center		Employer identification number 03-0177161

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990) (2022)

Schedule B (Form 990) (2022)

Page 4


Name of organization Carlos G Otis Health Care Center			Employer identification number 03-0177161
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990) (2022)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

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

OMB No. 1545-0047

2021

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Carlos G Otis Health Care Center

Employer identification number

03-0177161

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

Political campaign activity expenditures. See instructions .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities. See instructions ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990) 2021

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990) 2021

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Yes

3,532

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

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

3,532

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures. See Instructions .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Part II-B, Line 1:	The Carlos G. Otis Health Care Center is a member of the Vermont Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations was likely made available for lobbying expenditures on behalf of the Carlos G. Otis Health Care Center and other member organizations in furtherance of their exempt purposes. Carlos G. Otis HealthCare Center does not directly perform any lobbying activities. The dues paid by the HealthCare Center during this tax period were as follows: - AHA, portion of dues available for lobbying: $702 - VAHHS, portion of dues available for lobbying: $2,830

Return Reference

Explanation

Part II-B, Line 1:

The Carlos G. Otis Health Care Center is a member of the Vermont Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations was likely made available for lobbying expenditures on behalf of the Carlos G. Otis Health Care Center and other member organizations in furtherance of their exempt purposes. Carlos G. Otis HealthCare Center does not directly perform any lobbying activities. The dues paid by the HealthCare Center during this tax period were as follows: - AHA, portion of dues available for lobbying: $702 - VAHHS, portion of dues available for lobbying: $2,830

Schedule C (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

Carlos G Otis Health Care Center

Employer identification number

03-0177161

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 ....	3,837,791	3,726,261	3,897,999	3,421,086	3,228,802
b	Contributions ...	43,397	1,211,226
c	Net investment earnings, gains, and losses	346,864	-448,720	-171,738	476,913	192,284
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...	267,642	650,976
f	Administrative expenses ....
g	End of year balance ......	3,960,410	3,837,791	3,726,261	3,897,999	3,421,086

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

71.920 %

Permanent endowment SchDMd Bullet

28.080 %

Term endowment SchDMd Bullet

0 %

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)

Yes

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Yes

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 .....	30,549		30,549
b	Buildings ....	9,562,586	7,606,188	1,956,398
c	Leasehold improvements
d	Equipment ....	8,120,578	5,712,549	2,408,029
e	Other .....	477,263	68,101	409,162
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				4,804,138

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)Beneficial Interest in Net Assets of GCF				9,287,890
(2)Deposits with Trustee				7,535
(3)Malpractice Reserve Coverage and Assets				1,150,000
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				10,445,425

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
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	1,173,109
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	33,783,800
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	600,415
e	Add lines 2a through 2d .....................			2e	600,415
3	Subtract line 2e from line 1..................			3	33,183,385
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	978,260
c	Add lines 4a and 4b....................			4c	978,260
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	34,161,645

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	33,638,016
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	0
3	Subtract line 2e from line 1...................			3	33,638,016
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	978,260
c	Add lines 4a and 4b.....................			4c	978,260
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	34,616,276

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
Part V, Line 4:	The Carlos G. Otis Health Care Center and the Grace Cottage Foundation use their endowment funds to assist in the provision of health care and care services. The goal of the endowment funds is to provide a source of financial support to the Organization's patient care activities. The Organization appropriates the earnings from the endowment funds to offset the costs of patient care activities according to the intent of the donor. The endowment funds are invested in a prudent manner with regard to preserving principal while providing reasonable returns. A portion of endowment funds are quasi-endowment funds, designated assets set aside by the Board of Trustees over which the Board retains control and may, at its discretion, subsequently use for other purposes. Accordingly, the endowment includes both endowment funds restricted in perpetuity from expenditure by donors, and other funds for which the governing board or state regulations require that such funds be treated in a manner similar to the restricted endowments. All endowment funds are to fund capital improvements, hospital maintenance, and/or patient and care services.
Part X, Line 2:	OHCC and the Foundation are tax-exempt corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Internal Revenue Code. In addition, the Foundation qualifies for the charitable contribution deduction under Section 170(b)(1)(a) and had been classified as an organization that is not a private foundation under Section 509(a)(3). Management evaluated the Organization's tax positions and concluded the Organization has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements.
Part XI, Line 2d - Other Adjustments:	Change in Beneficial Interest in Net Assets of Grace Cottage Foundation 600,415.
Part XI, Line 4b - Other Adjustments:	Provision for Bad Debt 978,260.
Part XII, Line 4b - Other Adjustments:	Provision for Bad Debt 978,260.

Schedule D (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20a.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2022

Open to Public Inspection

Name of the organization

Carlos G Otis Health Care Center

Employer identification number

03-0177161

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

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

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

Yes

100% 150% 200% Other 25000.0000000000 %

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	215,350		215,350	0.640 %
b	Medicaid (from Worksheet 3, column a) . . . . .	5,465,168	2,117,584	3,347,584	9.950 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	5,680,518	2,117,584	3,562,934	10.590 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	347,576	188,687	158,889	0.470 %
f	Health professions education (from Worksheet 5) . . .
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	12,957	0	12,957	0.040 %
j	Total. Other Benefits . .	360,533	188,687	171,846	0.510 %
k	Total. Add lines 7d and 7j .	6,041,051	2,306,271	3,734,780	11.100 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2022

Schedule H (Form 990) 2022

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

606,243

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

28,527

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

11,586,984

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

11,772,713

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

-185,729

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2022

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	Grace Cottage Hospital 185 Grafton Road Townshend,VT05353 www.gracecottage.org 962	X	X	X	X

Schedule H (Form 990) 2022

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	Grace Cottage Hospital
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 20

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

Yes

6 a

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

Yes

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

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

Yes

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

Hospital facility’s website (list url): See Part V, Section C

Other website (list url): See Part V, Section C

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21

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

Yes

If "Yes" (list url): See Part V, Section C

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Yes

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2022

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	Grace Cottage Hospital
Name of hospital facility or letter of facility reporting group

Yes

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

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

Yes

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

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 250.000000000000%
and FPG family income limit for eligibility for discounted care of 350.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

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

See Part V, Section C

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

See Part V, Section C

A plain language summary of the FAP was widely available on a website (list url):
See Part V, Section C

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2022

Page 6

Part VFacility Information (continued)

Billing and Collections

	Grace Cottage Hospital
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2022

Page 7

Part VFacility Information (continued)

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

	Grace Cottage Hospital
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2022

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Grace Cottage Hospital	Part V, Section B, Line 5: As required by Vermont statute and Treasury Regulation 501(r), Grace Cottage Hospital conducts a Community Health Needs Assessment (CHNA) every three years. Our most recent CHNA was done collaboratively in 2021 with Brattleboro Memorial Hospital (BMH) and the Brattleboro Retreat. These three healthcare organizations focused on involving as many stakeholders and community members as possible in the data collection process, which took place from January to June 2021. Secondary data was collected from multiple sources including: U.S. Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, U.S. Census, National Institute of Health, Feeding America, Vermont Department of Health, Vermont Department of Labor, Vermont Department of Education, Vermont Department of Transportation, Vermont Foodbank, Vermont Town and County Data Pages, and the Windham Regional Commission. The secondary data was benchmarked against state and national trends, where possible. Primary data was obtained through a consumer survey and a secondary survey of representatives of medically underserved populations. The consumer survey was distributed in both paper copy as well as online. In total, 2,194 surveys were collected for Windham County. The secondary survey was held to collect qualitative data on at-risk populations. The following medically underserved populations were represented in the secondary survey: - Elderly/Senior Population - HIV+ Individuals - Homeless Population - Refugees & Migrants - LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning Individuals) - Racial and Ethnic Minority Populations - Terminally ill individuals - Low-income individualsThe three hospitals set up a steering committee made up of individuals from the State of Vermont Department of Health, Brattleboro Memorial Hospital, Grace Cottage Hospital, and The Brattleboro Retreat. Additionally, the participating organizations engaged a wide range of stakeholders through the surveys, including health care providers, human service organizations, and other nonprofit organizations. Grace Cottage identified the following as High Priority Significant Health Needs in our service area: Mental Health Issues (Anxiety, Depression, Social Isolation, Stress), Substance Abuse, and Nutritional Fitness/Diabetes.The 2022 (tax year 2021) Community Health Needs Assessment was adopted by the Grace Cottage Board of Trustees on July 16, 2021, and the Implementation Plan was approved by the Board on November 19, 2021. An updated Implementation Plan is available for public viewing at:https://gracecottage.org/about-us/our-hospital/community-health-needs-assessment/.
Grace Cottage Hospital	Part V, Section B, Line 6a: The 2021 Community Health Needs Assessment was conducted with Brattleboro Memorial Hospital and The Brattleboro Retreat.
Grace Cottage Hospital	Part V, Section B, Line 11: Please refer to the 2021 CHNA Implementation Plan for information on how the Hospital is addressing the significant needs identified in its most recently conducted CHNA. Additionally, the 2023 Annual Update to the Implementation Plan may be found on our website at:https://gracecottage.org/wp-content/uploads/2024/04/2023-CHNA-Implementation-Plan-Annual-Update.pdfWhile a significant health need in our service area, Grace Cottage Hospital is not addressing dental issues as we do not provide dental services. The Level 2 & 3 Priorities identified in the 2021 CHNA - Healthy Aging, High Blood Pressure, Cancer (especially colon cancer), Arthritis, Basic Needs, and Physical Fitness - are addressed with all patients on an on-going and personal basis.
Grace Cottage Hospital	Part V, Section B, Line 13b: Generally, Grace Cottage Hospital uses the Federal Poverty Guidelines to determine eligibility for financial assistance. However, applications may be reviewed on a case-by-case basis and at times financial assistance granted even if a patient is above the prescribed FPG level or qualifies only for a lesser reduction in fees if there is a prevailing circumstance that justifies additional financial support.
Grace Cottage Hospital	Part V, Section B, Line 20e: Grace Cottage Hospital (GCH) located in rural, mountainous Townshend, VT provides services to patients, whether a community member, second homeowner, or vacationer, through our Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation. Taking pride in the community we serve, we make every attempt possible to notify patients of the Reduced Fee Program and Formal Payment Plan options at GCH that will allow patients to receive care without undue hardship. The following are some of the steps currently in place, to notify patients of the available options:- All registration areas of the Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation Services have visible signs on display notifying patients of our Reduced Fee Program.- All registration staff upon verification of no insurance, limited insurance coverage with high patient responsibility portions, or communication from patient indicating difficulty with paying bill, will offer a Reduced Fee Application, Policy, and business card for our Resource Advocate, identifying the many services she provides to patients free of charge and her contact information. Staff will also offer to schedule an appointment for the patient with Resource Advocate for assistance in completing the Reduced Fee Application, troubleshooting issues with insurance, and/or applying for insurance coverage whether it is primary or secondary.- Patients receive at least 5 billing statements over the course of 120-day time frame (patients in a formal payment plan or whom have a billing issue arise may increase the number of statements to be received or increase the number of days to complete the 5 billing statement cycle). Every statement has a message that notifies them of the Reduced Fee Program and steps to take to get started.- Once a patient balance is past due (>30 days from date of first patient billing) Patient Accounts Specialists contact patients via phone in an attempt to alert patient to past due balance, offer a formal payment plan if balance unable to be paid in full. If/when patient indicates difficulty in paying their bill, Patient Accounts Specialists will notify patient of the Reduced Fee Program and offer to mail the application and policy to them. Patient Accounts Specialists note the patient account with a briefing of the phone call. If a patient balance is aged >120 days from the date of the first billing statement and a potential to be sent to a third- party collections agency the account is reviewed, if there is a note from patient accounts indicating a Reduced Fee application and policy have been mailed to the patient within the last 45 days a hold will be placed on transferring the balance to the third-party collections agency. After 45-60 days if no Reduced Fee application or communication from the patient the balance will be transferred to the third-party collection agency at that time.- All Reduced Fee applications are processed with required documentation to determine eligibility in accordance with our Sliding Fee Scale based on Federal Poverty Guidelines. If missing required documents, a written request is sent to the patient and application held while awaiting documents. All processed applications are filed, written notice of eligibility is mailed to the patient, eligibility is noted on patient's account and adjustments are made manually after insurance processing and prior to a billing statement being mailed to the patient, and all applications are documented on a yearly spreadsheet showing household members, date of application (eligibility begin date), expiration date, whether they are eligible, percentage they are eligible for, and comments for case by case applications that identifies parameters for this approval/denial i.e.: only one date of service.
Schedule H, Part V, Section B, Line 7a, 7b and 10a:	The Hospital's 2021 (tax year 2020) CHNA is available at: https://gracecottage.org/pdf/2021-CHNA-Report-9-10-21.pdfAdditionally, the 2022 Updates to the Hospital's Needs Assessment is available at:https://gracecottage.org/wp-content/uploads/2023/03/CHNA-Update-2022.pdfThe Hospital's 2021 CHNA Implementation Plan is available at: https://gracecottage.org/wp-content/uploads/2022/06/2021-CHNA-Implementation-Plan-Final-11-19-21.pdfThe Hospital's 2023 Annual Update to the Implementation Plan is available at: https://gracecottage.org/wp-content/uploads/2024/04/2023-CHNA-Implementation-Plan-Annual-Update.pdfPast year CHNA and CHNA Implementation Plans may be found on the Hospital's website at:https://gracecottage.org/about-us/our-hospital/community-health-needs-assessment/
Schedule H, Part V, Section B, Line 16a-16c:	The Hospital's Financial Assistance Policy is available on its website at: https://gracecottage.org/wp-content/uploads/2021/01/16.0050-REDUCED-FEE-FREE-CARE-POLICY-rev-1-2021.pdfThe Hospital's Financial Assistance Application is available on its website at: https://gracecottage.org/wp-content/uploads/2019/08/16.0050-REDUCED-FEE-FREE-CARE-APPLICATION.pdfThe Hospital's Plain Language Summary is available on its website at: https://gracecottage.org/wp-content/uploads/2022/02/16.0050-REDUCED-FEE-FREE-CARE-PLAIN-LANGUAGE-SUMMARY-updated-2-21-22.pdf

Schedule H (Form 990) 2022

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?2
Name and address		Type of Facility (describe)
1	1 - Messenger Valley Pharmacy 170 Grafton Road Townshend,VT05353	Pharmacy
2	2 - Grace Cottage Family Health 185 Grafton Road Townshend,VT05353	Rural health clinic
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2022

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
Part I, Line 3c:	N/A
Part I, Line 6a:	N/A
Part I, Line 7:	The amounts reported for Charity Care and Means-Tested Government Programs were calculated using a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges.
Part I, Line 7g:	N/A
Part I, Line 7, Column (f):	The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 978,260.
Part II, Community Building Activities:	See previous and subsequent narrative responses.
Part III, Line 2:	The cost of the bad debt expense reported on line 2 was calculated by applying the ratio of patient care cost-to-charges (calculated on Worksheet 2) to the total bad debt expense. The amount of bad debt expense for accounts written off as bad debt is the account balance after all charity care discounts, contractual allowances, and insurance/patient payments have been applied. Any cash collected on accounts previously written off is included as an offset to bad debt expense.
Part III, Line 3:	The amount of bad debt expense (at cost) attributable to patients eligible under our charity care policy reported on line 3 was estimated based on a review of Reduced Fee/Free Care Applications. The number of approved completed applications versus the number of incomplete applications was compared and a ratio applied to the Charity Care balance to estimate this number. It is felt that this estimate should actually be much higher because, though we work hard to educate our patients regarding the charity care policy, including having a Resource Advocate to help patients complete them if they require assistance, many of the applications we distribute to patients are not returned. Knowing our patient population as we do, we believe it is primarily attributable to patients not wanting to share the income information.
Part III, Line 4:	Footnote 1 of the Organization's audited financial statements detail the Organization's significant accounting policies, including the Organization's treatment of accounts receivable and uncollectible amounts.
Part III, Line 8:	Medicare allowable costs reported in the Medicare Cost Report are reported in accordance with CMS Guidelines using the cost-to-charge ratio methodology.As a Critical Access Hospital (CAH), the Organization is eligible for reimbursement of up to 101% of allowable Medicare costs and services. However, the Organization is subject to a 2% Medicare Sequestration, which resulted in a Medicare Shortfall reported on its Form 990, Schedule H, Part III, Section B.
Part III, Line 9b:	Grace Cottage Hospital does not pursue collections actions against patients for amounts qualified for financial assistance. If a patient is unable to pay a balance in full after reduced fees and financial assistance have been applied, the patient is required to set up an acceptable payment plan per the collections policy. Any patient making acceptable monthly payments on their balance will not be at risk for further collections actions and/or forfeiture of their reduced fee care or financial assistance. However, any balance remaining after that discount that goes unpaid as agreed upon will follow the collections actions outlined in the Hospital's collection policy. Failure to resolve the balance in full or any missed payments will result in forfeiture of reduced fees and/or financial assistance, and the patient's account will be placed with a collections agency for further action. Additionally, the patient will not be eligible for reduced fees or financial assistance until a substantial effort is put forth to rectify the outstanding balance.
Part VI, Line 2:	Grace Cottage Hospital is such a small hospital in a rural, relatively sparsely populated area that our community leaders, patients, and members of the public are quick to inform our administrators and our medical staff about how Grace Cottage serves the healthcare needs of the public. Grace Cottage's small size ensures that we can be responsive to community requests made via our website, our monthly e-newsletter from the CEO to 3500+ community members, e-mails to members of our staff, or informal face-to-face meetings with people in the communities we serve.
Part VI, Line 3:	Although we are Vermont's smallest Critical Access Hospital, Grace Cottage Hospital believes that quality health care should be available to all; and that we all have a responsibility to help others in need regardless of their ability to pay. Posters and brochures detailing the availability of help with billing, public programs, and charity care are displayed in high traffic areas throughout the Hospital, rural health clinic and pharmacy, as well as listed on the Hospital's website. The staff reaches out to patients in a variety of ways to ensure that they are aware that help is available. During fiscal year 2023, the Hospital continued to employ a Patient Resource Advocate to help uninsured and underinsured patients locate and procure services for which they may qualify. The Patient Resource Advocate's services are free of charge for community members (those 65 and older were also encouraged to contact Senior Solutions, formerly Southeastern Vermont Council on Aging). The Hospital's Patient Resource Advocate helps many people with a wide variety of resource issues, helping to fill out necessary forms and making connections for patients with other federal, state and local resources. This employee is an expert in filling out reduced fee applications, finding sources for reduced-cost or free prescription medications, and locating other avenues of support.
Part VI, Line 4:	Grace Cottage Hospital plays a vital role in healthcare for this rural, mountainous community. Its federal designation as a critical access hospital recognizes its importance in providing health care to an otherwise medically underserved community. The Hospital's emergency department is especially vital to members of the community, who would otherwise have to travel many miles on winding, mountainous highways to reach emergency medical care at another hospital. Grace Cottage Hospital is located in Windham County, in southeastern Vermont. According to the U.S. Census Bureau, Windham County has an estimated total of 43,714 residents. Grace Cottage Hospital's patient base is approximately 30,000 residents, mostly from 21 surrounding towns. The median household income of Windham County, Vermont, is $50,917 (U.S. Census Bureau "Quick Facts," updated 2016). Income statistics for the total population served by Grace Cottage Hospital are not available because Grace Cottage only requires income information from patients requesting reduced fees or free care.
Part VI, Line 5:	Grace Cottage Hospital is a Critical Access Hospital located in rural, mountainous Townshend, Vermont. The Hospital is served by a Board of Trustees consisting of local citizens active in community businesses and organizations. Only one of the twelve trustees, a physician, is a hospital employee. All trustees reside or work in the Hospital's service area and bring a wealth of community input to the Hospital's strategic planning process. The Hospital extends medical staff privileges to all qualified physicians in the community.Grace Cottage Hospital applies any surplus funds towards improving its ability to provide quality patient care and being an integral part of assuring the health and well-being of the communities we serve. For example, in view of the fact that Mental Health was identified as a High Priority Significant Need in our Community Health Needs Assessment, Grace Cottage continues to employ both a full-time psychiatric nurse practitioner and a full-time licensed clinical social worker. Both professionals are embedded in the family health practice, where they are key players in the healthcare team. Despite its small size, Grace Cottage Hospital is committed to giving back to the community to the greatest extent possible. Grace Cottage's Community Health Team has been able to provide free consultations, open to everyone in the community served by Grace Cottage. Members of the Community Health Team include a Diabetes Educator and an RN Care Coordinator. Grace Cottage Hospital is a very active partner in numerous community collaborations and programs, including (but not limited to): - West River Valley Thrives: supporting and promoting healthy lifestyle choices, with an emphasis on the prevention of alcohol, tobacco, and other drug use by young people. - Townshend Community Hope and Action: promoting a healthy, connected community through area events and education. - West River Valley Food Group/Vermont Food Bank: organizing the procurement and distribution of food to those in need. A Veggie Van Go truck hosted by Grace Cottage comes from the Vermont Food Bank to Newfane once a month for free food distribution of fresh produce and other healthy food items. No proof of eligibility is required. On average, 200 individuals take the free food home to their families. - Windham County Consortium on Substance Use (COSU) is a multi-agency collaboration which focuses efforts and education/awareness within communities to address the devastating impacts of heroin, fentanyl and other substances on Windham County. Highlights include: collaborative prevention, harm reduction, treatment and recovery efforts. These efforts are bolstered by a three-year, $1 million federal Health Resources & Services Administration (HRSA) grant as well as a VT Department of Health Community Action grant through the Centers for Disease Control & Prevention, both awarded to COSU and its fiscal agent, Health Care & Rehabilitation Services of Southeastern Vermont, Inc. (HCRS), starting on September 1st, 2019. COSU ended its collaboration at the completion of the grant cycle in August of 2022. Some of the agencies chose to carry on this important work, and have formed a new consortium called Community Substance Use Response (COSU); Grace Cottage is a collaborating partner with this consortium. - Accountable Communities for Health: a network of partners that support measurable improvement in meeting the needs of families and individuals in our community. Focus is developing systems to improve community health and well-being; supporting appropriate use of resources; and improving access to community services. - Community Wellness: Current programs offered include: strong bones exercise classes, beginner Tai Chi, and advanced Tai Chi. In addition, area non-profit organizations providing health-related and emergency preparedness-related services to the community are provided with meeting and training space at the Hospital. In response to the last Community Health Needs Assessment, the Hospital has worked collaboratively with local schools and organizations to promote healthy, fun activities and provides opportunities that make the most of staying as healthy as possible. Heavily promoted activities included a 5K in the spring. Grace Cottage Hospital plays a pivotal role in Emergency/Disaster Preparedness in this rural, mountainous area of Windham County, Vermont. The Hospital works collaboratively with: - The local town volunteer fire and first responder rescue departments; - The regional ambulance service, Rescue Inc.; - Windham County Regional Commission - the Local Emergency Planning Committee covering the towns that Grace Cottage serves; - The local Citizens Emergency Response Team (CERT); - The local Radio Amateur Civil Emergency Service (RACES) - West River Radio Club meets and stores equipment at Grace Cottage Hospital; - Vermont Association of Hospitals and Health Systems; - Vermont Department of Health.Grace Cottage Hospital staff participate in onsite training for disaster preparedness as well as offsite training with other hospitals.
Part VI, Line 6:	N/A
Part VI, Line 7, Reports Filed With States	VT

Schedule H (Form 990) 2022

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

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

Attach to Form 990.
SchJMediumBullet

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

OMB No. 1545-0047

2022

Open to Public Inspection

Name of the organization

Carlos G Otis Health Care Center

Employer identification number

03-0177161

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

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

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

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

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

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

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

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

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

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

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

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

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

Yes

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2022

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1Douglas DiVello CEO	(i) (ii)	256,546 ------------- 0	34,473 ------------- 0	33,327 ------------- 0	9,150 ------------- 0	39,654 ------------- 0	373,150 ------------- 0	0 ------------- 0
2Stephen A Brown CFO	(i) (ii)	269,953 ------------- 0	400 ------------- 0	34,508 ------------- 0	9,150 ------------- 0	24,955 ------------- 0	338,966 ------------- 0	0 ------------- 0
3George Terwilliger MD Physician	(i) (ii)	289,297 ------------- 0	0 ------------- 0	1,669 ------------- 0	8,107 ------------- 0	25,355 ------------- 0	324,428 ------------- 0	0 ------------- 0
4Timothy P Shafer MD Trustee/Physician	(i) (ii)	230,541 ------------- 0	12,549 ------------- 0	2,729 ------------- 0	7,528 ------------- 0	25,355 ------------- 0	278,702 ------------- 0	0 ------------- 0
5Philip Schafer PA-C Physician Assistant	(i) (ii)	193,149 ------------- 0	10,300 ------------- 0	36,271 ------------- 0	7,314 ------------- 0	24,301 ------------- 0	271,335 ------------- 0	0 ------------- 0
6Jeremy Morrison MD Physician	(i) (ii)	209,168 ------------- 0	6,493 ------------- 0	1,669 ------------- 0	6,698 ------------- 0	36,700 ------------- 0	260,728 ------------- 0	0 ------------- 0
7Kimona Alin MD Physician	(i) (ii)	197,946 ------------- 0	0 ------------- 0	835 ------------- 0	6,241 ------------- 0	38,230 ------------- 0	243,252 ------------- 0	0 ------------- 0
8Ewa Arnold MD Physician	(i) (ii)	190,705 ------------- 0	0 ------------- 0	1,092 ------------- 0	4,859 ------------- 0	38,022 ------------- 0	234,678 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2022

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference

Explanation

Part I, Line 7

Physician contracts provide the opportunity to receive additional payments for productivity above minimum thresholds. For the period reported, two physicians listed in Part VII were under such a contract: Dr. Jeremy Morrison, and Dr. Timothy Shafer. Both received an incentive compensation payment: Dr. Jeremy Morrison received $6,193 and Dr. Timothy Shafer received $12,222. The CEO's contract provides an opportunity to earn annual incentive compensation of up to a maximum of 15% of annual base salary upon attainment of mutually agreed upon goals. This incentive compensation opportunity may be modified from time to time at the discretion of the Board of Trustees. For the period reported, Douglas DiVello received a payment of $34,373.

Schedule J (Form 990) 2022

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

Carlos G Otis Health Care Center

Employer identification number

03-0177161

Return Reference	Explanation
Form 990, Part VI, Section A, line 4	During the period covered by this Form 990, Carlos G. Otis Health Care Center (the "Corporation") made effective the following changes to its formally adopted bylaws: - Members of the Board of Trustees shall no longer serve more than four (4) consecutive, complete terms; previously, members of the Board of Trustees could serve no longer than three (3) consecutive terms. - The newly amended bylaws allow for only a single appointed Vice President serving as an officer on the Board at any time; previously, the Board would allow multiple individuals to serve as Vice Presidents on the Board simultaneously. - The role of the Vice President was expanded to be as follows: The Vice President shall perform their duties according to the descriptive title, priorities, duties, and powers from time to time prescribed for them, and shall, at all times when requested by the President, assist the President in the conduct of the affairs of the Corporation. Should the President become incapacitated or unable to fulfill his/her duties, the Vice President will become Acting President. When so acting, the Vice President will have all the legal powers and duties of the President. Upon assuming the role of Acting President, the Vice President shall call a special meeting of the Executive Committee. The Executive Committee will determine if the Acting President should remain in the role as Acting President in a situation where the Board President's incapacity is temporary, or if the position of Board President should be filled for the remainder of the term. - The role and responsibilities of the CEO was amended to include the following: Should the CEO become incapacitated or unable to fulfill his/her duties, the Chief Financial Officer (CFO) shall serve as Acting CEO, with confirmation by the Executive Committee within a reasonable time. The Executive Committee will thereafter determine if the Acting CEO should remain in the role as Acting CEO in a situation where the CEO's incapacity is temporary, or whether a search for a new CEO is necessary. When so acting, the CFO will have all the legal powers and duties of the CEO.
Form 990, Part VI, Section B, line 11b	A draft of the Form 990 is initially reviewed in detail by Carlos G. Otis Health Care Center's key finance employees. Thereafter, the final draft is provided to the full Board for review prior to filing with the IRS.
Form 990, Part VI, Section B, line 12c	A copy of the conflict of interest policy is distributed annually to the Board of Trustees and each Trustee signs to confirm that they have thoroughly read, understand, and agree to comply with the conflict of interest policy.
Form 990, Part VI, Section B, line 15	CEO's Compensation: The CEO's compensation and benefits are reviewed, adjusted and voted on by the full Board annually. The Board used external market compensation data to determine the CEO's initial compensation when hired and annually uses such data to compare OHCC's CEO compensation with that of other hospital executives in the Northeast region. The CEO is excused from Board discussion and voting on issues surrounding CEO compensation and benefits. Compensation of other hospital employees: The CEO reviews the salaries of employees annually and determines compensation based on performance and salary ranges, using regional salary range data for comparison.
Form 990, Part VI, Section C, line 19	Upon request, Carlos G. Otis Health Care Center, Inc. makes its governing documents, conflict of interest policy, and financial statements available to the public.
Form 990, Part VII, Section A:	The compensation reported for Dr. Timothy Shafer was for his services as a full-time physician. He was not compensated for his services as a member of OHCC's Board of Trustees.
Form 990, Part XI, line 9:	Change in Beneficial Interest in Net Assets of GCF 600,416.
Form 990, Part XI, Line 2c:	The Finance and Audit Committee oversees the audit process for the Carlos G. Otis Health Care Center, Inc. and Grace Cottage Foundation, Inc. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for both fiscal years.

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

Carlos G Otis Health Care Center

Employer identification number

03-0177161

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)Grace Cottage Foundation Inc PO Box 1 Townshend,VT05353 03-0343282	Solicit contributions for the funding of health care services by OHCC	VT	501(c)(3)	Line 12a, I	Carlos G Otis Health Care Center	Yes

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

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

Yes

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) Grace Cottage Foundation Inc	Q	378,373	Actual per books
(2) Grace Cottage Foundation Inc	C	1,469,246	Actual per books
(3) Grace Cottage Foundation Inc	E	5,907,017	Actual per books

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: Provision of health care services.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	12
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2021 (Part V, line 2a) ......	5	255
6	Total number of volunteers (estimate if necessary) .............	6	16
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) .........	1,646,159	1,755,873
9	Program service revenue (Part VIII, line 2g) .........	29,588,353	32,430,987
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-6,138	-25,215
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	0	0
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	31,228,374	34,161,645
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)	19,936,915	21,654,859
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 351,245
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	11,566,441	12,961,417
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	31,503,356	34,616,276
19	Revenue less expenses. Subtract line 18 from line 12.......	-274,982	-454,631
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	18,760,118	19,995,508
21	Total liabilities (Part X, line 26).............	4,173,390	5,262,995
22	Net assets or fund balances. Subtract line 21 from line 20.....	14,586,728	14,732,513

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 31,421,451 including grants of $ 0 ) (Revenue $ 32,430,987 )
	Grace Cottage Hospital is a critical access hospital offering 24-hour emergency services, inpatient acute and skilled care, 24-hour diagnostic imaging services, a full-service laboratory, a pharmacy, a variety of outpatient medical care services, including physical therapy, occupational therapy, and speech therapy, and a rural health clinic providing primary care and psychiatric services.

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 expenses31,421,451

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W-2/1099-MISC/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
(18) Kimona Alin MD........................................................................ Physician	28.20 .......................0.00	X	198,781	0	44,471
(19) Ewa Arnold MD........................................................................ Physician	29.13 .......................0.00	X	191,797	0	42,881

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	2,013,620	0	311,619

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	1,469,247
e	Government grants (contributions)		1e	269,126

f	All other contributions, gifts, grants, and similar amounts not included above		1f	17,500

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

h Total. Add lines 1a-1f.......		1,755,873

		Business Code
2a	Patient Service Revenue	621400	26,257,444	26,257,444
b	Pharmacy Revenue	456110	5,697,376	5,697,376
c	GCF Administration/Other	621400	378,373	378,373
d	Cafeteria Revenue	722514	79,099	79,099
e	Other Health Services	621990	18,695	18,695
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		32,430,987

3 Investment income (including dividends, interest, and othersimilar amounts) ......			1,256			1,256
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	26,471		7b
c	Gain or (loss)	-26,471		7c
d	Net gain or (loss).........			-26,471			-26,471
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.....			34,161,645	32,430,987	0	-25,215

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 ...........	1,058,263	278,807	779,456
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........	15,910,890	14,536,961	1,127,193	246,736
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	385,974	355,236	24,684	6,054
9	Other employee benefits .......	3,128,760	2,789,818	291,994	46,948
10	Payroll taxes ...........	1,170,972	1,026,739	127,098	17,135
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	4,412		4,412
c	Accounting ...........	84,720		84,720
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)	2,223,856	2,220,395	3,461
12	Advertising and promotion ....	90,669	598	85,281	4,790
13	Office expenses .......	1,219,207	1,059,578	141,588	18,041
14	Information technology ......	870,085	780,783	87,097	2,205
15	Royalties ..
16	Occupancy ...........	288,247	280,445	7,802
17	Travel ............	137,373	109,299	19,905	8,169
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	15,634	15,634
20	Interest ...........	65,364	65,364
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	944,225	944,225
23	Insurance ...	392,936	332,880	58,889	1,167
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	Medical Supplies/Lab	4,165,343	4,165,343
b	Provision for Bad Debt	978,260	978,260
c	Medicaid Tax	961,770	961,770
d	Equipment Repair	348,314	348,314
e	All other expenses	171,002	171,002
25	Total functional expenses. Add lines 1 through 24e	34,616,276	31,421,451	2,843,580	351,245
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 ........			2,056,981	1	775,632
2	Savings and temporary cash investments .........			28,787	2	31,556
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			2,578,059	4	2,744,968
5	Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			876,250	8	923,286
9	Prepaid expenses and deferred charges ......			234,558	9	270,503
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	18,190,976
b	Less: accumulated depreciation	10b	13,386,838	4,290,482	10c	4,804,138
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 ...........			8,695,001	15	10,445,425
16	Total assets. Add lines 1 through 15 (must equal line 33)...			18,760,118	16	19,995,508

17	Accounts payable and accrued expenses .....	2,183,287	17	2,662,529
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 ..	1,990,103	23	1,427,357
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	0	25	1,173,109
26	Total liabilities. Add lines 17 through 25..	4,173,390	26	5,262,995

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	10,748,936	27	11,094,939
28	Net assets with donor restrictions ...........	3,837,792	28	3,637,574
	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 ...........	14,586,728	32	14,732,513
33	Total liabilities and net assets/fund balances ........	18,760,118	33	19,995,508