Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
ARBOR HEALTH |
911033860 | 3 | Yes | 694 | 0 | |
| (B)
CASCADE MEDICAL |
910856279 | 3 | Yes | 694 | 0 | |
| (C)
COLUMBIA COUNTY HEALTH SYSTEM |
910741968 | 3 | Yes | 694 | 0 | |
| (D)
FERRY COUNTY |
910879683 | 3 | Yes | 694 | 0 | |
| (E)
FORKS COMMUNITY HOSPITAL |
916001732 | 3 | Yes | 694 | 0 | |
| (F)
JEFFERSON HEALTHCARE |
910928081 | 3 | Yes | 694 | 0 | |
| (G)
KITTITAS VALLEY HEALTHCARE |
910757683 | 3 | Yes | 694 | 0 | |
| (H)
KLICKITAT VALLEY HEALTH |
916001738 | 3 | Yes | 694 | 0 | |
| (I)
LAKE CHELAN HEALTH |
911196271 | 3 | Yes | 694 | 0 | |
| (J)
LINCOLN HOSPITAL |
910758051 | 3 | Yes | 694 | 0 | |
| (K)
MASON GENERAL HOSPITAL |
910836763 | 3 | Yes | 694 | 0 | |
| (L)
NEWPORT COMMUNITY HOSPITAL |
910541383 | 3 | Yes | 694 | 0 | |
| (M)
OCEAN BEACH HOSPITAL |
916001012 | 3 | Yes | 694 | 0 | |
| (N)
SKYLINE HOSPITAL |
916000960 | 3 | Yes | 694 | 0 | |
| (O)
SNOQUALMIE VALLEY HOSPITAL |
910908129 | 3 | Yes | 694 | 0 | |
| (P)
SUMMIT PACIFIC MEDICAL CENTER |
911158307 | 3 | Yes | 693 | 0 | |
| (Q)
WHIDBEY GENERAL HOSPITAL |
910843135 | 3 | Yes | 693 | 0 | |
| (R)
WHITMAN HOSPITAL & MEDICAL CLINICS |
911451777 | 3 | Yes | 693 | 0 | |
| (S)
WILLAPA HARBOR HOSPITAL |
916002007 | 3 | Yes | 693 | 0 | |
|
Total 19
|
13,182 | 0 | ||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf .... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) .. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal
year beginning in) ![]() |
(a) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | ||||||
| 6 | Total. Add lines 1 through 5 | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support. (Subtract line 7c from line 6.) | ||||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2020 | (b) 2021 | (c) 2022 | (d) 2023 | (e) 2024 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by 0.035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2024 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-2024 |
(iii) Distributable Amount for 2024 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2024 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2024 (reasonable cause required-- explain in Part VI).
See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2024: | ||||
| a From 2019....... | ||||
| b From 2020....... | ||||
| c From 2021....... | ||||
| d From 2022....... | ||||
| e From 2023....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2024 distributable amount | ||||
|
i
Carryover from 2019 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2024 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2024 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2024, 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 2024. 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 2025. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a Excess from 2020..... | ||||
| b Excess from 2021..... | ||||
| c Excess from 2022..... | ||||
| d Excess from 2023..... | ||||
| e Excess from 2024..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART I, LINE 11H | JEFFERSON HEALTHCARE 91-0928081 3 X 694 0 KITTITAS VALLEY HEALTHCARE 91-0757683 3 X 694 0 KLICKITAT VALLEY HEALTH 91-6001738 3 X 694 0 LAKE CHELAN HEALTH 91-1196271 3 X 694 0 LINCOLN HOSPITAL 91-0758051 3 X 694 0 MASON GENERAL HOSPITAL 91-0836763 3 X 694 0 NEWPORT COMMUNITY HOSPITAL 91-0541383 3 X 694 0 OCEAN BEACH HOSPITAL 91-6001012 3 X 694 0 SKYLINE HOSPITAL 91-6000960 3 X 694 0 SNOQUALMIE VALLEY HOSPITAL 91-0908129 3 X 694 0 SUMMIT PACIFIC MEDICAL CENTER 91-1158307 3 X 693 0 WHIDBEY GENERAL HOSPITAL 91-0843135 3 X 693 0 WHITMAN HOSPITAL & MEDICAL CLINICS 91-1451777 3 X 693 0 WILLAPA HARBOR HOSPITAL 91-6002007 3 X 693 0 |
| PART IV, SECTION A, LINE 2 | THE COLLABORATIVE SUPPORTS HOSPITALS THAT ARE GOVERNMENTAL ENTITIES OWNED AND OPERATED BY A PUBLIC HOSPITAL DISTRICT AND IS EXEMPT FROM TAXATION AS A POLITICAL SUBDIVISION OF THE STATE RATHER THAN IRC 501(C)(3). IF THE MEMBERS HAD NOT ALREADY BEEN DESIGNATED A POLITICAL SUBDIVISION OF THE STATE, THEY WOULD QUALIFY AS DESCRIBED IN IRC 170(B)(1)(A)(III) AS EXCLUDED FROM PRIVATE FOUNDATION STATUS UNDER IRC 509(A)(1). |
| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
|---|---|
| FORM 990 - ORGANIZATION'S MISSION | TO ASSIST PUBLIC HOSPITAL DISTRICTS AND NONPROFIT HOSPITALS WITH THE CRITICAL ACCESS HOSPITAL DESIGNATION IN THE STATE OF WASHINGTON TO WORK COLLABORATIVELY TO STIMULATE INNOVATION AND AGILE PARTNERSHIPS THAT IMPROVE RURAL HEALTH CARE QUALITY, EFFICIENCY AND SUSTAINABILITY. |
| FORM 990, PAGE 6, PART VI, LINE 6 | THE COLLABORATIVE HAS VOTING MEMBERS. VOTING MEMBERSHIP IS AVAILABLE TO PUBLIC HOSPITAL DISTRICTS AND RURAL HOSPITALS WITH THE CRITICAL ACCESS HOSPITAL DESIGNATION IN THE STATE OF WASHINGTON. |
| FORM 990, PAGE 6, PART VI, LINE 7A | VOTING MEMBERS EACH APPOINT ONE REPRESENTATIVE TO SERVE ON THE BOARD OF DIRECTORS, TYPICALLY THEIR OWN CEO. THE MEMBER HOSPITAL REPRESENTATIVES CONSTITUTE THE GOVERNING BOARD APPOINTED BY THE MEMBERS. |
| FORM 990, PAGE 6, PART VI, LINE 9 | ERIC MOLL 901 MOUNTAIN VIEW DRIVE SHELTON , WA 98584 AARON EDWARDS 110 S APPLE BLOSSOM DRIVE CHELAN, WA 98816 MATT KOLLMAN 211 SKYLINE DRIVE WHITE SALMON, WA 98672 JENNIFER REED 36 KLONDIKE ROAD REPUBLIC, WA 99166 ROBERT MACH 521 ADAMS AVENUE MORTON, WA 98356 DIANE BLAKE 817 COMMERCIAL STREET LEAVENWORTH, WA 98826 SHANE MCGUIRE 1012 S 3RD STREET DAYTON, WA 99328 HEIDI ANDERSON 530 BOGACHIEL WAY FORKS, WA 98331 MIKE GLENN 834 SHERIDAN PORT TOWNSEND, WA 98368 JASON ADLER 603 S CHESTNUT ST ELLENSBURG, WA 98926 JONATHAN HATFIELD 310 S. ROOSEVELT GOLDENDALE, WA 98620 TYSON LACY 10 NICHOLLS STREET DAVENPORT, WA 99122 MERRY-ANN KEANE 714 W PINE STREET NEWPORT, WA 99156 RENEE JENSEN 9801 FRONTIER AVENUE SE SNOQUALMIE, WA 98065 NATHAN STAGGS 101 N. MAIN STREET COUPEVILLE, WA 98239 HANK HANIGAN 1200 W. FAIRVIEW STREET COLFAX, WA 99111 JOSH MARTIN 600 E MAIN ST ELMA, WA 98541 MATTHEW KEMPTON PO BOX 438 SOUTH BEND, WA 98586 KIM MANUS 714 PINE ST NEWPORT, WA 99156 |
| FORM 990, PAGE 6, PART VI, LINE 11B | THE BOARD HAS DESIGNATED THE FINANCE COMMITTEE TO REVIEW AND APPROVE THE IRS FORM 990. A COPY OF THE 990 IS PROVIDED TO THE EXECUTIVE DIRECTOR AND FINANCE COMMITTEE WHO REVIEW THE FORM, SCHEDULES, AND RELATED ATTACHMENTS. ANY COMMENTS OR QUESTIONS ARE ADDRESSED WITH THE PREPARER. ONCE MANAGEMENT IS SATISFIED WITH THE 990, A FINAL APPROVAL IS GIVEN TO THE PREPARER BEFORE FINALIZING THE RETURN. |
| FORM 990, PAGE 6, PART VI, LINE 12C | WHENEVER A DIRECTOR OR OFFICER HAS A FINANCIAL OR PERSONAL INTEREST IN ANY MATTER COMING BEFORE THE BOARD OF DIRECTORS, THE AFFECTED PERSON SHALL FULLY DISCLOSE THE NATURE OF THE INTEREST AND WITHDRAW FROM DISCUSSION AND VOTING ON THE MATTER. ANY TRANSACTION OR VOTE INVOLVING A POTENTIAL CONFLICT OF INTEREST SHALL BE APPROVED ONLY WHEN A MAJORITY OF DISINTERESTED DIRECTORS DETERMINE THAT IT IS IN THE BEST INTEREST OF THE CORPORATION TO DO SO. THE MINUTES OF MEETINGS AT WHICH SUCH VOTES ARE TAKEN RECORD SUCH DISCLOSURE, ABSTENTION AND RATIONALE FOR APPROVAL. |
| FORM 990, PAGE 6, PART VI, LINE 15A | THE MAIN SOURCE AVAILABLE TO THE COLLABORATIVE IN REGARD TO FAIR MARKET VALUE IN COMPENSATION IS THE NATIONAL COOPERATIVE OF HEALTH NETWORK (NCHN) SURVEY. NCHN CONDUCTS A SALARY SURVEY EVERY TWO YEARS REGARDING TOP OFFICIAL COMPENSATION. |
| FORM 990, PAGE 6, PART VI, LINE 15B | SEE FORM 990, PART VI, LINE 15A. |
| FORM 990, PAGE 6, PART VI, LINE 19 | THE COLLABORATIVE MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART VII | COMPENSATION BY RELATED ORGANIZATIONS OF THE BOARD MEMBERS LISTED IN 990, PART VII CAN BE FOUND ON THE DOH WEBSITE BY CLICKING ON THE PARTICULAR YEAR, AND PARTICULAR MEMBER AS LISTED AT SCHEDULE A, PART I, LINE 12H AT THE FOLLOWING URL: HTTPS://WWW.DOH.WA.GOV/DATAANDSTATISTICALREPORTS/HEALTHCAREINWASHINGTON/HOS PITALANDPATIENTDATA/HOSPITALFINANCIALDATA/HOSPITALEMPLOYEECOMPENSATION |
| FORM 990, PART IX, LINE 11G | OTHER PROFESSIONAL FEES 205,576 11,233 0 |
| Software ID: | |
| Software Version: |