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)
WAHIAWA GENERAL HOSPITAL |
990269825 | 3 | Yes | 58,367 | 0 | |
|
Total 1
|
58,367 | 0 | ||||
Calendar year
(or fiscal year beginning in)
![]() |
(a) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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) 2019 | (b) 2020 | (c) 2021 | (d) 2022 | (e) 2023 | (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 2023 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-2023 |
(iii) Distributable Amount for 2023 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2023 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2023 (reasonable cause required-- explain in Part VI).
See instructions. |
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| 3 Excess distributions carryover, if any, to 2023: | ||||
| a From 2018....... | ||||
| b From 2019....... | ||||
| c From 2020....... | ||||
| d From 2021....... | ||||
| e From 2022....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2023 distributable amount | ||||
|
i
Carryover from 2018 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2023 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2023 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2023, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2023. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2024. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2019..... | ||||
| b Excess from 2020..... | ||||
| c Excess from 2021..... | ||||
| d Excess from 2022..... | ||||
| e Excess from 2023..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
| Return Reference | Explanation |
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| FORM 990, PART VI, SECTION A, LINE 6 | MEMBERS AND RIGHTS WAHIAWA GENERAL HOSPITAL IS THE SOLE MEMBER OF WAHIAWA HOSPITAL FOUNDATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | DESCRIPTION OF CLASSES OF PERSONS AND THE NATURE OF THEIR RIGHTS AS A SOLE MEMBER, WAHIAWA GENERAL HOSPITAL, ELECTS ALL MEMBERS OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION A, LINE 7B | DESCRIBE CLASSES OF PERSONS, DECISIONS REQUIRING APPR & VOTING RIGHTS WHILE THE BOARD OF DIRECTORS OF THE FOUNDATION IS GIVEN THE GENERAL AUTHORITY IN THE DIRECTION AND MANAGEMENT OF THE AFFAIRS OF THE FOUNDATION, THE MEMBER RETAINS THE EXCLUSIVE RIGHT TO MAKE OR APPROVE CERTAIN FINANCIAL DECISIONS OF THE FOUNDATION, WHICH ACTIONS, UNLESS OTHERWISE REQUIRED BY LAW (INCLUDING REQUIREMENTS TO OBTAIN OR MAINTAIN TAX EXEMPTION), SHALL BE TAKEN ONLY FOLLOWING CONSULTATION WITH THE BOARD OF DIRECTORS OF THE FOUNDATION. SUCH FINANCIAL DECISIONS OF THE FOUNDATION INCLUDE: A. THE ADOPTION OF THE ANNUAL OPERATING AND CAPITAL BUDGETS AND OTHER EXPENDITURE PLANS OF THE FOUNDATION, RECOGNIZING THAT ANNUAL BUDGETS AND OTHER EXPENDITURE PLANS SHALL BE DEVELOPED AND ADOPTED BY THE BOARD OF DIRECTORS OF THE FOUNDATION AND SUBMITTED TO THE MEMBER FOR APPROVAL; B. THE SALE, LEASE, ASSIGNMENT OR EXCHANGE OF ALL, OR SUBSTANTIALLY ALL, OF THE PROPERTY AND ASSETS OF THE FOUNDATION; C. THE CREATION, OWNERSHIP OR ACQUISITION OF, OR AFFILIATION WITH, ANY OTHER ORGANIZATION; D. THE DISSOLUTION OF THE FOUNDATION; E. THE INCURRING OF ANY FINANCIAL OBLIGATION OR MAKING OF EXPENDITURE WHICH IS NOT BUDGETED OR WHICH DEVIATES FROM THE FOUNDATION'S ANNUAL OPERATING AND CAPITAL BUDGETS IF THE AMOUNT OF SUCH FINANCIAL OBLIGATION EXPENDITURE EXCEEDS $2,000; F. THE SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, GRANT OF SECURITY INTEREST, OR OTHER TRANSFER OR ENCUMBRANCE (COLLECTIVELY, "TRANSFER") OF: (I) ANY OF THE REAL PROPERTY OR FIXTURES OF THE FOUNDATION; (II) ANY OF THE PERSONAL PROPERTY AND ASSETS OF THE FOUNDATION, IF THE AMOUNT OF VALUE OF ANY SUCH TRANSFER EXCEEDS $5,000; G. THE BORROWING OR LENDING OF MONEY OR THE CREATION OF INDEBTEDNESS THROUGH THE GUARANTY OF ANOTHER'S DEBT OR SIMILAR ACTION; AND H. THE GIVING OR APPROVAL OF GRANTS OR CONTRIBUTIONS TO ANY PARTY OTHER THAN THE HOSPITAL IN EXCESS OF $10,000; I. THE ENGAGEMENT OF ANY MANAGEMENT COMPANY OR OTHER ENTITY OR INDIVIDUAL FOR THE PURPOSE OF DIRECTING OR MANAGING ALL OR SUBSTANTIALLY ALL OF THE PROPERTIES OR BUSINESS AFFAIRS OF THE FOUNDATION. |
| FORM 990, PART VI, SECTION B, LINE 11B | DESCRIBE THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 - THE FORM 990 WAS APPROVED BY THE BOARD BEFORE SUBMISSION TO THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | DESCRIPTION OF PROCESS TO MONITOR TRANSACTION OF CONFLICT OF INTEREST BOARD MEMBERS COMPLETE THE CONFLICT OF INTEREST FORM ANNUALLY AND SUBMIT IT TO ADMINISTRATION. ANY CONFLICTS ARE DISCLOSED TO THE BOARD. FOUNDATION CURRENTLY DOES NOT HAVE ANY EMPLOYEES. |
| FORM 990, PART VI, SECTION C, LINE 19 | AVAILABILITY OF GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY & FINANCIAL STATEMENTS TO THE GENERAL PUBLIC - THE FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY IS AVAILABLE UPON REQUEST. GOVERNING DOCUMENTS ARE NOT AVAILABLE AT THIS TIME. |
| FORM 990 - GOOD FAITH STATEMENT | WAHIAWA GENERAL HOSPITAL ("HOSPITAL") WAS FORMED BY THE WAHIAWA HOSPITAL ASSOCIATION ("ASSOCIATION") IN 1989 TO OWN, MANAGE AND OPERATE ITS HOSPITAL-BASED HEALTHCARE SERVICES THE ASSOCIATION IS THE SOLE MEMBER OF THE HOSPITAL. THE HOSPITAL ESTABLISHED WAHIAWA HOSPITAL FOUNDATION ("FOUNDATION") IN 2000 TO SUPPORT FUND RAISING, CHARITABLE, EDUCATIONAL AND SCIENTIFIC ACTIVITIES FOR THE HOSPITAL. THE HOSPITAL IS THE SOLE MEMBER OF THE FOUNDATION. THE HOSPITAL HAS FACED LONG-STANDING FINANCIAL CHALLENGES FOR A DECADE OR MORE AND HAS PURSUED VARIOUS OPPORTUNITIES TO BECOME PART OF A LARGER HOSPITAL ORGANIZATION TO FULFILL THE HOSPITAL'S MISSION TO PROVIDE QUALITY HEALTHCARE TO THE CENTRAL OAHU AND NORTH SHORE COMMUNITIES. AS A RESULT, EFFECTIVE OCTOBER 27, 2023, THE HOSPITAL AND ASSOCIATION ENTERED INTO A PURCHASE AND SALE AGREEMENT TO SELL CERTAIN LAND, BUILDING, FURNITURE, EQUIPMENT AND INVENTORY OF THE HOSPITAL AND SKILLED NURSING FACILITY TO THE QUEEN'S HEALTH SYSTEMS (QHS), A 501(C)(3). THE SALES PRICE EXCEEDS THE CARRYING VALUE OF THE ASSETS AND THE CLOSING DATE AND THE SALE CLOSED ON APRIL 2, 2024. EFFECTIVE DECEMBER 20, 2023, THE HOSPITAL AND ASSOCIATION'S BOARD APPROVED A PLAN TO BEGIN WINDING DOWN THE OPERATIONS OF THE HOSPITAL UPON COMPLETION OF THE SALE OF CERTAIN LAND, BUILDING, FURNITURE, EQUIPMENT AND INVENTORY TO THE QHS. THE BOARD OF DIRECTORS OF THE HOSPITAL DETERMINED THAT AFTER WINDING UP THE REMAINING BUSINESS AFFAIRS OF THE HOSPITAL, THE HOSPITAL WOULD BE DISSOLVED. ARTICLES OF DISSOLUTION WERE SUBSEQUENTLY FILED WITH THE STATE OF HAWAII FOR THE HOSPITAL AND THE ENTITY IS SHOWN AS DISSOLVED AS OF JUNE 28, 2024. ON FEBRUARY 7, 2024, THE FOUNDATION'S BOARD OF DIRECTORS DETERMINED THAT WITH THE DISSOLUTION OF THE HOSPITAL, THE PURPOSE OF THE FOUNDATION WILL HAVE BEEN FULFILLED AND COMPLETED, AND THAT THE FOUNDATION SHOULD BE DISSOLVED. ON APRIL 3, 2024, THE FOUNDATION'S BOARD ADOPTED THE FINAL RESOLUTION TO DISSOLVE THE FOUNDATION AND ARTICLES OF DISSOLUTION WERE SUBSEQUENTLY FILED WITH THE STATE OF HAWAII AND THE ENTITY IS SHOWN AS DISSOLVED AS OF MAY 16, 2024. PART OF THE FOUNDATION'S ASSETS INCLUDED COOKSEY TRUST ASSETS WHICH CALLED FOR THE SUCCESSOR HOSPITAL IN WAHIAWA TO BECOME THE BENEFICIARY OF THE TRUST IN THE EVENT THAT THE HOSPITAL CEASED TO OPERATE. THE PROMISSORY NOTES OUTSTANDING, REFLECTING THE OBLIGATIONS OF THE HOSPITAL TO PAY THE FOUNDATION, WERE ASSIGNED TO QHS UPON DISSOLUTION. ACCORDING TO THE BOARD'S RESOLUTION, THE REMAINING ASSETS OF THE FOUNDATION AFTER PAYMENT OF ALL OUTSTANDING DEBTS AND OBLIGATIONS WOULD BE DONATED AND DISTRIBUTED TO THE HOSPITAL. THE ASSOCIATION PLANS TO CONTINUE ON WITH ITS OPERATIONS TO THE BEST OF ITS ABILITY. HISTORICALLY, THE ACCOUNTING PERSONNEL OF THE HOSPITAL HAD TAKEN CARE OF THE ACCOUNTING FOR THE FOUNDATION AND ASSOCIATION. UPON THE HOSPITAL'S DISSOLUTION AND SALE OF SUBSTANTIALLY ALL ASSETS TO QHS, THE ACCOUNTING PERSONNEL MOVED ON TO DIFFERENT JOBS AFTER WRAPPING UP AS MUCH AS THEY COULD OF THE BOOKS AND ARE NO LONGER WORKING WITH ANY OF THE ENTITIES. AS THE ENTITY HAS DISSOLVED, THERE IS A SUBSTANTIAL LACK OF INFORMATION AVAILABLE, AND THE RETURN WAS COMPLETED WITH AS MUCH INFORMATION AS POSSIBLE. THE ORGANIZATION HAS MADE ITS BEST EFFORTS TO COMPLY WITH TAX LAWS BASED UPON THE INFORMATION AVAILABLE AT THE TIME OF FILING. RATHER THAN FILE A DELINQUENT TAX RETURN, THE ORGANIZATION AND TAX PROFESSIONALS MADE THEIR BEST EFFORTS TO DETERMINE THE PROPER TAX TREATMENT AND REPORTING OF VARIOUS ITEMS BASED ON THE ORGANIZATION'S AUDITED FINANCIALS. |
| FORM 990, PART XI, LINE 9: | LIQUIDATING ADJUSTMENT -124. |
| Software ID: | |
| Software Version: |