2024-11-04T06:55:02-06:00 2023-12-31 351178661 BLUE & CO LLC 500 N MERIDIAN ST SUITE 200 INDIANAPOLIS IN 46204 990 2023-01-01 311072162 WITHAM HEALTH SERVICES FOUNDATION INC WITH 7654858100 2705 NORTH LEBANON STREET LEBANON IN 460523005 CARI ANN GUENTHER FOUNDATION COORDINATOR 7654858100 2024-11-04 1 1 TYLER K GREENE CPA P00057872 3176334705 2024-11-04 2023 2024-10-15 13:58:12Z CARI ANN GUENTHER 2705 NORTH LEBANON STREET LEBANON IN 460523005 438735 0 X WWW.WITHAM.ORG X 1983 IN TO SUPPORT WITHAM HEALTH SERVICES, INC. 14 12 0 46 0 0 277526 372960 0 0 25222 65575 -36881 -75002 265867 363533 24886 131700 0 0 0 0 0 0 33078 161920 120665 186806 252365 79061 111168 6735479 7393629 21427 18751 6714052 7374878 WITHAM HEALTH SERVICES FOUNDATION IS DEDICATED TO THE HOSPITAL'S QUEST FOR QUALITY CARE. THROUGH FUND DEVELOPMENT, AMBASSADORSHIP AND EDUCATION, WE WILL ASSIST THE HOSPITAL IN MAINTAINING ITS FINANCIAL GROWTH. 0 0 79464 SUPPORT PROVIDED FOR PROGRAMS AT WITHAM HEALTH SERVICES. 131700 131700 MEDICAL AND NONMEDICAL PROFESSIONAL LOANS AND SCHOLARSHIPS 211164 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 8 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 14 12 0 0 0 0 1 1 0 1 0 0 0 0 1 1 1 1 1 0 0 0 IN X CARI ANN GUENTHER 7654858100 2605 NORTH LEBANON STREET LEBANON IN 460523005 HONORABLE REBECCA MCCLURE PRESIDENT 2.00 0.00 X X 0 0 0 PT BUNTIN MD VICE PRESIDENT 2.00 0.00 X X 0 0 0 KELLY PETIT TREASURER 2.00 0.00 X X 0 0 0 RUSSELL ROBERTS SECRETARY 2.00 0.00 X X 0 0 0 TODD BYRD BOARD MEMBER 2.00 0.00 X 0 0 0 JOHN GARBER MD BOARD MEMBER 2.00 0.00 X 0 0 0 ALLYSON GUTWEIN BOARD MEMBER 2.00 0.00 X 0 0 0 ARCH HAWKINS BOARD MEMBER 2.00 4.00 X 0 0 0 MICHAEL HORNBECKER MD BOARD MEMBER 2.00 40.00 X 0 378059 0 DR MARK JANICKI BOARD MEMBER 2.00 40.00 X 0 240495 32772 JACK JONES BOARD MEMBER 2.00 4.00 X 0 0 0 GARY LANPHER BOARD MEMBER 2.00 0.00 X 0 0 0 JOE LEPAGE BOARD MEMBER 2.00 0.00 X 0 0 0 KRISTI REYNOLDS BOARD MEMBER 2.00 0.00 X 0 0 0 CARI ANN GUENTHER FOUNDATION COORDINATOR 40.00 0.00 X 0 56362 21082 0 674916 53854 0 0 1 0 0 59904 219126 93930 372960 65575 65575 200 219126 75202 -75002 -75002 363533 0 0 -9427 X 94484 94484 37216 37216 11750 11750 17751 702 17049 83123 75000 8123 4279 4279 3762 3762 252365 211164 8123 33078 1165350 1265464 3035672 2678211 37595 42569 10856 5429 2486006 3401956 6735479 7393629 21427 18751 21427 18751 X 5564022 6138454 1150030 1236424 6714052 7374878 6735479 7393629 111168 549658 0 X X 0 1 X 1 0 X X 1 WITHAM HEALTH SERVICES INC 351151208 3 1 173948 0 1 173948 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1150030 135956 80487 130049 1236424 1151620 74787 -69350 7027 1150030 926468 196664 58585 30097 1151620 925031 203825 39104 241492 926468 778584 144560 66076 64189 925031 0.00000 0.00000 1.00000 1 0 0 X 929622 549658 549658 379964 17751 -34182 -16431 363533 268796 34182 34182 234614 17751 17751 252365 PART V, LINE 4: THE FOUNDATION HAS TEMPORARILY RESTRICTED FUNDS CAPITAL CAMPAIGN INITIATED TO DIRECTLY ASSIST THE HOSPITAL IN MAINTAINING PROGRAMS AND SERVICES. PART X, LINE 2: THE FOUNDATION IS REQUIRED TO FILE FEDERAL FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, WHICH IS AN INFORMATIONAL RETURN ONLY. ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE FOUNDATION AND RECOGNIZE A TAX LIABILITY IF THE FOUNDATION HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY VARIOUS FEDERAL AND STATE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED THE TAX POSITIONS TAKEN BY THE FOUNDATION, AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2023 AND 2022, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE ACCOMPANYING FINANCIAL STATEMENTS. THE FOUNDATION HAS FILED ITS FEDERAL AND STATE INCOME TAX RETURNS FOR PERIODS THROUGH DECEMBER 31, 2022. THESE INCOME TAX RETURNS ARE GENERALLY OPEN TO EXAMINATION BY THE RELEVANT TAXING AUTHORITIES FOR A PERIOD OF THREE YEARS FROM THE LATER OF THE DATE THE RETURN WAS FILED OR ITS DUE DATE (INCLUDING APPROVED EXTENSIONS). PART XI, LINE 4B - OTHER ADJUSTMENTS: OTHER EXPENSES -1,104. FUNDRAISING EXPENSE -33,078. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 33,078. OTHER EXPENSES 1,104. GOLF 54750 54550 200 4968 40 15676 GALA 164576 164576 2639 9900 21470 2500 18009 219326 219126 200 2639 14868 21510 2500 33685 75202 -75002 1 WITHAM MEMORIAL HOSPITAL 2605 N LEBANON STREET LEBANON IN 46052 351151208 GOV'T HOSPITAL 94484 0 OPERATING EXPENSES 1 0 PROFESSIONAL LOAN/TUITION ASSISTANCE 11 37216 BOOK PART I, LINE 2: THE ORGANIZATION PROVIDES HOSPITAL EMPLOYEES WITH PROFESSIONAL LOANS AND TUITION ASSISTANCE. FOR EVERY YEAR THE RECIPIENT CONTINUES TO WORK FOR THE ORGANIZATION, THE NOTE RECEIVABLE IS REDUCED $2,000. IF THE RECIPIENT DISCONTINUES WORKING FOR THE ORGANIZATION, THE NOTE RECEIVABLE WILL BE DUE IN FULL. 0 0 0 0 0 0 0 0 0 MICHAEL HORNBECKER MD BOARD MEMBER 0 153510 0 210549 0 14000 0 0 0 0 0 378059 0 0 DR MARK JANICKI BOARD MEMBER 0 214551 0 20000 0 5944 0 0 0 32772 0 273267 0 0 PART I AND PART II, RELATED PARTY COMPENSATION: ALL COMPENSATION REPORTED ON SCHEDULE J WAS PAID BY RELATED ORGANIZATION, WITHAM HEALTH SERVICES, INC. ALL POLICIES RELATING TO THE COMPENSATION FOR INDIVIDUALS LISTED ON SCHEDULE J ARE POLICIES OF THE RELATED ORGANIZATION AND NOT WITHAM HEALTH SERVICES FOUNDATION, THE FILING ORGANIZATION. LINE 1A: THE FILING ORGANIZATION DID NOT PROVIDE ANY ITEMS LISTED IN PART I, LINE 1A. LINE 1B AND 2: NOT APPLICABLE. LINE 3: THE ORGANIZATION'S METHOD FOR ESTABLISHING COMPENSATION IS DETERMINED BY APPROVAL FROM THE BOARD OF DIRECTORS, WHICH IS COMPLETED BY THE RELATED ORGANIZATION, WITHAM HEALTH SERVICES. PART II, LINE (1), COLUMN (B) AND (D): THE COMPENSATION REPORTED DURING THE CURRENT YEAR DOES NOT RELATE TO SERVING AS A BOARD MEMBER FOR WITAHM HEALTH SERVICES FOUNDATION. FORM 990, PART VI, SECTION A, LINE 6 THE FOUNDATION SHALL HAVE ONE CLASS OF MEMBERSHIP. THE MEMBERS OF THE FOUNDATION SHALL BE THOSE ADULT INDIVIDUALS WHO ANNUALLY SUBSCRIBE. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 8B WITHAM HEALTH SERVICES DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE PROCESS OF REVIEWING THE FORM 990 ENTAILS A DETAILED REVIEW BY THE ORGANIZATION'S MANAGEMENT AND ACCOUNTING DEPARTMENT. THE GOVERNING BODY RECEIVES A COPY UPON REQUEST AFTER INFORMING THE GOVERNING BODY THE FORM 990 INCLUDING REQUESTED SCHEDULES, AS ULTIMATELY FILED WITH THE IRS HAS BEEN COMPLETED. FORM 990, PART VI, SECTION B, LINE 12C THE WRITTEN CONFLICT OF INTEREST POLICY IS REGULARLY AND CONSISTENTLY MONITORED AND COMPLIANCE ENFORCED BY THE BOARD PRESIDENT. THE SCOPE OF THIS POLICY INCLUDES BOARD MEMBERS OF THE FOUNDATION. THE POLICY IS IN PLACE TO PROVIDE PRINCIPLES AND GUIDELINES IN WHICH TO CONDUCT A PERSON'S BEHAVIOR AND ACTIONS THAT WOULD SUPPORT THE ORGANIZATION'S MISSION AND VALUES. ANNUALLY, A CONFLICT OF INTEREST FORM IS SIGNED AND REVIEWED WITH EACH NEW ELECTION OF GOVERNING BOARD MEMBERS AND DOCUMENTED IN THE BOARD MINUTES. THE COVERED PERSONS MUST DISCLOSE ANY POTENTIAL CONFLICT OF INTERESTS AS SOON AS THEY BECOME AWARE AND REFRAIN FROM PARTICIPATING IN ANY DELIBERATION OR DECISIONS IN REGARDS TO ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 75,000. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 75,000. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 8,123. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,123. PART XII, LINE 2C, OVERSIGHT OF AUDIT: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF INDEPENDENT ACCOUNTANT AND NO PROCESSES HAVE CHANGED FROM PRIOR YEAR. WITHAM HEALTH SERVICES INC 2605 N LEBANON ST LEBANON IN 46052 351151208 HOSPITAL IN GOV'T HOSPITAL N/A N/A 0 CENTRAL INDIANA HEALTH ASSOCIATION INC 2605 N LEBANON ST LEBANON IN 46052 208226797 HEALTHCARE SERVICES IN 501(C)(3) LINE 12A, I N/A 0 0 1 0 1 0 0 0 1 0 0 1 0 1 1 1 1 1 0 0