2023-11-14T11:03:24-06:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 391775074 MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO MEMO 6083398371 PO BOX 40 FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA VICE-CHAIR 6083398371 2023-10-17 1 FRANK PEREZ-GUERRA 999009999 1 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-17 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z MOUNDVIEW MEMORIAL HEALTHCARE FOUNDATION FRANK PEREZ-GUERRA PO BOX 40 FRIENDSHIP WI 53934 118772 0 X WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW/FOUNDATION X 1993 WI THE MEMORIAL HEALTHCARE FOUNDATION'S MISSION IS TO SUPPORT MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THROUGH FUND RAISING AND PUBLIC AWARENESS. 14 10 0 40 0 0 44246 63651 0 0 25876 37121 371 -3946 70493 96826 16197 40503 0 0 0 0 0 0 0 0 0 16197 40503 54296 56323 966913 1494969 0 0 966913 1494969 THE MEMORIAL HEALTHCARE FOUNDATION'S MISSION IS TO SUPPORT MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THROUGH FUND RAISING AND PUBLIC AWARENESS. 0 0 40503 40503 0 THE PURPOSE OF THE FOUNDATION IS TO RAISE FUNDS WHICH WILL BE USED TO SUPPORT MOUNDVIEW MEMORIAL HOSPITAL & CLINICS THROUGH ACTIVITIES OF ANNUAL GIVING, CAPITAL CAMPAIGN AND SPECIAL EVENTS, WHICH WILL BE USED TO BENEFIT THE FRIENDSHIP AND ADAMS COMMUNITIES. 40503 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 14 10 0 0 1 0 1 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 WI X FRANK PEREZ-GUERRA 6083398371 402 W LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA VICE CHAIR & CEO GMHC 1.00 40.00 X X 0 190450 31881 GREG HUTCHESON DIRECTOR 1.00 40.00 X 0 168330 27814 LORI WITTIG DIRECTOR 1.00 40.00 X 0 118688 7843 MANDY RICHARDSON DIRECTOR 1.00 40.00 X 0 93783 25031 CARRIE EASTERLY DIRECTOR 1.00 40.00 X 0 54025 21241 KEVIN MOORE VICE CHAIR 1.00 X X 0 0 0 JASON HOHENSTEIN TREASURER 1.00 X X 0 0 0 JESSE SCHABLE SECRETARY 1.00 X X 0 0 0 RICHARD STERNHAGEN EX-OFFICIO 1.00 2.50 X X 0 0 0 LIZ HENDRICKSEN DIRECTOR 1.00 X 0 0 0 LAURIE INDA DIRECTOR 1.00 X 0 0 0 BONNIE NACHREINER DIRECTOR 1.00 X 0 0 0 TOM WERMUTH DIRECTOR 1.00 X 0 0 0 KARA WORMET DIRECTOR 1.00 X 0 0 0 0 625276 113810 0 0 1 0 0 45504 18147 63651 12331 12331 24790 0 24790 24790 24790 18000 45504 21946 -3946 -3946 96826 0 0 33175 40503 40503 40503 40503 0 0 579336 119058 387577 871253 0 504658 966913 1494969 0 0 X 966913 990311 0 504658 966913 1494969 966913 1494969 X 56323 -79374 551107 X 0 0 0 X X 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 390944012 3 1 40503 0 1 40503 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 PART IV, SECTION A, LINE 1 THE MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO. (THE "FOUNDATION") HAS A HISTORIC AND CONTINUING RELATIONSHIP WITH MOUNDVIEW MEMORIAL HOSPITAL & CLINICS (THE "HOSPITAL"). THE HOSPITAL IS AND HISTORICALLY HAS BEEN THE SOLE CORPORATE MEMBER OF THE FOUNDATION. IN ADDITION, THE MISSION OF THE FOUNDATION IS TO SUPPORT THE HOSPITAL THROUGH FUND RAISING AND PUBLIC AWARENESS. SINCE THE FOUNDATION'S INCEPTION, IT HAS FINANCIALLY SUPPORTED PROJECTS AT THE HOSPITAL BASED ON THE NEEDS OF THE COMMUNITIES IT SERVICES. THE FOUNDATION PROVIDES LIFESAVING EQUIPMENT, UPGRADES, AND IMPROVEMENTS TO THE HOSPITAL AS WELL AS FUNDS LOCAL HEALTHCARE PROGRAMS. PART IV, SECTION A, LINE 6 THE SUPPORTING ORGANIZATION WILL MAKE GRANTS TO ORGANIZATIONS THAT THE SUPPORTED ORGANIZATION ITSELF WOULD SUPPORT DUE TO THE SUPPORTED ORGANIZATION'S EXEMPT PURPOSE. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 387577 1070051 -81716 1375912 307241 80336 387577 253190 8348 45703 307241 210345 14063 28782 253190 213822 7405 -10882 210345 0.63322 0.36678 0.00000 0 0 0 ASSETS HELD IN CHARITABLE TRUST 504658 504658 PART V, LINE 4: THE PURPOSE OF THE ENDOWMENT FUND IS TO SUPPORT HOSPITAL OPERATIONS. GOLF TOURNAMENT 63504 45504 18000 600 300 11620 8220 1206 63504 45504 18000 600 300 11620 8220 1206 21946 -3946 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC 402 WEST LAKE STREET FRIENDSHIP WI 53934 390944012 501(C)(3) 40503 0 FUNDING OF MEDICAL EQUIPMENT AND CAPITAL PROJECTS 1 0 PART I, LINE 2: THE BOARD OF DIRECTORS APPROVES GRANTS MADE TO THE HOSPITAL. 0 0 0 0 0 0 0 0 0 FRANK PEREZ-GUERRA VICE CHAIR & CEO GMHC 0 190450 0 0 0 0 0 7737 0 24144 0 222331 0 0 GREG HUTCHESON DIRECTOR 0 168330 0 0 0 0 0 6320 0 21494 0 196144 0 0 SCHEDULE J, PART 1, LINE 3 A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. FORM 990, PART VI, SECTION A, LINE 4 GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE FOUNDATION IS MOUNDVIEW MEMORIAL HOSPITAL & CLINICS. FORM 990, PART VI, SECTION A, LINE 7A MOUNDVIEW MEMORIAL HOSPITAL & CLINICS HAS THE AUTHORITY TO ELECT AND REMOVE DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS ARE SUBJECT TO RATIFICATION OF MOUNDVIEW MEMORIAL HOSPITAL & CLINICS: AMENDMENT OF THE BYLAWS, MERGER & CONSOLIDATION OR DISSOLUTION, CREATION OF SUBSIDIARIES OR AFFILIATES, ADOPTION OF THE ANNUAL REPORT, SELECTION AND RETENTION OF THE EXECUTIVE DIRECTOR, CAPITAL EXPENDITURES IN EXCESS OF $25,000, EXTENSION OF ANY LOANS BY OR BORROWINGS OF AMOUNTS GREATER THAT $25,000, SALE OF ANY CAPITAL ASSETS WITH BOOK OR MARKET VALUE EXCEEDING $10,000 FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO ACTING COMMITTEES WITHIN THE ORGANIZATION FORM 990, PART VI, SECTION B, LINE 11B THE IRS FORM 990 IS REVIEWED BY MANAGEMENT AND PROVIDED TO THE FINANCE COMMITTEE AND THEN ENTIRE BOARD PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE BOARD AND BY THE HOSPITAL CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. FORM 990, PART XI, LINE 9: TRANSFER OF ASSETS TO MANAGE FROM HOSPITAL 551,107. BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING AND RADIOLOGIC SCIENCE COLLEGE WI 501(C)(3) LINE 2 BELLIN HEALTH SYSTEMS INC 1 BELLIN GUNDERSEN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 920504278 PARENT WI 501(C)(3) LINE 12B, II N/A 0 BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512904 SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(C)(3) LINE 12B, II BELLIN GUNDERSEN HEALTH SYSTEMS INC 1 BELLIN MEMORIAL HOSPITAL INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 390884478 HEALTH CARE WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 1 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PSYCHIATRIC HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 1 COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDEPENDENT LIVING WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN CLINIC LTD 1910 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN ADMINSTRATIVE SVC 1910 SOUTH AVENUE LA CROSSE WI 54601 391606449 SUPPORTING ORG WI 501(C)(3) LINE 12B, II GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN CREDENTIALING SVC INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORTING ORG WI 501(C)(3) LINE 12B, II N/A 0 GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) LINE 7 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 HARMONY COMMUNITY HEALTHCARE INC 815 MAIN AVENUE SOUTH HARMONY MN 55939 410711606 HEALTHCARE MN 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(C)(3) LINE 12B, II BELLIN HEALTH SYSTEMS INC 1 LUTHERAN HOUSING OF LA CROSSE 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDEPENDENT LIVING WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 LUTHERAN REAL ESTATE HOLDING CORP 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM 1 MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS 402 WEST LAKE STREET FRIENDSHIP WI 53934 390944012 HOSPITAL WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVENUE OCONTO WI 54153 061745397 HEALTH CARE WI 501(C)(3) LINE 3 BELLIN MEMORIAL HOSPITAL INC 1 PALMER LUTHERAN HEALTH CENTER 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTHCARE IA 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 SAINT ELIZABETH'S HOSPITAL OF WABASHA 1200 GRANT BLVD WABASHA MN 55981 410693877 HEALTHCARE MN 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 ST JOSEPH'S HEALTH SERVICES INC 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER AVENUE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(C)(3) LINE 12A, I GUNDERSEN LUTHERAN HEALTH SYSTEM 1 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54301 391809171 FOUNDATION WI 501(C)(3) LINE 7 BELLIN HEALTH SYSTEMS INC 1 TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(C)(3) LINE 12A, I TRI-COUNTY MEMORIAL HOSPITAL 1 TRI-COUNTY MEMORIAL HOSPITAL 18601 LINCOLN STREET WITHEHALL WI 54773 390704510 HEALTHCARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TRI-STATE AMBULANCE INC 235 CAUSEWAY BOLEVARD LA CROSSE WI 54603 391965415 MEDICAL TRANSPORT WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BOLEVARD LA CROSSE WI 54603 391962965 MEDICAL TRANSPORT WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTHCARE WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM 1 GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI N/A C 0 3REALESTATE LLC 1900 SOUTH AVENUE LA CROSSE WI 54601 RENTAL WI N/A C 0 BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI N/A C 0 BELLIN INVESTMENTS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391564939 OTHER WI N/A C 0 GUNDERSEN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI N/A C 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS C 551107 FMV