OMB 1545-50 Under setion 501, 57, or 4947(1) of the Internal Revenue Code Form (exept lak lung enefit trust or private foundation) Sponsoring organizations of donor advised funds, organizations that operate one or more hospital failities, and ertain ontrolling Department of the Treasury organizations as defined in setion 5(13) must file Form 990. All other organizations with gross reeipts less than 00,000 and total Internal Revenue Servie assets less than 500,000 at the end of the year may use this form. Open to Puli The organization may have to use a opy of this return to satisfy state reporting requirements. Inspetion A For the 0 alendar year, or tax year eginning and ending B Chek if appliale: C Name of organization D Employer identifiation numer Address hange Name hange Initial return Numer and street (or P.O. ox, if mail is not delivered to street address) Room/suite E Telephone numer Terminated P.O. DRAWER Z 540-839-7104 Amended return City or town, state or ountry, and ZIP + 4 F Group Exemption HOT SPRINGS, VA 4445 Appliation pending Numer G Aounting Method: Cash Arual Other (speify) H Chek if the organization is not I Wesite: N/A required to attah Shedule B J Tax-exempt status (hek only one) 501(3) 501 ( ) (insert no.) 4947(1) or 57 (Form 990, 990-EZ, or 990-PF). K Chek if the organization is not a setion 509(3) supporting organization or a setion 57 organization and its gross reeipts are normally not more than Revenue Expenses Net Assets 50,000. A Form 990-EZ or Form 990 return is not required though Form 990-N (e-postard) may e required (see instrutions). But if the organization hooses to file a return, e sure to file a omplete return. L Add lines 5, 6, and 7, to line 9 to determine gross reeipts. If gross reeipts are 00,000 or more, or if total assets (I, line 5, olumn (B) elow) are 500,000 or more, file Form 990 instead of Form 990-EZ 38,715. Revenue, Expenses, and Changes in Net Assets or Fund Balanes (see the instrutions for ) Chek if the organization used Shedule O to respond to any question in this 1 Contriutions, gifts, grants, and similar amounts reeived ~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1 37,955. LHA 3 4 6 8 9 10 13 14 a d Memership dues and assessments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3 Investment inome SEE SCHEDULE O 4 760. Other revenue (desrie in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 8 Total revenue. Add lines 1,, 3, 4, 5, 6d, 7, and 8 9 38,715. Grants and similar amounts paid (list in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SEE SCHEDULE O 10 36,000. 15 Printing, puliations, postage, and shipping ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 16 Other expenses (desrie in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 17 Total expenses. Add lines 10 through 16 18 19 0 1 Program servie revenue inluding government fees and ontrats 5a Gross amount sale of assets other than inventory~~~~~~~~~~~~~ Less: ost or other asis and sales expenses ~~~~~~~~~~~~~~~~~ For Paperwork Redution At Notie, see the separate instrutions. ~~~~~~~~~~~~~~~~~~~~~~~ Gain or (loss) sale of assets other than inventory (Sutrat line 5 line 5a) ~~~~~~~~~~~~~~~ Gaming and fundraising events Gross inome gaming (attah Shedule G if greater than 15,000) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Gross inome fundraising events (not inluding fundraising events reported on line 1) (attah Shedule G if the sum of suh gross inome and ontriutions exeeds 15,000) Less: diret expenses gaming and fundraising events ~~~~~~~~~~~~~~ ~~~~~~~~~~ 5a 5 6a of ontriutions Net inome or (loss) gaming and fundraising events (add lines 6a and 6 and sutrat line 6) ~~~~~~~~~ 7a Gross sales of inventory, less returns and allowanes ~~~~~~~~~~~~~ Less: ost of goods sold ~~~~~~~~~~~~~~~~~~~~~~~~~~ Gross profit or (loss) sales of inventory (Sutrat line 7 line 7a) 6 6 7a 7 ~~~~~~~~~~~~~~~~~~~ Benefits paid to or for memers~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Salaries, other ompensation, and employee enefits ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Professional fees and other payments to independent ontrators ~~~~~~~~~~~~~~~~~~~~~~~~ Oupany, rent, utilities, and maintenane ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Exess or (defiit) for the year (Sutrat line 17 line 9) Net assets or fund alanes at eginning of year ( line 7, olumn (A)) (must agree with end-of-year figure reported on prior year s return) ~~~~~~~~~~~~~~~~~~~~~~~ Other hanges in net assets or fund alanes (explain in Shedule O) ** PUBLIC DISCLOSURE COPY ** Short Form Return of Organization Exempt From Inome Tax 990-EZ 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~ Net assets or fund alanes at end of year. Comine lines 18 through 0 5 6d 7 13 14 15 16 17 18 19 0 1 736. 36,736. 1,979. 139,74. 0. 141,71. Form 990-EZ (0) 3171 01--13 1
Form 990-EZ (0) Page I Balane Sheets (see the instrutions for I) Chek if the organization used Shedule O to respond to any question in this I (A) Beginning of year (B) End of year Cash, savings, and investments ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 139,74. 141,71. 3 Land and uildings ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4 Other assets (desrie in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~~~ 4 5 Total assets ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 139,74. 5 141,71. 6 Total liailities (desrie in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~ 0. 6 0. 7 Net assets or fund alanes (line 7 of olumn (B) must agree with line 1) 139,74. 7 141,71. II Statement of Program Servie Aomplishments (see the instrutions for II) Expenses (Required for setion Chek if the organization used Shedule O to respond to any question in this II 501(3) and 501(4) What is the organization s primary exempt purpose? SEE SCHEDULE O organizations and setion Desrie the organization s program servie aomplishments for eah of its three largest program servies, as measured y expenses. In a lear and onise 4947(1) trusts; optional manner, desrie the servies provided, the numer of persons enefited, and other relevant information for eah program title. for others.) 8 TO ASSIST BATH COMMUNITY HOSPITAL IN PURCHASE OF MAJOR MEDICAL EQUIPMENT. 3 9 (Grants 36,000. ) If this amount inludes foreign grants, hek here 8a 36,736. 30 (Grants ) If this amount inludes foreign grants, hek here 9a (Grants ) If this amount inludes foreign grants, hek here 30a 31 Other program servies (desrie in Shedule O) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ (Grants ) If this amount inludes foreign grants, hek here 31a 3 Total program servie expenses (add lines 8a through 31a) 3 36,736. V List of Offiers, Diretors, Trustees, and Key Employees List eah one even if not ompensated. (see the instrutions for V) Chek if the organization used Shedule O to respond to any question in this V Name and title Average hours Reportale Health enefits, (e) Estimated ompensation (Forms ontriutions to per week devoted to W-/1099-MISC) employee enefit amount of other position (if not paid, enter -0-) plans, and deferred ompensation ompensation JOANNE INGALLS CO-CHARIMAN 0.00 0. 0. 0. FRANZ VON SCHILLING CO-CHAIRMAN 0.00 0. 0. 0. LIZ MCCARTHY AMORY MELLEN, III GEORGE PHILLIPS SUSAN PHILLIPS JAMES REDINGTON, M.D. JEAN HOWELL CARL BEHRENS 317 01--13 Form 990-EZ (0)
Form 990-EZ (0) Page 3 Part V Other Information (Note the Shedule A and personal enefit ontrat statement requirements in the instrutions for Part V) Chek if the organization used Sh. O to respond to any question in this Part V Yes No 33 Did the organization engage in any signifiant ativity not previously reported to the IRS? If "Yes," provide a detailed desription of eah ativity in Shedule O ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 33 34 36 37a 38a 39 41 Did the organization file Form 10-POL for this year? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 37 a d e 4a 43 Were any signifiant hanges made to the organizing or governing douments? If "Yes," attah a onformed opy of the amended douments if they reflet a hange to the organization s name. Otherwise, explain the hange on Shedule O (see instrutions) ~~~~~~ 35a Did the organization have unrelated usiness gross inome of 1,000 or more during the year usiness ativities (suh as those reported on lines, 6a, and 7a, among others)? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Shedule O ~~~~~~~~~~ Was the organization a setion 501(4), 501(5), or 501(6) organization sujet to setion 6033(e) notie, reporting, and proxy tax requirements during the year? If "Yes," omplete Shedule C, II ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the organization undergo a liquidation, dissolution, termination, or signifiant disposition of net assets during the year? If "Yes," omplete appliale parts of Shedule N Enter amount of politial expenditures, diret or indiret, as desried in the instrutions ~~~~~ 37a 0. Did the organization orrow, or make any loans to, any offier, diretor, trustee, or key employee or were any suh loans made in a prior year and still outstanding at the end of the tax year overed y this return? If "Yes," omplete Shedule L, I and enter the total amount involved ~~~~~~~~~~~~~~ 38 N/A Setion 501(7) organizations. Enter: Initiation fees and apital ontriutions inluded on line 9 ~~~~~~~~~~~~~~~~~~~~~ Gross reeipts, inluded on line 9, for puli use of lu failities ~~~~~~~~~~~~~~~~~~ 40a Setion 501(3) organizations. Enter amount of tax imposed on the organization during the year under: setion 49 0. ; setion 49 0. ; setion 4955 0. Setion 501(3) and 501(4) organizations. Did the organization engage in any setion 4958 exess enefit transation during the year, or did it engage in an exess enefit transation in a prior year that has not een reported on any of its prior Forms 990 or 990-EZ? If "Yes," omplete Shedule L, ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Setion 501(3) and 501(4) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under setions 49, 4955, and 4958 ~~~~~~~~~~~~~~~ Setion 501(3) and 501(4) organizations. Enter amount of tax on line 40 reimursed y the organization ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All organizations. At any time during the tax year, was the organization a party to a prohiited tax shelter transation? If "Yes," omplete Form 8886-T ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 40e List the states with whih a opy of this return is filed NONE The organization s ooks are in are of JASON PARET Telephone no. 540-839-7059 Loated at 106 PARK DR, HOT SPRINGS, VA ZIP + 4 4445 At any time during the alendar year, did the organization have an interest in or a signature or other authority over a finanial aount in a foreign ountry (suh as a ank aount, seurities aount, or other finanial aount)? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes," enter the name of the foreign ountry: See the instrutions for exeptions and filing requirements for Form TD F 90-.1, Report of Foreign Bank and Finanial Aounts. At any time during the alendar year, did the organization maintain an offie outside of the U.S.? ~~~~~~~~~~~~~~~~~~~~ If "Yes," enter the name of the foreign ountry: Setion 4947(1) nonexempt haritale trusts filing Form 990-EZ in lieu of Form 1041 - Chek here and enter the amount of tax-exempt interest reeived or arued during the tax year ~~~~~~~~~~~~~~~~~ 43 N/A 39a 39 N/A N/A 0. 0. 34 35a 35 35 36 38a 40 4 4 N/A Yes No 44a d 3173 01--13 Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must e ompleted instead of Form 990-EZ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the organization operate one or more hospital failities during the year? If "Yes," Form 990 must e ompleted instead of Form 990-EZ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Did the organization reeive any payments for indoor tanning servies during the year? ~~~~~~~~~~~~~~~~~~~~~~~~ If "Yes" to line 44, has the organization filed a Form 70 to report these payments? If "No," provide an explanation in Shedule O ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 45a Did the organization have a ontrolled entity within the meaning of setion 5(13)? ~~~~~~~~~~~~~~~~~~~~~~~~ 45 Did the organization reeive any payment or engage in any transation with a ontrolled entity within the meaning of setion 5(13)? If "Yes," Form 990 and Shedule R may need to e ompleted instead of Form 990-EZ (see instrutions) 44a 44 44 44d 45a 45 Yes No Form 990-EZ (0) 3
Form 990-EZ (0) 46 50 Did the organization engage, diretly or indiretly, in politial ampaign ativities on ehalf of or in opposition to andidates for puli offie? If "Yes," omplete Shedule C, Part VI Setion 501(3) organizations only All setion 501(3) organizations must answer questions 47-49 and 5, and omplete the tales for lines 50 and 51 If "Yes," was the related organization a setion 57 organization? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Complete this tale for the organization s five highest ompensated employees (other than offiers, diretors, trustees and key employees) who eah reeived more than 100,000 of ompensation the organization. If there is none, enter "None." Name and title of eah employee Average hours Reportale Health enefits, (e) Estimated ompensation (Forms ontriutions to paid more than 100,000 per week devoted to W-/1099-MISC) employee enefit amount of other position plans, and deferred NONE ompensation ompensation 46 49 Page 4 Yes No Chek if the organization used Shedule O to respond to any question in this Part VI Yes No 47 48 Did the organization engage in loying ativities or have a setion 501(h) eletion in effet during the tax year? If "Yes," omplete Sh. C, I Is the organization a shool as desried in setion 170(1)(A)(ii)? If "Yes," omplete Shedule E ~~~~~~~~~~~~~~~~~~~ 47 48 49a Did the organization make any transfers to an exempt non-haritale related organization? ~~~~~~~~~~~~~~~~~~~~~~ 49a f Total numer of other employees paid over 100,000 ~~~~~~~~~~~~~~~~ 51 Complete this tale for the organization s five highest ompensated independent ontrators who eah reeived more than 100,000 of ompensation the organization. If there is none, enter "None." NONE Name and address of eah independent ontrator paid more than 100,000 Type of servie Compensation d Total numer of other independent ontrators eah reeiving over 100,000 ~~~~~~~~~~~~~~ 5 Did the organization omplete Shedule A? Note: All setion 501(3) organizations and 4947(1) nonexempt haritale trusts must attah a ompleted Shedule A Yes Under penalties of perjury, I delare that I have examined this return, inluding aompanying shedules and statements, and to the est of my knowledge and elief, it is true, orret, and omplete. Delaration of preparer (other than offier) is ased on all information of whih preparer has any knowledge. Sign Here = = Signature of offier FRANZ VON SCHILLING, CHAIRMAN Type or print name and title Print/Type preparer s name Preparer s signature Date Chek if PTIN Paid self- employed Preparer JAMES R. FRIES 08/09/13 P01306 Use Only Firm s name BROWN, EDWARDS & COMPANY, LLP Firm s EIN 54-0504608 9 9 Firm s address 9 4 NEWMAN AVENUE Phone no. (540) 434-6736 HARRISONBURG, VA 801 May the IRS disuss this return with the preparer shown aove? See instrutions Yes No Date No Form 990-EZ (0) 3174 01--13 4
SCHEDULE A (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Servie Complete if the organization is a setion 501(3) organization or a setion 4947(1) nonexempt haritale trust. Attah to Form 990 or Form 990-EZ. See separate instrutions. OMB 1545-0047 Open to Puli Inspetion Name of the organization Employer identifiation numer Reason for Puli Charity Status (All organizations must omplete this part.) See instrutions. The organization is not a private foundation eause it is: (For lines 1 through, hek only one ox.) 1 3 4 5 6 7 8 9 10 e f g h A hurh, onvention of hurhes, or assoiation of hurhes desried in setion 170(1)(A)(i). A shool desried in setion 170(1)(A)(ii). (Attah Shedule E.) A hospital or a ooperative hospital servie organization desried in setion 170(1)(A)(iii). A medial researh organization operated in onjuntion with a hospital desried in setion 170(1)(A)(iii). Enter the hospital s name, ity, and state: An organization operated for the enefit of a ollege or university owned or operated y a governmental unit desried in setion 170(1)(A)(iv). (Complete I.) A federal, state, or loal government or governmental unit desried in setion 170(1)(A)(v). An organization that normally reeives a sustantial part of its support a governmental unit or the general puli desried in setion 170(1)(A)(vi). (Complete I.) A ommunity trust desried in setion 170(1)(A)(vi). (Complete I.) An organization that normally reeives: (1) more than 33 1/3% of its support ontriutions, memership fees, and gross reeipts ativities related to its exempt funtions - sujet to ertain exeptions, and () no more than 33 1/3% of its support gross investment inome and unrelated usiness taxale inome (less setion 5 tax) usinesses aquired y the organization after June 30, 1975. See setion 509(). (Complete II.) An organization organized and operated exlusively to test for puli safety. See setion 509(4). An organization organized and operated exlusively for the enefit of, to perform the funtions of, or to arry out the purposes of one or more pulily supported organizations desried in setion 509(1) or setion 509(). See setion 509(3). Chek the ox that desries the type of supporting organization and omplete lines e through h. a Type I Type II Type III - Funtionally integrated d Type III - Non-funtionally integrated By heking this ox, I ertify that the organization is not ontrolled diretly or indiretly y one or more disqualified persons other than foundation managers and other than one or more pulily supported organizations desried in setion 509(1) or setion 509(). If the organization reeived a written determination the IRS that it is a Type I, Type II, or Type III supporting organization, hek this ox Sine August 17, 006, has the organization aepted any gift or ontriution any of the following persons? (i) (ii) (iii) Puli Charity Status and Puli Support ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A person who diretly or indiretly ontrols, either alone or together with persons desried in (ii) and (iii) elow, the governing ody of the supported organization? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A family memer of a person desried in (i) aove? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A 35% ontrolled entity of a person desried in (i) or (ii) aove? ~~~~~~~~~~~~~~~~~~~~~~~~ Provide the following information aout the supported organization(s). 0 g(i) g(ii) g(iii) Yes No (i) Name of supported (ii) EIN (iii) Type of organization (iv) Is the organization (v) Did you notify the (vi) Is the (vii) (desried on lines 1-9 in ol. (i) listed in your organization in ol. organization in ol. Amount of monetary organization (i) organized in the support aove or IRC setion governing doument? (i) of your support? U.S.? (see instrutions) ) Yes No Yes No Yes No BATH COMMUNITY HO54-05059133 36,000. Total LHA For Paperwork Redution At Notie, see the Instrutions for Form 990 or 990-EZ. 301-04- 1 36,000. Shedule A (Form 990 or 990-EZ) 0 5
Shedule A (Form 990 or 990-EZ) 0 Page I Support Shedule for Organizations Desried in Setions 170(1)(A)(iv) and 170(1)(A)(vi) (Complete only if you heked the ox on line 5, 7, or 8 of or if the organization failed to qualify under II. If the organization fails to qualify under the tests listed elow, please omplete II.) Setion A. Puli Support Calendar year (or fisal year eginning in) 1 3 4 5 Total. Add lines 1 through 3 ~~~ 6 Puli support. Sutrat line 5 line 4. Calendar year (or fisal year eginning in) 7 8 9 10 13 assets (Explain in V.) ~~~~ Total support. Add lines 7 through 10 008 009 010 0 (e) 0 (f) Total 008 009 010 0 (e) 0 (f) Total First five years. If the Form 990 is for the organization s first, seond, third, fourth, or fifth tax year as a setion 501(3) organization, hek this ox and stop here Setion C. Computation of Puli Support Perentage 14 15 16a 33 1/3% support test - 0. If the organization did not hek the ox on line 13, and line 14 is 33 1/3% or more, hek this ox and 17a 10% -fats-and-irumstanes test - 0. If the organization did not hek a ox on line 13, 16a, or 16, and line 14 is 10% or more, 18 Gifts, grants, ontriutions, and memership fees reeived. (Do not inlude any "unusual grants.") ~~ Tax revenues levied for the organization s enefit and either paid to or expended on its ehalf ~~~~ The value of servies or failities furnished y a governmental unit to the organization without harge ~ The portion of total ontriutions y eah person (other than a governmental unit or pulily supported organization) inluded on line 1 that exeeds % of the amount shown on line, olumn (f) ~~~~~~~~~~~~ Setion B. Total Support Amounts line 4 ~~~~~~~ Gross inome interest, dividends, payments reeived on seurities loans, rents, royalties and inome similar soures ~ Net inome unrelated usiness ativities, whether or not the usiness is regularly arried on ~ Other inome. Do not inlude gain or loss the sale of apital Gross reeipts related ativities, et. (see instrutions) ~~~~~~~~~~~~~~~~~~~~~~~ Puli support perentage for 0 (line 6, olumn (f) divided y line, olumn (f)) ~~~~~~~~~~~~ Puli support perentage 0 Shedule A, I, line 14 ~~~~~~~~~~~~~~~~~~~~~ stop here. The organization qualifies as a pulily supported organization ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 33 1/3% support test - 0. If the organization did not hek a ox on line 13 or 16a, and line 15 is 33 1/3% or more, hek this ox and stop here. The organization qualifies as a pulily supported organization ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ and if the organization meets the "fats-and-irumstanes" test, hek this ox and stop here. Explain in V how the organization meets the "fats-and-irumstanes" test. The organization qualifies as a pulily supported organization ~~~~~~~~~~~~~~~ 10% -fats-and-irumstanes test - 0. If the organization did not hek a ox on line 13, 16a, 16, or 17a, and line 15 is 10% or more, and if the organization meets the "fats-and-irumstanes" test, hek this ox and stop here. Explain in V how the organization meets the "fats-and-irumstanes" test. The organization qualifies as a pulily supported organization ~~~~~~~~ Private foundation. If the organization did not hek a ox on line 13, 16a, 16, 17a, or 17, hek this ox and see instrutions 14 15 Shedule A (Form 990 or 990-EZ) 0 % % 30-04- 6
Shedule A (Form 990 or 990-EZ) 0 II Support Shedule for Organizations Desried in Setion 509() Calendar year (or fisal year eginning in) 1 3 4 5 6 The value of servies or failities furnished y a governmental unit to the organization without harge ~ Total. Add lines 1 through 5 ~~~ 7a Amounts inluded on lines 1,, and 3 reeived disqualified persons Amounts inluded on lines and 3 reeived other than disqualified persons that exeed the greater of 5,000 or 1% of the amount on line 13 for the year ~~~~~~ Add lines 7a and 7 ~~~~~~~ 8 Puli support (Sutrat line 7 line 6.) Calendar year (or fisal year eginning in) 9 Amounts line 6 ~~~~~~~ 10a Gross inome interest, dividends, payments reeived on seurities loans, rents, royalties and inome similar soures ~ Unrelated usiness taxale inome (less setion 5 taxes) usinesses aquired after June 30, 1975 ~~~~ 13 008 009 010 0 (e) 0 (f) Total 008 009 010 0 (e) 0 (f) Total 14 First five years. If the Form 990 is for the organization s first, seond, third, fourth, or fifth tax year as a setion 501(3) organization, hek this ox and stop here Setion C. Computation of Puli Support Perentage 15 16 Puli support perentage 0 Shedule A, II, line 15 Setion D. Computation of Investment Inome Perentage 17 18 Page 3 Puli support perentage for 0 (line 8, olumn (f) divided y line 13, olumn (f)) ~~~~~~~~~~~~ 15 % 19a 33 1/3% support tests - 0. If the organization did not hek the ox on line 14, and line 15 is more than 33 1/3%, and line 17 is not 0 (Complete only if you heked the ox on line 9 of or if the organization failed to qualify under I. If the organization fails to qualify under the tests listed elow, please omplete I.) Setion A. Puli Support Gifts, grants, ontriutions, and memership fees reeived. (Do not inlude any "unusual grants.") ~~ Gross reeipts admissions, merhandise sold or servies performed, or failities furnished in any ativity that is related to the organization s tax-exempt purpose Gross reeipts ativities that are not an unrelated trade or usiness under setion 513 ~~~~~ Tax revenues levied for the organization s enefit and either paid to or expended on its ehalf ~~~~ Setion B. Total Support Add lines 10a and 10 ~~~~~~ Net inome unrelated usiness ativities not inluded in line 10, whether or not the usiness is regularly arried on ~~~~~~~ Other inome. Do not inlude gain or loss the sale of apital assets (Explain in V.) ~~~~ Total support. (Add lines 9, 10,, and.) Investment inome perentage for 0 (line 10, olumn (f) divided y line 13, olumn (f)) Investment inome perentage 0 Shedule A, II, line 17 ~~~~~~~~~~~~~~~~~~ 16 ~~~~~~~~ 17 % more than 33 1/3%, hek this ox and stop here. The organization qualifies as a pulily supported organization ~~~~~~~~~~ 33 1/3% support tests - 0. If the organization did not hek a ox 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%, hek this ox and stop here. The organization qualifies as a pulily supported organization~~~~ Private foundation. If the organization did not hek a ox on line 14, 19a, or 19, hek this ox and see instrutions 303-04- Shedule A (Form 990 or 990-EZ) 0 7 18 % %
Shedule B (Form 990, 990-EZ, or 990-PF) Department of the Treasury Internal Revenue Servie Attah to Form 990, Form 990-EZ, or Form 990-PF. OMB 1545-0047 Name of the organization Employer identifiation numer Organization type(hek one): ** PUBLIC DISCLOSURE COPY ** Shedule of Contriutors 0 Filers of: Setion: Form 990 or 990-EZ 501( 3 ) (enter numer) organization 4947(1) nonexempt haritale trust not treated as a private foundation 57 politial organization Form 990-PF 501(3) exempt private foundation 4947(1) nonexempt haritale trust treated as a private foundation 501(3) taxale private foundation Chek if your organization is overed y the General Rule or a Speial Rule. Note. Only a setion 501(7), (8), or (10) organization an hek oxes for oth the General Rule and a Speial Rule. See instrutions. General Rule For an organization filing Form 990, 990-EZ, or 990-PF that reeived, during the year, 5,000 or more (in money or property) any one ontriutor. Complete Parts I and II. Speial Rules For a setion 501(3) organization filing Form 990 or 990-EZ that met the 33 1/3% support test of the regulations under setions 509(1) and 170(1)(A)(vi) and reeived any one ontriutor, during the year, a ontriution of the greater of (1) 5,000 or () % of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II. For a setion 501(7), (8), or (10) organization filing Form 990 or 990-EZ that reeived any one ontriutor, during the year, total ontriutions of more than 1,000 for use exlusively for religious, haritale, sientifi, literary, or eduational purposes, or the prevention of ruelty to hildren or animals. Complete Parts I, II, and III. For a setion 501(7), (8), or (10) organization filing Form 990 or 990-EZ that reeived any one ontriutor, during the year, ontriutions for use exlusively for religious, haritale, et., purposes, ut these ontriutions did not total to more than 1,000. If this ox is heked, enter here the total ontriutions that were reeived during the year for an exlusively religious, haritale, et., purpose. Do not omplete any of the parts unless the General Rule applies to this organization eause it reeived nonexlusively religious, haritale, et., ontriutions of 5,000 or more during the year ~~~~~~~~~~~~~~~~~ Caution. An organization that is not overed y the General Rule and/or the Speial Rules does not file Shedule B (Form 990, 990-EZ, or 990-PF), ut it must answer "No" on V, line, of its Form 990; or hek the ox on line H of its Form 990-EZ or on, line of its Form 990-PF, to ertify that it does not meet the filing requirements of Shedule B (Form 990, 990-EZ, or 990-PF). LHA For Paperwork Redution At Notie, see the Instrutions for Form 990, 990-EZ, or 990-PF. Shedule B (Form 990, 990-EZ, or 990-PF) (0) 3451-1-
Shedule B (Form 990, 990-EZ, or 990-PF) (0) Name of organization Employer identifiation numer Page Contriutors (see instrutions). Use dupliate opies of if additional spae is needed. Name, address, and ZIP + 4 Total ontriutions Type of ontriution 1 Person Payroll 30,000. Nonash (Complete I if there is a nonash ontriution.) Name, address, and ZIP + 4 Total ontriutions Type of ontriution Person Payroll Nonash (Complete I if there is a nonash ontriution.) Name, address, and ZIP + 4 Total ontriutions Type of ontriution Person Payroll Nonash (Complete I if there is a nonash ontriution.) Name, address, and ZIP + 4 Total ontriutions Type of ontriution Person Payroll Nonash (Complete I if there is a nonash ontriution.) Name, address, and ZIP + 4 Total ontriutions Type of ontriution Person Payroll Nonash (Complete I if there is a nonash ontriution.) Name, address, and ZIP + 4 Total ontriutions Type of ontriution Person Payroll Nonash (Complete I if there is a nonash ontriution.) 345-1- Shedule B (Form 990, 990-EZ, or 990-PF) (0) 9
Shedule B (Form 990, 990-EZ, or 990-PF) (0) Page 3 Name of organization Employer identifiation numer I Nonash Property (see instrutions). Use dupliate opies of I if additional spae is needed. Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived Desription of nonash property given FMV (or estimate) (see instrutions) Date reeived 3453-1- Shedule B (Form 990, 990-EZ, or 990-PF) (0) 10
Shedule B (Form 990, 990-EZ, or 990-PF) (0) Page 4 Name of organization Employer identifiation numer II Exlusively religious, haritale, et., individual ontriutions to setion 501(7), (8), or (10) organizations that total more than 1,000 for the year. Complete olumns through (e) and the following line entry. For organizations ompleting II, enter the total of exlusively religious, haritale, et., ontriutions of 1,000 or less for the year. (Enter this information one.) Use dupliate opies of II if additional spae is needed. Purpose of gift Use of gift Desription of how gift is held (e) Transfer of gift Transferee s name, address, and ZIP + 4 Relationship of transferor to transferee Purpose of gift Use of gift Desription of how gift is held (e) Transfer of gift Transferee s name, address, and ZIP + 4 Relationship of transferor to transferee Purpose of gift Use of gift Desription of how gift is held (e) Transfer of gift Transferee s name, address, and ZIP + 4 Relationship of transferor to transferee Purpose of gift Use of gift Desription of how gift is held (e) Transfer of gift Transferee s name, address, and ZIP + 4 Relationship of transferor to transferee 3454-1- Shedule B (Form 990, 990-EZ, or 990-PF) (0)
SCHEDULE O (Form 990 or 990-EZ) Department of the Treasury Internal Revenue Servie Name of the organization Supplemental Information to Form 990 or 990-EZ Complete to provide information for responses to speifi questions on Form 990 or 990-EZ or to provide any additional information. Attah to Form 990 or 990-EZ. 0 OMB 1545-0047 Open to Puli Inspetion Employer identifiation numer FORM 990-EZ, PART I, LINE 4, OTHER INVESTMENT INCOME: DESCRIPTION OF PROPERTY: AMOUNT: INTEREST INCOME 760. FORM 990-EZ, PART I, LINE 10, PAYMENTS TO AFFILIATES: AFFILIATE NAME: HOSPITAL AFFILIATE ADDRESS: P.O. DRAWER Z HOT SPRINGS, VA 4445 PURPOSE OF PAYMENT: FOR PURCHASE OF EQUIPMENT AMOUNT OF PAYMENT: 36,000. FORM 990-EZ, PART III, PRIMARY EEMPT PURPOSE - TO SUPPORT BATH COUNTY COMMUNITY HOSPITAL S PLANS FOR DEVELOPMENT AND COMMUNITY PROGRAMS THROUGH PHILANTHROPY. FORM 990-EZ, PART V, INFORMATION REGARDING PERSONAL BENEFIT CONTRACTS: THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY, OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT. THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY, OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT. LHA For Paperwork Redution At Notie, see the Instrutions for Form 990 or 990-EZ. Shedule O (Form 990 or 990-EZ) (0) 3 01-04-13
Form 8868 Appliation for Extension of Time To File an Exempt Organization Return (Rev. January 013) OMB 1545-1709 Department of the Treasury Internal Revenue Servie File a separate appliation for eah return. If you are filing for an Automati 3-Month Extension, omplete only and hek this ox ~~~~~~~~~~~~~~~~~~~ If you are filing for an Additional (Not Automati) 3-Month Extension, omplete only I (on page of this form). Do not omplete I unless you have already een granted an automati 3-month extension on a previously filed Form 8868. Eletroni filing (e-file). You an eletronially file Form 8868 if you need a 3-month automati extension of time to file (6 months for a orporation required to file Form 990-T), or an additional (not automati) 3-month extension of time. You an eletronially file Form 8868 to request an extension of time to file any of the forms listed in or I with the exeption of Form 8870, Information Return for Transfers Assoiated With Certain Personal Benefit Contrats, whih must e sent to the IRS in paper format (see instrutions). For more details on the eletroni filing of this form, visit www.irs.gov/efile and lik on e-file for Charities & Nonprofits. Automati 3-Month Extension of Time. Only sumit original (no opies needed). A orporation required to file Form 990-T and requesting an automati 6-month extension - hek this ox and omplete only ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All other orporations (inluding 10-C filers), partnerships, REMICs, and trusts must use Form 7004 to request an extension of time to file inome tax returns. Type or print File y the due date for filing your return. See instrutions. Name of exempt organization or other filer, see instrutions. Employer identifiation numer (EIN) or Numer, street, and room or suite no. If a P.O. ox, see instrutions. P.O. DRAWER Z City, town or post offie, state, and ZIP ode. For a foreign address, see instrutions. HOT SPRINGS, VA 4445 Soial seurity numer (SSN) Enter the Return ode for the return that this appliation is for (file a separate appliation for eah return) ~~~~~~~~~~~~~~~~~ 0 1 Appliation Is For Form 990 or Form 990-EZ Form 990-BL Form 470 (individual) Form 990-PF Form 990-T (se. 401 or 408 trust) 1 Return Code 01 0 03 04 05 Appliation Is For Form 990-T (trust other than aove) 06 Form 8870 JASON PARET The ooks are in the are of 106 PARK DR - HOT SPRINGS, VA 4445 Telephone 540-839-7059 FA Return Code Form 990-T (orporation) 07 Form 1041-A Form 470 Form 57 Form 6069 If the organization does not have an offie or plae of usiness in the United States, hek this ox~~~~~~~~~~~~~~~~~ If this is for a Group Return, enter the organization s four digit Group Exemption Numer (GEN). If this is for the whole group, hek this ox. If it is for part of the group, hek this ox and attah a list with the names and EINs of all memers the extension is for. I request an automati 3-month (6 months for a orporation required to file Form 990-T) extension of time until AUGUST 15, 013, to file the exempt organization return for the organization named aove. The extension is for the organization s return for: alendar year0 or tax year eginning, and ending. 08 09 10 If the tax year entered in line 1 is for less than months, hek reason: Initial return Final return Change in aounting period 3a 3841 01-1-13 If this appliation is for Form 990-BL, 990-PF, 990-T, 470, or 6069, enter the tentative tax, less any nonrefundale redits. See instrutions. If this appliation is for Form 990-PF, 990-T, 470, or 6069, enter any refundale redits and estimated tax payments made. Inlude any prior year overpayment allowed as a redit. Balane due. Sutrat line 3 line 3a. Inlude your payment with this form, if required, y using EFTPS (Eletroni Federal Tax Payment System). See instrutions. Caution. If you are going to make an eletroni fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO for payment instrutions. LHA For Privay At and Paperwork Redution At Notie, see instrutions. Form 8868 (Rev. 1-013) 13 3a 3 3 0. 0. 0.