SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
HOLZER MEDICAL CENTER - JACKSON
 
Employer identification number

31-1724085
Return Reference Explanation
FORM 990, PART VI, SECTION A, LINE 6 HOLZER HEALTH SYSTEM IS THE SOLE MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7B HOLZER MEDICAL CENTER - JACKSON'S DECISIONS THAT ARE MADE BY THEIR BOARD OF DIRECTORS CAN BE OVERRULED BY HOLZER HEALTH SYSTEM'S BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND THE CFO OF HOLZER HEALTH SYSTEM REVIEW FORM 990. A COPY WILL BE PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY AND ARE REVIEWED BY THE CONFLICT OF INTEREST REVIEW COMMITTEE. MEMBERS OF THE BOARD ARE AWARE THAT THEY SHOULD DISCLOSE CONFLICTS WHEN THEY ARISE, AND MEMBERS ABSTAIN FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS WHERE A CONFLICT IS PRESENT.
FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART XI, LINE 9: TRANSFER TO AFFILIATE -1,294,000. CHANGE IN TEMPORARILY RESTRICTED NET ASSETS -1,200.
FORM 990, PART XI, LINE 2C: THE AUDIT OVERSIGHT PROCESS AND THE PROCESS OF SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR.
FORM 990, AUDITED FINANCIAL STATEMENTS ATTACHMENT: THE RETURN WAS PREPARED USING DRAFT FINANCIAL STATEMENTS. THE EXPECTED ISSUANCE OF THE AUDITED FINANCIAL STATEMENTS IS JULY 2015. THE FORM 990 WILL BE AMENDED TO INCLUDE A COPY OF THE FINALIZED FINANCIAL STATEMENTS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2013

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