efile Public Visual Render
ObjectId: 201511289349302461 - Submission: 2015-05-08
TIN: 23-7204872
SCHEDULE N
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Liquidation, Termination, Dissolution, or Significant Disposition of Assets
Complete if the organization answered "Yes" to Form 990, Part IV, lines 31 or 32; or Form 990-EZ, line 36.
Attach certified copies of any articles of dissolution, resolutions, or plans.
Attach to Form 990 or 990-EZ.
Information about Schedule N (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
13
Open to Public
Inspection
Name of the organization
EDWARD JOHN NOBLE HOSPITAL
Employer identification number
23-7204872
Part I
Liquidation, Termination, or Dissolution.
Complete this part if the organization answered "Yes" to Form 990, Part IV, line 31, or Form 990-EZ, line 36.
Part I can be duplicated if additional space is needed.
1
(a)
Description of asset(s)
distributed or transaction
expenses paid
(b)
Date of
distribution
(c)
Fair market value of
asset(s) distributed or
amount of transaction
expenses
(d)
Method of
determining FMV for
asset(s) distributed or
transaction expenses
(e)
EIN of recipient
(f)
Name and address of recipient
(g)
IRC section
of recipient(s) (if
tax-exempt) or type
of entity
Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization?
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2a
b
Become an employee of, or independent contractor for, a successor or transferee organization?
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2b
c
Become a direct or indirect owner of a successor or transferee organization?
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2c
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization's liquidation, termination, or dissolution?
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2d
e
If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or Form 990-EZ.
Cat. No. 50087Z
Schedule N (Form 990 or 990-EZ) (2013)
Page 2
Schedule N (Form 990 or 990-EZ) (2013)
Page
2
Part I
Liquidation, Termination, or Dissolution
(continued)
Note.
If the organization distributed all of its assets during the tax year, then Form 990, Part X, column (B), line 16 (Total assets), and line 26 (Total liabilities), should equal -0-.
Yes
No
3
Did the organization distribute its assets in accordance with its governing instrument(s)? If "No," describe in Part III
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3
4a
Is the organization required to notify the attorney general or other appropriate state official of its intent to dissolve, liquidate, or terminate?
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4a
b
If "Yes," did the organization provide such notice?
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4b
5
Did the organization discharge or pay all of its liabilities in accordance with state laws?
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5
6a
Did the organization have any tax-exempt bonds outstanding during the year?
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6a
b
Did the organization discharge or defease all of its tax-exempt bond liabilities during the tax year in accordance with the Internal Revenue Code and state laws?
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6b
c
If "Yes" to line 6b, describe in Part III how the organization defeased or otherwise settled these liabilities. If "No," explain in Part III.
Part II
Sale, Exchange, Disposition, or Other Transfer of More Than 25% of the Organization's Assets.
Complete this part if the organization answered "Yes" to Form 990, Part IV, line 32, or Form 990-EZ, line 36. Part II can be duplicated if additional space is needed.
1
(a)
Description of asset(s)
distributed or transaction
expenses paid
(b)
Date of
distribution
(c)
Fair market value of
asset(s) distributed or
amount of transaction
expenses
(d)
Method of
determining FMV for
asset(s) distributed or
transaction expenses
(e)
EIN of recipient
(f)
Name and address of recipient
(g)
IRC section
of recipient(s) (if
tax-exempt) or type
of entity
CASH & CASH EQUIVALENTS
12-31-2013
293,822
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
PATIENT ACCOUNTS RECEIVABLE
12-31-2013
1,762,896
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
OTHER RECEIVABLES
12-31-2013
112,418
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
GRANTS RECEIVABLE
12-31-2013
1,202,753
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
INVESTMENTS
12-31-2013
30,286
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
ASSETS LIMITED AS TO USE
12-31-2013
128,414
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
PROPERTY AND EQUIPMENT
12-31-2013
13,268,368
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
OTHER ASSETS
12-31-2013
420,360
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
LONG TERM DEBT
12-31-2013
-5,120,410
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS
12-31-2013
-594,972
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
DUE TO DORMITORY AUTHORITY OF THE STATE OF NEW YORK
12-31-2013
-1,500,000
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
TEMPORARILY RESTRICTED NET ASSETS
12-31-2013
-54,334
46-4249555
GOUVERNEUR HOSPITAL
77 WEST BARNEY STREET
GOUVERNEUR
,
NY
13642
501(C)(3)
Yes
No
2
Did or will any officer, director, trustee, or key employee of the organization:
a
Become a director or trustee of a successor or transferee organization?
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2a
b
Become an employee of, or independent contractor for, a successor or transferee organization?
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2b
c
Become a direct or indirect owner of a successor or transferee organization?
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2c
d
Receive, or become entitled to, compensation or other similar payments as a result of the organization’s significant disposition of assets?
.
.
.
.
.
.
.
2d
e
If the organization answered "Yes" to any of the questions on lines 2a through 2d, provide the name of the person involved and explain in Part III.
Schedule N(Form 990 or 990-EZ) (2013)
Page 3
Schedule N (Form 990 or 990-EZ) (2013)
Page
3
Part III
Supplemental Information.
Provide the information required by Part I, lines 2e and 6c, and Part II, line 2e. Also complete this part to provide any additional information.
Return Reference
Explanation
PART II, LINE 2E:
PERSON(S) INVOLVED: MIKE BURGESSMARK BRACKETTANDREW WILLIAMSNICOLAS GARNER
Schedule N (Form 990 or 990-EZ) (2013)
Additional Data
Software ID:
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