|
|
|
(A) Total community benefit expenses |
(B) Direct offsetting revenue |
(C) Net community benefit expense (subtract col. (B) from col. (A) from lines 1-5) |
| 1. Community Health Improvement Services |
| a. |
_______________________________________________________ |
1a. |
___________ |
___________ |
___________ |
| b. |
_______________________________________________________ |
1b. |
___________ |
___________ |
___________ |
| c. |
_______________________________________________________ |
1c. |
___________ |
___________ |
___________ |
| d. |
_______________________________________________________ |
1d. |
___________ |
___________ |
___________ |
| e. |
_______________________________________________________ |
1e. |
___________ |
___________ |
___________ |
| f. |
_______________________________________________________ |
1f. |
___________ |
___________ |
___________ |
| g. |
_______________________________________________________ |
1g. |
___________ |
___________ |
___________ |
| h. |
_______________________________________________________ |
1h. |
___________ |
___________ |
___________ |
| i. |
_______________________________________________________ |
1i. |
___________ |
___________ |
___________ |
| j. |
_______________________________________________________ |
1j. |
___________ |
___________ |
___________ |
| 2. Worksheet subtotal (add lines 1a through 1j) |
2. |
___________ |
___________ |
___________ |
| 3. Community Benefit Operations |
| a. |
_______________________________________________________ |
3a. |
___________ |
___________ |
___________ |
| b. |
_______________________________________________________ |
3b. |
___________ |
___________ |
___________ |
| c. |
_______________________________________________________ |
3c. |
___________ |
___________ |
___________ |
| d. |
_______________________________________________________ |
3d. |
___________ |
___________ |
___________ |
| 4. Worksheet subtotal (add lines 3a through 3d) |
4. |
___________ |
___________ |
___________ |
| 5. Worksheet total (add lines 2 and 4; enter amounts from columns (A), (B), and (C) on Part I, line 7e, columns (c), (d), and (e), respectively) |
5. |
___________ |
___________ |
___________ |
| 6. Total expense (enter amount from Form 990, Part IX, Line 25, column (A) and include the organization's share of joint venture expenses) |
6. |
|
|
___________ |
| 7. Percent of total expense (line 5, column (C) divided by line 6; enter amount on Part I, line 7e, column (f)) |
7. |
|
|
_________% |
