Community Health Improvement Services and Community Benefit Operations (Part I, line 7e)


NARRATIVE REQUIRED: No

Worksheet 4 (Click here for Worksheet 4 instructions)




(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.

_________%

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