Form Ag-Cbp-I Annual Non Profit Hospital Community Benefits Plan Report (Page 2 of 2) in pdf

REPORT Community Benefits actually provided other than charity care:

See instructions for completing Section 4 of the Annual Non Profit Hospital Community Benefits Plan Report.

Community Benefit Type

Language Assistant Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Government Sponsored Indigent Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Donations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Volunteer Services

a) Employee Volunteer Services . . . . . . . . . . . . . . . . . $____________

b) Non-Employee Volunteer Services . . . . . . . . . . . . . $____________

c) Total (add lines a and b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Government-sponsored program services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $___________

Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Subsidized health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Bad debts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Other Community Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________

Attach a schedule for any additional community benefits not detailed above.

ATTACH Audited Financial Statements for the reporting period.

Under penalty of perjury, I the undersigned declare and certify that I have examined this Annual Non Profit Hospital Community

Benefits Plan Report and the documents attached thereto. I further declare and certify that the Plan and the Annual Non Profit

Hospital Community Benefits Plan Report and the documents attached thereto are true and complete.

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Name / Title (Please Print)

Phone: Area Code / Telephone No.

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Date.

Signature

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