2022-08-09T11:42:32-05:00 2021-12-31 010523282 Berry Dunn McNeil & Parker LLC 1000 Elm Street 4th Floor Manchester NH 03101 990 2021-01-01 200999212 Indian Stream Health Center Inc INDI 6032378336 141 Corliss Lane Colebrook NH 03756 Matthew Streeter CFO 6033265610 2022-08-05 1 Matthew Streeter 999009999 Barbara J McGuan CPA P00219457 6036697337 2022-08-05 0 AAL1 IAL1 2021 2022-09-23 18:48:47Z X Matthew Streeter 141 Corliss Lane Colebrook NH 03756 5675031 0 X www.indianstream.org X 2005 NH To provide excellent preventive, acute, and wellness-focused health care to residents within the organization's service area regardless of patient's ability to pay. We will focus our resources to maximize the quality of life of area residents in a cost-effective and efficient manner. X 9 9 61 10 52330 0 3160613 3217361 2753251 2439756 1557 689 10725 17225 5926146 5675031 0 0 0 0 3722077 2676022 0 0 0 2214790 2810121 5936867 5486143 -10721 188888 2959451 0 1107890 0 1851561 0 X To provide excellent preventive, acute, and wellness-focused health care to residents within the organization's service area regardless of patient's ability to pay. We will focus our resources to maximize the quality of life of area residents in a cost-effective and efficient manner. 0 1 4179836 2456981 Provide primary health care to the residents of the Colebrook, NH region and ensure a transition at the closing of the merger for primary care and pharmacy operations to UCVH and its affiliates. 4179836 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 7 0 1 61 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 0 NH X Matthew Streeter 6033265610 8 Clover Lane Whitefield NH 03598 Gail Fisher President 8.00 X X 0 0 0 Suzanne Phinney Vice President 3.00 X 0 0 0 David Thatcher Treasurer 3.00 X X 0 0 0 Mike Burtnick Secretary 3.00 X X 0 0 0 Myriam Beauchesne Director 1.00 X 0 0 0 Sharon Belleville Director 1.00 X 0 0 0 Margaret Fitzgerald Director 1.00 X 0 0 0 Linda Lomasney Director 1.00 X 0 0 0 Frank Sawicki Director 1.00 X 0 0 0 Amber Dodge Past Director 1.00 X 0 0 0 Sergio Zullich CEO 40.00 X 205647 0 30850 Arthur Nichols Interim CFO 32.00 X 58630 0 190 Jose Zirena Past CFO 40.00 X 90068 0 13810 Greg Culley Past CEO 40.00 X 23239 0 0 377584 0 44850 1 0 1 0 Sheenan Phinney Bass & Green PA 28 State Street 22nd Floor Boston MA 02109 Legal Services 508003 Locums Tenens PO Box 405547 Atlanta GA 303845547 Locums Tenens Providers 270048 EHRlang LLC 70 Saint Nicholas Ave Worcester MA 01606 IT Service Desk, Admin, and Application 161280 Barton Associates Inc PO Box 417844 Boston MA 022417844 Locums Tenens Providers 119981 4 3217361 3217361 Pharmacy Revenue 624100 1332625 1280295 52330 Net Patient Service Re 624100 966297 966297 Nursing Services 624100 140834 140834 2439756 689 689 Other Income 900099 17225 17225 17225 5675031 2404651 52330 689 X 422734 422734 1899853 1822190 77663 35569 34522 1047 153205 152377 828 164661 131729 32932 499832 499832 30316 30316 780666 667872 112794 15516 12412 3104 39703 31763 7940 71642 57314 14328 172125 137700 34425 7231 5785 1446 15509 12407 3102 214435 171548 42887 46720 37376 9344 Pharmacy Costs 858498 858498 Other Expenses 57928 46343 11585 5486143 4179836 1306307 0 170606 0 251561 0 56653 0 245071 0 0 0 0 107672 0 51688 0 0 0 2076200 0 0 0 0 0 0 2959451 0 245512 0 34086 0 656598 0 171694 0 1107890 0 X 1851561 0 1851561 0 2959451 0 X 188888 -2040449 X X 0 1 X 1 1 1 X 2266573 2030828 2371856 3160613 3217361 13047231 4386429 3912820 3719613 2692451 2387426 17098739 6653002 5943648 6091469 5853064 5604787 30145970 0 0 0 30145970 1706 980 9150 10632 689 23157 1706 980 9150 10632 689 23157 126175 48377 62450 0 237002 71870 85844 14015 17225 188954 6726578 6156647 6163011 5926146 5622701 30595083 0.98530 0.98400 0.00080 0.00080 X Schedule A, Part III, Line 12, Explanation of Other Income: Other Income - 2017 Amount: $ 71,870. 2018 Amount: $ 85,844. 2019 Amount: $ 14,015. 2021 Amount: $ 17,225. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 5675031 0 5675031 0 5675031 5486143 0 5486143 0 5486143 Part X, Line 2: The Organization is a public charity under Section 501(c)(3) of the Internal Revenue Code (Code). As a public charity, the Organization is exempt from state and federal income taxes on income earned in accordance with its tax-exempt purpose. Unrelated business income is subject to state and federal income tax. Management has evaluated the Organization's tax positions and concluded that the Organization has no unrelated business income or uncertain tax positions that require adjustment to the financial statements. X X X X 0 0 0 0 0 0 0 1 0 Sergio Zullich CEO 172591 0 20000 0 13056 0 5173 0 25677 0 236497 0 0 0 Part I, Line 7 Due to the vacancy in the CEO position in February 2021 and the expected merger of Indian Stream Health Center near the end of 2021, Sergio Zullich, Pharmacy Director, was appointed to assume the CEO role, continuing to serve in a leadership role in the pharmacy. Mr. Zullich's CEO agreement provided he would be paid $15,000 and $5,000 bonuses upon completion of a specified number of months in his CEO role. He was paid those bonuses upon completion of the required months of serving in the CEO role. Cash & Cash Equivalents 2021-12-31 921913 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Grants receivable 2021-12-31 25892 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Patients Accounts Receivable 2021-12-31 640076 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Inventory - Pharmacy 2021-12-31 128769 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Prepaid Expenses 2021-12-31 84863 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Land 2021-12-31 60000 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Building, net of accumluated depreciation 2021-12-31 1355772 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Building Improvements, net of accumulated depreciation 2021-12-31 50774 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Leasehold Improvements, net of accumulated depreciation 2021-12-31 165402 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Furniture & Fixtures, net of accumulated depreciation 2021-12-31 11578 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Computers & Equipment, net of accumulated depreciation 2021-12-31 218875 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Accounts payable and accrued expenses assumed 2021-12-31 -135133 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Deferred revenue and refundable advances assumed 2021-12-31 -798736 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 Long-term debt assumed 2021-12-31 -689596 Value at time of sale 020276210 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 501(c)3 1 0 0 0 1 1 1 0 0 Part I, Line 2e: Person(s) Involved: David Thatcher and Gail Fisher both became Directors on the UCVH Board of Directors. Form 990, Part III, line 3 On December 31, 2021, the Organization merged with and into Upper Connecticut Valley Hospital Association, Inc. (UCVH), upon which time the separate corporate existence of the Organization ceased and UCVH continued its corporate existence as the surviving corporation, with all of the estate, assets, property, rights, privileges, immunities, powers and franchises of the Organization vesting in UCVH as the surviving corporation, all pursuant to an Agreement and Plan of Merger agreed to by both parties and approved by the State of New Hampshire Department of Justice, Charitable Trust Unit. Form 990, Part VI, Section B, line 11b The form 990 has historically been reviewed by the finance committee before filing. Because Indian Stream Health Center (ISHC) was acquired by Upper Connecticut Valley Hospital (UCVH) and ceased operations on 12/31/21, the 2021 form 990 will be reviewed by the Interim Financial Analyst and Interim CFO of ISHC in place at ISHC as of 12/31/21 and by the CFO of North Country Health (parent organization of acquiring organization UCVH). The Form will be provided to the entire UCVH Board prior to filing. Form 990, Part VI, Section B, line 12c Indian Stream Health Center Inc. requires their board members to annually sign a form stating what other organizations they were involved in. The board members are not allowed to vote on issues if they pertain to another organization the board member is involved with. Form 990, Part VI, Section B, line 15 Historically, the Board of Directors of Indian Stream Health Center, Inc. checked salary information from other FQHCs and review the Form 990s of the other nonprofits to obtain comparability information for the officers' salaries. The organization also participated in NACHC's salary survey. Because of the expected merger of ISHC into UCVH at year end, no new comparative surveys were conducted in 2021. Form 990, Part VI, Section C, line 19 Organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. Form 990, Part IX, line 11g Other professional fees: Program service expenses 667,872. Management and general expenses 112,794. Fundraising expenses 0. Total expenses 780,666. Form 990, Part XI, line 9: Net Asset transfer to Upper Connecticut Valley Hospital -2,040,449. Form 990, Part XII, line 2c The health center has not changed its oversight process for the audit of its financial statements or its selection process of its independent accountant during the year, except that final audited financial statements were presented to the acquiring organization's (UCVH) board of directors.