CLARK FORK VALLEY HOSPITAL FOUNDATION INC: Form 990EZ, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- CLARK FORK VALLEY HOSPITAL FOUNDATION INC (EIN 81-0304386)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-05-11
- IRS object ID
- 202221319349202147
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-05-11T12:33:23-05:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 810497523 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JORDAHL & SLITER PLLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 8600 | AddressLine1Txt |
| City | KALISPELL | CityNm |
| State Abbreviation | MT | StateAbbreviationCd |
| ZIP | 599041600 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990EZ | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 810304386 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLARK FORK VALLEY HOSPITAL FOUNDATION | BusinessNameLine1Txt |
| Business Name Line2 | INC | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CLAR | BusinessNameControlTxt |
| Phone | 4068264858 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 768 | AddressLine1Txt |
| City | PLAINS | CityNm |
| State Abbreviation | MT | StateAbbreviationCd |
| ZIP | 59859 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | STEVE SEILHYMER | PersonNm |
| Person Title | PRESIDENT | PersonTitleTxt |
| Phone | 6129862041 | PhoneNum |
| Signature | 2022-04-29 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | STEVE | PersonFirstNm |
| Person Last | SEILHYMER | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | JUSTIN P SLITER | PreparerPersonNm |
| PTIN | P00188996 | PTIN |
| Phone | 4067521040 | PhoneNum |
| Preparation | 2022-04-29 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990-EZ IRS990EZ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Website Address | N/A | WebsiteAddressTxt |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Gross Receipts | $40,483 | GrossReceiptsAmt |
| Info In Schedule O Part I | Yes (X) | InfoInScheduleOPartIInd |
| Contributions Gifts Grants Etc | $28,838 | ContributionsGiftsGrantsEtcAmt |
| Investment Income | $5,172 | InvestmentIncomeAmt |
| Sale Of Assets Gross | $18 | SaleOfAssetsGrossAmt |
| Cost Or Other Basis Expense Sale | $13 | CostOrOtherBasisExpenseSaleAmt |
| Gain Or Loss From Sale Of Assets | $5 | GainOrLossFromSaleOfAssetsAmt |
| Fundraising Gross Income | $6,455 | FundraisingGrossIncomeAmt |
| Special Events Direct Expenses | $915 | SpecialEventsDirectExpensesAmt |
| Special Events Net Income Loss | $5,540 | SpecialEventsNetIncomeLossAmt |
| Total Revenue | $39,555 | TotalRevenueAmt |
| Grants And Similar Amounts Paid | $19,000 | GrantsAndSimilarAmountsPaidAmt |
| Fees And Other Pymt To Ind Cntrct | $1,961 | FeesAndOtherPymtToIndCntrctAmt |
| Printing Publications Postage | $775 | PrintingPublicationsPostageAmt |
| Other Expenses Total | $1,011 | OtherExpensesTotalAmt |
| Total Expenses | $22,747 | TotalExpensesAmt |
| Excess Or Deficit For Year | $16,808 | ExcessOrDeficitForYearAmt |
| Net Assets Or Fund Balances BOY | $155,742 | NetAssetsOrFundBalancesBOYAmt |
| Other Changes In Net Assets | $8,993 | OtherChangesInNetAssetsAmt |
| Net Assets Or Fund Balances EOY | $181,543 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part II | Yes (X) | InfoInScheduleOPartIIInd |
Cash Savings And Investments CashSavingsAndInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $32,460 | BOYAmt |
| EOY | $47,256 | EOYAmt |
Other Assets Total Detail OtherAssetsTotalDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $123,282 | BOYAmt |
| EOY | $134,287 | EOYAmt |
Form990 Total Assets Form990TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $155,742 | BOYAmt |
| EOY | $181,543 | EOYAmt |
Sum Of Total Liabilities SumOfTotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Net Assets Or Fund Balances NetAssetsOrFundBalancesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $155,742 | BOYAmt |
| EOY | $181,543 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Primary Exempt Purpose | THE FOUNDATION IS A SOLE SUPPORT ORGANIZATION TOTALLY COMMITTED TO SUPPORTING THE FUNCTION AND PURPOSE OF CLARK FORK VALLEY HOSPITAL. | PrimaryExemptPurposeTxt |
Program Srvc Accomplishment ProgramSrvcAccomplishmentGrp (4 entries)
| Description Program Srvc AccomDescriptionProgramSrvcAccomTxt | Grants And AllocationsGrantsAndAllocationsAmt | Program Service ExpensesProgramServiceExpensesAmt |
|---|---|---|
| RAISING AWARENESS OF THE HOSPITAL, ITS FUNCTION, AND THE IMPACT OF RURAL HEALTHCARE WITHIN THE COMMUNITY AND GENERATING PHILANTHROPIC SUPPORT FROM THE COMMUNITY. | $0 | $0 |
| PROVIDING FINANCIAL SUPPORT TO CLARK FORK VALLEY HOSPITAL. | $19,000 | $0 |
| COMMUNICATING AND ASSISTING IN VARIOUS PROGRAMS THROUGHOUT THE HOSPITAL. | $0 | $0 |
| ASSISTING IN THE ACKNOWLEDGEMENT AND OVERSIGHT OF VOLUNTEERISM AT THE HOSPITAL. | $0 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $0 | TotalProgramServiceExpensesAmt |
Officer Director Trustee Empl OfficerDirectorTrusteeEmplGrp (5 entries)
| TitleTitleTxt | Average Hrs Per Wk Devoted To PosAverageHrsPerWkDevotedToPosRt | CompensationCompensationAmt | Employee Benefit ProgramEmployeeBenefitProgramAmt | Expense Account Other AllwncExpenseAccountOtherAllwncAmt |
|---|---|---|---|---|
| STEVE SEILHYMER | ||||
| PRESIDENT | 0.25 | $0 | $0 | $0 |
| STEVE EBERHARDT | ||||
| SECRETARY-TREASURER | 0.25 | $0 | $0 | $0 |
| JANICE BLAKE | ||||
| DIRECTOR | 0.25 | $0 | $0 | $0 |
| DACY HOLLAND | ||||
| DIRECTOR | 0.25 | $0 | $0 | $0 |
| KAY NYGAARD | ||||
| DIRECTOR | 0.25 | $0 | $0 | $0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part V | Yes (X) | InfoInScheduleOPartVInd |
| Activities Not Previously Rpt | 0 | ActivitiesNotPreviouslyRptInd |
| Chg Made To Orgnzng Doc Not Rpt | 0 | ChgMadeToOrgnzngDocNotRptInd |
| Organization Had UBI | 0 | OrganizationHadUBIInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Organization Dissolved Etc | 0 | OrganizationDissolvedEtcInd |
| Direct Indirect Pltcl Expend | $0 | DirectIndirectPltclExpendAmt |
| Made Loans To From Officers | 0 | MadeLoansToFromOfficersInd |
| Tax Imposed Under IRC4911 | $0 | TaxImposedUnderIRC4911Amt |
| Tax Imposed Under IRC4912 | $0 | TaxImposedUnderIRC4912Amt |
| Tax Imposed Under IRC4955 | $0 | TaxImposedUnderIRC4955Amt |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| Tax Imposed On Organization Mgr | $0 | TaxImposedOnOrganizationMgrAmt |
| Tax Reimbursed By Organization | $0 | TaxReimbursedByOrganizationAmt |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THE ORGANIZATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 768 | AddressLine1Txt |
| City | PLAINS | CityNm |
| State Abbreviation | MT | StateAbbreviationCd |
| ZIP | 59859 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 4068264858 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Donor Advised Fnds | 0 | DonorAdvisedFndsInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Tanning Services Provided | 0 | TanningServicesProvidedInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| School Operating | 0 | SchoolOperatingInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Part VI Of Comp Of Hghst Pd Empl | NONE | PartVIOfCompOfHghstPdEmplTxt |
| Part VI Hghst Pd Cntrct Prof Srvc | NONE | PartVIHghstPdCntrctProfSrvcTxt |
| Filed Schedule A | Yes (1) | FiledScheduleAInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | Yes (X) | SupportingOrganization509a3Ind |
| Supporting Org Type1 | Yes (X) | SupportingOrgType1Ind |
| Supported Organizations | 1 | SupportedOrganizationsCnt |
Supported Org Information SupportedOrgInformationGrp
Supported Organization Name SupportedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLARK FORK VALLEY HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 810475376 | EIN |
| Organization Type | 3 | OrganizationTypeCd |
| Governing Document Listed | Yes (1) | GoverningDocumentListedInd |
| Support | $19,000 | SupportAmt |
| Other Support | $0 | OtherSupportAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supported Organizations Total | 1 | SupportedOrganizationsTotalCnt |
| Support Sum | $19,000 | SupportSumAmt |
| Other Support Sum | $0 | OtherSupportSumAmt |
Form990 Sch A Supporting Org Form990SchASupportingOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Listed By Name Governing Doc | Yes (1) | ListedByNameGoverningDocInd |
| Suprt Org No IRS Determination | 0 | SuprtOrgNoIRSDeterminationInd |
| Supported Org Section C456 | 0 | SupportedOrgSectionC456Ind |
| Supported Org Not Organized US | 0 | SupportedOrgNotOrganizedUSInd |
| Organization Change Suprt Org | 0 | OrganizationChangeSuprtOrgInd |
| Support Non Supported Org | 0 | SupportNonSupportedOrgInd |
| Payment Substantial Contribtr | 0 | PaymentSubstantialContribtrInd |
| Loan Disqualified Person | 0 | LoanDisqualifiedPersonInd |
| Controlled Disqualified Prsn | 0 | ControlledDisqualifiedPrsnInd |
| Disqualified Prsn Controll Int | 0 | DisqualifiedPrsnControllIntInd |
| Disqualified Prsn Ownr Int | 0 | DisqualifiedPrsnOwnrIntInd |
| Excess Business Holdings Rules | 0 | ExcessBusinessHoldingsRulesInd |
| Contribution Controller | 0 | ContributionControllerInd |
| Contribution Family | 0 | ContributionFamilyInd |
| Contribution35 Controlled | 0 | Contribution35ControlledInd |
Form990 Sch A Type1 Suprt Org Form990SchAType1SuprtOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Power Appoint Majority Dir Trst | Yes (1) | PowerAppointMajorityDirTrstInd |
| Operate Benefit Non Suprt Org | 0 | OperateBenefitNonSuprtOrgInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990-EZ, PART I, LINE 4 - OTHER INVESTMENT INCOME | DESCRIPTION: INTEREST INCOME. AMOUNT: 903. DESCRIPTION: DIVIDEND INCOME. AMOUNT: 4,269. TOTAL INCLUDED ON FORM 990-EZ, LINE 4: 5,172. |
| FORM 990-EZ, PART I, LINE 10 - GRANTS AND SIMILAR AMOUNTS PAID | ACTIVITY CLASSIFICATION: EQUIPMENT PURCHASE. GRANTEE NAME: CLARK FORK VALLEY HOSPITAL. GRANTEE ADDRESS: 10 KRUGER ROAD PLAINS, MT 59859. GRANTEE RELATIONSHIP: SUPPORTED ORGANIZATION. DATE OF GIFT: 11/17/21. AMOUNT GIVEN: 19,000. |
| FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES | DESCRIPTION: MEMBERSHIPS AND DUES. AMOUNT: 160. DESCRIPTION: BANK FEES. AMOUNT: 851. TOTAL TO FORM 990-EZ, LINE 16: 1,011. |
| FORM 990-EZ, PART I, LINE 20 - OTHER CHANGES IN NET ASSETS | DESCRIPTION: UNREALIZED GAIN ON INVESTMENTS. AMOUNT: 8,993. |
| FORM 990-EZ, PART II, LINE 24 - OTHER ASSETS | DESCRIPTION: INVESTMENTS. BEG. OF YEAR AMOUNT: 123,282. END OF YEAR AMOUNT: 134,287. |
Transfer Prsnl Bnft Contracts Decl TransferPrsnlBnftContractsDecl
| Field | Value | IRS element (for citing) |
|---|---|---|
| Declaration | THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT. | DeclarationDesc |