2021-05-14T12:49:37-05:00 2020-06-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2019-07-01 810247705 CMC MISSOULA INC CMCM 4067284100 PO BOX 4091 MISSOULA MT 59806 SCOTT HACKER BOARD CHAIR 4067284100 2021-05-14 1 ROBERT E SCHILE P00369682 6123764500 2021-05-14 2019 2022-09-23 18:48:47Z SCOTT HACKER PO BOX 4091 MISSOULA MT 59806 4096422 0 X N/A X 1948 MT TO PERFORM POST-CLOSING DUTIES AND OBLIGATIONS UNDER THE TERMS OF THE ASSET PURCHASE AGREEMENT. 4 4 0 0 0 0 0 0 0 0 232131 248581 1682576 52515 1914707 301096 0 500000 0 0 20000 16000 0 0 0 2450181 323150 2470181 839150 -555474 -538054 12228217 9720154 3103788 1023888 9124429 8696266 TO PERFORM POST-CLOSING DUTIES AND OBLIGATIONS UNDER THE TERMS OF THE ASSET PURCHASE AGREEMENT. 0 0 839150 500000 0 ACTIVITIES IN THE PERIOD SINCE THE SALE OF HOSPITAL OPERATIONS TO REGIONALCARE HOSPITAL PARTNERS IN JANUARY 2015 INCLUDE EXECUTING POST-SALE RESPONSIBILITIES IN ACCORDANCE WITH THE ASSET PURCHASE AND MONITORING AGREEMENTS. 839150 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 16 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 4 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 0 0 0 0 0 X JAN K PARKS CPA 4062400344 PO BOX 1629 MISSOULA MT 59806 SCOTT HACKER BOARD CHAIR 1.50 X X 4000 0 0 JAN PARKS VICE CHAIR 1.50 X X 4000 0 0 BILL JOHNSTON SECRETARY 1.50 X X 4000 0 0 TANYA ASK BOARD MEMBER 1.50 X 4000 0 0 16000 0 0 0 0 0 0 GARLINGTON LOHN & ROBINSON 350 RYMAN STREET MISSOULA MT 59802 LEGAL SERVICES 133287 1 304951 304951 3738956 3795326 -56370 -56370 -56370 MOUNTAIN STATE HEALTH SETTLEMENT 900099 52515 52515 52515 301096 0 0 301096 500000 500000 16000 16000 164474 164474 22308 22308 33104 33104 24198 24198 369 369 2 2 84 84 21841 21841 SETTLEMENT EXPENSE 56770 56770 839150 839150 0 0 754496 678601 313675 731187 1582912 52517 1437975 958650 8108773 7268813 30386 30386 12228217 9720154 57562 4888 22316 3023910 1019000 3103788 1023888 X 9124429 8696266 9124429 8696266 12228217 9720154 -538054 109891 0 X 0 0 0 X 0 1635497 1497139 625802 342621 304951 4406010 1635497 1497139 625802 342621 304951 4406010 4519828 1046476 644391 1682576 52515 7945786 6155325 2543615 1270193 2025197 357466 12351796 0.00000 0.86540 0.35670 0.03830 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME - 2015 AMOUNT: $ 4,519,828. 2016 AMOUNT: $ 1,046,476. 2017 AMOUNT: $ 644,391. 2018 AMOUNT: $ 1,682,576. 2019 AMOUNT: $ 52,515. 0 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1019000 1019000 0 HEADWATERS HEALTH FOUNDATION OF WESTERN MONTANA PO BOX 7964 MISSOULA MT 59807 811099715 501 (C) (3) 500000 0 TO TRANSFER ASSETS IN EXECUTION OF POST SALE RESPONSIBILITIES IN ACCORDANCE WITH THE ASSET PURCHASE AND MONITORING AGREEMENTS. 1 0 FORM 990, PART VI, SECTION A, LINE 7B THE RESTATED ARTICLES OF INCORPORATION AND/OR THE RESTATED BYLAWS MAY BE AMENDED BY A SUPERMAJORITY VOTE OF THE BOARD OF DIRECTORS, BUT ONLY WITH THE APPROVAL OF THE MONTANA ATTORNEY GENERAL AS REQUIRED UNDER THE TERMS OF THE ORGANIZATION'S AGREEMENT DATED JANUARY 9, 2015, WITH THE ATTORNEY GENERAL, WHICH APPROVAL IS REQUIRED FOR TEN (10) YEARS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 AND RELATED SCHEDULES WAS GIVEN TO THE BOARD OF DIRECTORS FOR REVIEW AND APPROVAL PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE BOARD IS REQUIRED TO COMPLETE AND SIGN A CONFLICT OF INTEREST FORM THAT SPECIFICALLY ASKS ABOUT OUTSIDE INTERESTS, OUTSIDE ACTIVITIES, GIFTS, GRATUITIES, AND ENTERTAINMENT, AND INSIDE INFORMATION AND OTHER INTEREST. ON THIS SAME FORM, BOARD MEMBERS MUST ALSO CERTIFY THAT THEY HAVE A CONTINUING RESPONSIBILITY TO OBSERVE AND APPLY THE PROVISIONS OF THE POLICY. THIS CERTIFICATION REQUIRES THAT THEY UPDATE THEIR CONFLICT OF INTEREST FORM SHOULD ANY NEW CONFLICTS DEVELOP. ANY BOARD MEMBER WITH A CONFLICT OF INTEREST MAY NOT VOTE, INFLUENCE, OR PARTICIPATE IN ANY WAY ON ANY MATTER THAT THEY, OR THEIR RELATIVES, HAVE A SUBSTANTIAL INTEREST. THE ANNUAL CONFLICT OF INTEREST FORMS ARE MONITORED BY THE BOARD CHAIR. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST.