2020-04-13T14:24:32-05:00 2019-05-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-06-01 731719218 MADELIA COMMUNITY HOSPITAL FOUNDATION MADE 5076423255 121 DREW AVENUE SOUTHEAST MADELIA MN 56062 JEFF MENGENHAUSEN MCH CEO 5076423255 2020-04-10 1 RYAN ENGEBRETSON P01585625 6123764500 67.137.57.251 2020-04-10 11:07:53 CD P F7E35B63400230345D2F018ED440CE5992BA784B 2FBEFE20CA9FBCE9975C8DD0893E71CECAC97200 2018 2020-11-06 18:47:13Z JEFF MENGENHAUSEN 121 DREW AVENUE SOUTHEAST MADELIA MN 56062 319265 0 X WWW.MCHOSPITAL.ORG X 2004 MN TO SUPPORT THE MISSION OF MADELIA COMMUNITY HOSPITAL, INCORPORATED. 9 9 0 85 0 0 185301 289324 0 0 8962 15529 -346 3527 193917 308380 121980 146426 0 0 50437 48329 0 0 3703 9274 19351 181691 214106 12226 94274 767663 938768 150718 157853 616945 780915 X MADELIA COMMUNITY HOSPITAL FOUNDATION EXISTS TO BE STEWARDS OF DONATIONS GIVEN TO SUPPORT THE STATE-OF-THE-ART HEALTH SERVICES PROVIDED BY MADELIA COMMUNITY HOSPITAL. THE FOUNDATION, SERVES AS THE BRIDGE BETWEEN MADELIA COMMUNITY HOSPITAL, ITS PATIENTS, AREA FRIENDS AND SUPPORTERS. 0 0 170641 146426 THE MADELIA COMMUNITY HOSPITAL FOUNDATION CONTINUE ITS MISSION: THE FOUNDATION EXISTS TO BE STEWARD OF DONATIONS GIVEN TO SUPPORT THE STATE-OF-THE-ART HEALTH SERVICES PROVIDED BY MADELIA COMMUNITY HOSPITAL & CLINIC. THROUGH THE GENEROSITY OF DONORS AND SPONSORS, THE FOUNDATION SUPPORTED THE HOSPITAL AND SURROUNDING COMMUNITIES, PROMOTING AND IMPROVING HEALTH AND WELLNESS.THE FOUNDATION:- COMPLETED FUNDING THE PURCHASE OF A 3D MAMMOGRAPHY MACHINE. THE TOTAL COST OF THIS EQUIPMENT IS JUST OVER $220,000; FY 2019 FUNDING PROVIDED BY THE FOUNDATION WAS $95,255.- CONTINUED ITS SUPPORT OF HEALTH CARE EDUCATION BY OFFERING MADELIA STUDENT SCHOLARSHIPS FOR GRADUATING SENIORS AND AREA RESIDENTS. THIS YEAR'S RECIPIENTS WERE FAITH BERGEMAN OF MADELIA HIGH SCHOOL AND OLIVIA FLACK OF LAKE CRYSTAL WELLCOME MEMORIAL HIGH SCHOOL (FOUNDATION HEALTHCARE SCHOLARSHIPS) AND MARNE SKARPHOL (YOSHIKO MASTERS MEMORIAL SCHOLARSHIP).THE FOUNDATION HOSTED THREE ANNUAL EVENTS (MAINTENANCE EVENTS):- PROVIDED THE COMMUNITY WITH HIGH QUALITY BELL BICYCLE HELMETS AT SIGNIFICANTLY REDUCED COSTS. THE FOUNDATION PARTNERED WITH THE MADELIA POLICE DEPARTMENT AND MADELIA LANES TO OFFER ICE CREAM CONE COUPONS TO CHILDREN OBSERVED RIDING THEIR BIKES WHILE WEARING A HELMET.- THE 14TH ANNUAL GOLF OUTING AT THE MADELIA GOLF COURSE ATTRACTED 74 GOLFERS AND RAISED NEARLY $10,000 TO SUPPORT THE HOSPITAL & CLINIC.- THE 5K RUN/WALK DREW RUNNERS AND WALKERS FROM SOUTHERN MINNESOTA HELD IN CONJUNCTION WITH MADELIA'S PARK DAYS. ANDERSON RACE MANAGEMENT GENEROUSLY CONTRIBUTED THEIR TIME AND EXPERTISE TO HELP THE 5K RUN /WALK PROMOTE THE ACTIVITIES OF THE FOUNDATION. MORE THAN 100 PARTICIPANTS, AGES 6 - 71, PARTICIPATED.FUNDRAISING:- THE FOUNDATION RECEIVED THE FINAL SETTLEMENT FROM THE ERVIN TANDE ESTATE. THE TOTAL GIFT WAS $340,000 RECEIVED IN FY2018 AND FY2019- THE BIENNIAL GALA CELEBRATED THE HOSPITAL'S CENTENNIAL. 172 INDIVIDUALS ATTENDED AND HELPED RAISE A NET OF $24,750.- MAIL SOLICITATIONS RAISED $6,120.- THE FOUNDATION MADE A TOTAL TRANSFER OF $120,000 TO THE HOSPITAL & CLINIC IN FY 2019. 170641 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 MN X X MONIQUE HOFFMANN-URBAN 5076423255 121 DREW AVENUE SOUTHEAST MADELIA MN 56062 JAMES HOPMAN BOARD PRESIDENT 0.20 X X 0 0 0 DAN GAHLER BOARD TREASURER 0.20 X X 0 0 0 MARGARET KOBEROSKI BOARD SECRETARY 0.20 X X 0 0 0 TOM AMES BOARD MEMBER 0.20 X 0 0 0 AUDRIE HAYCRAFT BOARD MEMBER 0.20 X 0 0 0 COLLEN JACOBS BOARD MEMBER 0.20 X 0 0 0 YURI JELOKOV BOARD MEMBER 0.20 X 0 0 0 ALLIE KIECKER BOARD MEMBER 0.20 X 0 0 0 JOELEEN KRIER BOARD MEMBER 0.20 X 0 0 0 JEFF MENGENHAUSEN MCH CEO 0.20 40.00 X X 0 144475 28449 DENNIS ARDUSER MCH GOVERNING BOARD PRESID 0.20 1.00 X X 0 1800 0 BRUCE TAYLOR EXECUTIVE DIRECTOR 32.00 X 42873 0 1786 MONIQUE HOFFMANN-URBAN MCH CFO 0.20 40.00 X 0 100782 16298 42873 247057 46533 0 0 1 0 0 32992 256332 289324 15529 15529 14412 32992 10885 3527 3527 308380 0 0 19056 146426 146426 43100 21550 21550 1772 886 886 3457 1729 1728 MISCELLANEOUS 19250 15547 3703 MEETINGS & TRAVEL 101 50 51 214106 170641 39762 3703 531714 702819 10853 10853 0 0 235949 235949 767663 938768 150718 157853 150718 157853 X 380996 404966 140000 235949 235949 616945 780915 767663 938768 X 94274 -6731 76427 X X 0 1 X 1 0 X X 1 MADELIA COMMUNITY HOSPITAL INC 410758512 3 1 146426 0 1 146426 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 235949 235949 235949 235949 235949 235949 235949 235949 122717 113232 235949 0.00000 1.00000 0.00000 0 0 10853 10853 0 0 PERMANENTLY RESTRICTED ENDOWMENTS 235949 235949 DUE TO RELATED PARTY 157853 157853 X PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS ARE TO BE PERIODICALLY DETERMINED BY THE FOUNDATION BOARD OF DIRECTORS TO SUPPORT THE PURPOSE OF THE FOUNDATION. PART X, LINE 2: THE FOUNDATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICES AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE FOUNDATION FOLLOWS THE GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. GALA 31167 24750 6417 0 1756 4285 372 GOLF OUTING 13042 8242 4800 766 1340 293 2 3195 3195 2073 47404 32992 14412 766 3096 4578 372 2073 10885 3527 1 MADELIA COMMUNITY HOSPITAL INCORPORATED 121 DREW AVENUE SOUTHEAST MADELIA MN 56062 410758512 501(C)(3) 146426 FUNDS FOR THE PURCHASE OF EQUIPMENT AND SUPPLIES. 0 0 0 0 0 0 0 0 0 JEFF MENGENHAUSEN MCH CEO 0 144475 0 0 0 0 0 0 0 28449 0 172924 0 0 PART I, LINE 3 THE CEO WAS PAID BY MADELIA COMMUNITY HOSPITAL, A RELATED ORGANIZATION. WHEN DETERMINING HIS COMPENSATION THE FOLLOWING METHODS WERE USED: 1. COMPENSATION COMMITTEE 2. WRITTEN EMPLOYMENT CONTRACT 3. COMPENSATION SURVEY OR STUDY 4. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE CHAIRPERSON, THE VICE CHAIRPERSON, THE EXECUTIVE DIRECTOR, THE SECRETARY, AND THE TREASURER AS EX OFFICIO VOTING MEMBERS THEREOF. THE EXECUTIVE COMMITTEE SHALL HAVE AND EXERCISE THE FULL AUTHORITY OF THE BOARD EXCEPT AS OTHERWISE LIMITED BY LAW, BY THE BOARD, OR BY THESE BYLAWS. THE EXECUTIVE COMMITTEE SHALL TRANSACT THE BUSINESS OF THE FOUNDATION DURING THE PERIOD BETWEEN MEETINGS OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE FOUNDATION IS MADELIA COMMUNITY HOSPITAL, INCORPORATED. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER IS ALLOWED TO ELECT MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE BOARD OF DIRECTORS SUBSEQUENT TO FILING THE FORM 990 WITH THE IRS. THE FORM 990 WILL BE PRESENTED BY FINANCE AT THE REGULAR MEETING OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE FOUNDATION'S CONFLICT OF INTEREST POLICY APPLIES TO ALL MEMBERS OF THE BOARD AND CORPORATE OFFICERS, AGENTS AND EMPLOYEES OF THE FOUNDATION. IT IS THE OBLIGATION OF THE FOUNDATION'S MANAGEMENT TO PUBLICIZE THIS POLICY TO ALL SUCH PARTIES ON A RECURRING BASIS. THE CONFLICT OF INTEREST POLICY AND AN ANNUAL DISCLOSURE STATEMENT ARE CIRCULATED TO DIRECTORS AND OFFICERS TO ASSIST THEM IN CONSIDERING SUCH DISCLOSURES, BUT DISCLOSURE IS APPROPRIATE WHENEVER A CONFLICT MAY OCCUR. THE WRITTEN NOTICES OF DISCLOSURE OF CONFLICTS OR DUALITIES OF INTEREST ARE FILED WITH THE EXECUTIVE DIRECTOR OR ANY OTHER OFFICER. IF A CONFLICT OF INTEREST EXISTS, THE CONFLICTED INDIVIDUAL REFRAINS FROM BOTH DISCUSSION AND VOTING ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 MADELIA COMMUNITY HOSPITAL FOUNDATION STAFFING IS FUNDED THROUGH THE MADELIA COMMUNITY HOSPITAL, INC., THAT ENSURES THAT THE COMPENSATION PAID TO ITS EMPLOYEES AND ADMINISTRATIVE STAFF BE CONSISTENT WITH POLICY AND PROVIDE EQUITABLE STANDARDS FOR WAGE AND BENEFITS BASED ON ANNUAL REGIONAL SURVEY OF COMPARABLE ENTITIES. THE GOVERNING BOARD REVIEWS ANNUALLY THE FOUNDATION DIRECTOR'S PERFORMANCE AND THE BASIS IS THE ANNUAL MEDISOTA SALARY SURVEY AND RATE INCREASE AS AWARDED TO ALL STAFF. FORM 990, PART VI, SECTION C, LINE 19 MADELIA COMMUNITY HOSPITAL FOUNDATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC AT THE ANNUAL CORPORATION MEETING AND UPON REQUEST. FORM 990, PART XI, LINE 9: RECONCILIATION FOR DONATION TO RELATED ENTITY 146,426. ROUNDING 1. DONATIONS MADE TO FOUNDATION, BUT WAS TRANSFERRED TO HOSPITAL ALREADY -70,000. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS OF THE FOUNDATION ASSUME RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE MADELIA COMMUNITY HOSPITAL'S BOARD OF DIRECTORS SELECT THE INDEPENDENT ACCOUNTANT DUE TO THE CONSOLIDATED AUDIT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART IX, LINES 5-10 MADELIA COMMUNITY HOSPITAL FOUNDATION DOES NOT HAVE ANY EMPLOYEES. THE SALARY AND BENEFITS EXPENSES ON PAGE 10 OF THE 990 ARE AMOUNTS THAT ARE ALLOCATED TO MADELIA COMMUNITY HOSPITAL FOUNDATION FROM MADELIA COMMUNITY HOSPITAL FOR MADELIA COMMUNITY HOSPITAL FOUNDATION'S PORTION OF THE EXPENSES. MADELIA COMMUNITY HOSPITAL INCORPORATED 121 DREW AVENUE SE MADELIA MN 56062 410758512 HOSPITAL MN 501(C)(3) 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 0 MADELIA COMMUNITY HOSPITAL INCORPORATED B 146426 MARKET VALUE