2018-11-28T11:42:56-06:00 2018-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-07-01 810247705 CMC MISSOULA INC CMCM 4067284100 PO BOX 4091 MISSOULA MT 59806 JAN PARKS VICE CHAIR 4067284100 2018-11-26 1 KACIE MCEWEN P01599614 6123764500 67.137.57.251 2018-11-26 08:58:01 CS P D58F7A891376973A2C688259087F0D91BA8942CB 648BA5686E5CDD146CA310A02774B929465828AB 2017 2019-02-21 02:37:17Z SCOTT HACKER PO BOX 4091 MISSOULA MT 59806 1270193 0 X WWW.CMC-INC-MISSOULA.ORG 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 9013975 614326 1046476 644391 10060451 1258717 0 12567508 0 0 16000 12000 0 0 0 404749 160202 420749 12739710 9639702 -11480993 22880729 10569152 1381595 1076869 21499134 9492283 TO PERFORM POST-CLOSING DUTIES AND OBLIGATIONS UNDER THE TERMS OF THE ASSET PURCHASE AGREEMENT. 0 0 12739710 12567508 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. DURING FISCAL YEAR ENDING JUNE 30, 2017, CMC MISSOULA, INC. DONATED $99,242,241 TO HEADWATERS HEALTH FOUNDATION OF WESTERN MONTANA. 12739710 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 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 4065417160 619 SW HIGGINS AVENUE N MISSOULA MT 59803 SCOTT HACKER BOARD CHAIR 1.50 X X 3000 0 0 JAN PARKS VICE CHAIR 1.50 X X 3000 0 0 BILL JOHNSTON SECRETARY 1.50 X X 3000 0 0 TANYA ASK BOARD MEMBER 1.50 X 3000 0 0 12000 0 0 0 0 0 0 0 625802 625802 11476 -11476 -11476 -11476 MISCELLANEOUS REVENUE 900099 644391 644391 644391 1258717 0 0 1258717 12567508 12567508 12000 12000 8270 8270 17570 17570 95247 95247 5704 5704 362 362 128 128 160 160 750 750 21160 21160 SETTLEMENT EXPENSE 10851 10851 12739710 12739710 0 0 399389 565358 8275758 158271 2396626 1917300 11778570 7897837 30386 30386 22880729 10569152 820 1955 88369 55508 1292406 1019406 1381595 1076869 X 21499134 9492283 21499134 9492283 22880729 10569152 -11480993 -525858 0 X 0 0 0 X 374123 190927 565050 165940075 107360251 273300326 166314198 107551178 273865376 0 0 0 273865376 888215 653375 1635497 1497139 625802 5300028 888215 653375 1635497 1497139 625802 5300028 9766995 4082686 4519828 1046476 644391 20060376 176969408 112287239 6155325 2543615 1270193 299225780 0.91520 0.92750 0.01770 0.01270 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME - 2013 AMOUNT: $ 9,766,995. 2014 AMOUNT: $ 4,082,686. 2015 AMOUNT: $ 4,519,828. 2016 AMOUNT: $ 1,046,476. 2017 AMOUNT: $ 644,391. 0 THIRD PARTY PAYABLE 1019406 1019406 0 HEADWATERS HEALTH FOUNDATION OF WESTERN MONTANA PO BOX 7964 MISSOULA MT 59807 811099715 501(C)(3) 12567508 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 WILL BE 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.