2013-02-15T10:48:29-06:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 420680407 GREAT RIVER MEDICAL CENTER GREA 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 TODD SLADKY 3197681000 2013-02-15 1 KOREY L BOELTER P00775161 6123764500 2011 2016-02-25 16:41:14Z MARK RICHARDSON 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 172262744 0 X WWW.GREATRIVERMEDICAL.ORG X 1895 IA IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY HEALTH CARE. 13 12 1730 437 471812 -29900 9137222 958666 160733018 171863980 684667 600055 399942 -1252695 170954849 172170006 3990000 4237225 0 0 82773616 80877822 0 0 85282 73068872 74896042 159832488 160011089 11122361 12158917 308090680 347121271 83059070 105853530 225031610 241267741 X GREAT RIVER MEDICAL CENTER IS DEDICATED TO IMPROVING THE REGION'S HEALTH BY PROVIDING HIGH-QUALITY CARE, WORLD-CLASS CUSTOMER SERVICE, AND UNCOMPROMISING VALUE FOR OUR PATIENTS AND THEIR FAMILIES. 0 0 155320687 4237225 171863980 THE 213-BED ACUTE AND 143-BED LONG-TERM CARE HOSPITAL HAD 7,982 PATIENT ADMISSIONS AND 69,508 PATIENT DAYS OF MEDICAL CARE. IN ADDITION, NUMEROUS OUTPATIENT AND EMERGENCY ROOM PROCEDURES WERE PERFORMED. GREAT RIVER MEDICAL CENTER HAS ACCEPTED PAYMENT FROM MEDICARE AND MEDICAID REDUCING THE MEDICAL BILLS FOR AREA RESIDENTS BY $131,175,694. COMMUNITY BENEFIT INFORMATION: SCHOOL PARTNERING: $4,339COMMUNITY EDUCATION: $210COMMUNITY INITIATIVE PARTICIPATION: $15,253SCREENING/FIRST AID: $6,711PRENATAL EDUCTION: $15,960HEALTH FAIRS: $6,428SUPPORT GROUPS: $493COMMUNITY LIBRARY: $29,450CASH DONATIONS: $4,237,225TOTAL: $316,069 155320687 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 91 0 1730 1 1 1 0 0 0 0 0 0 0 0 0 X 13 12 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X CHRISTINE DES JARDINS 3197681000 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 X KENNETH ASPELMEIER 1.00 X 0 0 0 KENT GAUDIAN 1.00 X X 0 0 0 MICHAEL MCCOY MD 1.00 X 0 0 0 LORRIN DEBLICK 1.00 X 0 0 0 DENNIS HINKLE 1.00 X 0 0 0 JACK HOBBS 1.00 X 0 0 0 JAN TOWNE 1.00 X 0 0 0 JO ELLEN HOTH MD 1.00 X 0 0 0 ROBERT MCCULLEY 1.00 X X 0 0 0 MARK RICHARDSON 1.00 X X 0 931563 43690 DAN WIEDEMEIER 1.00 X X 0 0 0 ROBERT FLEMING 1.00 X 0 0 0 WILLIAMS DAWS MD 1.00 X 0 0 0 TONY HAYES 1.00 X 0 464067 41120 TODD SLADKY 1.00 X 0 424267 41677 DARWIN COOLEY 40.00 X 162650 0 30203 JON WILLIAMS 40.00 X 126780 0 23796 GAIL BOYD 40.00 X 128655 0 18541 JOHN MERCER III 40.00 X 134130 0 29226 TED SMITH 40.00 X 123478 0 19798 675693 1819897 248051 29 0 1 0 CARL A NELSON CO 1815 DES MOINES AVE BURLINGTON IA 52601 BUILDING CONSTRUCTION 18189785 SOUTHEASTERN IOWA MEDICAL SERVICES INC 1221 S GEAR AVE WEST BURLINGTON IA 52655 PHYSICIANS 3613749 MUTUAL CONSULTING & MANAGEMENT SERVICES 1221 S GEAR AVE WEST BURLINGTON IA 52655 EXECUTIVE MANAGEMENT 2969136 HORTY ELVING & ASSOCIATES 505 EAST GRANT STREET MINNEAPOLIS MN 55404 ARCHITECTURE 888099 EXECUTIVE HEALTH RESOURCES INC 15 CAMPUS BLVD SUITE 200 NEWTOWN SQUARE PA 19073 PHYSICIAN ADVISORS 354859 7 958666 958666 PATIENT SERVICE INCOME 621110 166945627 166945627 OTHER OPERATING INCOME 621300 4918353 4446541 471812 171863980 614471 614471 98897 66448 32449 32449 32449 11874 26290 -14416 -14416 -14416 MISCELLANEOUS INCOME 900099 94085 94085 LOSS ON BOND REFINANCE 900099 -1379229 -1379229 -1285144 172170006 171392168 471812 -652640 4237225 4237225 1555394 1555394 61592482 61433498 109142 49842 2770559 2763988 4145 2426 10410699 10376211 22547 11941 4548688 4537542 7767 3379 1413742 1413742 46725 10200 36525 87400 87400 13352372 12984064 354377 13931 19011335 18997422 12504 1409 707802 575835 131967 297382 291113 5469 800 2896609 2896609 11888677 11729839 158838 1698774 1087439 611335 BAD DEBT 9731455 9731455 DRUGS 8217908 8217908 OTHER EXPENSES 3979622 3899215 80090 317 FOOD 1566239 1551124 13878 1237 160011089 155320687 4605120 85282 6873726 17874399 19145274 19406050 673087 519733 2770752 2509787 1660000 1666347 289196472 144807724 127836228 144388748 147816225 159894789 1315388 861418 308090680 347121271 6347512 10775232 62315273 79123333 14396285 15954965 83059070 105853530 X 220583863 236853104 3202523 3250655 1245224 1163982 225031610 241267741 308090680 347121271 X 12158917 4077214 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 30646 30646 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: GREAT RIVER MEDICAL CENTER PAID DUES TO THE AMERICAN HOSPITAL ASSOCIATION AND THE IOWA HOSPITAL ASSOCIATION. THESE ASSOCIATIONS PARTICIPATE IN LOBBYING ACTIVITIES RELATED TO HEALTHCARE. 5159725 5159725 97932705 30826427 67106278 9549238 4692053 4857185 151472059 109289244 42182815 25082745 25082745 144388748 152441343 F CASH AND SHORT-TERM INVESTMENTS 2001773 F INSURANCE COMPANY ANNUITY DEPOSITS 5451673 F 159894789 DEFERRED COMPENSATION LIABILITY 1034032 THIRD PARTY PAYABLE 1557463 PTO RESERVE 7039315 FAIR VALUE OF CASH FLOW HEDGING SWAP 6191655 PLEDGES LIABILITY 132500 15954965 1 1 X 1 X 1 X 0.0 1 1 1 0 1 1 3489419 3489419 0.02320 18073727 18121781 -48054 0.00000 21563146 18121781 3441365 0.02320 78844 78844 0.00050 4237225 4237225 0.02820 4316069 4316069 0.02870 25879215 18121781 7757434 0.05190 1 9731455 2335549 52919145 71493834 -18574689 X 1 1 1 1 GREAT RIVER MEDICAL CENTER

1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655

X X X GREAT RIVER MEDICAL CENTER 1 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X X 1 0 1 X X 0 0 PART I, LINE 3C: THE ORGANIZATION USES THE FPG TO DETERMINE FREE OR DISCOUNTED CARE. INDIVIDUALS WHO ARE BELOW 200% OF THE FPG QUALIFY FOR FREE CARE. IN MOST INSTANCES, THEY HAVE TO PROVIDE FINANCIAL DOCUMENTATION AND FILL OUT A CHARITY CARE APPLICATION. WE ALSO USE A PRESUMPTIVE CHARITY CARE PROGRAM THAT ANALYZES PUBLIC AND PRIVATE DATABASES TO HELP DETERMINE ELIGIBILITY FOR CHARITY CARE. THESE INDIVIDUALS DO NOT HAVE ANY OTHER DOCUMENTATION TO PROVIDE. THIS PROGRAM IS USED AFTER COLLECTION ATTEMPTS HAVE BEEN DISCONTINUED. EXTRAORDINARY ASSETS ARE TAKEN IN TO CONSIDERATION WHEN DETERMINING CHARITY CARE ELIGIBILITY. MEDICALLY INDIGENT INDIVIDUALS ARE COVERED UNDER THE SAME CHARITY CARE POLICY. INDIVIDUALS BETWEEN 200% AND 300% OF THE FEDERAL POVERTY LIMITS ARE GRANTED CHARITY ON A SLIDING SCALE. PART I, LINE 7: THE AMOUNTS INCLUDED IN PART I, LINE 7 WERE CALCULATED USING A RATIO OF COST TO CHARGES DERIVED FROM WORKSHEET 2 OF THE IRS SCHEDULE H INSTRUCTIONS. PART I, L7 COL(F): BAD DEBT EXPENSES OF $9,731,455 WERE SUBTRACTED FROM THE TOTAL EXPENSES OF $160,011,089 IN CALCULATING THE PERCENTAGES IN PART I, LINE 7, COLUMN F. PART III, LINE 4: THE FOLLOWING IS FROM THE "ACCOUNTS RECEIVABLE AND ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS" PARAGRAPH IN NOTE 1 TO THE GREAT RIVER MEDICAL CENTER, GRMC FOUNDATION AND GREAT RIVER FOUNDATION, INC. COMBINED FINANCIAL STATEMENTS:"PATIENT RECEIVABLES WHERE A THIRD-PARTY PAYOR IS RESPONSIBLE FOR PAYING THE AMOUNT ARE CARRIED AT A NET AMOUNT DETERMINED BY THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED, LESS AN ESTIMATE MADE FOR CONTRACTUAL ADJUSTMENTS OR DISCOUNTS PROVIDED TO THIRD-PARTY PAYORS. PATIENT RECEIVABLES DUE DIRECTLY FROM PATIENTS ARE CARRIED AT THE ORIGINAL CHARGE FOR THE SERVICE PROVIDED LESS AMOUNTS COVERED BY THIRD-PARTY PAYORS AND LESS AN ESTIMATED ALLOWANCE FOR DOUBTFUL RECEIVABLES BASED ON A REVIEW OF ALL OUTSTANDING AMOUNTS ON A MONTHLY BASIS. MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS, BY HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS AND BY CONSIDERING THE PATIENTS' FINANCIAL HISTORY, CREDIT HISTORY AND CURRENT ECONOMIC CONDITIONS. THE MEDICAL CENTER DOES NOT CHARGE INTEREST ON PATIENT RECEIVABLES. PATIENT RECEIVABLES ARE WRITTEN OFF AS BAD DEBT EXPENSES WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PEVIOUSLY WRITTEN OFF ARE RECORDED AS A REDUCTION OF BAD DEBT EXPENSE WHEN RECEIVED."THE AMOUNT OF BAD DEBT EXPENSE REPORTED IN PART III, LINE 2 IS CALCULATED AS FOLLOWS: PAYMENT ARRANGEMENT INCLUDE PROSPECTIVELY DETERMINED RATES PER DISCHARGE, REIMBURSED COSTS, DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS, AND OTHERS FOR SERVICES RENDERED, INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY INCLUDED IN PART III, LINE 3 IS DETERMINED AS FOLLOWS: IF AN INDIVIDUAL DOES NOT HAVE A RESIDENCE THAT CAN BE USED TO RUN THROUGH THE PRESEUMPTIVE CHARITY CARE APPLICATION AND THEY DO NOT FILL OUT THE APPROPRIATE PAPERWORK TO APPLY FOR CHARITY, THEIR ACCOUNT BALANCE WILL BE WRITTEN OFF TO BAD DEBT. BASED UPON A REVIEW OF CHARITY APPLICATIONS THAT WERE REJECTED DUE TO INCOMPLETE/MISSING INFORMATION, IT HAS BEEN DETERMINED THAT APPROXIMATELY 24% OF THE APPLICATIONS WE RECEIVE ARE REJECTED BUT THE PATIENT APPEARS TO QUALIFY FOR CHARITY BUT THEY HAVEN'T NOT COMPLETED THE APPROPRIATE FORMS. PART III, LINE 8: A COST-TO-CHARGE RATIO AS DETERMINED BY THE 2012 MEDICARE COST REPORT WAS USED TO DETERMINE THE AMOUNTS IN PART III, LINES 5 AND 6. THE SHORTFALL REPORTED ON PART III, LINE 7 REPRESENTS THE CO-INSURANCE AND PATIENT DEDUCTIBLE AMOUNTS. PART III, LINE 9B: COLLECTION EFFORTS ARE DISCONTINUED ONCE THE PATIENT HAS BEEN APPROVED FOR CHARITY CARE. GREAT RIVER MEDICAL CENTER PART V, SECTION B, LINE 19D: THE MAXIMUM AMOUNT THAT CAN BE CHARGED IS BASED ON A CHARITY CARE MATRIX BASED ON THE FPG AND FAMILY SIZE. PART VI, LINE 2: GRMC IS AN ACTIVE PARTICIPANT IN COMMUNITY AND COUNTY GOVERNMENT TASK FORCES ON HEALTH NEEDS ASSESSMENT AND HEALTH SERVICES PLANNING AND COORDINATION. GRMC ASSESSES OUR COMMUNITIES' NEEDS THROUGH PROGRAMS WE OFFER, REQUESTS THAT ARE RECEIVED, AND OUR OWN STAFF INVOLVEMENT IN THEIR COMMUNITIES. WE ALSO COLLABORATE WITH OTHER COMMUNITY ORGANIZATIONS AS WELL, WHEN OUR SERVICES ARE NEEDED. AN ANNUAL HEALTH FAIR IS HOSTED TO PROVIDE INFORMATION AND EDUCATION TO OUR COMMUNITY ABOUT HEALTH ISSUES AND TO PROMOTE OUR HEALTHCARE SERVICES. WE ENCOURAGE OUR COMMUNITY MEMBERS TO TAKE AN ACTIVE ROLE IN THEIR OWN HEALTH CARE BY TAKING STEPS TOWARDS A HEALTHIER LIFESTYLE THROUGH MEMBERSHIP TO OUR GYM, A MULTITUDE OF EXERCISE PROGRAMS OFFERED THROUGH OUR FACILITY, AND OFFERING MANY WELLNESS PROGRAMS TO THE COMMUNITY. PART VI, LINE 3: FINANCIAL COUNSELORS MEET WITH PATIENTS. THE PATIENT FILLS OUT A QUESTIONAIRRE THAT HELPS THEM DETERMINE IF THEY QUALIFY FOR MEDICAID, CRIME VICTIMS, COBRA, AND OTHER MISC PROGRAMS. ON THE STATEMENTS, THERE IS PRINTED INFORMATION ABOUT FINANCIAL ASSISTANCE AND THE FINANCIAL ASSISTANCE APPLICATION IS ON THE HOSPITAL WEBSITE. THERE ARE PLANS TO ALSO HAVE THE CHARITY CARE POLICY AVAILABLE VIA THE WEB. PART VI, LINE 4: A REVIEW CONDUCTED BY THE MEDICAL CENTER ANALYZING THE ORIGIN OF PATIENTS UTILIZING THE SERVICES PROVIDED BY MEDICAL CENTER DURING THE FISCAL YEAR ENDED JUNE 30, 2012 INDICATES THAT DES MOINES COUNTY COMPRISES THE MEDICAL CENTER'S PRIMARY SERVICE AREA AND THAT THE SECONDARY SERVICE AREA OF THE MEDICAL CENTER CONSISTS OF HENRY, LEE AND LOUISA COUNTIES IN IOWA AND HANCOCK AND HENDERSON COUNTIES IN ILLINOIS. THE DES MOINES COUNTY POPULATION IS ESTIMATED AT 40,169 RESIDENTS FOR 2011, WITH BURLINGTON AND WEST BURLINGTON TOTALING 28,532 AS OF 2011. THE OVER 65 AGE GROUP IS CURRENTLY 17.7% OF THE POPULATION WHICH IS HIGHER THAN THE STATE AVERAGE OF 14.9%. THE MEDIAN HOUSEHOLD INCOME WAS $43,111 COMPARED TO THE STATE AVERAGE OF $50,451. DES MOINES COUNTY POPULATION BELOW POVERTY LEVEL IS 14.4% COMPARED TO THE STATE AVERAGE OF 11.9%. GREAT RIVER MEDICAL CENTER IS PART OF A LARGER HEALTH SYSTEM THAT CONSISTS OF ONE HOSPITAL, MULTIPLE SPECIALTY PHYSICIAN CLINICS, HOME HEALTH SERVICES, A HOSPICE HOUSE, AMBULANCE SERVICES, A DAY CARE CENTER, THREE PHARMACIES, A DURABLE MEDICAL EQUIPMENT COMPANY, AND A LONG-TERM CARE NURSING HOME. PART VI, LINE 5: GRMC IS INVOLVED IN GETTING PHYSICIANS AND HEALTHCARE WORKERS TO THE AREA TO IMPROVE THE ACCESS TO HEALTHCARE NEEDS IN THE MEDICAL CENTER'S SERVICE AREA. GRMC ALSO PROMOTES HEALTH CARE RELATED JOBS EDUCATION BY WORKING CLOSELY WITH SOUTHEASTERN COMMUNITY COLLEGE AND THEIR NURSING PROGRAM.THE HOSPITAL ALSO PROVIDES MEMBERSHIP TO ALL PHYSICIANS WHO MEET MEMBERSHIP AND CLINICAL REQUIREMENTS. SURPLUS FUNDS ARE INVESTED IN IMPROVED AND/OR UPDATED CAPITAL EQUIPMENT TO ALLOW FOR BETTER CARE OF THE PATIENTS THAT ARE SERVED. PART VI, LINE 6: GREAT RIVER HEALTH SYSTEM SERVES AS A HOLDING COMPANY OF VARIOUS SUBSIDIARIES PROVIDING HEALTH CARE IN WEST BURLINGTON, IOWA. 1 COMMUNITY ACTION OF SOUTHEAST IOWA 2850 MT PLEASANT ST SUITE 108 BURLINGTON IA 52601 420923961 501C3 40000 MEDICAL ASSISTANCE PROGRAM GROW GREATER BURLINGTON 610 N 4TH ST SUITE 200 BURLINGTON IA 52601 420982794 501C3 25000 COMMUNITY BENEFIT THE SALVATION ARMY 217 S 3RD STREET BURLINGTON IA 52601 133485289 501C3 20000 CAPITAL CAMPAIGN SOUTHEASTERN COMMUNITY COLLEGE 1500 W AGENCY RD WEST BURLINGTON IA 52655 420926823 501C3 20000 NURSING PROGRAM THE UNIVERSITY OF IOWA FOUNDATION PO BOX 4550 IOWA CITY IA 522444550 426004813 501C3 15000 COMMUNITY BENEFIT NORTH HENDERSON CO AMBULANCE 809 PUTMAN ST OQUAWKA IL 61469 364089806 501C3 13200 RESCUE EQUIPMENT IOWA WESLEYAN COLLEGE 601 N MAIN ST MT PLEASANT IA 52641 420680332 501C3 10000 NURSING PROGRAM MORNING SUN COMMUNITY AMBULANCE PO BOX 174 MORNING SUN IA 52640 421322329 501C3 8515 RESCUE EQUIPMENT SPECIAL NEEDS FOUNDATION OF DES MOINES COUNTY 829 HARRISON AVENUE BURLINGTON IA 52601 421090677 501C3 7500 MEDICAL EQUIPMENT GREAT RIVER FOUNDATION 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421469162 501C3 4000000 COMMUNITY BENEFIT RELATED TO THE GENERAL OPERATIONS OF SEIMS. 10 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTEES ARE REQUIRED TO PROVIDE FOLLOW-UP INFORMATION WHEN THE PROJECT IS CARRIED OUT OR COMPLETED. IF GRANTEES DON'T COMPLY, GRMC DOES NOT PROVIDE FURTHER GRANTS TO THEM. 0 0 0 0 0 0 0 0 0 MARK RICHARDSON 0 424878 0 283234 0 223451 0 9800 0 33890 0 975253 0 0 TONY HAYES 0 310577 0 86498 0 66992 0 9800 0 31320 0 505187 0 0 TODD SLADKY 0 257772 0 86498 0 79997 0 9800 0 31877 0 465944 0 0 DARWIN COOLEY 162093 0 0 0 557 0 9736 0 20467 0 192853 0 0 0 JON WILLIAMS 126780 0 0 0 0 0 7466 0 16330 0 150576 0 0 0 JOHN MERCER III 134130 0 0 0 0 0 7382 0 21844 0 163356 0 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 2: THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY GREAT RIVER HEALTH SYSTEMS, A RELATED ORGANIZATION. THE FOLLOWING WERE USED BY GREAT RIVER HEALTH SYSTEMS IN DETERMINING THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. FORM 990 OF OTHER ORGANIZATIONS 4. WRITTEN EMPLOYMENT CONTRACT 5. COMPENSATION SURVEY OR STUDY 6. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE IOWA FINANCE AUTHORITY 521699886 462466BV4 2008-07-01 37475000 PROCEEDS USED TO REFUND SERIES 1997 ADJUSTABLE DEMAND REVENUE BONDS 0 0 0 DES MOINES COUNTY IOWA 426004310 250087AA1 2012-04-04 60000000 PROCEEDS USED TO REFUND SERIES 2001 HEALTHCARE REVENUE BONDS 0 0 0 5685000 37475000 375000 37100000 2027 0 1 1 1 666667 48000000 665624 17854376 29480000 2027 0 1 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 3 BOND PROCEEDS THE TOTAL PROCEEDS OF THE 2012 BOND ISSUE INCLUDED ON PART II, LINE 3 OF COLUMN A, DOES NOT MATCH THE TOTAL ISSUE PRICE INCLUDED ON PART I, LINE B OF COLUMN E BECAUSE ONLY A PORTION OF THE TOTAL ISSUE WAS RELEASED ON A MONTHLY BASIS RESULTING IN GRMC ONLY RECEIVING $48 MILLION OF THE TOTAL ISSUANCE AS OF FISCAL YEAR END JUNE 30, 2012. CONTRIBUTION REVENUES FORM 990, PART I, LINE 8 FOR THE YEAR ENDED JUNE 30, 2012, IT WAS DECIDED BY MANAGEMENT TO TREAT ANY INTERCOMPANY NET ASSET TRANSFERS AS RECONCILING ITEMS TO NET ASSETS INSTEAD OF CLASSIFYING THEM AS CONTRIBUTION REVENUES. RECONCILING ITEMS ARE INCLUDED IN PART XI, LINE 5. DUE TO THIS CHANGE, THE CONTRIBUTION REVENUES ARE NOT COMPARABLE BETWEEN THE CURRENT YEAR AND PRIOR YEAR FORM 990. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE CHAIRMAN OF THE BOARD, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, AND TWO OR MORE ADDITIONAL TRUSTEES. WHEN THE BOARD IS NOT IN SESSION, THE EXECUTIVE COMMITTEE SHALL HAVE AND EXERCISE THE POWER AND AUTHORITY OF THE BOARD TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OR BY STATUTE. THE EXECUTIVE COMMITTEE HAS GENERAL RESPONSIBILITY FOR THE INVESTMENT OF AN ENDOWMENT AND OTHER CAPITAL FUNDS OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 3 ALL EXECUTIVE LEADERSHIP FUNCTIONS FOR GREAT RIVER MEDICAL CENTER, AND ITS SUBSIDIARIES ARE PROVIDED BY MUTUAL CONSULTING AND MANAGEMENT SERVICES, INC. MUTUAL CONSULTING AND MANAGEMENT SERVICES IS A SUBSIDIARY OF RIVERVIEW SYSTEMS LTD, WHICH IS A SUBSIDIARY OF GREAT RIVER HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 6 GREAT RIVER HEALTH SYSTEMS INC., IS THE SOLE MEMBER OF GREAT RIVER MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A ONE TRUSTEE IS THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF GREAT RIVER MEDICAL CENTER AND THE REMAINING TRUSTEES ARE ELECTED BY THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MATTERS ARE AUTHORIZED ONLY AFTER APPROVAL OF THE MEMBER: A. MERGER,CONSOLIDATION, OR DISSOLUTION OF GREAT RIVER MEDICAL CENTER WITH ANY OTHER CORPORATION OR LEGAL ENTITY. B. ANY CHANGE IN GREAT RIVER MEDICAL CENTER'S ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11 GREAT RIVER MEDICAL CENTER FORM 990 WILL BE SENT OUT BY SECURE EMAIL MESSAGE TO ALL BOARD MEMBERS PRIOR TO FILING. IF THERE ARE ANY QUESTIONS, THEY CAN CONTACT THE ACCOUNTING OFFICE OR THEY CAN BE ADDRESSED AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C EVERY YEAR, THE ACCOUNTING MANAGER IN THE ACCOUNTING DEPARTMENT PROVIDES TO THE BOARD THE MEANING OF THE CONFLICT OF INTEREST STATEMENT, HOW IT APPLIES, HOW IT IMPACTS THE BOARD, AND WHAT THEIR RESPONSIBILITIES ARE. ALL BOARD MEMBERS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST FORM AND THE FORM IS THEN REVIEWED BY THE ACCOUNTING MANAGER. RELATIONSHIPS NOTED ON THE FORM MAY BE DISCUSSED WITH THE BOARD MEMBER IF THERE ARE QUESTIONS. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THEY MAY NOT PARTICIPATE IN DISCUSSIONS OF THE TRANSACTION AND MAY NOT VOTE ON MATTERS RELATED TO THE TRANSACTION. FORM 990, PART VI, SECTION C, LINE 19 GREAT RIVER MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST. EXPLANATION FOR HOURS WORKED FORM 990, PART VII, SECTION A MARK RICHARDSON, CEO, TONY HAYES, COO, AND TODD SLADKY, CFO EACH SERVE AS OFFICERS FOR GREAT RIVER HEALTH SYSTEMS AND ITS RELATED ORGANIZATIONS IDENTIFIED IN SCHEDULE R. EACH INDIVIDUAL SPENDS APPROXIMATELY 40 HOURS PER WEEK COLLECTIVELY SERVING AS OFFICERS FOR ALL OF THE RELATED ORGANIZATIONS. IN ADDITION TO THE ABOVE, ROBERT FLEMMING AND KENNETH ASPELMEIER SERVE AS BOARD MEMBERS FOR GREAT RIVER HEALTH SYSTEMS, GREAT RIVER MEDICAL CENTER, GRMC FOUNDATION, AND GREAT RIVER FOUNDATION. EACH INDIVIDUAL SPENDS APPROXIMATELY 1 HOUR PER WEEK COLLECTIVELY SERVING AS BOARD MEMBERS FOR THE ORGANIZATIONS LISTED ABOVE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -76,891. UNREALIZED GAIN ON INTEREST RATE SWAP -2,522,108. TRANSFER FROM RELATED PARTY 6,676,213. TOTAL TO FORM 990, PART XI, LINE 5: 4,077,214. FORM 990, PART XII, LINE 2C THIS PROCESS IS CONSISTENT WITH PRIOR YEARS. GREAT RIVER HEALTH SYSTEMS INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193185 HEALTH CARE IA 501(C)(3) 11 - TYPE 2 N/A 0 GRMC FOUNDATION INC 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421193186 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) 11 - TYPE 2 GRHS 0 GREAT RIVER FOUNDATION 1221 SOUTH GEAR AVENUE WEST BURLINGTON IA 52655 421469162 SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) 11 - TYPE 2 GRHS 0 RIVERVIEW SYSTEMS LTD PO BOX 640 WEST BURLINGTON IA 52655 421191960 MEDICAL SERVICES IA GRHS C GREAT RIVER MEDICAL SERVICES INC 1201 WEST AGENCY ROAD WEST BURLINGTON IA 52655 421493449 MEDICAL SERVICES IA GRHS C 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0