2012-04-30T15:24:19-05:00 2011-06-30 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2010-07-01 450231181 LUTHERAN CHARITY ASSOCIATION LUTH 7012521050 419 FIFTH STREET NE JAMESTOWN ND 584013360 ALAN O'NEIL 7012521050 2012-04-24 1 RICHARD RUVELSON 9525483400 2012-04-24 2010 2016-02-24 21:20:13Z JAMESTOWN HOSPITAL ALAN O'NEIL 419 FIFTH STREET NE JAMESTOWN ND 584013360 28628546 0 X WWW.JAMESTOWNHOSPITAL.COM X 1927 ND TO COMPASSIONATELY REVOLUTIONIZE HEALTHCARE IN THE HEARTLAND. 10 10 358 112 0 0 268792 1488870 26067323 26333441 579952 474773 136601 331462 27052668 28628546 0 0 0 0 15087385 15714644 0 0 0 10379634 10885898 25467019 26600542 1585649 2028004 49713952 73203276 25725131 46902922 23988821 26300354 X PROVIDE HEALTH CARE SERVICES TO JAMESTOWN AND THE SURROUNDING AREA. 0 0 22872134 26664903 JAMESTOWN REGIONAL MEDICAL CENTER IS A 25 BED CRITICAL ACCESS HOSPITAL PROVIDING SHORT-TERM ACUTE INPATIENT, OUTPATIENT, SWING BED, HOME HEALTH AND HOSPICE HEALTH CARE SERVICES. THE NEAREST PROVIDER OF HEALTH CARE SERVICES IS MORE THEN 35 MILES AWAY AND JAMESTOWN REGIONAL MEDICAL CENTER IS LOCATED 100 MILES AWAY FROM THE NEAREST MAJOR HEALTH SERVICE CENTERS IN FARGO OR BISMARCK, NORTH DAKOTA. WE ALSO PROVIDE SPACE FOR A SATELLITE DIALYSIS UNIT OPERATED BY MEDCENTER ONE, BISMARCK, NORTH DAKOTA. JAMESTOWN REGIONAL MEDICAL CENTER MAKES MEDICAL CARE ACCESSIBLE TO THE ENTIRE COMMUNITY IT SERVES. IN ADDITION TO THE ROUTINE INPATIENT AND OUTPATIENT HEALTH CARE SERVICES WE PROVIDE THE FOLLOWING SPECIALTY SERVICES TO THE COMMUNITIES WE SERVE:* CARDIAC CARE AND REHABILITATION: IN ADDITION TO EMERGENCY AND INTENSIVE CARE UNITS OUR CARDIAC SERVICES INCLUDE CARDIOLITE STRESS, ADENOSCAN AND ADENOWALK CARDIOLITE IMAGING TESTS AND SPECT IMAGING TESTS FOR ACCURATE DIAGNOSIS; AND MONITORED DIET AND EXERCISE PROGRAMS THROUGHOUT THE HOSPITAL STAY AND THROUGH OUTPATIENT CARE IN OUR CARDIAC REHABILITATION CENTER.* MAMMOGRAPHY: OUR MAMMOGRAPHY UNIT WAS DESIGNED FOR WOMEN AND IS STAFFED BY FEMALE PROFESSIONALS. * EMERGENCY CARE: OUR EMERGENCY CENTER IS STAFFED 24 HOURS A DAY THROUGHOUT THE YEAR AND HANDLES EVERYTHING FROM BROKEN BONES TO HEART ATTACKS.* HOME HEALTH SERVICES: SERVICES PROVIDED TO THE HOME BOUND INCLUDE NURSING, PHYSICAL, OCCUPATIONAL, SPEECH AND SOCIAL SERVICES.* HOSPICE: PROVIDE FOR THE PHYSICAL AND PSYCHOLOGICAL NEEDS OF THE TERMINALLY ILL AND HELP ACCOMODATE THEIR FAMILIES THROUGH A FULL RANGE OF HOSPICE SERVICES.* NUTRITIONAL COUNSELING: OUR REGISTERED DIETITIANS PROVIDE NUTRITIONAL ASSESSMENTS AND PERSONALIZED DIET PLANS TO OPTIMIZE HEALTH AND SPEED RECOVERY THROUGH PROPER NUTRITION.* PHYSICAL AND OCCUPATIONAL THERAPY: PROVIDE A FULL RANGE OF SERVICES TO HELP PATIENTS RECOVER FROM ON-THE-JOB, SPORTS-RELATED INJURIES AND CERTAIN DEBILITATING DISEASES.* SOCIAL SERVICES AND SUPPORT GROUPS: OUR FACILITY PROVIDES A WIDE RANGE OF SUPPORT IN THE COORDINATION OF SERVICES BY OUR SOCIAL SERVICE DEPARTMENT AND SUPPORT GROUPS TO HELP OUR PATIENTS AND THEIR FAMILIES COPE WITH THE EMOTIONAL AND FINANCIAL EFFECTS OF ILLNESS.* PODIATRY SERVICES: OUR LICENSED AND CREDENTIALED DOCTOR OF PODIATRY MEDICINE TREATS EVERYTHING FROM FLAT FEET TO BUNIONS WITH MODERATE THERAPEUTIC TECHNIQUES.* SPEECH AND HEARING SERVICES: WE EMPLOY LICENSED AUDIOLOGIST AND SPEECH THERAPISTS THAT CAN HELP CORRECT HEARING LOSS AND SPEECH DIFFICULTIES.* SURGERY CENTER: OUR INPATIENT AND OUTPATIENT SURGERY CENTER IS CAPABLE OF HANDLING A WIDE VARIETY OF GENERAL AND SPECIALIZED SURGICAL PROCEDURES INCLUDING LAPAROSCOPIC AND CATARACT PROCEDURES.* WELLNESS PROGRAMS: OUR WELLNESS CENTER OFFERS THE COMMUNITY A FULL SCHEDULE OF CLASSES ON SUBJECTS RANGING FROM HEALTHY DIET, FITNESS AND PREVENTATIVE CARE ALONG WITH A FULLY EQUIPPED FITNESS CENTER TO HELP THE PEOPLE WE SERVE LEARN HOW TO MODIFY THEIR LIFESTYLES FOR A HEALTHIER LIFE.* OTHER SUPPORT SERVICES:* LABORATORY, PATHOLOGY AND RADIOLOGY SERVICES: FULL RANGE OF SERVICES TO PROVIDE ACCURATE DIAGNOSIS FOR TREATMENT* MEDICAL LIBRARY: VIDEO, WRITTEN AND ONLINE MATERIALS TO HELP KEEP OUR STAFF UP-TO-DATE AND AS A RESOURCE FOR OUR COMMUNITY.* CARE LINE: WE OPERATE AN EMERGENCY RESPONSE TELEPHONE BASED RESPONSE CENTER TO ENABLE THE FRAIL ELDERLY TO REMAIN INDEPENDENT IN THEIR HOMES.* VOLUNTEERS AND VOLUNTEER SERVICES: WE HAVE, ON THE AVERAGE, 112 COMMUNITY VOLUNTEERS PROVIDING APPROXIMATELY 6,435 HOURS OF SERVICE TO THE HOSPITAL AND THE PATIENTS WE SERVE. SOME OF THE MANY AREAS THEY PROVIDE SERVICES ARE AS FOLLOWS:* SENIOR COMPANIONS: HELPING SENIOR CITIZENS MAINTAIN INDEPENDENCE BY READING TO THEM, HELPING WITH SHOPPING, ETC.* HOSPICE: ASSISTING HOSPICE PATIENTS AND FAMILIES COPE WITH TERMINAL ILLNESS.* CHILDREN'S TLC: VOLUNTEERS PROVIDE PARENTS WITH A BREAK WITH THEIR CHILDREN THAT ARE HOSPITALIZED.* TELECARE: MAINTAIN CONTACT WITH YOUR FRIENDS OR FAMILY MEMBER THROUGH TELEPHONE CALLS TO THEIR HOME.* GIFT SHOPPE: OPERATED FOR THE CONVENIENCE OF FRIENDS AND FAMILY OF HOSPITAL PATIENTS TO OBTAIN CARDS, FLOWERS AND SMALL GIFTS FOR PATIENTS IN OUR FACILITY. * CARING TOUCH: A PARTNERSHIP WITH JAMESTOWN COLLEGE TO PROVIDE SUPPORT OF PATIENTS BOTH IN THE HOSPITAL AND AFTER THEY RETURN HOME.* OTHER SERVICES: COMMUNITY MEMBERS VOLUNTEER THEIR SERVICES TO HELP OUT IN TIMES OF NEED IN MOST SERVICE AREAS ASSISTING PATIENTS AND THEIR FAMILIES. SERVICES PROVIDED DURING FYE JUNE 30, 2011:*4,241 INPATIENT DAYS OF WHICH 184 WERE SWING BED AND 9 HOSPICE DAYS OF CARE* 41% MEDICARE IS THE PERCENTAGE OF INPATIENT DAYS* 17.7% MEDICAID IS THE PERCENTAGE OF INPATIENT DAYS* 7,921 EMERGENCY VISITS OF WHICH 769 RESULTED IN INPATIENT ADMISSIONS* 26,111 TOTAL OUTPATIENT VISITS* 2,357 OUTPATIENT SURGICAL PROCEDURE VISITS INCLUDING OUTPATIENT SURGERY AND SCOPES* 305 LIVE BIRTHS* 1,720 CARDIAC REHAB VISITS* 4,868 HOME HEALTH VISITS* 3,426 HOSPICE DAYS OF CARE* 5,147 DIALYSIS TREATMENTS* $369,709 IN FREE CARE* 112 VOLUNTEERS PROVIDED 6,435 HOURS OF VOLUNTEER SERVICE.IN SUMMARY, JAMESTOWN HOSPITAL IS A 25 BED CRITICAL ACCESS HOSPITAL, GEOGRAPHICALLY LOCATED IN RURAL SOUTH-CENTRAL NORTH DAKOTA. THE CLOSEST MEDICAL FACILITY IS MORE THAN 35 MILES AWAY AND THE CLOSEST COMPARABLE MEDICAL SERVICES ARE 100 MILES FROM JAMESTOWN. 22872134 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 31 0 358 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X ALAN O'NEIL 7019524802 419 FIFTH STREET NE JAMESTOWN ND 584013360 HARVEY HUBER 1.00 X X 0 0 0 CONNIE KRAPP 1.00 X X 0 0 0 REV TERRY ANDERSON 1.00 X X 0 0 0 JOANNE OTTMAR 1.00 X X 0 0 0 ERIC MONSON MD 1.00 X 0 0 0 SHANDA TRAISER PH D 1.00 X 0 0 0 DEBRA GEIR MD 1.00 X 0 0 0 DR JAMES R TORRANCE MD 1.00 X 0 0 0 DENNIS D POZARNSKY 1.00 X 0 0 0 DAVID MATHISON MD 1.00 X 0 0 0 MARTIN I RICHMAN 40.00 X 185516 0 33637 ALAN O'NEIL 40.00 X 146629 0 18549 DR ALFONSO FINDLEY 40.00 X 646352 0 14460 DR PHILIP JYSTAD 40.00 X 285005 0 52018 DR MANUEL HARRIS 40.00 X 246045 0 50532 DR SCOTT GOECKE 40.00 X 227872 0 11710 KATHRYN KOVAR 40.00 X 145515 0 15772 1882934 0 196678 15 0 1 0 AMERISOURCE BERGEN PO BOX 959 VALLEY FORGE PA 19482 PHARMACEUTICAL SERVICES 893775 NATIONAL MEDICAL RESOURCES INC 2900 E BROADWAY AVE SUITE 1 BISMARCK ND 58501 ER PHYSICIANS 828309 OWENS & MINOR 2151 COUNTY ROAD H2 WEST MOUNDS VIEW MN 55112 MEDICAL-SURGICAL SERVICES 571486 IMAGING SOLUTIONS INC 2829 UNIVERSITY DRIVE S FARGO ND 58103 DIAGNOSTIC IMAGING SERVICES 446034 HEALTHCARE MANAGEMENT SYSTEMS 3102 WEST END AVE SUITE 400 NASHVILLE TN 37203 SOFTWARE SERVICES 266109 19 650000 838870 1488870 NET PATIENT SERVICE RE 621400 25823583 25823583 WELLNESS/LIFELINE/CARE 900099 183406 183406 RENTAL INCOME 531120 115338 115338 CONSULTATION SERVICES 541900 87958 87958 ER COVERAGE REIMBURSEM 541900 59137 59137 64019 64019 26333441 268001 268001 206272 500 206272 500 206772 206772 CAFETERIA 900099 170149 170149 OTHER REVENUE 900099 127243 127243 GIFT SHOP SALES 453220 29598 29598 4472 4472 331462 28628546 26460684 0 678992 397869 397869 12407589 10960823 1446766 787176 694180 92996 1250086 1106995 143091 871924 773066 98858 58110 58110 2231556 1826975 404581 189565 2279 187286 2455241 2131319 323922 199615 43041 156574 547469 513890 33579 94893 74125 20768 80929 29877 51052 45461 45461 1315937 1315937 173436 57304 116132 DRUG EXPENSE 1169520 1169520 BAD DEBT EXPENSE 1080129 1080129 OTHER EXPENSE 939257 742433 196824 FOOD EXPENSE 188878 188878 BLOOD EXPENSE 115902 115902 26600542 22872134 3728408 0 113744 75395 3467648 2527574 3535085 3778667 436352 449477 187800 142271 77435884 24982353 21467397 52453531 5713653 7889978 1010137 14792273 4876246 49713952 73203276 5580201 8810377 1555000 790000 18039626 36960699 550304 341846 25725131 46902922 X 23988821 26300354 23988821 26300354 49713952 73203276 X 2028004 283529 X X 0 1 0 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5836 5836 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: THE ORGANIZATION PAYS DUES TO VARIOUS PROFESSIONAL ORGANIZATIONS. A PORTION OF THOSE DUES ARE USED TOWARDS LOBBYING EXPENSES. 691427 691427 7618752 5501412 2117340 23207148 19480941 3726207 45918557 45918557 52453531 UNAMORTIZED DEBT ISSUE COSTS 752378 RELATED PARTY RECEIVABLE 162202 HEALTH SAVINGS FUND 397373 BOND FUND 2974229 BOND RESERVE 479750 PROPERTY HELD FOR INVESTMENT AT COST 110314 4876246 CAPITAL LEASE OBLIGATION 341846 341846 28628546 26600542 2028004 283529 283529 2311533 28912075 283529 283529 28628546 0 28628546 26600542 0 26600542 0 26600542 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE ORGANIZATION'S FEDERAL INFORMATIONAL RETURNS FOR TAX YEARS 2007 AND SUBSEQUENT YEARS REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 1 X 1 1 0 0 253243 253243 0.00990 2506386 2398051 108335 0.00420 2759629 2398051 361578 0.01410 2759629 2398051 361578 0.01410 0 739866 330070 8806294 8862646 -56352 X 1 1 1 1 JAMESTOWN HOSPITAL

419 5TH ST NE JAMESTOWN ND 58401

X X X X JAMESTOWN HOSPITAL 1 PART I, LINE 7: THE COSTING METHODOLOGY IS THE COST TO CHARGES RATIO. DURING THE YEAR THERE WAS INCREASE IN SPECIFIC SERVICES, SUCH AS OB SERVICES, WHICH HAVE A HIGHER MEDICAID REIMBURSMENT RATE. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1080129. PART II: JAMESTOWN HOSPITAL PROVIDES SEVERAL LOW COST EDUCATIONAL TRAINING SESSIONS AT THE HOSPITAL AND AT DIFFERENT LOCATIONS IN THE COMMUNITY. FOR EXAMPLE, JAMESTOWN HOSPITAL PROVIDES BREAST FEEDING, CAR SEAT TRAINING, PRENATAL TRAINING, AND HAPPIEST BABY ON THE BLOCK CLASSES. NEW YEAR NEW YOU FITNESS CHALLENGE WAS INTRODUCED IN 2008 TO ENCOURAGE AREA RESIDENTS TO MAKE POSITIVE LIFESTYLE CHANGES AND REDUCE THE RISK OF HEART DISEASE, DIABETES, OBESITY AND TOBACCO USE. PART III, LINE 4: WE CALCULATED THE REASONABLE COST OF POSSIBLE ELIGIBLE CHARITY CARE THAT WENT TO BAD DEBT BY TAKING THE AVERAGE CLAIM PER GUARANTOR THAT QUALIFIED FOR CHARITY CARE TIMES THE GUARANTORS THAT TOOK APPLICATIONS AND DID NOT FOLLOW THROUGH ON THE PROCESS. THIS AMOUNT WAS BROUGHT DOWN TO COST BY TAKING THAT NUMBER TIMES THE RATIO OF PATIENT CARE COST TO CHARGES. THE CARRYING AMOUNTS OF PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. PART III, LINE 8: THE COSTING METHODOLOGY USED IS COST TO CHARGE RATIO AS REQUIRED BY MEDICARE. SHORTFALL IS NOT INDICATIVE OF ANY CHANGE IN COMMUNITY BENEFIT AS THE COSTING METHODOLOGY AND DETERMINATION OF ALLOWABLE COSTS HAVE NOT CHANGED FROM PRIOR YEAR. PART III, LINE 9B: NO COLLECTIONS EFFORT WILL BE MADE BY JAMESTOWN HOSPITAL OR ITS COLLECTION AGENCIES ON THE PERCENTAGE OF COMMUNITY CARE APPROVED. HOWEVER, PATIENTS MUST HAVE COMPLETED THE COMMUNITY CARE APPLICATION PROCESS, ESTABLISH THEIR ELIGIBILITY, AND HAVE BEEN APPROVED. IF SUCH A PATIENT IS MISTAKENLY BILLED, HOSPITAL STAFF WILL APOLOGIZE FOR THE ERROR AND CORRECT THE MISTAKE. PART VI, LINE 2: JAMESTOWN HOSPITAL HAS PARTNERED WITH CENTRAL VALLEY HEALTH AND OTHER LOCAL AGENCIES TO DEVELOP A COMMUNITY HEALTH ASSESSMENT FOR THE 5 COUNTIES, STUTSMAN, BARNES, LOGAN, WELLS AND LAMOURE, SERVED BY CENTRAL VALLEY HEALTH AND JAMESTOWN HOSPITAL. THIS ROLE IS PART OF THE HOSPITAL'S 5 YEAR STRATEGIC PLAN. PART VI, LINE 3: ALL PATIENTS RECEIVE A "PAYMENT GUIDELINES" BROCHURE AT TIME OF REGISTRATION, WHICH NOTIFIES THE PATIENTS ON HOW TO APPLY FOR CHARITY CARE AS WELL AS EXPLAINS THE CLAIM FILING PROCESS, RESPONSIBLE PARTY, CO-PAYS AND PAYMENTS. ALL PRIVATE PAY PATIENTS RECEIVE A LETTER WHICH LISTS CHARITY CARE AS A PAYMENT ALTERNATIVE TO THOSE WHO QUALIFY. OUR WEBSITE CONTAINS A CHARITY LINK WHICH EXPLAINS THE PROGRAM AND ALLOWS FORMS TO BE DOWNLOADED AND PRINTED. PART VI, LINE 4: JAMESTOWN HOSPITAL SERVES A NINE COUNTY AREA OF SOUTH CENTRAL NORTH DAKOTA. THE PRIMARY INDUSTRY IS AGRICULTURE. THE POPULATION IS 52,155 WITH 21% OVER THE AGE OF 65. THE AVERAGE AGE IS 42. MALE AND FEMALE POPULATION IS SPLIT EVENLY. AVERAGE INCOME BY HOUSEHOLD IS $53,650. THERE ARE TWO COLLEGES WITHIN JAMESTOWN HOSPITAL TRADE AREA. JAMESTOWN HOSPITAL IS THE ONLY BIRTHING CENTER WITHIN IN A 90 MILE RADIUS. PART VI, LINE 6: A MAJORITY OF THE GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF JAMESTOWN HOSPITAL, NOR FAMILY MEMBERS THEREOF. JAMESTOWN HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY FOR SOME OF ITS DEPARTMENTS. JAMESTOWN HOSPITAL IS IN THE PROCESS OF CONSTRUCTING A REPLACEMENT HOSPITAL WHICH WILL HAVE MANY UPGRADES IN TECHNOLOGY, MOST OF WHICH ARE RELATED TO IMPROVING PATIENT CARE. PART VI, LINE 7: N/A X 1 1 X X X 0 0 0 0 0 0 0 0 0 MARTIN I RICHMAN 185516 0 0 0 0 0 19854 0 13783 0 219153 0 0 0 ALAN O'NEIL 146629 0 0 0 0 0 12995 0 5554 0 165178 0 0 0 DR ALFONSO FINDLEY 646352 0 0 0 0 0 0 0 14460 0 660812 0 0 0 DR PHILIP JYSTAD 285005 0 0 0 0 0 27443 0 24575 0 337023 0 0 0 DR MANUEL HARRIS 246045 0 0 0 0 0 26563 0 23969 0 296577 0 0 0 DR SCOTT GOECKE 227872 0 0 0 0 0 0 0 11710 0 239582 0 0 0 KATHRYN KOVAR 145515 0 0 0 0 0 0 0 15772 0 161287 0 0 0 PART I, LINE 1A BASED ON APPROPRIATENESS AND THE EXPECTATION THAT THE CEO HAVE A VOLUNTARY PRESENCE IN THE COMMUNITY, THE CEO IS AUTHORIZED TO HAVE SOME SOCIAL CLUB DUES PAID ON HIS/HER BEHALF BY THE HOSPITAL. CITY OF JAMESTOWN 456002099 2003-06-26 5740000 REFUNDING PRIOR ISSUE 0 0 0 4950000 5740000 5740000 2003 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 FORM 990, PART VI, SECTION B, LINE 11 THE PREPARER OF FORM 990 EMAILS A COPY OF THE FINAL 990 TO THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. THE CHIEF FINANCIAL OFFICER PERFORMS A DETAIL REVIEW OF FORM 990. THE CHIEF FINANCIAL OFFICER PROVIDES EACH VOTING BOARD MEMBER WITH A COPY OF FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS ARE ASKED AT EVERY BOARD MEETING WHETHER OR NOT ANYONE HAS A DUALITY OF INTEREST OR CONFLICT OF INTEREST. DIRECTORS HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST ON ANY MATTER WHICH COMES BEFORE THE BOARD SHALL NOT VOTE ON THE MATTER OR USE THEIR PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING SHALL REFLECT THAT A DISCLOSURE OF DUALITY OR CONFLICT OF INTEREST WAS MADE, AND THE DIRECTOR MAKING SUCH A DISCLOSURE SHALL NOT BE COUNTED IN DECLARING A QUORUM FOR THE DETERMINATION OF THE MATTER. THIS PROVISION SHALL NOT BE CONSTRUED AS PREVENTING THE DIRECTOR FROM BRIEFLY STATING A POSITION ON THE MATTER NOR FROM ANSWERING PERTINENT QUESTIONS. FORM 990, PART VI, SECTION B, LINE 15 FOR THE CEO, THE BOARD CHAIRMAN CONVERSES WITH AN HR CONSULTANT ON MARKET WAGES AND EVALUATION PROCESS. EVALUATION FORMS ARE TYPICALLY COMPLETED BY BOARD MEMBERS AND THE BOARD CHAIRMAN CONDUCTS THE ACTUAL EVALUATION. COMPARABILITY DATA WAS USED BY THOSE WITHOUT CONFLICT AND THE DECISIONS WERE DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. PRIOR YEAR 990S CAN BE OBTAINED BY REQUEST OR THROUGH GUIDESTAR. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 283,529. FORM 990, PART XII, LINE 2C THE CHIEF FINANCIAL OFFICER ASSUMES OVERSIGHT OF THE AUDIT OF THE ORGANIZATION'S FINANCIAL STATEMENTS. THE BOARD OF DIRECTORS WITH THE CHIEF FINANCIAL OFFICER ASSUME RESPONSIBLILITY FOR SELECTION OF AN INDEPENDENT ACCOUNTANT. JAMESTOWN HOSPITAL FOUNDATION INC 419 5TH ST NE JAMESTOWN ND 58401 363348763 FUNDRAISING ND 501(C)(3) LINE 11A, I LUTHERAN CHARITY ASSOCIATION 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 JAMESTOWN HOSPITAL FOUNDATION INC C 650000 COST JAMESTOWN HOSPITAL FOUNDATION INC E 46000000 COST JAMESTOWN HOSPITAL FOUNDATION INC O 162202 COST