COMMUNITY HOSPITAL HEALTH FOUNDATION: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- COMMUNITY HOSPITAL HEALTH FOUNDATION (EIN 47-0693261)
- Tax period
- 2009-07-01 to 2010-06-30
- Filed
- 2011-01-25
- IRS object ID
- 201100259349301100
- Schema version
- 2009v1.7
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule G
- Schedule I
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-01-25T15:20:59-06:00 | Timestamp |
| Tax Period End Date | 2010-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON SESTAK & QUIST LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8807 INDIAN HILLS DRIVE SUITE 300 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 681144123 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470693261 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITAL HEALTH FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | COMM | NameControl |
| Phone | 3083447222 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 801 WEST C STREET PO BOX 1328 | AddressLine1 |
| City | MCCOOK | City |
| State | NE | State |
| ZIP Code | 69001 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TERRI SHIPSHOCK | Name |
| Title | EXECUTIVE DIRECTOR | Title |
| Phone | 3083447222 | Phone |
| Date Signed | 2011-01-22 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Harvey D Johnson | Name |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | TERRI SHIPSHOCK | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 801 WEST C STREET PO BOX 1328 | AddressLine1 |
| City | MCCOOK | City |
| State | NE | State |
| ZIP Code | 69001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 764052 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | WWW.CHHFMCCOOK.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1985 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | TO SOLICIT GIFTS, GRANTS, DEVICES AND BEQUESTS FOR THE USE AND BENEFIT OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 10 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 10 | NbrIndependentVotingMembers |
| Total Nbr Employees | 2 | TotalNbrEmployees |
| Total Nbr Volunteers | 40 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 170687 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 541843 | ContributionsGrantsCurrentYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -14040 | InvestmentIncomePriorYear |
| Investment Income Current Year | 74449 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 10760 | OtherRevenuePriorYear |
| Other Revenue Current Year | 16153 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 167407 | TotalRevenuePriorYear |
| Total Revenue Current Year | 632445 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 103304 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 100981 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 138312 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 147726 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 110315 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 32474 | OtherExpensePriorYear |
| Other Expenses Current Year | 32816 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 274090 | TotalExpensesPriorYear |
| Total Expenses Current Year | 281523 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -106683 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 350922 | RevenuesLessExpensesCY |
| Total Assets BOY | 2441232 | TotalAssetsBOY |
| Total Assets EOY | 2905699 | TotalAssetsEOY |
| Total Liabilities BOY | 47425 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 5999 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 2393807 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 2899700 | NetAssetsOrFundBalancesEOY |
| Mission Description | TO GENERATE FUNDS TO SECURE THE FUTURE OF COMMUNITY HOSPITAL BY STIMULATING PUBLIC AWARENESS AND SUPPORT. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 100981 | Expense |
| Grants | 100981 | Grants |
| Description | TO AID COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF THE HOSPITAL OR ITS PROGRAMS AND SERVICES. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK PROVIDES ACUTE, PREVENTATIVE, AND OTHER HEALTHCARE SERVICES ON A NONDISCRIMINITORY BASIS AND IN AN ENVIRONMENT WHICH IS RESPONSIVE TO THE UNIQUE NEEDS OF ITS PATIENTS. FUNDRAISING ACTIVITIES INCLUDE A GOLF TOURNAMENT, AN EVENING FOR HOSPICE GALA AND ANNUAL APPEALS. | Description |
| Total Program Service Expense | 100981 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 1 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 1 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 8 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 2 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 1 | QuidProQuoContributions |
| Quid Pro Quo Disclosure | 1 | QuidProQuoDisclosure |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 10 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 10 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TERRI SHIPSHOCK EXECUTIVE DIRECTOR | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 3083447222 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 801 WEST C STREET | AddressLine1 |
| City | MCCOOK | City |
| State | NE | State |
| ZIP Code | 69001 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (11 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| COREY BROCKWAY | ||||||
| CHAIR | 1.00 | X | X | 0 | 0 | 0 |
| kristI CLAPP | ||||||
| vICE CHAIR | 1.00 | X | X | 0 | 0 | 0 |
| janE STULL | ||||||
| seCRETARY | 1.00 | X | X | 0 | 0 | 0 |
| RON SMITH | ||||||
| TREASURER | 1.00 | X | X | 0 | 0 | 0 |
| BRIAN ESCH | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| JIM ULRICH | ||||||
| MEMBER | 1.00 | X | 0 | 162182 | 40598 | |
| MARTY CONROY | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| DAVE SMITH | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| SARA RIPPEN | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| KEN FOSTER | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| TERRI SHIPSHOCK | ||||||
| EXECUTIVE DIRECTOR | 40.00 | X | 76130 | 0 | 14291 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 76130 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 162182 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 54889 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Fundraising Events | 37748 | FundraisingEvents |
| All Other Contributions | 504095 | AllOtherContributions |
| Total Contributions | 541843 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 71287 | TotalRevenueColumn |
| Exclusion | $71,287 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 100000 | Securities |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 96838 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 3162 | Securities |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 3162 | TotalRevenueColumn |
| Exclusion | $3,162 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 50922 | GrossIncomeFundraisingEvents |
| Cntrbtns Rprtd Fundraising Events | 37748 | CntrbtnsRprtdFundraisingEvents |
| Fundraising Direct Expenses | 34769 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 16153 | TotalRevenueColumn |
| Exclusion | $16,153 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 632445 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $90,602 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 100981 | Total |
| Program Services | 100981 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 97311 | Total |
| Management And General | 24328 | ManagementAndGeneral |
| Fundraising | 72983 | Fundraising |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 31234 | Total |
| Management And General | 15617 | ManagementAndGeneral |
| Fundraising | 15617 | Fundraising |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2186 | Total |
| Management And General | 1093 | ManagementAndGeneral |
| Fundraising | 1093 | Fundraising |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9004 | Total |
| Management And General | 4502 | ManagementAndGeneral |
| Fundraising | 4502 | Fundraising |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7991 | Total |
| Management And General | 2521 | ManagementAndGeneral |
| Fundraising | 5470 | Fundraising |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5663 | Total |
| Management And General | 5663 | ManagementAndGeneral |
Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 16390 | Total |
| Management And General | 16390 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1245 | Total |
| Fundraising | 1245 | Fundraising |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 970 | Total |
| Management And General | 18 | ManagementAndGeneral |
| Fundraising | 952 | Fundraising |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 910 | Total |
| Fundraising | 910 | Fundraising |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 395 | Total |
| Management And General | 95 | ManagementAndGeneral |
| Fundraising | 300 | Fundraising |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | FundraisingFundraising |
|---|---|---|
| NEWSLETTER EXPENSE | 4906 | 4906 |
| MISCELLANEOUS EXPENSES | 2337 | 2337 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 281523 | Total |
| Program Services | 100981 | ProgramServices |
| Management And General | 70227 | ManagementAndGeneral |
| Fundraising | 110315 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 690672 | BOY |
| EOY | 554539 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 37400 | BOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1684807 | BOY |
| EOY | 2329657 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 28353 | BOY |
| EOY | 21503 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2441232 | BOY |
| EOY | 2905699 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 47425 | BOY |
| EOY | 5999 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 47425 | BOY |
| EOY | 5999 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1075486 | BOY |
| EOY | 1204564 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 257839 | BOY |
| EOY | 193148 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1060482 | BOY |
| EOY | 1501988 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2393807 | BOY |
| EOY | 2899700 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2441232 | BOY |
| EOY | 2905699 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 0 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | X | SupportingOrganization509a3 |
| Supporting Org509a3 Type1 | X | SupportingOrg509a3Type1 |
| Contrib By Controlling Individual | 0 | ContribByControllingIndividual |
| Contribution By Related Party | 0 | ContributionByRelatedParty |
| Contrib By35 Controlled Entity | 0 | ContribBy35ControlledEntity |
Supported Org Information SupportedOrgInformation
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470533373 | EIN |
| Type Of Organization | LINE 3 | TypeOfOrganization |
| Listed In Governing Doc | 1 | ListedInGoverningDoc |
| Supported Organization Notified | 1 | SupportedOrganizationNotified |
| Organized In US | 1 | OrganizedInUS |
| Amount | $97,101 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Number Of Supported Orgs | 1 | TotalNumberOfSupportedOrgs |
| Sum Of Amounts | 97101 | SumOfAmounts |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 1545264 | BeginningOfYearBalance |
| Contributions | 441506 | Contributions |
| Investment Earnings Or Losses | 165360 | InvestmentEarningsOrLosses |
| Other Expenditures | 45171 | OtherExpenditures |
| Administrative Expenses | 11858 | AdministrativeExpenses |
| End Of Year Balance | 2095101 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 1852460 | BeginningOfYearBalance |
| Contributions | 42818 | Contributions |
| Investment Earnings Or Losses | -288173 | InvestmentEarningsOrLosses |
| Grants Or Scholarships | 0 | GrantsOrScholarships |
| Other Expenditures | 47008 | OtherExpenditures |
| Administrative Expenses | 14833 | AdministrativeExpenses |
| End Of Year Balance | 1545264 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 0.28310 | BoardDesignatedEOYBalance |
| Permanent Endowment EOY Balance | 0.71690 | PermanentEndowmentEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
| Total Of Book Value Land Buildings | 0 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | PAYABLE TO AFFILIATE | Description |
| Amount | $5,999 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 5999 | TotalOfAmounts |
| Total Revenue | 632445 | TotalRevenue |
| Total Expenses | 281523 | TotalExpenses |
| Excess Or Deficit For Year | 350922 | ExcessOrDeficitForYear |
| Other | $154,971 | OtherAmount |
| Total Adjustments | 154971 | TotalAdjustments |
| Excess Or Deficit Per FS | 505893 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 822185 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | 189740 | OtherRevenues |
| Revenue Not Rptd F990 | 189740 | RevenueNotRptdF990 |
| Revenue Subtotal | 632445 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 632445 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 316292 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 34769 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 34769 | ExpensesNotRptdF990 |
| Expenses Subtotal | 281523 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 281523 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part V, Line 4: | Description of Intended Use of Endowment Funds: | THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED IN SUPPORT OF THE COMMUNITY HOSPITAL'S PROGRAMS AND PROJECTS, INCLUDING PROPERTY AND EQUIPMENT PURCHASES, SCHOLARSHIPS, HOSPICE PROGRAMS, REHABILITATION SERVICES AND OTHERS. |
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | The Foundation is a not-for-profit corporation as described in Section 501(c)(3) of the Internal Revenue Code and IS exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Internal Revenue Service has established standards to be met to maintain tax-exempt status. In general, such standards require the Foundation to meet a community benefit standard and comply with various laws and regulations. The Foundation accounts for uncertainties in accounting for income tax assets and liabilities using guidance included in FASB ASC 740, Income Taxes. The Foundation recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. At June 30, 2010 and 2009, the Foundation had no uncertain tax positions accrued. |
| Part XI, Line 8 - Other Adjustments: | NET CHANGE IN UNREALIZED LOSSES ON OTHER THAN TRADING SECURITIES: 154971. | |
| Part XII, Line 2d - Other Adjustments: | SPECIAL EVENTS EXPENSE: 34769. UNREALIZED GAINS: 154971. | |
| Part XIII, Line 2d - Other Adjustments: | SPECIAL EVENTS EXPENSE: 34769. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | GOLF EVENT | NameOfEvent1 |
| Gross Receipts Event1 | 45611 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 21323 | CharitableContributionsEvent1 |
| Gross Revenue Event1 | 24288 | GrossRevenueEvent1 |
| Cash Prizes Event1 | 13200 | CashPrizesEvent1 |
| Rent Facility Costs Event1 | 7228 | RentFacilityCostsEvent1 |
| Food And Beverage Event1 | 3393 | FoodAndBeverageEvent1 |
| Other Direct Expenses Event1 | 2646 | OtherDirectExpensesEvent1 |
| Name Of Event2 | DINNER EVENT | NameOfEvent2 |
| Gross Receipts Event2 | 43059 | GrossReceiptsEvent2 |
| Charitable Contributions Event2 | 16425 | CharitableContributionsEvent2 |
| Gross Revenue Event2 | 26634 | GrossRevenueEvent2 |
| Cash Prizes Event2 | 100 | CashPrizesEvent2 |
| Rent Facility Costs Event2 | 2100 | RentFacilityCostsEvent2 |
| Food And Beverage Event2 | 3480 | FoodAndBeverageEvent2 |
| Other Direct Expenses Event2 | 2622 | OtherDirectExpensesEvent2 |
| Gross Receipts Total | 88670 | GrossReceiptsTotal |
| Charitable Contributions Total | 37748 | CharitableContributionsTotal |
| Gross Revenue Total Events | 50922 | GrossRevenueTotalEvents |
| Cash Prizes Total Events | 13300 | CashPrizesTotalEvents |
| Rent Facility Costs Total Events | 9328 | RentFacilityCostsTotalEvents |
| Food And Beverage Total Events | 6873 | FoodAndBeverageTotalEvents |
| Other Direct Expenses Total Events | 5268 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 34769 | DirectExpenseSummaryEvents |
| Net Income Summary | 16153 | NetIncomeSummary |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 1 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1301 EAST H STREET PO BOX 1328 | AddressLine1 |
| City | MCCOOK | City |
| State | NE | State |
| ZIP Code | 69001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 470533373 | EINOfRecipient |
| IRC Section | 501(C)(3) | IRCSection |
| Amount Of Cash Grant | 97101 | AmountOfCashGrant |
| Purpose Of Grant | GENERAL SUPPORT, EQUIPMENT, SUPPLIES, PATIENT EDUCATION, TRAINING AND SCHOLARSHIPS | PurposeOfGrant |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Nbr Of501 C3 And Govt Grants | 1 | TotalNbrOf501C3AndGovtGrants |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Procedure for Monitoring Grants in the U.S.: | Identifier |
| Return Reference | Part I, Line 2: | ReturnReference |
| Explanation | Schedule I, Part I, Line 2: GRANTS ARE MADE ONLY TO SELECTED 501(C)(3) ORGANIZATIONS AND OTHER EXEMPT ORGANIZATIONS. | Explanation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JIM ULRICH | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Base Compensation Filing Org | 0 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 162182 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 0 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 0 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 0 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 11536 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 0 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 29062 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 0 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 202780 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section A, line 6 | THE COMMUNITY HOSPITAL FOUNDATION HAS ONE MEMBER, THE COMMUNITY HOSPITAL ASSOCIATION. THE COMMUNITY HOSPITAL ASSOCIATION APPOINTS SIX OF THE TEN MEMBERS OF THE FOUNDATION'S BOARD OF DIRECTORS. THE REMAINING FOUR DIRECTORS INCLUDE THREE DIRECTORS FROM THE HOSPITAL ASSOCIATION'S BOARD (ONE OF WHOM IS THE THE CHAIRMAN OF THE BOARD) AND THE PRESIDENT OF THE HOSPITAL ASSOCIATION. |
| Form 990, Part VI, Section A, line 7a | VACANCIES FROM DIRECTORS WHOSE TERMS EXPIRE DURING THE ORGANIZATION'S TAX YEAR ARE FILLED BY NEW DIRECTORS APPOINTED BY THE FOUNDATION'S SOLE MEMBER, THE COMMUNITY HOSPITAL ASSOCIATION (SEE FORM 990, PART VI, SECTION A, LINE 6). VACANCIES OTHER THAN BY TERM EXPIRATION, ARE FILLED BY A MAJORITY VOTE OF THE REMAINING DIRECTORS OF THE FOUNDATION. |
| Form 990, Part VI, Section B, line 11 | Community Hospital HEALTH Foundation's Form 990 is prepared by the firm Seim Johnson. Management receives draft copies of the completed form 990 for review. After management has reviewed the returns, complete copies are distributed to all members of the Board of Directors of the Community Hospital HEALTH Foundation and the returns are approved for filing by the Board. Board approval is required prior to signature and submission of the returns to the IRS. |
| Form 990, Part VI, Section B, line 12c | The Community Hospital HEALTH Foundation policY requires all employees, contractors, and agents to report any conflicts of interest that arise. In addition, the Foundation has a conflict of interest policy that is applicable to directors, officers, members of committees and subcommittees with board-delegated powers and key employees. THE POLICY requires, among other things, all applicable persons to disclose any relationships that may create a conflict of interest. ALL APPLICABLE PERSONS are required to complete an annual disclosure of all such relationships. All such relationships are disclosed to the entire board and senior management, and any and all conflicts or potential conflicts are monitored by senior management. |
| Form 990, Part VI, Section B, line 15 | Community Hospital Foundation's process for determining the compensation of the executive director (ED) is as follows: The Executive Committee of the Board of Directors is responsible for setting the salary of the ED. Annually, the Committee conducts a review of the ED's performance, abilities, and overall effectiveness. The Committee is presented with salary and compensation survey data that is compiled by the human resource department. All source documentation is given to the Committee as well as summaries provided for ease of reference. The Executive Committee conducts the performance review with the ED and follows with a meeting in private chambers to discuss the review and to deliberate any and all changes to the employment agreement, including compensation and goals for the following year. Contemporaneous records are kept of all survey and comparability data used along with the results and decisions of the Executive Committee's meeting on compensation. |
| Form 990, Part VI, Section C, line 19 | Community Hospital Foundation makes its governing documents, conflict of interest policy, form 1023, form 990 and financial statements available to the public upon request. Any individual that would like a copy of any of the above mentioned documents can inspect those documents in person at the Foundation's office during normal business hours or request a copy in person, by phone, or by mail, and we will provide a copy free of charge. |
| FORM 990, PART XI, LINE 2C | Community Hospital Health Foundation has a separate committee from the hospital for budget and finance recommendations/decisions. The Foundation's management staff does take most of its major fiscal oversight decisions, including auditor selection, review and acceptance of audited financial statements, and tax review to the committee for a recommendation and then to the full Board for action. The full Board has ultimate oversight of all fiscal matters. |
| Form 990, PART VI, LINE 14: | CURRENTLY, THE FOUNDATION IS WORKING ON FINALIZING ITS OWN DOCUMENT RETENTION/DESTRUCTION POLICY. UNTIL THE DOCUMENT IS COMPLETED, THE FOUNDATION UTILIZES THE COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK'S POLICY AS NECESSARY. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1301 EAST H STREET PO BOX 1328 | AddressLine1 |
| City | MCCOOK | City |
| State | NE | State |
| ZIP Code | 69001 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470533373 | EIN |
| Primary Activities | HEALTHCARE; SUPPORTED ORGANIZATION | PrimaryActivities |
| Legal Domicile State | NE | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | 3 | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 1 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |