2011-01-25T15:20:59-06:00 2010-06-30 SEIM JOHNSON SESTAK & QUIST LLP 8807 INDIAN HILLS DRIVE SUITE 300 OMAHA NE 681144123 990 2009-07-01 470693261 COMMUNITY HOSPITAL HEALTH FOUNDATION COMM 3083447222 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 TERRI SHIPSHOCK 3083447222 2011-01-22 1 Harvey D Johnson 4023302660 2009 2016-02-24 21:20:13Z TERRI SHIPSHOCK 801 WEST C STREET PO BOX 1328 MCCOOK NE 69001 764052 0 X WWW.CHHFMCCOOK.ORG X 1985 NE TO SOLICIT GIFTS, GRANTS, DEVICES AND BEQUESTS FOR THE USE AND BENEFIT OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK. 10 10 2 40 0 0 170687 541843 0 -14040 74449 10760 16153 167407 632445 103304 100981 0 138312 147726 0 110315 32474 32816 274090 281523 -106683 350922 2441232 2905699 47425 5999 2393807 2899700 TO GENERATE FUNDS TO SECURE THE FUTURE OF COMMUNITY HOSPITAL BY STIMULATING PUBLIC AWARENESS AND SUPPORT. 0 0 100981 100981 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. 100981 1 1 0 0 0 0 0 0 1 1 1 0 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 8 0 1 2 1 0 0 0 0 0 1 1 0 0 0 10 10 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X TERRI SHIPSHOCK EXECUTIVE DIRECTOR 3083447222 801 WEST C STREET MCCOOK NE 69001 COREY BROCKWAY 1.00 X X 0 0 0 kristI CLAPP 1.00 X X 0 0 0 janE STULL 1.00 X X 0 0 0 RON SMITH 1.00 X X 0 0 0 BRIAN ESCH 1.00 X 0 0 0 JIM ULRICH 1.00 X 0 162182 40598 MARTY CONROY 1.00 X 0 0 0 DAVE SMITH 1.00 X 0 0 0 SARA RIPPEN 1.00 X 0 0 0 KEN FOSTER 1.00 X 0 0 0 TERRI SHIPSHOCK 40.00 X 76130 0 14291 76130 162182 54889 0 0 1 0 0 37748 504095 541843 71287 71287 100000 96838 3162 3162 3162 50922 37748 34769 16153 16153 632445 0 0 90602 100981 100981 97311 24328 72983 31234 15617 15617 2186 1093 1093 9004 4502 4502 7991 2521 5470 5663 5663 16390 16390 1245 1245 970 18 952 910 910 395 95 300 NEWSLETTER EXPENSE 4906 4906 MISCELLANEOUS EXPENSES 2337 2337 281523 100981 70227 110315 690672 554539 37400 1684807 2329657 28353 21503 2441232 2905699 47425 5999 47425 5999 X 1075486 1204564 257839 193148 1060482 1501988 2393807 2899700 2441232 2905699 X 0 1 0 X 0 X X 0 0 0 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 470533373 LINE 3 1 1 1 97101 1 97101 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1545264 441506 165360 45171 11858 2095101 1852460 42818 -288173 0 47008 14833 1545264 0.28310 0.71690 0 0 0 PAYABLE TO AFFILIATE 5999 5999 632445 281523 350922 154971 154971 505893 822185 189740 189740 632445 0 632445 316292 34769 34769 281523 0 281523 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. GOLF EVENT 45611 21323 24288 13200 7228 3393 2646 DINNER EVENT 43059 16425 26634 100 2100 3480 2622 88670 37748 50922 13300 9328 6873 5268 34769 16153 1 COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 470533373 501(C)(3) 97101 GENERAL SUPPORT, EQUIPMENT, SUPPLIES, PATIENT EDUCATION, TRAINING AND SCHOLARSHIPS 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: GRANTS ARE MADE ONLY TO SELECTED 501(C)(3) ORGANIZATIONS AND OTHER EXEMPT ORGANIZATIONS. X X X X 0 0 0 0 0 0 0 0 0 JIM ULRICH 0 162182 0 0 0 0 0 11536 0 29062 0 202780 0 0 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. COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK 1301 EAST H STREET PO BOX 1328 MCCOOK NE 69001 470533373 HEALTHCARE; SUPPORTED ORGANIZATION NE 501(C)(3) 3 N/A 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0