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COMMUNITY HOSPITAL HEALTH FOUNDATION: Form 990, tax year 2010

View the entire original 990 at ProPublica ↗

Organization
COMMUNITY HOSPITAL HEALTH FOUNDATION (EIN 47-0693261)
Tax period
2010-07-01 to 2011-06-30
Filed
2011-12-15
IRS object ID
201123509349300017
Schema version
2010v3.4
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 ReturnHeader

FieldValueIRS element (for citing)
Timestamp2011-12-15T12:40:18-06:00Timestamp
Tax Period End Date2011-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1SEIM JOHNSON LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line118081 BURT STREET SUITE 200AddressLine1
CityOMAHACity
StateNEState
ZIP Code680224722ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2010-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN470693261EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY HOSPITAL HEALTH FOUNDATIONBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlCOMMNameControl
Phone3083447222Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1801 WEST C STREET PO BOX 1328AddressLine1
CityMCCOOKCity
StateNEState
ZIP Code69001ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameTERRI SHIPSHOCKName
TitleEXECUTIVE DIRECTORTitle
Phone3083447222Phone
Date Signed2011-12-15DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameHARVEY D JOHNSONName
Phone4023302660Phone
FieldValueIRS element (for citing)
Tax Year2010TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonTERRI SHIPSHOCKNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1801 WEST C STREET PO BOX 1328AddressLine1
CityMCCOOKCity
StateNEState
ZIP Code69001ZIPCode
FieldValueIRS element (for citing)
Gross Receipts956609GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.CHHFMCCOOK.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1985YearFormation
State Legal DomicileNEStateLegalDomicile
Activity Or Mission DescriptionTO SOLICIT GIFTS, GRANTS, DEVICES AND BEQUESTS FOR THE USE AND BENEFIT OF COMMUNITY HOSPITAL ASSOCIATION OF MCCOOK.ActivityOrMissionDescription
Nbr Voting Members Governing Body10NbrVotingMembersGoverningBody
Nbr Independent Voting Members10NbrIndependentVotingMembers
Total Nbr Employees2TotalNbrEmployees
Total Nbr Volunteers40TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year541843ContributionsGrantsPriorYear
Contributions Grants Current Year534121ContributionsGrantsCurrentYear
Program Service Revenue Prior Year0ProgramServiceRevenuePriorYear
Program Service Revenue CY0ProgramServiceRevenueCY
Investment Income Prior Year74449InvestmentIncomePriorYear
Investment Income Current Year237815InvestmentIncomeCurrentYear
Other Revenue Prior Year16153OtherRevenuePriorYear
Other Revenue Current Year5387OtherRevenueCurrentYear
Total Revenue Prior Year632445TotalRevenuePriorYear
Total Revenue Current Year777323TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year100981GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY147049GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year147726SalariesEtcPriorYear
Salaries Etc Current Year145131SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year114711TotalFundrsngExpCurrentYear
Other Expense Prior Year32816OtherExpensePriorYear
Other Expenses Current Year38612OtherExpensesCurrentYear
Total Expenses Prior Year281523TotalExpensesPriorYear
Total Expenses Current Year330792TotalExpensesCurrentYear
Revenues Less Expenses Prior Year350922RevenuesLessExpensesPriorYear
Revenues Less Expenses CY446531RevenuesLessExpensesCY
Total Assets BOY2905699TotalAssetsBOY
Total Assets EOY3719456TotalAssetsEOY
Total Liabilities BOY5999TotalLiabilitiesBOY
Total Liabilities EOY85783TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY2899700NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY3633673NetAssetsOrFundBalancesEOY
Mission DescriptionTO GENERATE FUNDS TO SECURE THE FUTURE OF COMMUNITY HOSPITAL BY STIMULATING PUBLIC AWARENESS AND SUPPORT.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense147049Expense
Grants147049Grants
DescriptionTO 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 Expense147049TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities1FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations1GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10968NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees2NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions1QuidProQuoContributions
Quid Pro Quo Disclosure1QuidProQuoDisclosure
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members10NbrVotingGoverningBodyMembers
Number Independent Voting Members10NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1TERRI SHIPSHOCK EXECUTIVE DIRECTORBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number3083447222TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1801 WEST C STREETAddressLine1
CityMCCOOKCity
StateNEState
ZIP Code69001ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (11 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
COREY BROCKWAY
CHAIR1.00XX000
KRISTI CLAPP
VICE CHAIR1.00XX000
JANE STULL
SECRETARY1.00XX000
KEN FOSTER
TREASURER1.00XX000
BRIAN ESCH
MEMBER1.00X000
JIM ULRICH
MEMBER1.00X018002233741
MARTY CONROY
MEMBER1.00X000
DAVE SMITH
MEMBER1.00X000
SARA RIPPEN
MEMBER1.00X000
PAT MARVIN
MEMBER1.00X000
TERRI SHIPSHOCK
EXECUTIVE DIRECTOR40.00X77353018912
FieldValueIRS element (for citing)
Total Reportable Comp From Org77353TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs180022TotalReportableCompFrmRltdOrgs
Total Other Compensation52653TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources
Number Of Contractors GT100 K0NumberOfContractorsGT100K
Fundraising Events43427FundraisingEvents
All Other Contributions490694AllOtherContributions
Total Contributions534121TotalContributions

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column74752TotalRevenueColumn
Exclusion$74,752ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities300000Securities

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities136937Securities

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities163063Securities

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column163063TotalRevenueColumn
Exclusion$163,063ExclusionAmount
FieldValueIRS element (for citing)
Gross Income Fundraising Events47736GrossIncomeFundraisingEvents
Cntrbtns Rprtd Fundraising Events43427CntrbtnsRprtdFundraisingEvents
Fundraising Direct Expenses42349FundraisingDirectExpenses

Net Income From Fundraising Events NetIncomeFromFundraisingEvents

FieldValueIRS element (for citing)
Total Revenue Column5387TotalRevenueColumn
Exclusion$5,387ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column777323TotalRevenueColumn
Related Or Exempt Function Income0RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$243,202ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total147049Total
Program Services147049ProgramServices

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total75955Total
Management And General18989ManagementAndGeneral
Fundraising56966Fundraising

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total30877Total
Management And General15438ManagementAndGeneral
Fundraising15439Fundraising

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total7813Total
Management And General2524ManagementAndGeneral
Fundraising5289Fundraising

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total23577Total
Management And General8558ManagementAndGeneral
Fundraising15019Fundraising

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total6909Total
Management And General2188ManagementAndGeneral
Fundraising4721Fundraising

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total6008Total
Management And General6008ManagementAndGeneral

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total15259Total
Management And General15259ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total9013Total
Fundraising9013Fundraising

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1483Total
Management And General18ManagementAndGeneral
Fundraising1465Fundraising

Information Technology InformationTechnology

FieldValueIRS element (for citing)
Total910Total
Fundraising910Fundraising

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total549Total
Management And General50ManagementAndGeneral
Fundraising499Fundraising

Other Expenses OtherExpenses (2 entries)

DescriptionDescriptionTotalTotalFundraisingFundraising
MISCELLANEOUS EXPENSES30433043
NEWSLETTER EXPENSE23472347

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total330792Total
Program Services147049ProgramServices
Management And General69032ManagementAndGeneral
Fundraising114711Fundraising

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY554539BOY
EOY258186EOY

Pledges And Grants Receivable PledgesAndGrantsReceivable

FieldValueIRS element (for citing)
EOY136334EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY2329657BOY
EOY3306033EOY

Investments Program Related InvestmentsProgramRelated

FieldValueIRS element (for citing)
BOY21503BOY
EOY18903EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY2905699BOY
EOY3719456EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY5999BOY
EOY85783EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY5999BOY
EOY85783EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY1204564BOY
EOY1864457EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY193148BOY
EOY255992EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY1501988BOY
EOY1513224EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY2899700BOY
EOY3633673EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY2905699BOY
EOY3719456EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses446531ReconcilationRevenueExpenses
Reconcilation Other Changes287442ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee0AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3XSupportingOrganization509a3
Supporting Org509a3 Type1XSupportingOrg509a3Type1
Contrib By Controlling Individual0ContribByControllingIndividual
Contribution By Related Party0ContributionByRelatedParty
Contrib By35 Controlled Entity0ContribBy35ControlledEntity

Supported Org Information SupportedOrgInformation

Name Name

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY HOSPITAL ASSOCIATION OF MCCOOKBusinessNameLine1
FieldValueIRS element (for citing)
EIN470533373EIN
Type Of OrganizationLINE 3TypeOfOrganization
Listed In Governing Doc1ListedInGoverningDoc
Supported Organization Notified1SupportedOrganizationNotified
Organized In US1OrganizedInUS
Amount$144,591Amount
FieldValueIRS element (for citing)
Total Number Of Supported Orgs1TotalNumberOfSupportedOrgs
Sum Of Amounts144591SumOfAmounts

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance2095101BeginningOfYearBalance
Contributions11236Contributions
Investment Earnings Or Losses408161InvestmentEarningsOrLosses
Other Expenditures142894OtherExpenditures
Administrative Expenses35723AdministrativeExpenses
End Of Year Balance2335881EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance1545264BeginningOfYearBalance
Contributions441506Contributions
Investment Earnings Or Losses165360InvestmentEarningsOrLosses
Other Expenditures45171OtherExpenditures
Administrative Expenses11858AdministrativeExpenses
End Of Year Balance2095101EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance1852460BeginningOfYearBalance
Contributions42818Contributions
Investment Earnings Or Losses-288173InvestmentEarningsOrLosses
Other Expenditures47008OtherExpenditures
Administrative Expenses14833AdministrativeExpenses
End Of Year Balance1545264EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance0.35200BoardDesignatedEOYBalance
Permanent Endowment EOY Balance0.64800PermanentEndowmentEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs0EndowmentsHeldByRelatedOrgs
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
DescriptionPAYABLE TO AFFILIATEDescription
Amount$85,783Amount
FieldValueIRS element (for citing)
Total Of Amounts85783TotalOfAmounts
Total Revenue777323TotalRevenue
Total Expenses330792TotalExpenses
Excess Or Deficit For Year446531ExcessOrDeficitForYear
Other$287,442OtherAmount
Total Adjustments287442TotalAdjustments
Excess Or Deficit Per FS733973ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt1107114TotRevenueEtcAuditedFinclStmt
Other Revenues329791OtherRevenues
Revenue Not Rptd F990329791RevenueNotRptdF990
Revenue Subtotal777323RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form990777323TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt373141TotExpensesEtcAuditedFinclStmt
Other Expenses Included42349OtherExpensesIncluded
Expenses Not Rptd F99042349ExpensesNotRptdF990
Expenses Subtotal330792ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form990330792TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:PART V, LINE 4: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.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X: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 287,442.
PART XII, LINE 2D - OTHER ADJUSTMENTS:SPECIAL EVENTS EXPENSE 42,349. UNREALIZED GAINS 287,442.
PART XIII, LINE 2D - OTHER ADJUSTMENTS:SPECIAL EVENTS EXPENSE 42,349.

Schedule G IRS990ScheduleG

Events Information EventsInformation

FieldValueIRS element (for citing)
Name Of Event1GOLF EVENTNameOfEvent1
Gross Receipts Event148930GrossReceiptsEvent1
Charitable Contributions Event122512CharitableContributionsEvent1
Gross Revenue Event126418GrossRevenueEvent1
Cash Prizes Event114630CashPrizesEvent1
Rent Facility Costs Event16596RentFacilityCostsEvent1
Food And Beverage Event14459FoodAndBeverageEvent1
Other Direct Expenses Event11537OtherDirectExpensesEvent1
Name Of Event2DINNER EVENTNameOfEvent2
Gross Receipts Event242233GrossReceiptsEvent2
Charitable Contributions Event220915CharitableContributionsEvent2
Gross Revenue Event221318GrossRevenueEvent2
Rent Facility Costs Event21780RentFacilityCostsEvent2
Food And Beverage Event24422FoodAndBeverageEvent2
Entertainment Event26500EntertainmentEvent2
Other Direct Expenses Event22425OtherDirectExpensesEvent2
Gross Receipts Total91163GrossReceiptsTotal
Charitable Contributions Total43427CharitableContributionsTotal
Gross Revenue Total Events47736GrossRevenueTotalEvents
Cash Prizes Total Events14630CashPrizesTotalEvents
Rent Facility Costs Total Events8376RentFacilityCostsTotalEvents
Food And Beverage Total Events8881FoodAndBeverageTotalEvents
Entertainment Total Events6500EntertainmentTotalEvents
Other Direct Expenses Total Events3962OtherDirectExpensesTotalEvents
Direct Expense Summary Events42349DirectExpenseSummaryEvents
Net Income Summary5387NetIncomeSummary

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable

Recipient Name Business RecipientNameBusiness

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY HOSPITAL ASSOCIATION OF MCCOOKBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11301 EAST H STREET PO BOX 1328AddressLine1
CityMCCOOKCity
StateNEState
ZIP Code69001ZIPCode
FieldValueIRS element (for citing)
EIN Of Recipient470533373EINOfRecipient
IRC Section501(C)(3)IRCSection
Amount Of Cash Grant143451AmountOfCashGrant
Purpose Of GrantGENERAL SUPPORT, EQUIPMENT, SUPPLIES, PATIENT EDUCATION, TRAINING AND SCHOLARSHIPSPurposeOfGrant

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierPROCEDURE FOR MONITORING GRANTS IN THE U.S.:Identifier
Return ReferencePART I, LINE 2:ReturnReference
ExplanationSCHEDULE I, PART I, LINE 2: GRANTS ARE MADE ONLY TO SELECTED 501(C)(3) ORGANIZATIONS AND OTHER EXEMPT ORGANIZATIONS.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation CommitteeXCompensationCommittee
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII

FieldValueIRS element (for citing)
Name PersonJIM ULRICHNamePerson
Base Compensation Filing Org0BaseCompensationFilingOrg
Comp Based On Related Orgs180022CompBasedOnRelatedOrgs
Bonus Filing Org0BonusFilingOrg
Bonus Related Orgs0BonusRelatedOrgs
Other Compensation Filing Org0OtherCompensationFilingOrg
Other Compensation Related Orgs0OtherCompensationRelatedOrgs
Deferred Comp Filing Org0DeferredCompFilingOrg
Deferred Comp Related Orgs21741DeferredCompRelatedOrgs
Nontaxable Benefits Filing Org0NontaxableBenefitsFilingOrg
Nontaxable Benefits Related Orgs12000NontaxableBenefitsRelatedOrgs
Total Compensation Filing Org0TotalCompensationFilingOrg
Total Compensation Related Orgs213763TotalCompensationRelatedOrgs
Comp Report Prior990 Filing Org0CompReportPrior990FilingOrg
Comp Report Prior990 Related Orgs0CompReportPrior990RelatedOrgs

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (8 entries)

IdentifierIdentifierExplanationExplanationReturn ReferenceReturnReference
FORM 990, PART VI, SECTION A, LINE 6THE 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 7AVACANCIES 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 11COMMUNITY 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.
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 12C
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 B, LINE 15
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 VI, SECTION C, LINE 19
CHANGES IN NET ASSETS OR FUND BALANCES:NET CHANGE IN UNREALIZED LOSSES ON OTHER THAN TRADING SECURITIES 287,442. TOTAL TO FORM 990, PART XI, LINE 5: 287,442.FORM 990, PART XI, LINE 5:
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 XI, LINE 2C

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1COMMUNITY HOSPITAL ASSOCIATION OF MCCOOKBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11301 EAST H STREET PO BOX 1328AddressLine1
CityMCCOOKCity
StateNEState
ZIP Code69001ZIPCode
FieldValueIRS element (for citing)
EIN470533373EIN
Primary ActivitiesHEALTHCARE; SUPPORTED ORGANIZATIONPrimaryActivities
Legal Domicile StateNELegalDomicileState
Exempt Code Section501(C)(3)ExemptCodeSection
Public Charity Status3PublicCharityStatus
Direct Controlling Entity NAN/ADirectControllingEntityNA
Controlled Org0ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org1GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org1GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg