2021-11-15T09:56:44-06:00 2020-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2020-01-01 470686476 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION CHEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 KELLY UTLEY CFO 3082545825 2021-11-11 1 KELLY UTLEY 999009999 MEGAN L KOZIOL P01544037 4023302660 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z KELLY UTLEY 1000 POLE CREEK CROSSING SIDNEY NE 69162 38048 0 X WWW.SIDNEYRMC.COM X 1985 NE HEALTH CENTER FOUNDATION SUPPORTS SIDNEY REGIONAL MEDICAL CENTER IN THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICES. THROUGH OUR RESPONSIBLE DONATION MANAGEMENT, WE ARE HELPING TO ASSURE THAT OUR COMMUNITY WILL CONTINUE TO HAVE LOCAL, QUALITY HEALTH CARE AND CURRENT STATE-OF-THE-ART TECHNOLOGIES, IN A FACILITY MAINTAINED AND UPDATED TO MEET THE EMERGING AND GROWING NEEDS OF CHEYENNE COUNTY AND THE SURROUNDING REGIONS. 6 6 0 40 0 0 28875 18457 0 0 28189 19591 -6096 0 50968 38048 13014 11044 0 0 0 0 0 0 16007 11468 16007 24482 27051 26486 10997 1656652 1737974 0 2300 1656652 1735674 TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. 0 0 11044 11044 PROVIDE FUNDING TO SUPPORT SCHOLARSHIPS AND INTERN PROGRAMS FOR INDIVIDUALS CURRENTLY STUDYING IN THE HEALTH CARE FIELD. 0 0 PROVIDE SUPPORT TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, D/B/A SIDNEY REGIONAL MEDICAL CENTER, TO FURTHER THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICE. 0 0 PROVIDE FUNDING TO ASSIST WITH DENTAL PROCEDURES FOR THOSE IN NEED. 11044 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X KELLY UTLEY 3082545825 1000 POLE CREEK CROSSING SIDNEY NE 69162 BILL BUTKUS PRESIDENT 1.00 0.00 X X 0 0 0 SEAN DOYLE TREASURER 1.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 1.00 4.00 X 0 0 0 SHERI EHLER MEMBER 1.00 0.00 X 0 0 0 VICKIE SMITH MEMBER 1.00 0.00 X 0 0 0 NANCI MCCASLIN MEMBER 1.00 4.00 X 0 0 0 KELLY UTLEY EXECUTIVE DIRECTOR 1.00 39.00 X 0 199008 5706 0 199008 5706 0 0 1 0 0 1000 17457 18457 10470 10470 9121 0 9121 9121 9121 0 1000 0 0 38048 0 0 19591 11044 11044 2300 2300 70 70 3845 3845 536 536 484 484 3008 3008 MISCELLANEOUS FUNDRAISI 4763 4763 DUES & SUBSCRIPTIONS 1001 1001 27051 11044 0 16007 1080095 1090645 202590 58563 147035 144027 429522 503302 1656652 1737974 2300 0 2300 X 1411471 1482252 245181 253422 1656652 1735674 1656652 1737974 10997 68032 -7 0 X X 0 1 X 1 0 X X 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 470408242 3 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 SECTION D, LINE 3: THE SUPPORTED ORGANIZATION, CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC., APPOINTS 2 MEMBERS OF ITS BOARD OF DIRECTORS TO SIT ON THE BOARD OF DIRECTORS OF THE CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION. THESE DIRECTORS SERVE TO ASSIST IN THE DIRECTION OF THE FOUNDATION AND LEND A SIGNIFICANT VOICE TO ALL POLICIES AND PROCEDURES AND SERVE DURING THE ENTIRE YEAR. ADDITIONALLY, THE CFO OF THE CHEYENNE COUNTY HOSPITAL ASSOCIATION SERVES ON THE BOARD AS A FINANCIAL REPRESENTATIVE GIVING GUIDANCE TO THE BOARD AS NEEDED. SECTION E, LINE 2A: THE PURPOSE OF THE ORGANIZATION IS TO SUPPORT THE CHEYENNE COUNTY HOSPITAL ASSOCIATION TO ASSURE THAT THERE IS AND ALWAYS WILL BE A STRONG FOUNDATION SUPPORTING HEALTH CARE IN CHEYENNE COUNTY. DURING 2020, THE FOUNDATION'S ACTIVITIES WERE FOCUSED ON THE SUPPORT OF THE HEALTHCARE MISSION AND INCREASING COMMUNITY AWARENESS OF THE FOUNDATION ITSELF. SIDNEY REGIONAL MEDICAL CENTER REQUESTED SUPPORT FROM THE FOUNDATION IN THE FORM OF FUNDING FOR EDUCATION AND SCHOLARSHIPS. THE FOUNDATION ALSO FUNDED AND HOSTED INTERNS WHO FURTHERED THEIR HEALTHCARE EDUCATION BY SHADOWING AND WORKING WITHIN THE HOSPITAL ORGANIZATION. MANY OF THESE INTERNS, AS WELL AS SCHOLARSHIP RECIPIENTS OF THE FOUNDATION, GO ON AND SUCCEED IN THEIR HEALTHCARE PROFESSIONS AND RETURN TO THE SIDNEY, NEBRASKA AREA AFTER THEIR TRAINING AND EDUCATION IS COMPLETE. SECTION E, LINE 2B: IF THE FOUNDATION DIDN'T EXIST THERE WOULD STILL NEED TO BE A MECHANISM FOR ACCEPTING BEQUESTS AND OTHER GIFTS FROM PATIENTS, AS WELL AS FUNDRAISING FOR NEEDED EQUIPMENT AND FACILITIES IMPROVEMENTS. THE INTERN PROGRAM WOULD CONTINUE IN ORDER TO FURTHER THE RECRUITING EFFORTS BY THE HOSPITAL. THESE DEEPLY ROOTED EVENTS WOULD NEED TO CONTINUE TO BE HELD WITHIN THE COMMUNITY IN ORDER TO PROMOTE HEALTHY LIVING ACTIVITIES AND HOSPITAL COMMUNITY BENEFITS. 126483 126483 75188 57644 17544 919 919 0 144027 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2020, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. 1 INTERN PROGRAM 2 9044 SCHOLARSHIP PROGRAM 2 2000 PART I, LINE 2: CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION PROVIDES FUNDS TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, D/B/A SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE FUNDS ARE UTILIZED FOR ASSET PURCHASES AND OPERATIONS OF THE HOSPITAL. THE INTERNSHIP AND SCHOLARSHIP PROGRAM GRANTS LEARNING OPPORTUNITIES TO INDIVIDUALS IN THE AREA CURRENTLY STUDYING IN THE HEALTH CARE FIELD. 0 0 0 0 0 0 0 0 0 KELLY UTLEY EXECUTIVE DIRECTOR 0 198582 0 0 0 426 0 4337 0 1369 0 204714 0 0 PART I, LINE 3 KELLY UTLEY, THE EXECUTIVE DIRECTOR OF THE FOUNDATION, IS AN EMPLOYEE OF CHEYENNE COUNTY HOSPITAL ASSOCIATION, D/B/A SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE BOARD OF DIRECTORS OF THE MEDICAL CENTER REVIEWS MARKET COMPENSATION DATA FOR ALL HOSPITAL STAFF AND THE CEO OF THE MEDICAL CENTER APPROVES THE COMPENSATION FOR THE EXECUTIVE DIRECTOR. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 INFORMATION IS ACCUMULATED BY THE ACCOUNTING DEPARTMENT AND SUBMITTED TO THE INDEPENDENT PUBLIC ACCOUNTANTS FOR FURTHER REVIEW AND PREPARATION. COMMUNICATIONS BETWEEN THE INDEPENDENT PUBLIC ACCOUNTANTS AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. AFTER THE PREPARATION IS COMPLETE, THE EXECUTIVE DIRECTOR REVIEWS THE FORM 990. UPON APPROVAL, THE FORM 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE FORM 990 HAS BEEN REVIEWED BY ALL PARTIES, IT WILL BE SUBMITTED TO THE IRS ON OR BEFORE THE EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE IS REQUIRED TO BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF BOARD RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER ABSTAINS FROM DISCUSSION AND THE VOTE. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 15: AS THE ORGANIZATION DOES NOT HAVE ANY EMPLOYEES, THERE IS NO INDEPENDENT REVIEW AND APPROVAL OF COMPENSATION. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 1000 POLE CREEK CROSSING SIDNEY NE 69162 470408242 PROVIDING HEALTH CARE TO THOSE IN THE COMMUNITY NE 501(C)(3) LINE 3 N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 0 0