FAIRBURY ASSISTED LIVING FACILITY: Form 990, tax year 2018
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- Organization
- FAIRBURY ASSISTED LIVING FACILITY (EIN 47-0841274)
- Tax period
- 2018-10-01 to 2019-09-30
- Filed
- 2020-08-10
- IRS object ID
- 202002239349300015
- Schema version
- 2018v3.2
- 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2020-08-10T12:04:02-05:00 | ReturnTs |
| Tax Period End | 2019-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2018-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470841274 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRBURY ASSISTED LIVING FACILITY | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FAIR | BusinessNameControlTxt |
| Phone | 4027296100 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 828 22ND STREET | AddressLine1Txt |
| City | FAIRBURY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68352 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | CHANCE KLASEK | PersonNm |
| Person Title | SECRETARY | PersonTitleTxt |
| Phone | 4027293351 | PhoneNum |
| Signature | 2020-08-10 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MEGAN L KOZIOL | PreparerPersonNm |
| PTIN | P01544037 | PTIN |
| Phone | 4023302660 | PhoneNum |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 209.34.201.180 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2020-08-10 | IPDt |
| IP Tm | 07:33:17 | IPTm |
| IP Timezone | CD | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 05D57004E72D560A8AB00D9FF642C8776C6EAF55 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | C95AA154BB3428A46C5F7CAB7894FBC19C420CF6 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2018 | TaxYr |
| Build TS | 2020-09-23 17:36:50Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CEDARWOOD | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | CHANCE KLASEK | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2200 H STREET PO BOX 277 | AddressLine1Txt |
| City | FAIRBURY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68352 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $1,951,015 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | HTTPS://WWW.CEDARWOODAL.ORG/ | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 2001 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | CEDARWOOD STRIVES TO PROVIDE THE HIGHEST QUALITY OF HOSPITALITY, SERVICES, ACTIVITIES, SECURITY, COMPANIONSHIP AND FREEDOM TO TENANTS IN A CARING AND LOVING ENVIRONMENT THAT THE TENANTS ARE PROUD TO CALL THEIR HOME. CEDARWOOD'S SERVICES ARE PROVIDED TO THE RESIDENTS OF JEFFERSON COUNTY. | ActivityOrMissionDesc |
| Voting Members Governing Body | 6 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 41 | TotalEmployeeCnt |
| Total Volunteers | 8 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $112 | PYContributionsGrantsAmt |
| CY Contributions Grants | $100 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $1,788,255 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $1,942,276 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$3,185 | PYInvestmentIncomeAmt |
| CY Investment Income | $8,639 | CYInvestmentIncomeAmt |
| PY Other Revenue | $92,547 | PYOtherRevenueAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $1,877,729 | PYTotalRevenueAmt |
| CY Total Revenue | $1,951,015 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $620,179 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $605,210 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $1,022,111 | PYOtherExpensesAmt |
| CY Other Expenses | $1,042,927 | CYOtherExpensesAmt |
| PY Total Expenses | $1,642,290 | PYTotalExpensesAmt |
| CY Total Expenses | $1,648,137 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $235,439 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $302,878 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $2,905,826 | TotalAssetsBOYAmt |
| Total Assets EOY | $2,809,590 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $1,474,956 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $1,065,438 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $1,430,870 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $1,744,152 | NetAssetsOrFundBalancesEOYAmt |
| Mission | TO PROVIDE THE HIGHEST QUALITY OF HOSPITALITY, SERVICES, ACTIVITIES, SECURITY, COMPANIONSHIP AND FREEDOM TO TENANTS IN A CARING AND LOVING ENVIRONMENT THEY ARE PROUD TO CALL HOME. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $1,407,491 | ExpenseAmt |
| Revenue | $1,942,276 | RevenueAmt |
| Desc | CEDARWOOD ASSISTED LIVING FACILITY WAS CONSTRUCTED ADJACENT TO JEFFERSON COMMUNITY HEALTH CENTER, INC. (JCHC), A NEBRASKA NON-PROFIT HOSPITAL EXEMPT FROM INCOME TAXES UNDER I.R.C. 501(C)(3). THE PURPOSE OF THE 50-UNIT FACILITY IS TO MEET AN IDENTIFIABLE COMMUNITY NEED IN THE FAIRBURY AREA, AND TO DEVELOP A MORE COMPREHENSIVE CONTINUUM OF HEALTH CARE THAT COMPLEMENTS THE HEALTH CARE SERVICES ALREADY AVAILABLE ON THE CAMPUS OF JCHC. SIXTY-SEVEN RESIDENTS WERE SERVED FROM OCTOBER 2018 THROUGH SEPTEMBER 2019. FOURTEEN OF THESE RESIDENTS QUALIFIED UNDER THE MEDICAID WAIVER PROGRAM. TOTAL DAYS OF CARE PROVIDED WERE 18,729. | Desc |
| Total Program Service Expenses | $1,407,491 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | 0 | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | 0 | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 0 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 41 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 6 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | 0 | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | 0 | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | CHANCE KLASEK | PersonNm |
| Phone | 4027296856 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2200 H STREET PO BOX 277 | AddressLine1Txt |
| City | FAIRBURY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68352 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
| No Listed Persons Compensated | Yes (X) | NoListedPersonsCompensatedInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (9 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|
| HOMER WARD | ||||||
| CHAIRMAN | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| BRYCE BETKE | ||||||
| VICE CHAIRMAN | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| CHANCE KLASEK | ||||||
| SECRETARY | 5.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| REGINA BERGH | ||||||
| TREASURER | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| RUSSELL GRONEWOLD | ||||||
| TREASURER THRU 09/19 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| RICK STANTON | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| CAROL FRIESEN | ||||||
| BOARD MEMBER THRU 05/19 | 1.00 | Yes (X) | $0 | $0 | $0 | |
| DAVID REESE | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| CHAD JURGENS | ||||||
| PRESIDENT/CEO | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $0 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $0 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp
Contractor Name ContractorName
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JEFFERSON COMMUNITY HEALTH CENTER INC | BusinessNameLine1Txt |
Contractor Address ContractorAddress
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2200 H STREET PO BOX 277 | AddressLine1Txt |
| City | FAIRBURY | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68352 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Services | MANAGEMENT FEES AND OTHER CONTRACTED SER | ServicesDesc |
| Compensation | $569,664 | CompensationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 1 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $100 | AllOtherContributionsAmt |
| Total Contributions | $100 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| RESIDENT REVENUE | 623000 | $1,653,570 | $1,653,570 |
| MEDICAID PAYMENTS | 623000 | $282,956 | $282,956 |
| RENTAL INCOME | 900002 | $5,750 | $5,750 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $1,942,276 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $8,639 | TotalRevenueColumnAmt |
| Exclusion | $8,639 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,951,015 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $1,942,276 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $8,639 | ExclusionAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $520,205 | TotalAmt |
| Program Services | $424,550 | ProgramServicesAmt |
| Management And General | $95,655 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $42,783 | TotalAmt |
| Program Services | $37,228 | ProgramServicesAmt |
| Management And General | $5,555 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $42,222 | TotalAmt |
| Program Services | $34,458 | ProgramServicesAmt |
| Management And General | $7,764 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $97,205 | TotalAmt |
| Management And General | $97,205 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,810 | TotalAmt |
| Management And General | $12,810 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,978 | TotalAmt |
| Program Services | $2,199 | ProgramServicesAmt |
| Management And General | $8,779 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,260 | TotalAmt |
| Program Services | $12,125 | ProgramServicesAmt |
| Management And General | $135 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $91,254 | TotalAmt |
| Program Services | $82,526 | ProgramServicesAmt |
| Management And General | $8,728 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $66,558 | TotalAmt |
| Program Services | $65,823 | ProgramServicesAmt |
| Management And General | $735 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,462 | TotalAmt |
| Program Services | $2,435 | ProgramServicesAmt |
| Management And General | $27 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $721 | TotalAmt |
| Program Services | $713 | ProgramServicesAmt |
| Management And General | $8 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,276 | TotalAmt |
| Program Services | $40,820 | ProgramServicesAmt |
| Management And General | $456 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $217,514 | TotalAmt |
| Program Services | $215,112 | ProgramServicesAmt |
| Management And General | $2,402 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,015 | TotalAmt |
| Program Services | $18,805 | ProgramServicesAmt |
| Management And General | $210 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| RESIDENT MEALS | $454,863 | $454,863 | |
| DUES & SUBSCRIPTIONS | $14,907 | $14,742 | $165 |
| BAD DEBT | $1,104 | $1,092 | $12 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,648,137 | TotalAmt |
| Program Services | $1,407,491 | ProgramServicesAmt |
| Management And General | $240,646 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $108,378 | BOYAmt |
| EOY | $205,031 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $201,238 | BOYAmt |
| EOY | $206,322 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,625 | BOYAmt |
| EOY | $26,423 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $20,370 | BOYAmt |
| EOY | $14,150 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $5,717,064 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $3,641,675 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,281,468 | BOYAmt |
| EOY | $2,075,389 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $282,436 | BOYAmt |
| EOY | $280,964 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,311 | BOYAmt |
| EOY | $1,311 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,905,826 | BOYAmt |
| EOY | $2,809,590 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $53,752 | BOYAmt |
| EOY | $55,055 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,165,000 | BOYAmt |
| EOY | $861,200 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $152,630 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $103,574 | BOYAmt |
| EOY | $149,183 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,474,956 | BOYAmt |
| EOY | $1,065,438 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,430,870 | BOYAmt |
| EOY | $1,744,152 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,430,870 | BOYAmt |
| EOY | $1,744,152 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,905,826 | BOYAmt |
| EOY | $2,809,590 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $302,878 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $10,404 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org509a2 | Yes (X) | PubliclySupportedOrg509a2Ind |
Gifts Grants Contris Rcvd509 GiftsGrantsContrisRcvd509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $100 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $675 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $632 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $112 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $100 | CurrentTaxYearAmt |
| Total | $1,619 | TotalAmt |
Gross Receipts Admissions GrossReceiptsAdmissionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $1,830,191 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $1,866,344 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $1,861,517 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $1,788,255 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $1,942,276 | CurrentTaxYearAmt |
| Total | $9,288,583 | TotalAmt |
Total509 Total509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $1,830,291 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $1,867,019 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $1,862,149 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $1,788,367 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $1,942,376 | CurrentTaxYearAmt |
| Total | $9,290,202 | TotalAmt |
Amounts Rcvd Dsqlfy Person AmountsRcvdDsqlfyPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
Substantial Contributors Amt SubstantialContributorsAmtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
Subst And Dsqlfy Prsns Tot SubstAndDsqlfyPrsnsTotGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $0 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total509 | $9,290,202 | PublicSupportTotal509Amt |
Gross Investment Income509 GrossInvestmentIncome509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $12,809 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $3,069 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $3,705 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $7,144 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $8,639 | CurrentTaxYearAmt |
| Total | $35,366 | TotalAmt |
Investment Income And UBTI InvestmentIncomeAndUBTIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $12,809 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $3,069 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $3,705 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $7,144 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $8,639 | CurrentTaxYearAmt |
| Total | $35,366 | TotalAmt |
Other Income509 OtherIncome509Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus1 Year | $92,547 | CurrentTaxYearMinus1YearAmt |
| Total | $92,547 | TotalAmt |
Total Support Calendar Year TotalSupportCalendarYearGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $1,843,100 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $1,870,088 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $1,865,854 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $1,888,058 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $1,951,015 | CurrentTaxYearAmt |
| Total | $9,418,115 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support CY509 | 0.98640 | PublicSupportCY509Pct |
| Public Support PY509 | 0.98370 | PublicSupportPY509Pct |
| Investment Income CY | 0.00380 | InvestmentIncomeCYPct |
| Investment Income PY | 0.00600 | InvestmentIncomePYPct |
| Thirty Thr Pct Suprt Tests CY509 | Yes (X) | ThirtyThrPctSuprtTestsCY509Ind |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $60,427 | OtherCostOrOtherBasisAmt |
| Book Value | $60,427 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,339,443 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,336,817 | DepreciationAmt |
| Book Value | $2,002,626 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $221,660 | OtherCostOrOtherBasisAmt |
| Depreciation | $219,040 | DepreciationAmt |
| Book Value | $2,620 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $95,534 | OtherCostOrOtherBasisAmt |
| Depreciation | $85,818 | DepreciationAmt |
| Book Value | $9,716 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,075,389 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| RESIDENT SECURITY DEPOSITS | $85,261 |
| DUE TO JEFFERSON COMMUNITY HEALTH CENTER | $54,478 |
| PREPAID RENT | $9,444 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $149,183 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $1,961,419 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $10,404 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | $10,404 | RevenueNotReportedAmt |
| Revenue Subtotal | $1,951,015 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $1,951,015 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $1,648,137 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $1,648,137 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $1,648,137 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | CEDARWOOD IS A NOT-FOR-PROFIT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT THEY ARE 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 CEDARWOOD'S TAX EXEMPT STATUS. CEDARWOOD ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. CEDARWOOD RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2019 AND 2018, CEDARWOOD HAD NO UNCERTAIN TAX POSITIONS ACCRUED. | ExplanationTxt |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 611683496 | BondIssuerEIN |
| Bond Issued | 2012-01-18 | BondIssuedDt |
| Issue Price | $2,795,000 | IssuePriceAmt |
| Purpose | REFUND PRIOR BOND ISSUE (01/16/03) | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $1,920,000 | RetiredAmt |
| Total Proceeds | $2,795,000 | TotalProceedsAmt |
| In Reserve Fund | $280,964 | InReserveFundAmt |
| Issuance Costs From Proceeds | $55,900 | IssuanceCostsFromProceedsAmt |
| Working Capital Expenditures | $6,556 | WorkingCapitalExpendituresAmt |
| Other Spent Proceeds | $2,732,544 | OtherSpentProceedsAmt |
| Substantial Completion | 2004 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | Yes (1) | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | 0 | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | Yes (1) | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART II, COLUMN A, LINE 3: | THE TOTAL PROCEEDS DO NOT EQUAL THE SUMMATION OF LINES 4 - 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. |
| PART IV, COLUMN A, LINE 2C: | THE REBATE COMPUTATION WAS PERFORMED ON DECEMBER 31, 2016. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | THE MEMBERS OF THE CORPORATION ARE BRYAN HEALTH AND JEFFERSON COMMUNITY HEALTH CENTER, INC., BOTH NEBRASKA NON-PROFIT CORPORTIONS. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE MEMBERS OF THE CORPORATION, BRYAN HEALTH, A NEBRASKA NON-PROFIT CORPORATION, AND JEFFERSON COMMUNITY HEALTH CENTER, INC., A NEBRASKA NON-PROFIT CORPORATION, HAVE THE POWER TO APPOINT 3 TRUSTEES EACH, BOTH PERIODICALLY AND AS VACANCIES ARISE. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE BOARD WILL REVIEW THE FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, BOARD SECRETARY, PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | ON AN ANNUAL BASIS, OFFICERS AND TRUSTEES ARE REQUIRED TO SIGN THE "CONFLICT OF INTEREST STATEMENT." BY SIGNING THIS STATEMENT, THE OFFICERS AND TRUSTEES AGREE NOT TO USE HIS OR HER POSITION FOR PERSONAL PROFIT OR TO GAIN PERSONAL ADVANTAGE. THE OFFICERS AND TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING TO THE BOARD OF TRUSTEES ANY PERSON TO WHOM HE OR SHE IS CLOSELY RELATED OR ORGANIZATION WITH WHICH HE OR SHE IS AFFILIATED, WHO OR WHICH PRESENTLY TRANSACTS BUSINESS WITH THE CORPORATION OR MIGHT REASONABLY BE EXPECTED TO DO SO IN THE FUTURE. THE OFFICERS AND TRUSTEES ARE REQUIRED TO SUBMIT SUCH DISCLOSURE ON A CASE-BY-CASE BASIS. IT IS UNDERSTOOD THAT AFFILIATION WITH AN ORGANIZATION IS CONSIDERED TO EXIST WHEN AN OFFICER, TRUSTEE OR A MEMBER OF HIS OR HER IMMEDIATE FAMILY OR CLOSE RELATIVE IS AN OFFICER, DIRECTOR, PARTNER, EMPLOYEE OR AGENT OF THE ORGANIZATIONS OR OWNS 5% OF THE VOTING STOCK OR CONTROLLING INTEREST IN THE ORGANIZATION. THE OFFICERS AND TRUSTEES MUST ABSTAIN FROM VOTING ON ANY MOTION REGARDING THE DISCLOSED CONFLICT OF INTEREST. |
| FORM 990, PART VI, SECTION C, LINE 19 | FAIRBURY ASSISTED LIVING FACILITY'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART VII: | CHAD JURGENS, PRESIDENT/CEO, AND CHANCE KLASEK, SECRETARY, ARE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH CENTER, INC., AN UNRELATED ORGANIZATION THAT PROVIDES MANAGEMENT AND CLERICAL SERVICES FOR THE ORGANIZATION. THEREFORE, THE COMPENSATION IS PAID BY JEFFERSON COMMUNITY HEALTH CENTER, INC. AND IS INCLUDED IN PART IX, LINE 11A AS MANAGEMENT FEES. |
| FORM 990, PART XII, LINE 2C: | THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
| FORM 990, PART VI, SECTION B, LINE 14: | THE ORGANIZATION DOES NOT HAVE A WRITTEN POLICY, BUT IT DOES MAINTAIN DOCUMENTS IN ACCORDANCE WITH FEDERAL AND STATE LAWS. |
| FORM 990, PART VI, SECTION B, LINE 15: | AS NO OFFICER IS PAID BY THIS ORGANIZATION, NO INDEPENDENT REVIEW OR APPROVAL PROCESS IS CONDUCTED BY THIS ORGANIZATION. |
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