2018-11-15T16:16:56-06:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-01-01 411328097 RIDGEVIEW FOUNDATION RIDG 9524426010 500 SOUTH MAPLE STREET WACONIA MN 55387 BRENT WORDELMAN DIRECTOR OF FINANCE 9524426010 2018-11-14 1 DARRYN MCGARVEY P00958683 6123764500 2018-11-14 67.137.57.251 2018-11-14 20:50:10 PS P FD302F4D5CE3C660ABAF9933EAAEEC9F457F14F9 9C3E08EBF53FA5FA3C7B2B5BD0B3E335DF999A73 2017 2019-02-21 02:37:17Z MICHAEL PHELPS 500 SOUTH MAPLE STREET WACONIA MN 55387 13834274 0 X WWW.RIDGEVIEWMEDICAL.ORG X 1978 MN TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. 24 24 0 386 0 0 2308132 5569184 0 0 284914 1066374 -308851 -188269 2284195 6447289 1524664 2115672 0 0 0 0 0 0 0 593585 149409 2118249 2265081 165946 4182208 14906384 20536854 895797 1563039 14010587 18973815 RIDGEVIEW FOUNDATION IS AN INDEPENDENT NONPROFIT ORGANIZATION THAT PARTNERS WITH RIDGEVIEW MEDICAL CENTER IN ITS MISSION TO MAKE A POSITIVE DIFFERENCE IN THE QUALITY OF LIFE AND HEALTH FOR THE PEOPLE OF OUR AREA. 0 0 2115672 2115672 0 TO RAISE FUNDS EXCLUSIVELY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER, A NOT-FOR-PROFIT HOSPITAL IN WACONIA, MINNESOTA. DURING THE YEAR ENDED DECEMBER 31, 2017, RIDGEVIEW FOUNDATION EXPENSED A TOTAL OF $578,860 TO RIDGEVIEW MEDICAL CENTER. OF THIS, $205,143 WAS TRANSFERRED TO THE HOSPITAL TO SUPPORT THE BUILDING AND FURNISHING OF A HEART CENTER AND CATH LAB AT THE HOSPITAL, $70,260 WAS TRANSFERRED TO THE HOSPITAL FOR THE COMMUNICATIONS CENTER, AND $50,489 WAS TRANSFERRED TO THE HOSPITAL TO SUPPORT HOSPICE CARE ACTIVITES. THE REMAINING $252,968 TRANSFERRED TO THE HOSPITAL WAS USED FOR VARIOUS PROJECTS AND PROGRAMS DURING 2017.TO 2115672 1 1 0 0 0 0 0 0 0 1 1 0 0 1 0 1 1 1 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 8 0 0 0 0 0 0 0 1 1 0 0 0 0 X 24 24 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X GORDON GABLENZ 9524422191 500 SOUTH MAPLE STREET WACONIA MN 55387 CHUCK SPEVACEK CHAIRPERSON 0.50 X X 0 0 0 FRED GREEN VICE CHAIR 0.50 X X 0 0 0 DERMOT CROWLEY SECRETARY 0.50 X X 0 0 0 DARLA HOLMGREN TREASURER 0.50 X X 0 0 0 KATIE BARNES BOARD MEMBER 0.50 X 0 0 0 NANCY BACH BOARD MEMBER 0.50 0.00 X 0 0 0 JEAN BULLER BOARD MEMBER 0.50 0.00 X 0 0 0 BRETT COLBJORSEN BOARD MEMBER 0.50 0.00 X 0 0 0 JON CROW BOARD MEMBER 0.50 0.00 X 0 0 0 MIKE DRAZAN BOARD MEMBER 0.50 0.00 X 0 0 0 TIM FOSTER BOARD MEMBER 0.50 0.00 X 0 0 0 JOHN HAYES BOARD MEMBER 0.50 0.00 X 0 0 0 JIM LEONARD BOARD MEMBER 0.50 0.00 X 0 0 0 ROCHELLE LINDBERG BOARD MEMBER 0.50 0.00 X 0 0 0 SUSAN MILLER BOARD MEMBER 0.50 0.00 X 0 0 0 LINDA ROEBKE BOARD MEMBER 0.50 0.00 X 0 0 0 DR DANIEL ROSS DDS BOARD MEMBER 0.50 0.00 X 0 0 0 DR LORENE RUTHERFORD MD BOARD MEMBER 0.50 0.00 X 0 0 0 MARK STEINGAS BOARD MEMBER 0.50 0.00 X 0 0 0 CARLA STRUBLE BOARD MEMBER 0.50 0.00 X 0 0 0 LINDSEY THOMPSON BOARD MEMBER 0.50 0.00 X 0 0 0 JEFF WIGEN BOARD MEMBER 0.50 0.00 X 0 0 0 DAVID WINDSCHITL BOARD MEMBER 0.50 0.00 X 0 0 0 STEVE YETZER BOARD MEMBER 0.50 0.00 X 0 0 0 MICHAEL PHELPS PRESIDENT / CEO 0.50 49.50 X 0 1450467 37854 ROBERT STEVENS PRESIDENT / CEO (THRU JUNE 2017) 0.50 49.50 X 0 1656460 32826 GORDON GABLENZ CFO & CIO 4.00 46.00 X 0 663997 45865 DOUGLAS STASEK EXECUTIVE DIRECTOR 47.50 2.50 X 0 227460 40498 0 3998384 157043 0 0 1 0 0 1020318 406081 4142785 738958 5569184 297958 297958 7832782 7064366 768416 768416 768416 104500 1020318 280306 -175806 -175806 29850 42313 -12463 -12463 6447289 0 0 878105 2083672 2083672 32000 32000 10799 10799 21165 21165 63899 63899 13995 13995 39361 39361 MISCELLANEOUS EXPENSES 190 190 2265081 2115672 149409 0 843633 821571 1197732 1983753 1404800 4045396 76600 9697 9697 0 0 6239192 10374765 5144427 3311369 14906384 20536854 820797 1563039 75000 0 895797 1563039 X 8392906 9854929 2611028 6087848 3006653 3031038 14010587 18973815 14906384 20536854 4182208 781020 0 X 0 1 X 1 0 X 4409325 1665055 4017312 2308131 5569184 17969007 4409325 1665055 4017312 2308131 5569184 17969007 2724236 15244771 71712 95293 106017 127973 297958 698953 425042 122117 106718 67898 134350 856125 19524085 0.78080 0.90150 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: SPECIAL FUNDRAISING EVENTS CHARITABLE GAMING ACTIVITIES 7461924 12142 713500 713500 7474066 7021304 440620 176379 176379 7461924 5873869 1147435 2689 936 1753 7021304 5159988 629670 114473 28627 1635 5873869 1528949 3504360 148437 20121 1637 5159988 0.55690 0.40550 0.03760 0 0 9697 9697 0 0 ANNUITY CONTRACT 59378 ASSETS HELD IN CHARITABLE REMAINDER TRUST 399400 CASH SURRENDER VALUE LIFE INSURANCE POLICY 2852591 3311369 X 4683312 781020 675902 1512700 2969622 1713690 4733599 4733599 6447289 3221289 675902 280306 956208 2265081 0 2265081 PART V, LINE 4: THE EARNING FROM THE ENDOWMENT FUNDS ARE INTENDED TO BE USED FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER, A NOT-FOR-PROFIT HOSPITAL IN WACONIA, MINNESOTA. PART X, LINE 2: THE FOUNDATION HAS RECEIVED NOTIFICATION THAT IT QUALIFIES AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE U.S. INTERNAL REVENUE CODE AND CORRESPONDING PROVISIONS OF STATE LAW AND, ACCORDINGLY, IS NOT SUBJECT TO FEDERAL OR STATE INCOME TAXES. HOWEVER, ANY UNRELATED BUSINESS INCOME MAY BE SUBJECT TO TAXATION. DURING 2010, THE FOUNDATION REQUESTED AND WAS APPROVED TO RECLASSIFY FROM 509(A)(3) STATUS TO 509(A)(1) AND 170(B)(1)(A)(VI) STATUS WITH THE INTERNAL REVENUE SERVICE (IRS). THE FOUNDATION HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE FOUNDATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAD NO EFFECT ON THE FINANCIAL STATEMENTS. THE FOUNDATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 1,232,394. FUNDRAISING EVENT EXPENSES 280,306. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 4,055,680. EVENT PROCEEDS 653,534. PERMANENTLY RESTRICTED CONTRIBUTIONS 24,385. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 280,306. GOLF TOURNAMENT 568032 508932 59100 16776 148186 CASINO NIGHT 384435 355035 29400 2900 4676 18415 18497 1 172351 156351 16000 69440 1124818 1020318 104500 2900 21452 18415 236123 278890 -174390 29850 41513 800 0 29850 41513 800 42313 -12463 MN 1 0 0 0 0.00000 1.00000 GORDON GABLENZ 500 SOUTH MAPLE STREET WACONIA MN 55387 0 JAN HELD 53615 JAN HELD IS THE EVENTS COORDINATOR FOR THE FOUNDATION. SHE SUPERVISES ALL FUNDRAISING EVENTS AND FILLS OUT ALL OF THE PAPERWORK RELATED TO GAMING ACTIVITIES. X 0 1 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 501(C)(3) 548860 FUNDRAISING SUPPORT OF RIDGEVIEW MEDICAL CENTER 1 0 SCHOLARSHIPS 17 32000 PART I, LINE 2: GRANTS AND OTHER ASSISTANCE TO ENTITIES IN THE U.S.: TRANSFERS ARE TO RELATED ENTITIES UNDER COMMON MANAGEMENT AND TRACKED THROUGH THE INTERNAL FINANCIAL REPORTING PROCESS. GRANTS AND OTHER ASSISTANCE TO INDIVIDUALS IN THE U.S.: SCHOLARSHIP PAYMENTS ARE MADE DIRECTLY TO THE SCHOOL THAT THE STUDENT IS ATTENDING. 0 1 0 0 0 1 1 0 0 MICHAEL PHELPS PRESIDENT / CEO 0 368738 0 52130 0 1029599 0 10800 0 27054 0 1488321 0 0 ROBERT STEVENS PRESIDENT / CEO (THRU JUNE 2017) 0 443042 0 71627 0 1141791 0 10800 0 22026 0 1689286 0 0 GORDON GABLENZ CFO & CIO 0 303834 0 53085 0 307078 0 10800 0 35065 0 709862 0 0 DOUGLAS STASEK EXECUTIVE DIRECTOR 0 197254 0 26669 0 3537 0 7156 0 33342 0 267958 0 0 PART I, LINE 3 THE PRESIDENT/CEO IS COMPENSATED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. THE FOLLOWING WERE USED BY RIDGEVIEW MEDICAL CENTER TO DETERMINE THE PRESIDENT/CEO'S COMPENSATION: 1) COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) 2) INDEPENDENT COMPENSATION CONSULTANT 3) FORM 990 OF OTHER ORGANIZATIONS 4) WRITTEN EMPLOYMENT CONTRACT 5) COMPENSATION SURVEY OR STUDY 6) APROVAL BY THE BOARD OR COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) PART I, LINE 4B ROBERT STEVENS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $1,143,151 WAS CONTRIBUTED TO THE PLAN, $19,816 ACCRUED WITHIN THE PLAN, AND $592,724 WAS PAID OUT OF THE PLAN. MICHEL PHELPS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $1,038,790 WAS CONTRIBUTED TO THE PLAN AND $500,177 WAS PAID OUT OF THE PLAN. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER. DURING 2017, $315,740 WAS CONTRIBUTED TO THE PLAN, $7,874 ACCRUED WITHIN THE PLAN, AND $161,027 WAS PAID OUT OF THE PLAN. THESE DEFERRED COMPENSATION AMOUNTS ARE REPORTED ON A PRO-RATA BASIS WITHOUT REGARD TO THE INDIVIDUAL'S VESTING SCHEDULE. CURRENTLY, THE MAJORITY OF DEFERRED COMPENSATION IS NOT VESTED. PART I, LINE 6 THE OFFICERS OF RIDGEVIEW MEDICAL CENTER AND AFFILIATES RECEIVE BONUSES CONTINGENT ON THE NET EARNINGS OF THE CONSOLIDATED ENTITY AND GOALS ACHIEVED. X 120 FAIR MARKET VALUE X 2003 FAIR MARKET VALUE X 4 277424 FAIR MARKET VALUE X 4 2108 FAIR MARKET VALUE X GIFTS 95 277237 FAIR MARKET VALUE X AUCTION ITEMS 499 180066 FAIR MARKET VALUE 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE BOARD OF DIRECTORS OF THE FOUNDATION DESIGNATED SEVEN BOARD MEMBERS AS AN EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE ACTS ONLY DURING INTERVALS BETWEEN MEETINGS OF THE BOARD OF DIRECTORS OF THE FOUNDATION AND IS AT ALL TIMES SUBJECT TO THE CONTROL AND DIRECTION OF THE BOARD OF DIRECTORS OF THE FOUNDATION. DURING SUCH INTERVALS AND SUBJECT TO SUCH CONTROL AND DIRECTION, THE EXECUTIVE COMMITTEE HAS ALL OF THE AUTHORITY AND POWER OF THE BOARD OF DIRECTORS OF THE FOUNDATION IN THE MANAGEMENT OF THE BUSINESS OF THE FOUNDATION, SUBJECT TO SUCH LIMITATIONS AS THE BOARD OF DIRECTORS OF THE FOUNDATION MAY IMPOSE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 6 RIDGEVIEW MEDICAL CENTER IS THE SOLE MEMBER OF RIDGEVIEW FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON ELECTED BY THE BOARD OF DIRECTORS OF RIDGEVIEW FOUNDATION IS RATIFIED OR REJECTED BY THE BOARD OF DIRECTORS OF RIDGEVIEW MEDICAL CENTER, THE FOUNDATION'S SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B IN ADDITION TO THE APPOINTMENT OF DIRECTORS TO THE BOARD OF DIRECTORS OF RIDGEVIEW FOUNDATION, AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS OF THE FOUNDATION REQUIRE APPROVAL OF RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWED THE FORM 990 AND PROVIDED COPIES TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ANNUALLY REVIEW AND SIGN THE STATEMENTS FOR POTENTIAL CONFLICTS OF INTEREST POLICY. EACH MEMBER IS EXPECTED TO DISCLOSE ANY CONFLICT OF INTEREST THAT MAY ARISE DURING THE YEAR. IF IT IS DETERMINED THAT A CONFLICT OF INTEREST EXISTS, THE SITUATION WILL BE EXAMINED AND HANDLED APPROPRIATELY BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 ANY COMPENSATION RECEIVED BY OFFICERS OR BOARD MEMBERS OF RIDGEVIEW FOUNDATION IS DETERMINED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. FORM 990, PART VI, SECTION C, LINE 19 RIDGEVIEW FOUNDATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. RIDGEVIEW CLINICS 500 SOUTH MAPLE STREET WACONIA MN 55387 411651783 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 N/A 0 RIDGEVIEW INSURANCE COMPANY 60 E SOUTH TEMPLE STE 1800 SALT LAKE CITY UT 84111 454109041 CAPTIVE INSURANCE COMPANY UT 501(C)(3) LINE 12A, I RIDGEVIEW MEDICAL CENTER 0 SIBLEY MEDICAL CENTER 601 W CHANDLER ST ARLINGTON MN 55307 411801967 CRITICAL ACCESS HOSPITAL MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 MINNESOTA VALLEY HEALTH CENTER 621 S 4TH STREET LE SUEUR MN 56058 410837659 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER LCC 500 S MAPLE ST WACONIA MN 55387 205785920 CARDIOLOGY SERVICES MN N/A CHASKA PLAZA SURGERY CENTER 3000 HUNDERTMARK ROAD CHASKA MN 55318 450975783 SURGERY SERVICES MN N/A EXECUTIVE HEALTH MANAGEMENT SERVICES 500 SOUTH MAPLE STREET WACONIA MN 55387 411760239 MANAGEMENT SERVICES MN N/A C 0 CHARITABLE REMAINDER UNITRUST (1) CHARITABLE TRUST MN 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0