2017-11-14T12:35:18-06:00 2016-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2016-01-01 911772474 FAITH REGIONAL HEALTH SERVICES FOUNDATION FAIT 4026447301 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 JOHN WILKER VP FINANCE 4026447301 2017-11-10 1 MEGAN L KOZIOL P01544037 4023302660 209.34.201.180 2017-11-10 14:02:36 CS P E174F7C75A15FCA0AF1E43F729F0FF7E9FDF9AE2 E174F7C75A15FCA0AF1E43F729F0FF7E9FDF9AE2 2016 2017-02-10 21:41:12Z JOHN WILKER 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 1330242 0 X WWW.FRHS.ORG X 1996 NE TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. 19 18 0 45 0 0 1525744 1149134 0 0 42966 92068 -37995 -18518 1530715 1222684 35236 742878 0 0 0 0 0 0 33548 34527 51331 69763 794209 1460952 428475 11622257 12540773 122720 192958 11499537 12347815 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFITS OF FRHS OR ITS PROGRAMS AND SERVICES. 0 0 742878 742878 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE, PREVENTATIVE AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION OR DIAGNOSIS. 742878 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 19 18 1 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JOHN WILKER 4026447249 2700 WEST NORFOLK AVE STE 200 NORFOLK NE 68701 TODD WRAGGE MD PRESIDENT 1.00 0.00 X X 0 0 0 BRANDON DOKE VICE-PRESIDENT 1.00 0.00 X X 0 0 0 JACQUE COLLISON PRESIDENT-ELECT/ LCHA BOARD REPRESENTATIVE 1.00 1.00 X X 0 0 0 GORDON ADAMS MD PAST PRESIDENT 1.00 0.00 X X 0 0 0 RUSS MCKILLIP SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 DONALD BELL MD MEMBER 1.00 0.00 X 0 0 0 ALAN COLLISON MEMBER 1.00 0.00 X 0 0 0 PAT DELAY MEMBER 1.00 0.00 X 0 0 0 JAN EINSPAHR MEMBER 1.00 0.00 X 0 0 0 VIRGIL FROEHLICH MEMBER 1.00 0.00 X 0 0 0 DR TRISTAN HARTZELL MEMBER (FROM 2/24/2016) 1.00 40.00 X 0 2946020 34520 DONNA HERRICK LCH BOARD REPRESENTATIVE (THRU 2/24/16) 1.00 1.00 X 0 0 0 RICK HIGGINS MEMBER 1.00 0.00 X 0 0 0 PAT HUGHES MEMBER 1.00 0.00 X 0 0 0 ELEANOR MCINTOSH MEMBER (THRU 2/24/2016) 1.00 0.00 X 0 0 0 J PAUL MCINTOSH MEMBER 1.00 0.00 X 0 0 0 JIM SCHEER FRHS BOARD REPRESENTATIVE 1.00 1.00 X 0 0 0 TOM SCHUETH MEMBER 1.00 0.00 X 0 0 0 JOHN SEHI MEMBER 1.00 0.00 X 0 0 0 HARRIET STUDEBAKER MEMBER 1.00 0.00 X 0 0 0 TIMOTHY TIGHE MEMBER 1.00 0.00 X 0 0 0 MARK KLOSTERMAN CEO 1.00 40.00 X 0 517257 31301 JOHNATHAN WILKER VP FINANCE 1.00 40.00 X 0 214956 16792 JAKE CLAUSSEN FOUNDATION DIRECTOR 20.00 20.00 X 0 92153 8079 0 3770386 90692 0 0 1 0 0 141255 32635 975244 64794 1149134 92068 92068 89040 141255 107558 -18518 -18518 1222684 0 0 73550 742878 742878 17783 17783 2394 2394 CHILD ADVOCACY 16754 16754 NUCOR GOLF TOURNAMENT 10364 10364 SALES AND USE TAX 1964 1964 ANNUITY PAYMENTS 1369 1369 703 703 794209 742878 17783 33548 11343 614 5227071 5704356 3651 0 6380192 6835803 11622257 12540773 70520 122720 122438 122720 192958 X 1470009 1567227 4592228 5333278 5437300 5447310 11499537 12347815 11622257 12540773 428475 419803 0 X X 0 1 X 1 0 X X 1 FAITH REGIONAL HEALTH SERVICES 470796875 3 1 742878 0 1 742878 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7172111 10010 419803 7601924 7388088 11370 -209870 17477 7172111 7065293 12155 310640 166091 7221997 6024571 25899 1029674 14851 7065293 5578113 12162 444388 10092 6024571 0.00680 0.71660 0.27660 0 0 0 ANNUITY PAYABLE 122438 122438 X PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S (FRHS) CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S CHILDREN'S CARE FUND. DONORS MAY SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. PART X, LINE 2: FAITH REGIONAL HEALTH SERVICES (FRHS) AND FAITH REGIONAL HEALTH SERVICES FOUNDATION (THE FOUNDATION) ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND NEBRASKA STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. FAITH REGIONAL PHYSICIAN SERVICES (FRPS) IS A LIMITED LIABILITY COMPANY WHOLLY OWNED BY FRHS. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. FAITH ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2016 AND 2015, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. GOLF TOURNAMENT 49792 27388 22404 4550 4088 14805 4193 WINTER GALA 180503 113867 66636 1000 32397 19325 2875 24325 230295 141255 89040 5550 36485 34130 2875 28518 107558 -18518 1 FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 742878 FUNDING FOR HOSPITAL OPERATIONS AND PROJECTS 1 0 PART I, LINE 2: FAITH REGIONAL HEALTH SERVICES FOUNDATION PROVIDES GRANT MONEY TO FAITH REGIONAL HEALTH SERVICES, A RELATED 501(C)(3) ORGANIZATION. FAITH REGIONAL HEALTH SERVICES PROVIDES HEALTH CARE SERVICES TO INDIVIDUALS IN NORTHEAST NEBRASKA. 0 0 0 0 0 0 0 0 0 DR TRISTAN HARTZELL MEMBER (FROM 2/24/2016) 0 951117 0 1994251 0 652 0 7950 0 26570 0 2980540 0 0 MARK KLOSTERMAN CEO 0 507114 0 422 0 9721 0 7950 0 23351 0 548558 0 0 JOHNATHAN WILKER VP FINANCE 0 213105 0 422 0 1429 0 0 0 16792 0 231748 0 0 X 2 575 FMV X 8111 FMV X 5 1315 FMV X 4 1605 FMV X SPORTING EQUIPMENT 16 5713 FMV X TICKETS 21 5375 FMV X OTHER MISCELLANEOUS ITEMS 12 3476 FMV X GIFT BASKETS 17 3470 FMV X GIFT CERTIFICATES 15 3348 GIFT CERTIFICATE VAL X ELECTRONICS 7 2418 FMV X RECREATION TRIPS 2 1080 FMV 0 1 0 FORM 990, PART VI, SECTION A, LINE 2 JACQUE COLLISON AND ALAN COLLISON, BOTH BOARD MEMBERS, HAVE A FAMILY RELATIONSHIP. FURTHERMORE, BOARD MEMBERS ELEANOR MCINTOSH AND J. PAUL MCINTOSH, HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 7A FAITH REGIONAL HEALTH SERVICES FOUNDATION'S BYLAWS STATE ALL DIRECTORS SHALL BE APPOINTED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B BOARD MEMBER APPOINTMENT AND RETENTION DECISIONS MADE BY THE FOUNDATION BOARD ARE APPROVED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 AND ALL APPLICABLE SCHEDULES WERE PREPARED AND SIGNED BY SEIM JOHNSON, LLP IN OMAHA, NEBRASKA. COPIES OF THE COMPLETED RETURN WERE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL HEALTH SERVICES FOUNDATION BOARD MEMBERS COMPLETE A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. THESE STATEMENTS ARE REVIEWED BY A DIRECTOR OF THE FOUNDATION. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST STATEMENT, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VI, SECTION B, LINE 15: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT PAY COMPENSATION TO A CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OFFICERS OR KEY EMPLOYESS OF THE ORGANIZATION. THEREFORE, QUESTION 15A AND 15B ARE ANSWERED NO. FORM 990, PART XII, LINE 2C: FAITH REGIONAL HEALTH SERVICES FOUNDATION HAS AN AUDIT COMPLETED ON A CONSOLIDATED BASIS WITH FAITH REGIONAL HEALTH SERVICES AND FAITH REGIONAL PHYSICIAN SERVICES, LLC. THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THERE HAVE BEEN NO CHANGES IN THIS PROCESS FROM PRIOR YEARS. FAITH REGIONAL HEALTH SERVICES 2700 W NORFOLK AVE NORFOLK NE 68701 470769875 PROVIDE HEALTHCARE SERVICES TO THE NORTHEAST NEBRASKA REGION NE 501(C)(3) 3 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 0 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 3 N/A 0 FAITH REGIONAL HEALTH SERVICES PHO INC 2700 W NORFOLK AVE NORFOLK NE 68701 IMPROVE HEALTHCARE SERVICES NE PENDING FAITH REGIONAL HEALTH SERVICES 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0