ANTELOPE MEMORIAL HOSPITAL: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- ANTELOPE MEMORIAL HOSPITAL (EIN 47-0393176)
- Tax period
- 2015-07-01 to 2016-06-30
- Filed
- 2017-04-12
- IRS object ID
- 201701029349300135
- Schema version
- 2015v3.0
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-04-12T13:43:34-05:00 | ReturnTs |
| Tax Period End | 2016-06-30 | 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 | 2015-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470393176 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | ANTE | BusinessNameControlTxt |
| Phone | 4028874151 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JACK W GREEN | PersonNm |
| Person Title | ADMINISTRATOR | PersonTitleTxt |
| Phone | 4028874151 | PhoneNum |
| Signature | 2017-03-28 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | BARBARA J FAJEN | PreparerPersonNm |
| PTIN | P00400874 | PTIN |
| Phone | 4023302660 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JACK W GREEN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $15,987,253 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1974 | FormationYr |
| Legal Domicile State | NE | LegalDomicileStateCd |
| Activity Or Mission | TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 10 | VotingMembersIndependentCnt |
| Total Employee | 175 | TotalEmployeeCnt |
| Total Volunteers | 12 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $243,947 | PYContributionsGrantsAmt |
| CY Contributions Grants | $171,985 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $15,296,786 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $15,710,224 | CYProgramServiceRevenueAmt |
| PY Investment Income | $11,589 | PYInvestmentIncomeAmt |
| CY Investment Income | $49,246 | CYInvestmentIncomeAmt |
| PY Other Revenue | $49,732 | PYOtherRevenueAmt |
| CY Other Revenue | $50,131 | CYOtherRevenueAmt |
| PY Total Revenue | $15,602,054 | PYTotalRevenueAmt |
| CY Total Revenue | $15,981,586 | 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 | $7,518,666 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,946,833 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $2,715 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $7,394,639 | PYOtherExpensesAmt |
| CY Other Expenses | $7,266,279 | CYOtherExpensesAmt |
| PY Total Expenses | $14,913,305 | PYTotalExpensesAmt |
| CY Total Expenses | $15,213,112 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $688,749 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $768,474 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $18,836,446 | TotalAssetsBOYAmt |
| Total Assets EOY | $18,883,767 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $5,153,103 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $4,450,599 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $13,683,343 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $14,433,168 | NetAssetsOrFundBalancesEOYAmt |
| Mission | MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $13,192,872 | ExpenseAmt |
| Revenue | $15,710,224 | RevenueAmt |
| Desc | ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. | Desc |
| Total Program Service Expenses | $13,192,872 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | 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 | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | 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 | Yes (1) | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | 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 | 32 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 175 | 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 |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 10 | 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 | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | 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 | Yes (1) | 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 | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | 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 | MARTHA NELSON | PersonNm |
| Phone | 4028876282 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (17 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| JOHN MLNARIK | ||||||||
| PRESIDENT | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JAMES BLACKBURN | ||||||||
| VICE PRESIDENT | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| JOE KNIGHT | ||||||||
| SECRETARY/TREASURER | 4.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| PHILIP KLUTHE | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JAMES MEURET | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| GORDON SHRADER | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVID SULLIVAN | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| CHRISTOPHER TWIBELL | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JON SCHILLING | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| SAMANTHA STOLTZ | ||||||||
| MEMBER | 2.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| JACK W GREEN | ||||||||
| ADMINISTRATOR/CEO | 40.00 | 0.00 | Yes (X) | $176,971 | $0 | $10,866 | ||
| MARTHA NELSON | ||||||||
| CFO | 32.00 | 0.00 | Yes (X) | $109,679 | $0 | $22,750 | ||
| TROY DAWSON MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $355,422 | $0 | $35,885 | Yes (X) | ||
| ROGER RUDLOFF MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $315,691 | $0 | $26,164 | Yes (X) | ||
| WILLIAM B LOCKEE MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $262,070 | $0 | $22,540 | Yes (X) | ||
| PATRICIA GOOD APRN | ||||||||
| APRN | 40.00 | 0.00 | $124,252 | $0 | $14,199 | Yes (X) | ||
| KAREN GALLAGHER | ||||||||
| PHARMACIST | 40.00 | 0.00 | $117,658 | $0 | $7,656 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,461,743 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $140,060 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 8 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| TKO | |||||
| PO BOX 385 | NELIGH | NE | 68756 | NURSING SERVICES | $425,000 |
| OVERLAND REHAB SERVICES | |||||
| 405 JAMES STREET | VERDIGRE | NE | 68783 | PHYSICAL THERAPY SERVICES | $334,339 |
| NEBRASKA LABLINC | |||||
| PO BOX 26410 | FAIRVIEW PARK | OH | 44126 | REFERENCE LAB | $136,707 |
| FAITH REGIONAL HEALTH SERVICES | |||||
| PO BOX 869 | NORFOLK | NE | 68702 | PATIENT ECHO/STRESS TESTING | $129,397 |
| MEDTYPE TRANSCRIPTION INC | |||||
| 404 NORTH 28TH STREET | NORFOLK | NE | 68701 | TRANSCRIPTION | $121,714 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 6 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $171,985 | AllOtherContributionsAmt |
| Total Contributions | $171,985 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (5 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MEDICARE/MEDICAID PAYMENTS | 621400 | $8,955,350 | $8,955,350 |
| NET PATIENT SERVICE REVENUE | 621400 | $5,354,834 | $5,354,834 |
| 340B REVENUE | 611400 | $1,233,622 | $1,233,622 |
| EHR INCENTIVE PAYMENTS | 621400 | $151,000 | $151,000 |
| AMBULANCE | 621910 | $6,612 | $6,612 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $8,806 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $8,806 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $15,710,224 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $46,018 | TotalRevenueColumnAmt |
| Exclusion | $46,018 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $8,895 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $5,667 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $3,228 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $3,228 | TotalRevenueColumnAmt |
| Exclusion | $3,228 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | CAFETERIA | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $50,131 | TotalRevenueColumnAmt |
| Exclusion | $50,131 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $50,131 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,981,586 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $15,710,224 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $99,377 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $320,267 | TotalAmt |
| Management And General | $320,267 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $65,137 | TotalAmt |
| Program Services | $65,137 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,313,609 | TotalAmt |
| Program Services | $5,721,852 | ProgramServicesAmt |
| Management And General | $591,757 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $174,556 | TotalAmt |
| Program Services | $141,480 | ProgramServicesAmt |
| Management And General | $33,076 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $629,074 | TotalAmt |
| Program Services | $487,060 | ProgramServicesAmt |
| Management And General | $142,014 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $444,190 | TotalAmt |
| Program Services | $383,265 | ProgramServicesAmt |
| Management And General | $60,925 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $50,038 | TotalAmt |
| Management And General | $50,038 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $51,976 | TotalAmt |
| Management And General | $51,976 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,114,133 | TotalAmt |
| Program Services | $1,996,921 | ProgramServicesAmt |
| Management And General | $117,212 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $50,697 | TotalAmt |
| Program Services | $16,238 | ProgramServicesAmt |
| Management And General | $34,459 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $561,424 | TotalAmt |
| Program Services | $487,120 | ProgramServicesAmt |
| Management And General | $71,589 | ManagementAndGeneralAmt |
| Fundraising | $2,715 | FundraisingAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $340,607 | TotalAmt |
| Management And General | $340,607 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $209,152 | TotalAmt |
| Program Services | $192,694 | ProgramServicesAmt |
| Management And General | $16,458 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,967 | TotalAmt |
| Program Services | $37,480 | ProgramServicesAmt |
| Management And General | $4,487 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $84,257 | TotalAmt |
| Program Services | $77,627 | ProgramServicesAmt |
| Management And General | $6,630 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,238,726 | TotalAmt |
| Program Services | $1,141,252 | ProgramServicesAmt |
| Management And General | $97,474 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $155,235 | TotalAmt |
| Program Services | $155,235 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $1,805,982 | $1,805,982 | |
| BAD DEBT | $450,827 | $450,827 | |
| DUES & SUBSCRIPTIONS | $58,098 | $21,318 | $36,780 |
| MISCELLANEOUS EXPENSE | $46,099 | $6,398 | $39,701 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,061 | TotalAmt |
| Program Services | $4,986 | ProgramServicesAmt |
| Management And General | $2,075 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,213,112 | TotalAmt |
| Program Services | $13,192,872 | ProgramServicesAmt |
| Management And General | $2,017,525 | ManagementAndGeneralAmt |
| Fundraising | $2,715 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $118,554 | BOYAmt |
| EOY | $74,410 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,290,680 | BOYAmt |
| EOY | $6,044,481 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $129,714 | BOYAmt |
| EOY | $17,000 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,406,463 | BOYAmt |
| EOY | $1,367,354 | EOYAmt |
Receivables From Officers Etc ReceivablesFromOfficersEtcGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $19,444 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $56,251 | BOYAmt |
| EOY | $57,091 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $300,971 | BOYAmt |
| EOY | $341,961 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $166,447 | BOYAmt |
| EOY | $50,405 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $22,144,090 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $12,106,767 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,656,331 | BOYAmt |
| EOY | $10,037,323 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $483,685 | BOYAmt |
| EOY | $481,019 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $227,350 | BOYAmt |
| EOY | $393,279 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,836,446 | BOYAmt |
| EOY | $18,883,767 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,437,017 | BOYAmt |
| EOY | $1,528,875 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,625 | BOYAmt |
| EOY | $12,008 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,840,000 | BOYAmt |
| EOY | $2,290,000 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $846,461 | BOYAmt |
| EOY | $619,716 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,153,103 | BOYAmt |
| EOY | $4,450,599 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,553,185 | BOYAmt |
| EOY | $14,293,770 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $130,158 | BOYAmt |
| EOY | $139,398 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,683,343 | BOYAmt |
| EOY | $14,433,168 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,836,446 | BOYAmt |
| EOY | $18,883,767 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $768,474 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$18,649 | 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) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $1,519 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,519 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | PORTION OF THE DUES PAID TO THE NEBRASKA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION ARE ALLOCABLE TO LOBBYING ACTIVITIES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $63,764 | OtherCostOrOtherBasisAmt |
| Book Value | $63,764 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,589,135 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,390,976 | DepreciationAmt |
| Book Value | $3,198,159 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $11,900,658 | OtherCostOrOtherBasisAmt |
| Depreciation | $7,640,472 | DepreciationAmt |
| Book Value | $4,260,186 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,590,533 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,075,319 | DepreciationAmt |
| Book Value | $2,515,214 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $10,037,323 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | ESTIMATED THIRD-PARTY PAYER SETTLEMENT | Desc |
| Amt | $619,716 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $619,716 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $15,509,395 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$18,649 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | -$18,649 | RevenueNotReportedAmt |
| Revenue Subtotal | $15,528,044 | RevenueSubtotalAmt |
| Other Revenues Not Included | $453,542 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $453,542 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $15,981,586 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $14,759,570 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $14,759,570 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $453,542 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $453,542 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $15,213,112 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE HOSPITAL 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 EXEPMT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2016 AND 2015, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 2,715. PROVISION FOR BAD DEBTS 450,827. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 2,715. PROVISION FOR BAD DEBTS 450,827. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 125.000000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCareInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $104,563 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $104,563 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00710 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $831,816 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $621,347 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $210,469 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01430 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $936,379 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $621,347 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $315,032 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02140 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $22,444 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,714 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $18,730 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,625,204 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,015,352 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $609,852 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04130 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,647,648 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,019,066 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $628,582 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04260 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,584,027 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,640,413 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $943,614 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.06400 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $450,827 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $7,918,532 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $8,130,971 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$212,439 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | 0 | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 102 WEST 9TH STREET | AddressLine1Txt |
| City | NELIGH | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 68756 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.AMHNE.ORG | WebsiteAddressTxt |
| State License | 020001 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.AMHNE.ORG | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.AMHNE.ORG | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 125.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTP://WWW.AMHNE.ORG/PAGES/FINANCIALASSISTANCE/INDEX.HTML | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTP://WWW.AMHNE.ORG/PAGES/FINANCIALASSISTANCE/INDEX.HTML | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTP://WWW.AMHNE.ORG/PAGES/FINANCIALASSISTANCE/INDEX.HTML | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, SECTION A: | ANTELOPE MEMORIAL HOSPITAL OPERATES A 25-BED CRITICAL ACCESS HOSPITAL. THE HOSPITAL ALSO OFFERS PHYSICIAN CLINICS, CARDIAC REHAB AND HOME HEALTH. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: ANTELOPE MEMORIAL HOSPITAL RECEIVED INPUT FROM COMMUNITY REPRESENTATIVES OF THE SCHOOLS, LOCAL GOVERNMENT, POLICE, MINISTERIAL ASSOCIATION, CHAMBER OF COMMERCE, NURSING HOME, ASSISTED LIVING AND OTHER INTERESTED CITIZENS THROUGH THE USE OF SURVEYS AND COMMUNITY MEETINGS. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, NELIGH, NE (ANTELOPE COUNTY) AVERA CREIGHTON HOSPITAL, CREIGHTON, NE (KNOX COUNTY) AVERA SAINT ANTHONY'S HOSPITAL, O'NEILL, NE (HOLT COUNTY) OSMOND GENERAL HOSPITAL, OSMOND, NE (PIERCE COUNTY) PLAINVIEW COMMUNITY HOSPITAL, PLAINVIEW, NE (PIERCE COUNTY) NIOBRARA VALLEY HOSPITAL, LYNCH, NE (BOYD COUNTY) WEST HOLT MEMORIAL HOSPITAL, ATKINSON, NE (HOLT COUNTY) BROWN COUNTY HOSPITAL, AINSWORTH, NE (BROWN COUNTY) CHERRY COUNTY HOSPITAL, VALENTINE, NE (CHERRY COUNTY) ROCK COUNTY HOSPITAL, BASSETT, NE (BROWN COUNTY) |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) THE EVERGREEN ASSISTED LIVING FACILITY COTTONWOOD VILLA ASSISTED LIVING FACILITY GOOD SAMARITAN SOCIETY - ATKINSON PREGANCY RESOURCE CENTER FINISH LINE CHIROPRACTIC COUNSELING AND ENRICHMENT CENTER / BUILDING BLOCKS REGION 4 BEHAVIORAL HEALTH SYSTEM CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHSTAR SERVICES NCDHD BOARD OF HEALTH NORTH CENTRAL COMMUNITY CARE PARTNERSHIP AREA SUBSTANCE ABUSE PREVENTION COALITION O'NEILL CHAMBER OF COMMERCE CENTRAL NEBRASKA ECONOMIC DEVELOPMENT HOLT COUNTY ECONOMIC DEVELOPMENT KNOX COUNTY ECONOMIC DEVELOPMENT NELIGH ECONOMIC DEVELOPMENT PIERCE COUNTY ECONOMIC DEVELOPMENT UNIVERSITY OF NEBRASKA LINCOLN EXTENSION OFFICE, BROWN-ROCK-KEYA -PAHA COUNTY EWING PUBLIC SCHOOL LYNCH PUBLIC SCHOOL O'NEILL PUBLIC SCHOOL BOARD O'NEILL MINISTERIAL ASSOCATION WEST HOLT HEALTH MINISTRIES O'NEILL LIONS CLUB O'NEILL ROTARY CLUB MITCHELL EQUIPMENT - O'NEILL, NE FAMILY SERVICE CHILD CARE FOOD PROGRAM |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: CERTAIN STEPS, PROCEDURES AND PROGRAMS ARE BEING IMPLEMENTED ACCORDING TO THE IMPLEMENTATION PLAN FOR ALL NEEDS THAT ANTELOPE MEMORIAL HOSPITAL IS ABLE TO ADDRESS AT THIS TIME.THE IDENTIFIED NEEDS THAT ARE NOT BEING ADDRESSED CANNOT BE CURRENTLY SOLVED IN A MEANINGFUL WAY DUE TO FINANCIAL LIMITATION, LACK OF RESOURCES AND/OR LACK OF EXPERTISE. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 16I: ALTHOUGH THE CHARITY CARE POLICY DOES NOT SPECIFICALLY DESCRIBE HOW IT IS TO BE PUBLICIZED WITHIN THE COMMUNITY, IT DOES CONTAIN THIS STATEMENT: "ALL PATIENTS WILL BE NOTIFIED OF PROVIDER'S CHARITY CARE POLICY AS LEGALLY REQUIRED." THE CHARITY CARE POLICY IS MAILED TO ALL PATIENTS WITH THE EXTERNAL COLLECTION POLICY AND THE PATIENT'S INVOICE FOR SERVICES. |
| ANTELOPE MEMORIAL HOSPITAL | PART V, SECTION B, LINE 22D: CHARGES FOR SERVICES ARE THE SAME FOR ALL PATIENTS, WHETHER THEY ARE ELIGIBLE OR NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 5 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (5 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - AMH FAMILY PRACTICE | ||||
| 109 WEST 11TH STREET PO BOX 109 | NELIGH | NE | 68756 | FAMILY PRACTICE MEDICAL CLINIC |
| 2 - AMH CLEARWATER CLINIC | ||||
| 308 NEVADA STREET | CLEARWATER | NE | 68726 | FAMILY PRACTICE MEDICAL CLINIC |
| 3 - AMH ELGIN CLINIC | ||||
| 101 WEST CEDAR STREET | ELGIN | NE | 68636 | FAMILY PRACTICE MEDICAL CLINIC |
| 4 - ORCHARD MEDICAL CLINIC | ||||
| 103 WASHINGTON STREET | ORCHARD | NE | 68764 | FAMILY PRACTICE MEDICAL CLINIC |
| 5 - AMH TILDEN CLINIC | ||||
| 104 SOUTH CENTER | TILDEN | NE | 68781 | FAMILY PRACTICE MEDICAL CLINIC |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | NOT APPLICABLE: FEDERAL POVERTY GUIDELINES ARE USED TO DETERMINE ELIGIBILITY FOR PROVIDING FREE CARE TO LOW INCOME INDIVIDUALS. DISCOUNTED CARE IS NOT PROVIDED. PATIENTS ARE CATEGORIZED EITHER AS BEING ELIGIBLE FOR FREE CARE OR AS RESPONSIBLE FOR REGULAR PATIENT CHARGES. |
| PART I, LINE 7G: | SUBSIDIZED HEALTH SERVICES INCLUDE THREE PHYSICIAN CLINICS IN NEIGHBORING COMMUNITIES. |
| PART I, LN 7 COL(F): | THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $450,827. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | NOT APPLICABLE. |
| PART III, LINE 4: | THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8 AND 9 OF THE ATTACHED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET," "NET PATIENT SERVICE REVENUE AND "CHARITY CARE". |
| PART III, LINE 8: | "MEDICARE ALLOWABLE COSTS OF CARE" WAS CALCULATED FROM INFORMATION IN THE MEDICARE COST REPORT D, E, H & M WORKSHEETS, OR PS&R. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THIS IS A BENEFIT TO THE COMMUNITY BECAUSE THE HOSPITAL APPLIES OTHER FINANCIAL RESOURCES TO COVER THE UNREIMBURSED COSTS OF CARING FOR MEDICARE PATIENTS. MEDICARE PATIENTS WOULD HAVE TO TRAVEL INCONVENIENT DISTANCES FOR CARE IF THE HOSPITAL DID NOT HAVE THE RESOURCES TO CONTINUE TO PROVIDE MEDICAL CARE TO THEM. |
| PART III, LINE 9B: | THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 2: | ANTELOPE MEMORIAL HOSPITAL PERFORMED THE FOLLOWING PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES: - COMMUNITY HEALTH NEEDS ASSESSMENT (CNHA) - PLANNING MEETING AND CNHA RESULTS PRESENTATION - COMMUNITY FOCUS GROUP MEETINGS - CONFERENCE CALLS WITH DHHS PERSONNEL FOR INPUT, GUIDANCE, AND FEEDBACK - STRATEGIC PLANNING SESSIONS - CHIP DOCUMENT DRAFTING, EDITING, REVISION AND COMPLETION - COORDINATION OF CHIP WORK GROUP MEETINGS |
| PART VI, LINE 3: | ANTELOPE MEMORIAL HOSPITAL INCLUDES ITS PAYMENT POLICY WITH ALL STATEMENTS SENT TO PATIENTS. THIS POLICY EXPLAINS THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. |
| PART VI, LINE 4: | ANTELOPE MEMORIAL HOSPITAL IS THE ONLY ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA DUE TO THE CLOSURE OF TILDEN COMMUNITY HOSPITAL DURING THE PREVIOUS TAX YEAR. ANTELOPE MEMORIAL HOSPITAL ALSO PROVIDES SERVICE TO THE FOLLOWING FIVE NEBRASKA COUNTIES: BOONE, HOLT, KNOX, MADISON AND PIERCE. |
| PART VI, LINE 5: | NOT APPLICABLE. |
| PART VI, LINE 6: | ANTELOPE MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. |
| FORM 990, PART VI, LINE 7: | NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Independent Consultant | Yes (X) | IndependentConsultantInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (4 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JACK W GREEN | ||||||||||||||
| ADMINISTRATOR/CEO | $176,840 | $0 | $0 | $0 | $131 | $0 | $7,136 | $0 | $3,730 | $0 | $187,837 | $0 | $0 | $0 |
| TROY DAWSON MD | ||||||||||||||
| PHYSICIAN | $355,218 | $0 | $0 | $0 | $204 | $0 | $12,345 | $0 | $23,540 | $0 | $391,307 | $0 | $0 | $0 |
| ROGER RUDLOFF MD | ||||||||||||||
| PHYSICIAN | $315,487 | $0 | $0 | $0 | $204 | $0 | $12,345 | $0 | $13,819 | $0 | $341,855 | $0 | $0 | $0 |
| WILLIAM B LOCKEE MD | ||||||||||||||
| PHYSICIAN | $261,917 | $0 | $0 | $0 | $153 | $0 | $0 | $0 | $22,540 | $0 | $284,610 | $0 | $0 | $0 |
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 | THE COUNTY OF ANTELOPE NEBRASKA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 476006428 | BondIssuerEIN |
| CUSIP | 036654AH4 | CUSIPNum |
| Bond Issued | 2015-10-15 | BondIssuedDt |
| Issue Price | $2,290,000 | IssuePriceAmt |
| Purpose | REFUND PRIOR ISSUE (12/21/2010) | 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 |
| Total Proceeds | $2,290,031 | TotalProceedsAmt |
| Working Capital Expenditures | $9,228 | WorkingCapitalExpendituresAmt |
| Other Spent Proceeds | $2,198,780 | OtherSpentProceedsAmt |
| Unspent | $82,024 | UnspentAmt |
| Substantial Completion | 2006 | SubstantialCompletionYr |
| Current Refunding | Yes (1) | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| 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 |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | 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 | Yes (1) | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | 0 | 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | FORM 990, SCHEDULE K, PART II, LINE 3: | FormAndLineReferenceDesc |
| Explanation | THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS. | ExplanationTxt |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | WILLIAM B LOCKEE MD | PersonNm |
| Loan Purpose | PHYSICIAN RECRUITMENT | LoanPurposeTxt |
| Loan From Organization | Yes (X) | LoanFromOrganizationInd |
| Original Principal | $25,000 | OriginalPrincipalAmt |
| Balance Due | $19,444 | BalanceDueAmt |
| Default | 0 | DefaultInd |
| Board Or Committee Approval | Yes (1) | BoardOrCommitteeApprovalInd |
| Written Agreement | Yes (1) | WrittenAgreementInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $19,444 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PEGGY GREEN | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. | RelationshipDescriptionTxt |
| Transaction | $65,137 | TransactionAmt |
| Transaction | COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11 | THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO AND CEO REVIEW THE FORM 990 AND THE ADMINISTRATOR PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | ALL OFFICERS, DIRECTORS, COMMITTEE MEMBERS AND KEY EMPLOYEES SHALL REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE AND CERTIFICATION UPON INITIAL AFFILIATION WITH THE CORPORATION AND ON AN ANNUAL BASIS THEREAFTER. |
| FORM 990, PART VI, SECTION B, LINE 15A | SALARY COMPARISON DATA FROM THE NEBRASKA HOSPITAL ASSOCIATION IS USED TO COMPARE ADMINISTRATOR SALARY WITH THAT OF OTHER NEBRASKA CRITICAL ACCESS HOSPITALS. THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER SALARIES ARE DETERMINED USING THE NEBRASKA HOSPITAL ASSOCIATION SALARY SURVEYS AND ARE THEN SET BY THE BOARD OF DIRECTORS. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. |
| FORM 990, PART IX, LINE 11G | OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 1,066,986. MANAGEMENT AND GENERAL EXPENSES 76,055. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,143,041. THERAPIST FEES: PROGRAM SERVICE EXPENSES 760,660. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 760,660. NUCLEAR IMAGING FEES: PROGRAM SERVICE EXPENSES 110,678. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 110,678. MRI FEES: PROGRAM SERVICE EXPENSES 46,153. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 46,153. COLLECTION FEES: PROGRAM SERVICE EXPENSES 12,444. MANAGEMENT AND GENERAL EXPENSES 41,157. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 53,601. |
| FORM 990, PART XII, LINE 2C: | THE FULL BOARD OF DIRECTORS OVERSEES SELECTION OF AN INDEPENDENT ACCOUNTANT AND THE AUDIT OF THE ANTELOPE MEMORIAL HOSPITAL'S FINANCIAL STATEMENTS. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. |
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