2017-11-15T15:41:41-06:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-01-01 411328097 RIDGEVIEW FOUNDATION RIDG 9524426010 500 SOUTH MAPLE STREET WACONIA MN 55387 GORDON GABLENZ CFO & CIO 9524426010 2017-11-14 1 ROBERT E SCHILE 6123764500 67.137.57.251 2017-11-14 14:47:00 CS P 977139128611A4E36F514149905081B6C9A4065F 1FBCD4AA4D8DA69ACB92FF11632DDFE988DCF009 2016 2021-01-29 14:40:06Z ROBERT STEVENS 500 SOUTH MAPLE STREET WACONIA MN 55387 7863645 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. 23 23 0 446 0 0 4017312 2308132 0 0 313332 284914 -214237 -308851 4116407 2284195 2504417 1524664 0 0 0 0 0 0 0 74861 593585 2579278 2118249 1537129 165946 14558175 14906384 972894 895797 13585281 14010587 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 2058245 1524664 0 TO RAISE FUNDS EXCLUSIVELY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER,A NOT-FOR-PROFIT HOSPITAL IN WACONIA, MINNESOTA. DURING THE YEAR ENDEDDECEMBER 31, 2016, RIDGEVIEW FOUNDATION EXPENSED A TOTAL OF $944,552TO RIDGEVIEW MEDICAL CENTER. OF THIS, $223,089 WAS TRANSFERRED TO THE HOSPITAL TO SUPPORT THE BUILDING AND FURNISHING OF A HEART CENTER AND CATH LAB AT THE HOSPITAL, $157,530 WAS TRANSFERRED TO THE HOSPITAL FOR THE COMMUNICATIONS CENTER, AND $118,594 WAS TRANSFERRED TO THE HOSPITAL FOR THE RENOVATION OF THE MEDICAL/SURGICAL WING AND TO AID IN THE EXPANSION OF CRITICAL SERIVCES. THE REMAINING $445,339 TRANSFERRED TO THE HOSPITAL WAS USED FOR VARIOUS PROJECTS AND PROGRAMS DURING 2016. 2058245 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 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 6 0 0 0 0 0 0 0 1 1 0 0 0 0 X 23 23 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 COWLEY SECRETARY 0.50 X X 0 0 0 DARLA HOLMGREN TREASURER 0.50 X X 0 0 0 NANCY BACH BOARD MEMBER 0.50 X 0 0 0 KATHRYN BARNES BOARD MEMBER 0.50 X 0 0 0 BRIAN BENIEK BOARD MEMBER 0.50 X 0 0 0 JEAN BULLER BOARD MEMBER 0.50 X 0 0 0 JON CROW BOARD MEMBER 0.50 X 0 0 0 STACY DESAI BOARD MEMBER (THROUGH 2016) 0.50 X 0 0 0 MIKE DRAZAN BOARD MEMBER 0.50 X 0 0 0 TIM FOSTER BOARD MEMBER 0.50 X 0 0 0 JOHN HAYES BOARD MEMBER 0.50 X 0 0 0 GREG KUMMER BOARD MEMBER 0.50 X 0 0 0 JIM LEONARD BOARD MEMBER 0.50 X 0 0 0 RICK POLK BOARD MEMBER 0.50 X 0 0 0 LINDA ROEBKE BOARD MEMBER 0.50 X 0 0 0 DR DANIEL ROSS DDS BOARD MEMBER 0.50 X 0 0 0 DR LORENE RUTHERFORD MD BOARD MEMBER 0.50 X 0 0 0 MARK STEINGAS BOARD MEMBER 0.50 X 0 0 0 CARLA STRUBLE BOARD MEMBER 0.50 X 0 0 0 PAUL WHITTAKER BOARD MEMBER 0.50 X 0 0 0 JEFF WIGEN BOARD MEMBER 0.50 X 0 0 0 DAVID WINDSCHITL BOARD MEMBER 0.50 X 0 0 0 STEVE YOUNGSTEDT BOARD MEMBER (THROUGH 2016) 0.50 X 0 0 0 ROBERT STEVENS PRESIDENT / CEO 0.50 49.50 X 0 433264 23091 GORDON GABLENZ CFO & CIO 0.50 49.50 X 0 620943 25289 DOUGLAS STASEK EXECUTIVE DIRECTOR 47.50 2.50 X 0 215645 32406 0 1269852 80786 0 0 1 0 0 650897 1657235 407383 2308132 127973 127973 5359642 5202701 156941 156941 156941 55948 650897 363044 -307096 -307096 11950 13705 -1755 -1755 2284195 0 0 -23937 1507664 1507664 17000 17000 9391 9391 68971 68971 6039 6039 -24497 -24497 MISCELLANEOUS EXPENSES 533681 533581 100 2118249 2058245 60004 0 1082897 843633 2119349 1197732 1687738 1404800 100000 76600 9697 9697 0 0 4743202 6239192 4824989 5144427 14558175 14906384 872894 820797 100000 75000 972894 895797 X 8447251 8392906 2359344 2611028 2778686 3006653 13585281 14010587 14558175 14906384 165946 259360 0 X 0 1 X 1 0 X 1208259 4409325 1665055 4017312 2308131 13608082 1208259 4409325 1665055 4017312 2308131 13608082 13608082 65816 71712 95293 106017 127973 466811 298980 425042 122117 106718 67898 1020755 15095648 0.90150 0.89360 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: SPECIAL FUNDRAISING EVENTS CHARITABLE GAMING ACTIVITIES RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7021304 440620 176379 176379 0 7461924 5873869 1147435 2689 936 1753 7021304 5159988 629670 114473 28627 1635 5873869 1528949 3504360 148437 20121 1637 5159988 1456169 20090 64733 12043 1528949 0.55950 0.40290 0.03760 0 0 9697 9697 0 0 PLEDGE RECEIVABLE FROM RIDGEVIEW MEDICAL CENTER 2241518 ANNUITY CONTRACT 55613 ASSETS HELD IN CHARITABLE REMAINDER TRUST 370135 CASH SURRENDER VALUE LIFE INSURANCE POLICY 2477161 5144427 X 3086093 259360 645440 1851767 2756567 329526 1954669 1954669 2284195 3140438 645440 376749 1022189 2118249 0 2118249 PART V, LINE 4: TO SATISFY THE RESTRICTIONS OF DONORS. 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 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 STANDARDS 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 1,475,018. FUNDRAISING EVENT EXPENSES 363,044. CHARITABLE GAMING EVENT EXPENSES 13,705. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 1,019,857. EVENT PROCEEDS 706,845. PERMANENTLY RESTRICTED CONTRIBUTIONS 227,967. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 363,044. CHARITABLE GAMING EVENT EXPENSES 13,705. GOLF TOURNAMENT 502111 450078 52033 16870 234625 FALL HARVEST MOON 204734 200819 3915 60078 706845 650897 55948 16870 294703 311573 -255625 MN 1 0 0 0 1.00000 GORDON GABLENZ 500 SOUTH MAPLE STREET WACONIA MN 55387 0 JAN HELD 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 1 1 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 501(C)(3) 1507664 FUNDRAISING SUPPORT OF RIDGEVIEW MEDICAL CENTER 1 0 SCHOLARSHIPS 17 17000 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 ROBERT STEVENS PRESIDENT / CEO 0 430374 0 0 0 2890 0 9873 0 13218 0 456355 0 0 GORDON GABLENZ CFO & CIO 0 300816 0 0 0 320127 0 10600 0 14689 0 646232 0 0 DOUGLAS STASEK EXECUTIVE DIRECTOR 0 196324 0 0 0 19321 0 7111 0 25295 0 248051 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 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 PART I, LINE 4B ROBERT STEVENS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER THAT ACCRUED $254,368 DURING 2015. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN AT RIDGEVIEW MEDICAL CENTER THAT ACCRUED $506,054 DURING 2015. 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. X 3825 FAIR MARKET VALUE X 10 55768 FAIR MARKET VALUE X 8 2438 FAIR MARKET VALUE X AUCTION ITEMS 429 175851 FAIR MARKET VALUE X GIFTS 109 169500 FAIR MARKET VALUE 0 0 0 0 PART I, COLUMN (B): THE NUMBERS REPORTED IN PART I, COLUMN B, LINES 9 AND 19 ARE THE NUMBER OF DONATIONS RECEIVED. THE NUMBERS REPORTED IN PART I, COLUMN B, LINES 25 AND 26 ARE THE NUMBER DONATED ITEMS RECEIVED. 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 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 0 0