2016-11-15T15:11:36-06:00 2015-12-31 420714325 RSM US LLP 801 NICOLLET MALL SUITE 1100 MINNEAPOLIS MN 55402 990 2015-01-01 471693199 FARIBAULT AREA HOSPICE FOUNDATION FARI 5073324731 200 STATE AVENUE FARIBAULT MN 55021 KEN BETSINGER CHAIR 5073324731 2016-11-10 1 TODD A JACKSON P00092672 6123324300 2015 2017-02-10 21:41:12Z KEN BETSINGER 200 STATE AVENUE FARIBAULT MN 55021 614874 0 X N/A X 2014 MN TO IMPROVE THE QUALITY OF LIFE THROUGH COMFORT CARE, SUPPORT AND COMPASSION FOR PATIENTS AND THEIR LOVED ONES IN THE DISTRICT ONE HOSPITAL SERVICE AREA. 9 9 0 9 0 0 719000 614159 0 0 2 715 0 0 719002 614874 0 0 0 0 0 0 0 0 0 31 84 31 84 718971 614790 718971 1333761 0 0 718971 1333761 X FARIBAULT AREA HOSPICE FOUNDATION IS ORGANIZED AND OPERATED IN ACCORDANCE WITH IRC 501(C)(3) TO RAISE FUNDS FROM THE PUBLIC THAT ARE USED TO ENHANCE THE SCOPE AND QUALITY AND OTHERWISE SUPPORT THE MISSION OF FARIBAULT AREA HOSPICE, WHICH IS TO IMPROVE THE QUALITY OF LIFE THROUGH COMFORT CARE, SUPPORT AND COMPASSION FOR PATIENTS AND THEIR LOVED ONES IN THE DISTRICT ONE HOSPITAL SERVICE AREA. 0 0 THE FOUNDATION PROVIDES SUPPORT FOR INDIVIDUAL HOSPICE PATIENTS AND THEIR LOVED ONES TO IMPROVE THE QUALITY OF LIFE THROUGH COMFORT CARE, SUPPORT AND COMPASSION. THE FOUNDATION PROVIDES FINANCIAL ASSISTANCE TO HOSPICE PATIENTS AND THEIR FAMILIES TO ASSIST WITH EXPENSES, SUCH AS PAYMENT OF UTILITY BILLS, GIFT CARDS FOR GROCERIES AND OTHER HOUSEHOLD EXPENSES, ETC. THE FOUNDATION IS STILL IN THE PROCESS OF DEVELOPING THE STANDARD APPLICATION THAT WILL BE REQUIRED TO BE CONSIDERED FOR ASSISTANCE FROM THE FOUNDATION. THE FOUNDATION MAY ALSO MAKE DISTRIBUTIONS TO ORGANIZATIONS THAT QUALIFY AS PUBLIC CHARITIES TO SUPPORT THE EXEMPT PURPOSE OF PROVIDING FINANCIAL SUPPORT FOR ENHANCING THE SCOPE AND QUALITY AND OTHERWISE SUPPORTING THE MISSION OF THE FARIBAULT AREA HOSPICE, WHICH IS TO IMPROVE THE QUALITY OF LIFE THROUGH COMFORT CARE, SUPPORT AND COMPASSION FOR PATIENTS AND THEIR LOVED ONES IN THE DISTRICT ONE HOSPITAL SERVICE AREA. 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 1 1 0 MN X RICK MILLER DISTRICT ONE HOSPITAL 5073324731 200 STATE AVENUE FARIBAULT MN 55021 X KEN BETSINGER CHAIR 0.60 X X 0 0 0 PATTY VOEGELE VICE CHAIR 0.60 X X 0 0 0 GARY VOEGELE SECRETARY 0.60 X X 0 0 0 KEN KANGAS TREASURER 0.60 X X 0 0 0 KRIS DREVLOW VOTING BOARD MEMBER 0.60 X 0 0 0 AUDREY TEBO VOTING BOARD MEMBER 0.60 X 0 0 0 NORMAN SHULTZ VOTING BOARD MEMBER 0.60 X 0 0 0 CALISTA VOS VOTING BOARD MEMBER 0.60 X 0 0 0 CRAIG BRIEMHORST VOTING BOARD MEMBER 0.60 X 0 0 0 0 0 0 0 0 0 0 0 614159 614159 715 715 614874 0 0 715 X 84 84 84 0 84 0 718971 1333761 718971 1333761 0 0 X 718971 1333761 718971 1333761 718971 1333761 614790 0 X 0 0 0 X 0 36047 36047 36047 36047 36047 2 715 717 36764 X SCHEDULE A, PART VI, LIST OF UNUSUAL GRANTS: DESCRIPTION: DATE: 12/31/14 AMOUNT: 719000. DESCRIPTION: DATE: 06/01/15 AMOUNT: 578112. SCHEDULE A - 2014 SHORT YEAR THE FOUNDATION WAS INCORPORATED JULY 7, 2014; THEREFORE THE INITIAL 2014 RETURN IS THE SHORT PERIOD FROM 7/1/14 - 12/31/14. SCHEDULE A, PART II, UNUSUAL GRANTS THE FOUNDATION RECEIVED THE FOLLOWING UNUSUAL GRANTS FROM A TRUST: 12/31/2014 - $719,000 6/1/2015 - $578,111.53 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED BY RICK MILLER OF DISTRICT ONE HOSPITAL ON BEHALF OF THE BOARD OF DIRECTORS PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS ARE REQUIRED TO SIGN THE CONFLICT OF INTEREST ACKNOWLEDGEMENT/QUESTIONAIRE ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15 OFFICERS AND DIRECTORS OF THE FOUNDATION DO NOT RECEIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST FOR THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN SECTION 6104(D). FORM 990, PART IX, LINE 11G BANK ACCOUNT FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 84. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 84.