2016-11-15T15:43:41-06:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-01-01 411328097 RIDGEVIEW FOUNDATION RIDG 9524426010 500 SOUTH MAPLE STREET WACONIA MN 55387 GORDON GABLENZ CFO & CIO 9524426010 2016-11-14 1 KACIE MCEWEN P01599614 6123764500 2015 2017-02-10 21:41:12Z ROBERT STEVENS 500 SOUTH MAPLE STREET WACONIA MN 55387 8257589 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 0 418 0 0 1665055 4017312 0 0 488298 313332 -187400 -214237 1965953 4116407 1383796 2504417 0 0 0 0 0 0 0 107475 74861 1491271 2579278 474682 1537129 12752859 14558175 400338 972894 12352521 13585281 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 2504417 2504417 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, 2015, RIDGEVIEW FOUNDATION EXPENSED A TOTAL OF $2,504,417TO RIDGEVIEW MEDICAL CENTER. OF THIS, $1,450,000 WAS TRANSFERRED TO THE HOSPITAL FOR THE RENOVATION OF THE MEDICAL/SURGICAL WING AND TO AID IN THE EXPANSION OF CRITICAL SERVICES, $300,000 WAS TRANSFERRED TO THE HOSPITAL TO SUPPORT THE BUILDING AND FURNISHING OF A HEART CENTER AND CATH LAB AT THE HOSPITAL, $200,000 WAS TRANSFERRED TO THE HOSPITAL FOR THE WOMEN'S AND CHILDREN'S CENTER. THE REMAINING $554,417 TRANSFERRED TO THE HOSPITAL WAS USED FOR VARIOUS PROJECTS AND PROGRAMS DURING 2015. 2504417 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 5 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 9524426010 500 SOUTH MAPLE STREET WACONIA MN 55387 CHUCK SPEVACEK CHAIRPERSON 0.50 0.00 X X 0 0 0 FRED GREEN VICE CHAIR 0.50 0.00 X X 0 0 0 DERMOT COWLEY SECRETARY 0.50 0.00 X X 0 0 0 DARLA HOLMGREN TREASURER 0.50 0.00 X X 0 0 0 NANCY BACH BOARD MEMBER 0.50 0.00 X 0 0 0 KATHRYN BARNES BOARD MEMBER 0.50 0.00 X 0 0 0 BRIAN BENIEK BOARD MEMBER 0.50 0.00 X 0 0 0 JEAN BULLER BOARD MEMBER 0.50 0.00 X 0 0 0 JOHN CROW BOARD MEMBER 0.50 0.00 X 0 0 0 STACY DESAI BOARD MEMBER 0.50 0.00 X 0 0 0 TIM FOSTER BOARD MEMBER 0.50 0.00 X 0 0 0 GREG KUMMER BOARD MEMBER 0.50 0.00 X 0 0 0 JIM LEONARD BOARD MEMBER 0.50 0.00 X 0 0 0 BRIAN MACK BOARD MEMBER THROUGH JAN 2015 0.50 0.00 X 0 0 0 RICK POLK BOARD MEMBER 0.50 0.00 X 0 0 0 LINDA ROEBKE BOARD MEMBER 0.50 0.00 X 0 0 0 DANIEL ROSS BOARD MEMBER 0.50 0.00 X 0 0 0 DR LORENE RUTHERFORD 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 PAUL WHITTAKER BOARD MEMBER 0.50 0.00 X 0 0 0 JEFF WIGEN BOARD MEMBER 0.50 0.00 X 0 0 0 LARRY WILHELM BOARD MEMBER THROUGH JAN 2015 0.50 0.00 X 0 0 0 DAVID WINDSCHITL BOARD MEMBER 0.50 0.00 X 0 0 0 STEVE YOUNGSTEDT BOARD MEMBER 0.50 0.00 X 0 0 0 ROBERT STEVENS CEO 0.50 49.50 X 0 479589 21160 GORDON GABLENZ CFO & CIO 0.50 49.50 X 0 367625 30610 DOUGLAS STASEK EXECUTIVE DIRECTOR 47.50 2.50 X 0 239184 17696 0 1086398 69466 0 0 1 0 0 679347 3337965 168889 4017312 106017 106017 4027542 3820227 207315 207315 207315 90168 679347 310920 -220752 -220752 16550 10035 6515 6515 4116407 0 0 99095 2489417 2489417 15000 15000 8283 8283 1000 1000 31816 31816 5218 5218 19320 19320 MISCELLANEOUS EXPENSES 9224 9224 2579278 2504417 74861 0 1672816 1082897 846613 2119349 1720482 1787738 9697 9697 0 0 3571663 4286927 474051 456275 4467234 4824989 12752859 14558175 400338 872894 100000 400338 972894 X 6154672 8447251 4015083 2359344 2182766 2778686 12352521 13585281 12752859 14558175 1537129 -304369 0 X 0 1 X 1 0 X 1945444 1208259 4409325 1665055 4017312 13245395 1945444 1208259 4409325 1665055 4017312 13245395 13245395 28520 65816 71712 95293 106017 367358 257076 298980 425042 122117 106718 1209933 14822686 0.89360 0.97290 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 5873869 1147435 2689 936 1753 7021304 5159988 629670 114473 28627 1635 5873869 1528949 3504360 148437 20121 1637 5159988 1456169 20090 64733 12043 1528949 1228652 227270 48325 48078 1456169 0.56430 0.39580 0.03990 0 0 9697 9697 0 0 PLEDGE RECEIVABLE FROM RIDGEVIEW MEDICAL CENTER 3041672 ANNUITY CONTRACT 53725 ASSETS HELD IN CHARITABLE REMAINDER TRUST 368259 CASH SURRENDER VALUE LIFE INSURANCE POLICY 1361333 4824989 X 5881486 -304369 688674 3593666 3977971 1903515 2212892 2212892 4116407 3588907 688674 320955 1009629 2579278 0 2579278 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 REVEIW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 3,272,711. FUNDRAISING EVENT EXPENSES 310,920. CHARITABLE GAMING EVENT EXPENSES 10,035. PART XI, LINE 4B - OTHER ADJUSTMENTS: TEMPORARILY RESTRICTED CONTRIBUTIONS 847,457. EVENT PROCEEDS 769,515. PERMANENTLY RESTRICTED CONTRIBUTIONS 595,920. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EVENT EXPENSES 310,920. CHARITABLE GAMING EVENT EXPENSES 10,035. GOLF TOURNAMENT 590033 502359 87674 16870 223106 FALL HARVEST MOON 179482 176988 2494 69844 769515 679347 90168 16870 292950 309820 -219652 16550 6675 3360 0 16550 6675 3360 10035 6515 MN 1 0 0 0 1.00000 0.00000 GORDON GABLENZ 500 SOUTH MAPLE STREET WACONIA MN 55387 0 JAN HELD 68469 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 6675 1 RIDGEVIEW MEDICAL CENTER 500 SOUTH MAPLE STREET WACONIA MN 55387 311667875 501(C)(3) 2489417 FUNDRAISING SUPPORT OF RIDGEVIEW MEDICAL CENTER 1 0 SCHOLARSHIPS 15 15000 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 0 1 0 0 ROBERT STEVENS CEO 0 438935 0 0 0 40654 0 9990 0 11170 0 500749 0 0 GORDON GABLENZ CFO & CIO 0 300079 0 15000 0 52546 0 10600 0 20010 0 398235 0 0 DOUGLAS STASEK EXECUTIVE DIRECTOR 0 191360 0 15000 0 32824 0 7176 0 10520 0 256880 0 0 PART I, LINE 3 THE PRESIDENT/CEO IS COMPENSATED BY RIDGEVIEW MEDICAL CENTER, A RELATED PARTY. RIDGEVIEW MEDICAL CENTER USES THE FOLLOWING WHEN DETERMINING HIS 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 THAT ACCRUED $254,368 DURING 2015. MICHAEL PHELPS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN THAT ACCRUED $142,127 DURING 2015. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT SPLIT-DOLLAR WHOLE LIFE PLAN THAT ACCRUED $506,054 DURING 2015. THESE PLANS ARE OFFERED BY RIDGEVIEW MEDICAL CENTER. 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 7862 FAIR MARKET VALUE X 8 48850 FAIR MARKET VALUE X 3 1272 FAIR MARKET VALUE X GIFTS 70 79059 FAIR MARKET VALUE X AUCTION ITEMS 117 31846 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 11 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 11A, 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 INC 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