2014-02-13T08:32:23-06:00 2013-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-07-01 470393176 ANTELOPE MEMORIAL HOSPITAL ANTE 4028874151 PO BOX 229 NELIGH NE 68756 JACK W GREEN 4028874151 2014-02-10 1 BARBARA J FAJEN P00400874 4023302660 2012 2015-11-30 17:44:51Z JACK W GREEN PO BOX 229 NELIGH NE 68756 13663559 0 X WWW.AMHNE.ORG X 1974 NE 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. 8 8 176 10 0 0 599451 141801 12587516 13385928 62070 40539 34914 90900 13283951 13659168 0 0 0 0 6716620 7108413 0 0 0 5439417 6374151 12156037 13482564 1127914 176604 17077908 17278259 5362907 5378654 11715001 11899605 MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. 0 0 11928299 13441008 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. 11928299 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 30 0 1 176 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X MARTHA NELSON 4028876282 PO BOX 229 NELIGH NE 68756 JOHN MLNARIK 4.00 0.00 X X 0 0 0 JAMES BLACKBURN 4.00 0.00 X X 0 0 0 JOE KNIGHT 4.00 0.00 X X 0 0 0 PHILIP KLUTHE 2.00 0.00 X 0 0 0 JAMES MEURET 2.00 0.00 X 0 0 0 GORDON SHRADER 2.00 0.00 X 0 0 0 DAVID SULLIVAN 2.00 0.00 X 0 0 0 CHRISTOPHER TWIBELL 2.00 0.00 X 0 0 0 JACK W GREEN 40.00 0.00 X 154550 0 12941 MARTHA NELSON 36.00 0.00 X 88133 0 9684 ROGER RUDLOFF 40.00 0.00 X 322782 0 18635 TROY DAWSON 40.00 0.00 X 288088 0 18625 PATRICIA GOOD 40.00 0.00 X 115241 0 10378 KAREN GALLAGHER 40.00 0.00 X 106247 0 9965 1075041 0 80228 5 0 1 0 HAUSMANN CONSTRUCTION 8545 EXECUTIVE WOODS DRIVE SUITE 1 LINCOLN NE 68512 CONTRACTOR 2983206 TKO PO BOX 385 NELIGH NE 68756 NURSING SERVICES 425000 DAVIS DESIGN INC 1221 N STREET SUITE 600 LINCOLN NE 68508 ARCHITECTURE 373646 OVERLAND REHAB SERVICES 405 JAMES STREET VERDIGRE NE 68783 PHYSICAL THERAPY SERVICES 351554 MEDTYPE TRANSCRIPTION INC 404 NORTH 28TH STREET NORFOLK NE 68701 TRANSCRIPTION 127984 6 141801 141801 MEDICARE/MEDICAID PAYMENTS 621400 8136823 8136823 OTHER PATIENT SERVICE REVENUE 621400 5038141 5038141 340B REVENUE 621990 186464 186464 LIFELINE 621990 18600 18600 AMBULANCE 621910 5900 5900 13385928 29916 29916 15014 4391 10623 10623 10623 MISCELLANEOUS REVENUE 900099 55080 55080 CAFETERIA 900099 35820 35820 90900 13659168 13441008 0 76359 265308 265308 42722 42722 5343646 4836081 507565 166601 152250 14351 897387 789539 107848 392749 340403 52346 53605 53605 43072 43072 2255512 1949909 305603 38281 17791 20490 731926 590620 141306 199630 199630 42346 39027 3319 128010 128010 1092966 1092966 172218 172218 MEDICAL SUPPLIES 1126900 1126900 BAD DEBT 409482 409482 DUES & SUBSCRIPTIONS 32876 32876 LICENSES 21929 2861 19068 25398 5014 20384 13482564 11928299 1554265 0 1360605 1132795 3027043 1602251 48431 37722 1291974 1440609 480262 149530 299454 296150 26770 39114 20922835 8894401 9989954 12028434 442110 466102 111305 85552 17077908 17278259 1822907 1721720 3540000 3310000 0 346934 5362907 5378654 X 11713501 11883880 1500 15725 11715001 11899605 17077908 17278259 176604 8000 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1466 1466 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF NEBRASKA HOSPITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES ALLOCABLE TO LOBBYING ACTIVITIES. 63764 63764 6465891 2599409 3866482 10884016 5625592 5258424 3509164 669400 2839764 12028434 ESTIMATED THIRD-PARTY PAYER SETTLEMENT 346934 346934 X 13665323 8000 8000 13657323 1845 1845 13659168 13480719 0 13480719 1845 1845 13482564 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 EXEPMT 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, 2013 AND 2012, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL, STATE OR LOCAL TAX AUTHORITIES FOR YEARS ENDED PRIOR TO JUNE 30, 2010. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 1,845. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 1,845. 1 1 1 X 0 1 1 1 0 1 1 52650 52650 0.00400 656576 603671 52905 0.00400 709226 603671 105555 0.00800 34072 11295 22777 0.00170 963166 604839 358327 0.02740 997238 616134 381104 0.02910 1706464 1219805 486659 0.03710 1 409482 0 7411152 7139618 271534 X 1 0 1 1 ANTELOPE MEMORIAL HOSPITAL

102 WEST 9TH STREET NELIGH NE 68756

X X X ANTELOPE MEMORIAL HOSPITAL 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X 1 0 1 1 100.000000000000 0 0 1 1 X X 1 0 X 1 X 0 0 5 AMH FAMILY PRACTICE

109 WEST 11TH STREET PO BOX 109 NELIGH NE 68756

FAMILY PRACTICE MEDICAL CLINIC AMH CLEARWATER CLINIC

HIGHWAY 275 MAIN STREET CLEARWATER NE 68726

FAMILY PRACTICE MEDICAL CLINIC AMH ELGIN CLINIC

101 WEST CEDAR STREET ELGIN NE 68636

FAMILY PRACTICE MEDICAL CLINIC ORCHARD MEDICAL CLINIC

103 WASHINGTON STREET ORCHARD NE 68764

FAMILY PRACTICE MEDICAL CLINIC AMH TILDEN CLINIC

104 SOUTH CENTER TILDEN NE 68781

FAMILY PRACTICE MEDICAL CLINIC 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 6A: ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. PART I, LINE 7: THE COST TO CHARGE RATIO AS FOLLOWS WAS USED TO DETERMINE CHARITY CARE AND MEANS-TESTED GOVERNMENT PROGRAMS AT COST: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. OTHER COMMUNITY BENEFIT EXPENSES ARE STATED AT COST BASED ON ANTELOPE MEMORIAL HOSPITAL'S INTERNAL ACCOUNTING RECORDS. PART I, LINE 7G: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. PART I, L7 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 $409,482. PART II: N/A PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE BAD DEBT EXPENSE INCLUDED CALCULATING THE TOTAL ESTIMATE AMOUNTS BASED ON THE AGING TRIAL BALANCE REPORT THEN ADJUSTING FOR ALLOWANCES, RECOVERIES, OTHER CHANGES IN ACCOUNTS RECEIVABLE AND CHANGES TO REFUNDS CLEARING. WHEN CALCULATING BAD DEBT, ANY INSURANCE DISCOUNTS AND PATIENT PAYMENTS HAVE BEEN REMOVED FROM THE ACCOUNT BALANCES. THE BALANCE OF THE ACCOUNT IS USED TO CALCULATE THE BAD DEBT ESTIMATE.THE HOSPITAL'S FINANCIAL STATMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTE TITLED "PATIENT RECEIVABLES, NET" AND "CHARITY CARE":"PATIENT RECEIVABLES, NET" THE HOSPITAL REPORTS PATIENT ACCOUNTS RECEIVABLE FOR SERVICES RENDERED AT NET REALIZABLE AMOUNTS FROM THIRD-PARTY PAYERS, PATIENTS AND OTHERS. ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR THOSE ACCOUNTS OVER A CERTAIN AGE BASED ON DISCHARGE THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS."CHARITY CARE"THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. BECAUSE THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED IN THE STATEMENTS OF OPERATIONS.THE HOSPITAL IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTHCARE SERVICE TO ALL SEGMENTS OF SOCIETY, INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HOSPITAL PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEARS ENDED JUNE 30, 2013 AND 2012 WERE APPROXIMATELY $75,000 AND $83,000, RESPECTIVELY. 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. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. 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 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 3: ANTELOPE MEMORIAL HOSPITAL MET WITH COMMUNITY REPRESENTATIVES OF THE SCHOOLS, LOCAL GOVERNMENT, POLICE, MINISTERIAL ASSOCIATION, CHAMBER OF COMMERCE, NURSING HOME, ASSISTED LIVING, AND OTHER INTERESTED CITIZENS. ANTELOPE MEMORIAL HOSPITAL PART V, SECTION B, LINE 14G: 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 20D: CHARGES FOR SERVICES ARE THE SAME FOR ALL PATIENTS, WHETHER THEY ARE ELIGIBLE OR NOT ELIGIBLE 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 CHARITY CARE PROGRAM AND GIVES INSTRUCTIONS FOR THE APPLICATION PROCESS. PART VI, LINE 4: ANTELOPE MEMORIAL HOSPITAL IS THE LARGEST ACUTE CARE FACILITY SERVING THE ANTELOPE COUNTY AREA. CURRENTLY THERE ARE TWO HOSPITALS PROVIDING ACUTE CARE SERVICES WITHIN ANTELOPE COUNTY. THE 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 HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. 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. X X X 0 0 0 0 0 0 0 0 0 JACK W GREEN 154550 0 0 0 0 0 6113 0 6828 0 167491 0 0 0 ROGER RUDLOFF 322782 0 0 0 0 0 11697 0 6938 0 341417 0 0 0 TROY DAWSON 288088 0 0 0 0 0 11697 0 6928 0 306713 0 0 0 A HOSPITAL AUTH NO 1 OF ANTELOPE CTY NE 900198231 03665RBB5 2010-12-21 3770000 REFUND PRIOR ISSUE (7/1/2004) 0 0 0 A 460000 3770000 363963 3770000 2006 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 1 0 0 0 0 0 1 A 1 FORM 990, SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT EQUAL THE SUM OF LINES 4 THROUGH 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. FORM 990, SCHEDULE K, PART III, LINE 9: THE TAX COMPLIANCE AGREEMENT FOR THE ORGANIZATION'S 2010 BONDS SPECIFICALLY STATES THAT IT IS INTENDED TO SERVE AS PART OF ITS WRITTEN POLICIES AND PROCEDURES TO ENSURE POST-ISSUANCE COMPLIANCE RELATING TO ITS OUTSTANDING TAX-EXEMPT BOND OBLIGATIONS. THE AGREEMENT ALSO SETS FORTH POLICIES RELATING TO REMEDIAL ACTIONS RELATING TO SUCH OBLIGATIONS AS, AND TO THE EXTENT NECESSARY. THE ORGANIZATION INTENDS TO ADOPT SEPARATE GENERALLY-APPLICABLE POLICIES AND PROCEDURES ADDRESSING THESE MATTERS AT AN APPROPRIATE MEETING OF ITS BOARD OF DIRECTORS SUBSEQUENT TO THIS FILING. PEGGY GREEN FAMILY MEMBER OF JACK GREEN, CEO FOR ANTELOPE MEMORIAL HOSPITAL. 42722 COMPENSATION WAS PAID TO PEGGY GREEN FOR HER SERVICES AS AN EMPLOYEE OF ANTELOPE MEMORIAL HOSPTIAL. 0 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 REVIEWS FORM 990 AND 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 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.