FAIRBURY ASSISTED LIVING FACILITY: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- FAIRBURY ASSISTED LIVING FACILITY (EIN 47-0841274)
- Tax period
- 2012-10-01 to 2013-09-30
- Filed
- 2014-02-10
- IRS object ID
- 201440419349300124
- Schema version
- 2012v2.1
- 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 ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2014-02-10T11:25:06-06:00 | Timestamp |
| Tax Period End Date | 2013-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476097913 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 680224722 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470841274 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FAIRBURY ASSISTED LIVING FACILITY DBA CEDARWOOD | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | FAIR | NameControl |
| Phone | 4027293351 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 828 22ND STREET | AddressLine1 |
| City | FAIRBURY | City |
| State | NE | State |
| ZIP Code | 68352 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | CHANCE KLASEK | Name |
| Title | SECRETARY | Title |
| Phone | 4027293351 | Phone |
| Date Signed | 2014-02-03 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JULIE M GERKEN | Name |
| PTIN | P00400882 | PTIN |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | CHANCE KLASEK | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 277 | AddressLine1 |
| City | FAIRBURY | City |
| State | NE | State |
| ZIP Code | 68352 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 1500783 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.JCHCHEALTHCARE.ORG/CEDARWOOD-AL/ | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 2001 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | CEDARWOOD ASSISTED LIVING PROVIDES THE HIGHEST QUALITY OF HOSPITALITY, SERVICES, ACTIVITIES, SECURITY, COMPANIONSHIP AND FREEDOM TO TENANTS IN A CARING AND LOVING ENVIRONMENT THAT THE TENANTS ARE PROUD TO CALL THEIR HOME. CEDARWOOD'S SERVICES ARE PROVIDED TO THE RESIDENTS OF JEFFERSON COUNTY. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 6 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 6 | NbrIndependentVotingMembers |
| Total Nbr Employees | 38 | TotalNbrEmployees |
| Total Nbr Volunteers | 0 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 300 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 150 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 1443698 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 1500334 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -1864 | InvestmentIncomePriorYear |
| Investment Income Current Year | 299 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -57059 | OtherRevenuePriorYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 1385075 | TotalRevenuePriorYear |
| Total Revenue Current Year | 1500783 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 413826 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 427783 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 871385 | OtherExpensePriorYear |
| Other Expenses Current Year | 945348 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 1285211 | TotalExpensesPriorYear |
| Total Expenses Current Year | 1373131 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 99864 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 127652 | RevenuesLessExpensesCY |
| Total Assets BOY | 3279734 | TotalAssetsBOY |
| Total Assets EOY | 4322345 | TotalAssetsEOY |
| Total Liabilities BOY | 2966751 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 3881710 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 312983 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 440635 | NetAssetsOrFundBalancesEOY |
| Mission Description | NONE - SEE PAGE 1 FOR DESCRIPTION OF ACTIVITIES. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 1273810 | Expense |
| Revenue | 1500334 | Revenue |
| Description | CEDARWOOD ASSISTED LIVING FACILITY WAS CONSTRUCTED ADJACENT TO JEFFERSON COMMUNITY HEALTH CENTER (JCHC), A NEBRASKA NONPROFIT HOSPITAL EXEMPT FROM INCOME TAXES UNDER I.R.C. 501 (C)(3). THE PURPOSE OF THE 50-UNIT FACILITY IS TO MEET AN IDENTIFIABLE COMMUNITY NEED IN THE FAIRBURY AREA, AND TO DEVELOP A MORE COMPREHENSIVE CONTINUUM OF HEALTH CARE THAT COMPLEMENTS THE HEALTH CARE SERVICES ALREADY AVAILABLE ON THE CAMPUS OF JCHC. 61 RESIDENTS WERE SERVED FROM OCTOBER 2012 THROUGH SEPTEMBER 2013. EIGHT OF THESE RESIDENTS QUALIFIED UNDER THE MEDICAID WAIVER PROGRAM. TOTAL DAYS OF CARE PROVIDED WERE 16,753. | Description |
| Total Program Service Expense | 1273810 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 0 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 0 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 38 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 6 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 6 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 0 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 0 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHANCE KLASEK | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 4027296856 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 277 | AddressLine1 |
| City | FAIRBURY | City |
| State | NE | State |
| ZIP Code | 68352 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
| No Listed Persons Compensated | X | NoListedPersonsCompensated |
Form990 Part VII Section A Form990PartVIISectionA (7 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|---|
| HOMER WARD | |||||||
| CHAIRMAN | 1.00 | 0.00 | X | X | 0 | 0 | 0 |
| KENNETH FOSTER | |||||||
| VICE CHAIRMAN | 1.00 | 0.00 | X | X | 0 | 0 | 0 |
| CHANCE KLASEK | |||||||
| SECRETARY | 5.00 | 0.00 | X | X | 0 | 0 | 0 |
| RUSSELL GRONEWOLD | |||||||
| TREASURER | 1.00 | 0.00 | X | X | 0 | 0 | 0 |
| RICK STANTON | |||||||
| BOARD MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | |
| SHIRLEY TRAVIS | |||||||
| BOARD MEMBER | 1.00 | 0.00 | X | 0 | 0 | 0 | |
| CHAD JURGENS | |||||||
| PRESIDENT | 1.00 | 0.00 | X | 0 | 0 | 0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 0 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 0 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation
Name Of Contractor NameOfContractor
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JEFFERSON COMMUNITY HEALTH CENTER INC | BusinessNameLine1 |
Address Of Contractor AddressOfContractor
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 2200 H STREET PO BOX 277 | AddressLine1 |
| City | FAIRBURY | City |
| State | NE | State |
| ZIP Code | 68352 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description Of Services | MANAGEMENT FEES AND OTHER CONTRACTED SER | DescriptionOfServices |
| Compensation | 410776 | Compensation |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 1 | NumberOfContractorsGT100K |
| All Other Contributions | 150 | AllOtherContributions |
| Total Contributions | 150 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| RESIDENT REVENUE | 623000 | 749663 | 749663 |
| MEDICARE/MEDICAID PAYM | 623000 | 738817 | 738817 |
| RENTAL INCOME | 900002 | 11854 | 11854 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 1500334 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 299 | TotalRevenueColumn |
| Exclusion | $299 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1500783 | TotalRevenueColumn |
| Related Or Exempt Function Income | 1500334 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $299 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 368776 | Total |
| Program Services | 368776 | ProgramServices |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 27083 | Total |
| Program Services | 27083 | ProgramServices |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 31924 | Total |
| Program Services | 31924 | ProgramServices |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 75174 | Total |
| Management And General | 75174 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 11478 | Total |
| Management And General | 11478 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 373006 | Total |
| Program Services | 366696 | ProgramServices |
| Management And General | 6310 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7444 | Total |
| Program Services | 7444 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 58682 | Total |
| Program Services | 56148 | ProgramServices |
| Management And General | 2534 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 157848 | Total |
| Program Services | 157848 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1713 | Total |
| Program Services | 1713 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 235814 | Total |
| Program Services | 235814 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 19697 | Total |
| Program Services | 15872 | ProgramServices |
| Management And General | 3825 | ManagementAndGeneral |
Other Expenses OtherExpenses (2 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| DUES & SUBSCRIPTIONS | 4276 | 4276 |
| BAD DEBT | 216 | 216 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1373131 | Total |
| Program Services | 1273810 | ProgramServices |
| Management And General | 99321 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 104511 | BOY |
| EOY | 352145 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 718811 | BOY |
| EOY | 469121 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 19525 | BOY |
| EOY | 16262 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14966 | BOY |
| EOY | 20244 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 5590712 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 2182535 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2365104 | BOY |
| EOY | 3408177 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 56817 | BOY |
| EOY | 56396 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3279734 | BOY |
| EOY | 4322345 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 116737 | BOY |
| EOY | 190504 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2795000 | BOY |
| EOY | 3626547 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 55014 | BOY |
| EOY | 64659 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2966751 | BOY |
| EOY | 3881710 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 312983 | BOY |
| EOY | 440635 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 312983 | BOY |
| EOY | 440635 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3279734 | BOY |
| EOY | 4322345 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | 127652 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Separate | X | FinancialStatementSeparate |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org509a2 | X | PubliclySupportedOrg509a2 |
Gifts Grants Contrib Received509 GiftsGrantsContribReceived509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 2390 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 300 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus1 Year | 300 | CurrentTaxYearMinus1Year |
| Current Tax Year | 150 | CurrentTaxYear |
| Total | 3140 | Total |
Gross Receipts From Admissions GrossReceiptsFromAdmissions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1305362 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1356907 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1399288 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1443698 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1500334 | CurrentTaxYear |
| Total | 7005589 | Total |
Total509 Total509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1307752 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1357207 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1399288 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1443998 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1500484 | CurrentTaxYear |
| Total | 7008729 | Total |
Amts Recd From Disqual Persons AmtsRecdFromDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Amts From Subst Contributors AmtsFromSubstContributors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Support From DQ Ps Etc SupportFromDQPsEtc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total509 | 7008729 | PublicSupportTotal509 |
Gross Investment Income509 GrossInvestmentIncome509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 13564 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 5784 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 2895 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 2907 | CurrentTaxYearMinus1Year |
| Current Tax Year | 299 | CurrentTaxYear |
| Total | 25449 | Total |
Investment Income And UBTI InvestmentIncomeAndUBTI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 13564 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 5784 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 2895 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 2907 | CurrentTaxYearMinus1Year |
| Current Tax Year | 299 | CurrentTaxYear |
| Total | 25449 | Total |
Total Support Total TotalSupportTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1321316 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1362991 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1402183 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1446905 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1500783 | CurrentTaxYear |
| Total | 7034178 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Percentage509 | 0.99640 | PublicSupportPercentage509 |
| Prior Year Support Percentage | 0.99230 | PriorYearSupportPercentage |
| Investment Income Percentage | 0.00360 | InvestmentIncomePercentage |
| Prior Yr Invest Income Percentage | 0.00770 | PriorYrInvestIncomePercentage |
| Thirty Three Percnt Tests CY509 | X | ThirtyThreePercntTestsCY509 |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 60427 | OtherCostOrOtherBasis |
| Book Value | 60427 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5230650 | OtherCostOrOtherBasis |
| Depreciation | 1942770 | Depreciation |
| Book Value | 3287880 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 216081 | OtherCostOrOtherBasis |
| Depreciation | 172857 | Depreciation |
| Book Value | 43224 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 83554 | OtherCostOrOtherBasis |
| Depreciation | 66908 | Depreciation |
| Book Value | 16646 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 3408177 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | RESIDENT SECURITY DEPOSITS | Description |
| Amount | $64,659 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 64659 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 1500783 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 1500783 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 1500783 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 1373131 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 1373131 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 1373131 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | Identifier |
| Return Reference | PART X, LINE 2: | ReturnReference |
| Explanation | CEDARWOOD IS A NOT-FOR-PROFIT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT THEY ARE 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 CEDARWOOD'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE CEDARWOOD TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. CEDARWOOD ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. CEDARWOOD RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2013, CEDARWOOD HAD NO UNCERTAIN TAX POSITIONS ACCRUED. CEDARWOOD IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR FISCAL YEARS ENDED PRIOR TO SEPTEMBER 30, 2010. | Explanation |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 611683496 | IssuerEIN |
| Date Issued | 2012-01-18 | DateIssued |
| Issue Price | 2795000 | IssuePrice |
| Description Of Purpose | REFI PRIOR BOND ISSUE (01/06/03) | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Pool Financing | 0 | PoolFinancing |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Amount Retired | 260000 | AmountRetired |
| Total Proceeds | 2795000 | TotalProceeds |
| Amount In Reserve Fund | 279500 | AmountInReserveFund |
| Issuance Costs From Proceeds | 55900 | IssuanceCostsFromProceeds |
| Working Capital Expenditures | 6556 | WorkingCapitalExpenditures |
| Other Spent Proceeds | 2732544 | OtherSpentProceeds |
| Year Of Subst Completion | 2004 | YearOfSubstCompletion |
| Current Refunding | 1 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 1 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 0 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Bond Iss Meet Prvt Security Pay Test | 0 | BondIssMeetPrvtSecurityPayTest |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedProp |
| Non Qualified Bond Remed Procdrs | 0 | NonQualifiedBondRemedProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiled |
| Rebate Not Due Yet | 1 | RebateNotDueYet |
| Exception To Rebate | 1 | ExceptionToRebate |
| No Rebate Due | 0 | NoRebateDue |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Written Proc To Monitor Reqs | 0 | WrittenProcToMonitorReqs |
Form990 Schedule K Part V Form990ScheduleKPartV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Proc To Undertk Corrective Action | 0 | ProcToUndertkCorrectiveAction |
Form990 Schedule K Part VI Form990ScheduleKPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | PART II, LINE 3: | Identifier |
| Explanation | THE TOTAL PROCEEDS DO NOT EQUAL THE SUMMATION OF LINES 4 - 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (10 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | THE MEMBERS OF THE CORPORATION ARE BRYAN MEDICAL CENTER AND JEFFERSON COMMUNITY HEALTH CENTER, BOTH NEBRASKA NONPROFIT CORPORTIONS. | |
| FORM 990, PART VI, SECTION A, LINE 7A | THE MEMBERS OF THE CORPORATION, BRYAN MEDICAL CENTER, A NEBRASKA NONPROFIT CORPORATION, AND JEFFERSON COMMUNITY HEALTH CENTER, A NEBRASKA NONPROFIT CORPORATION, HAVE THE POWER TO APPOINT 3 TRUSTEES EACH, BOTH PERIODICALLY AND AS VACANCIES ARISE. | |
| FORM 990, PART VI, SECTION B, LINE 11 | A COPY OF THE 990 WILL BE E-MAILED TO EACH BOARD MEMBER. THE BOARD WILL REVIEW FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, BOARD SECRETARY, PRIOR TO FILING. | |
| FORM 990, PART VI, SECTION B, LINE 12C | ON AN ANNUAL BASIS, THE OFFICER IS REQUIRED TO SIGN THE "CONFLICT OF INTEREST STATEMENT." BY SIGNING THIS STATEMENT, THE TRUSTEE AGREES TO NOT USE HIS OR HER POSITION FOR PERSONAL PROFIT OR TO GAIN PERSONAL ADVANTAGE. THE TRUSTEE IS REQUIRED TO DISCLOSE IN WRITING TO THE BOARD OF TRUSTEES ANY PERSON TO WHOM HE OR SHE IS CLOSELY RELATED OR ORGANIZATION WITH WHICH HE OR SHE IS AFFILIATED, WHO OR WHICH PRESENTLY TRANSACTS BUSINESS WITH THE CORPORATION OR MIGHT REASONABLY BE EXPECTED TO DO SO IN THE FUTURE. THE TRUSTEE IS REQUIRED TO SUBMIT SUCH DISCLOSURE ON A CASE-BY-CASE BASIS. IT IS UNDERSTOOD THAT AFFILIATION WITH AN ORGANIZATION IS CONSIDERED TO EXIST WHEN A TRUSTEE OR A MEMBER OF HIS OR HER IMMEDIATE FAMILY OR CLOSE RELATIVE IS AN OFFICER, DIRECTOR, PARTNER, EMPLOYEE OR AGENT OF THE ORGANIZATIONS OR OWNS 5% OF THE VOTING STOCK OR CONTROLLING INTEREST IN THE ORGANIZATION. THE TRUSTEE MUST ABSTAIN FROM VOTING ON ANY MOTION REGARDING THE DISCLOSED CONFLICT OF INTEREST. | |
| FORM 990, PART VI, SECTION C, LINE 19 | FAIRBURY ASSISTED LIVING FACILITY'S GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. | |
| FORM 990, PART VII: | CHAD JURGENS, PRESIDENT, AND CHANCE KLASEK, SECRETARY, ARE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH CENTER, INC, AN UNRELATED ORGANIZATION THAT PROVIDES MANAGEMENT AND CLERICAL SERVICES FOR THE ORGANIZATION. THEREFORE, THE COMPENSATION IS PAID BY JEFFERSON COMMUNITY HEALTH CENTER, INC AND IS INCLUDED IN PART IX, LINE 11A AS MANAGEMENT FEES. | COMPENSATION |
| FORM 990, PART IX, LINE 11G | CONSULTING: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 6,310. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,310. OUTSIDE SERVICE - RESIDENT MEALS: PROGRAM SERVICE EXPENSES 349,858. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 349,858. OTHER: PROGRAM SERVICE EXPENSES 16,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 16,838. | OTHER FEES |
| FORM 990, PART XII, LINE 2C: | THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. | |
| FORM 990, PART VI, SECTION B, LINE 14: | THE ORGANIZATION DOES NOT HAVE A WRITTEN POLICY, BUT IT DOES MAINTAIN DOCUMENTS IN ACCORDANCE WITH FEDERAL AND STATE LAWS. | |
| FORM 990, PART VI, SECTION B, LINE 15: | AS NO OFFICER IS PAID BY THIS ORGANIZATION, NO INDEPENDENT REVIEW OR APPROVAL PROCESS IS CONDUCTED BY THIS ORGANIZATION. |
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