2014-02-14T16:42:02-06:00 2013-06-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-07-01 420859940 BURGESS HEALTH CENTER BURG 7124232311 1600 DIAMOND STREET ONAWA IA 51040 FRANCIS TRAMP 7124232311 2014-02-13 1 JULIE M GERKEN P00400882 4023302660 2012 2015-11-30 17:44:51Z FRANCIS TRAMP 1600 DIAMOND STREET ONAWA IA 51040 28090048 0 X WWW.BURGESSHC.ORG X 1959 IA TO PROVIDE HEALTHCARE SERVICES TO THE COMMUNITY 10 10 279 80 2048898 -39436 246050 51684 24373371 26139861 207751 435356 90641 68975 24917813 26695876 0 0 0 0 11657197 11932153 0 0 0 11930120 13369759 23587317 25301912 1330496 1393964 30530600 32020703 8662008 8088937 21868592 23931766 BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES IT SERVES BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES. 0 0 20580366 24090963 PROVIDES HEALTHCARE SERVICES TO COMMUNITY. 20580366 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 70 0 1 279 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X SHAWN GOSCH CFO 7124239213 1600 DIAMOND STREET ONAWA IA 51040 JIM WESTERGAARD 1.00 0.00 X X 0 0 0 TERRY FRAMKE 1.00 2.00 X X 0 0 0 STEVE PRATT 1.00 0.00 X X 0 0 0 JUDY CONNEALY 1.00 0.00 X 0 0 0 PAUL DUDLEY MD 1.00 0.00 X 0 0 0 JOHN GARRED JR MD 1.00 0.00 X 0 0 0 NEAL GORHAM 1.00 0.00 X 0 0 0 MARI MILLER 1.00 0.00 X 0 0 0 CHARLES SEDERSTROM 1.00 0.00 X 0 0 0 KEITH SCHRUNK OD 1.00 0.00 X 0 0 0 FRANCIS TRAMP 39.00 1.00 X 154920 0 21159 SHAWN GOSCH 39.00 1.00 X 104255 0 16540 MONTY MCKINVEN 40.00 0.00 X 354630 0 22407 WASEEM ALOUNK 40.00 0.00 X 278615 0 22594 PETER DAHER MD 40.00 0.00 X 217376 0 17848 JENNIFER SCHENNE 40.00 0.00 X 115515 0 3146 SCOTT NORTH 40.00 0.00 X 109956 0 25122 1335267 0 128816 8 0 1 0 FAMILY MEDICINE CLINIC 1614 DIAMOND ST ONAWA IA 51040 ER COVERAGE 374907 ST LUKES DEPARTMENT OF LAB SERVICES PO BOX 569 DES MOINES IA 50302 LAB SERVICES 223392 IP PATHWAYS LLC 2550 73RD ST URBANDALE IA 50322 COMPUTER SECURITY 170979 CPSI PO BOX 850309 MOBILE AL 36685 COMPUTER SUPPORT 166747 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI & DIAGNOSTIC SERVICES 161195 5 746 50938 51684 MEDICARE/MEDICAID PAYMENTS 624100 12434157 12434157 PATIENT REVENUE 624100 11065534 11065534 RETAIL PHARMACY 446110 2048898 2048898 MEANINGFUL USE INCENTIVE PAYMENTS 624100 246985 246985 MENTAL HEALTH APPR 624100 76668 76668 267619 267619 26139861 318221 318221 134361 65386 68975 68975 68975 1445921 1328786 117135 117135 117135 26695876 24090963 2048898 504331 296874 296874 9894336 8269385 1624951 111428 97719 13709 938744 809249 129495 690771 579251 111520 19721 19721 58070 58070 2289165 1816859 472306 187703 187703 1578798 972456 606342 314356 214557 99799 133431 98123 35308 166469 166469 1482206 760113 722093 88403 88403 MEDICAL SUPPLIES 3850499 3850499 RETAIL PHARMACY EXPENSE 1917899 1917899 BAD DEBT EXPENSE 793580 793580 MISCELLANEOUS EXPENSES 280783 6788 273995 208676 117782 90894 25301912 20580366 4721546 0 2407195 3499413 3594132 3161877 3664246 3763369 95934 154723 907515 906267 149090 212864 26968703 14892733 13248705 12075970 6072292 7948975 4014 3833 387477 293412 30530600 32020703 1492949 1701685 6800000 5847470 369059 539782 8662008 8088937 X 21868592 23931766 21868592 23931766 30530600 32020703 1393964 669210 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 55042 55042 18303441 7987638 10315803 8116130 6510460 1605670 494090 394635 99455 12075970 THIRD-PARTY PAYOR SETTLEMENTS 539782 539782 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HEALTH CENTER AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND 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 THE HEALTH CENTER AND FOUNDATION'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HEALTH CENTER AND FOUNDATION TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HEALTH CENTER AND FOUNDATION ACCOUNT FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HEALTH CENTER AND FOUNDATION RECOGNIZE THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2013, THE HEALTH CENTER AND FOUNDATION HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HEALTH CENTER IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL TAX AUTHORITIES FOR YEARS BEFORE 2010. 1 1 1 X 1 X 245.000000000000 1 1 0 1 1 628 282940 282940 0.01150 3482 1579373 916120 663253 0.02710 4110 1862313 916120 946193 0.03860 2775 30882 8503 22379 0.00090 11710 1901233 1657447 243786 0.00990 100 349 349 0.00000 14585 1932464 1665950 266514 0.01080 18695 3794777 2582070 1212707 0.04940 1 793580 555506 10170105 9983089 187016 X 1 1 1 1 BURGESS HEALTH CENTER

1600 DIAMOND STREET ONAWA IA 61040

X X X X BURGESS HEALTH CENTER 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X X 1 0 1 1 100.000000000000 1 245.000000000000 1 X X X X X X X 1 1 X X 1 0 X 1 X 0 0 4 BURGESS FAMILY CLINIC - SLOAN

409 EVANS SLOAN IA 51055

FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - DUNLAP

612 IOWA AVENUE DUNLAP IA 51529

FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - DECATUR

12TH BROADWAY DECATUR NE 68020

FAMILY MEDICAL CLINIC BURGESS FAMILY CLINIC - MAPLETON

513 SOUTH MUCKEY STREET MAPLETON IA 51304

FAMILY MEDICAL CLINIC PART I, LINE 6A: THE REPORT IS PREPARED BY THE STAFF OF BURGESS HEALTH CENTER. PART I, LINE 7: BURGESS HEALTH CENTER USES LYONS SOFTWARE TO TRACK ALL PROGAMS THROUGHOUT THE YEAR. WHEN A PROGRAM IS USED, THE PERSON IN CHARGE WILL TRACK THE PROGRAM IN THE SOFTWARE BY RECORDING THE CATEGORY, THE RELATED COSTS AND REVENUE AND THE NUMBER OF PARTICIPANTS. PART I, LINE 7G: ALL COSTS REPORTED ON PART I, LINE 7G ARE ATTRIBUTABLE TO THE PHYSICIAN CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 793580. PART II: BURGESS HEALTH CENTER DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE BAD DEBT EXPENSE: PART III, LINE 2: IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HEALTH CENTER 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 HEALTH CENTER 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 HEALTH CENTER 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. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, THE FOLLOWING IS THE TEXT OF THE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE," AND "CHARITY CARE":PATIENT RECEIVABLES, NET:THE HEALTH CENTER 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 HEALTH CENTER 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 HEALTH CENTER 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 HEALTH CENTER 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.NET PATIENT SERVICE REVENUE:THE HEALTH CENTER HAS AGREEMENTS WITH THIRD PARTY PAYORS THAT PROVIDE FOR PAYMENTS TO THE HEALTH CENTER AT AMOUNTS DIFFERENT FROM ITS ESTABLISHED RATES. PAYMENT ARRANGEMENTS INCLUDE REIMBURSED COSTS DISCOUNTED CHARGES AND PER DIEM PAYMENTS. NET PATIENT SERVICE REVENUE IS REPORTED AT THE ESTIMATED NET REALIZABLE AMOUNTS FROM PATIENTS, THIRD-PARTY PAYORS AND OTHERS FOR SERVICES RENDERED INCLUDING ESTIMATED RETROACTIVE ADJUSTMENTS UNDER REIMBURSEMENT AGREEMENTS WITH THIRD-PARTY PAYORS. RETROACTIVE ADJUSTMENTS ARE ACCRUED ON AN ESTIMATED BASIS IN THE PERIOD THE RELATED SERVICES ARE RENDERED AND ADJUSTED IN THE FUTURE PERIODS AS FINAL SETTLEMENTS ARE DETERMINED.CHARITY CARE:THE HEALTH CENTER 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 HEALTH CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE THEY ARE NOT REPORTED IN THE CONSOLIDATED STATEMENT OF OPERATIONS.THE HEALTH CENTER IS DEDICATED TO PROVIDING COMPREHENSIVE HEALTH CARE SERVICES TO ALL SEGMENTS OF SOCIETY INCLUDING THE AGED AND OTHERWISE ECONOMICALLY DISADVANTAGED. IN ADDITION, THE HEALTH CENTER PROVIDES A VARIETY OF COMMUNITY HEALTH SERVICES AT OR BELOW COST.ESTIMATED BAD DEBT FOR PATIENTS ELIGIBLE FOR CHARITY CARE WAS PROVIDED BY THE HEALTH CENTER'S FINANCIAL COUNSELOR WHO IS THE ONLY EMPLOYEE THAT ASSISTS THE PATIENTS WITH THEIR HOSPITAL BILL. THE FINANCIAL COUNSELOR IS THE EXPERT IN THIS AREA AND PROVIDES HER ESTIMATE BASED ON HER KNOWLEDGE OF THE PATIENTS SHE ASSISTS AND THE FINANCIAL ASSISTANCE POLICY. PART III, LINE 9B: BURGESS HEALTH CENTER HAS A FINANCIAL COUNSELOR WHO WILL REVIEW OUTSTANDING ACCOUNTS WITH PATIENTS TO HELP THEM QUALIFY FOR ASSISTANCE IN PAYING THE OUTSTANDING BILL. THIS ASSISTANCE INCLUDES COMPLETING PAPERWORK AND GATHERING SOURCE DOCUMENTS TO DETERMINE IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL COUNSELOR WILL ALSO ASSIST PATIENTS IN COMPLETING PAPERWORK IN ORDER FOR THEM TO QUALIFY FOR GOVERNMENT ASSISTANCE. BURGESS HEALTH CENTER PART V, SECTION B, LINE 3: IN ORDER TO ENSURE EXTERNAL INPUT WAS RECEIVED IN ADDITION TO RESPONSES TO THE SURVEY, THE FOLLOWING ENTITIES WERE CONTACTED FOR INPUT:- MONONA COUNTY PUBLIC HEALTH- BURGESS MEDICAL STAFF- MONONA COUNTY DENTISTSIN ADDITION, MONONA COUNTY PUBLIC HEALTH'S COMMUNITY HEALTH NEEDS IMPROVEMENT PLAN FOR MONONA COUNTY 2010-2011 WAS REVIEWED FOR IDENTIFIED COMMUNITY NEEDS AND PRIORITIES. BURGESS HEALTH CENTER PART V, SECTION B, LINE 18E: THE HEALTH CENTER MADE NO SUCH EFFORTS. BURGESS HEALTH CENTER PART V, SECTION B, LINE 20D: THE HOSPITAL USED DISCOUNTS OR WROTE OFF THE BALANCE DUE. PART VI, LINE 2: BURGESS HEALTH CENTER REVIEWS DATA FROM THE IOWA DEPARTMENT OF PUBLIC HEALTH. BURGESS HEALTH CENTER FOCUSES ON TOP ADMITS TO THE HOSPITAL AND REVIEWS THE AGGREGATE DATA FROM WELLNESS SCREENS. PART VI, LINE 3: PATIENTS' BILLS CONTAIN INFORMATION REGARDING THE HEALTH CENTER PROVIDING ASSISTANCE IF NEEDED AND GIVES CONTACT INFORMATION FOR THIS ASSISTANCE. IF A PATIENT HAS NOT RESPONDED TO THE BILL, THE FINANCIAL COUNSELOR WILL CONTACT THE PATIENT TO MAKE ARRANGEMENTS TO HELP THE PATIENT IN RECEIVING ASSISTANCE. PART VI, LINE 4: BURGESS HEALTH CENTER IS SITUATED IN MONONA COUNTY, IA. THE SERVICE AREA IS CONSIDERED RURAL SETTING WITH A POPULATION OF APPROXIMATELY 15,000. OF THIS POPULATION, 30% IS CONSIDERED ELDERLY WHICH IS ONE OF THE HIGHEST IF NOT THE HIGHEST % OF ELDERLY FOR ANY AREA IN THE STATE OF IOWA. THE SERVICE AREA RANKS LOW REGARDING THE MEDIAN HOUSEHOLD INCOME. THE IOWA MEDIAN HOUSEHOLD INCOME FOR 2011 WAS $49,545 WITH MONONA COUNTY HAVING A MEDIAN HOUSEHOLD INCOME OF $41,458 - APPROXIMATELY $8,000 LOWER. PART VI, LINE 5: PROMOTING THE HEALTH OF THE COMMUNITIES BURGESS HEALTH CENTER SERVES IS IMPORTANT TO THE HEALTH CENTER. FURTHERMORE, IT IS PART OF THE MISSION STATEMENT OF BURGESS HEALTH CENTER. - "BURGESS HEALTH CENTER IS COMMITTED TO IMPROVE THE QUALITY OF LIFE FOR THE PEOPLE AND COMMUNITIES WE SERVE BY PROVIDING EXCELLENT HEALTHCARE AND EXCEPTIONAL PATIENT EXPERIENCES."BURGESS HEALTH CENTER PARTNERS WITH OTHER ORGANIZATIONS IN THE COMMUNITY TO IMPROVE COMMUNITY HEALTH AND WELL BEING. BURGESS HEALTH CENTER PARTICIPATES IN MEDICARE, MEDICAID CHAMPUS AND TRICARE. PART VI, LINE 6: BURGESS HEALTH CENTER IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. REPORTS FILED WITH STATES PART VI, LINE 7 IA X X X 0 0 0 0 0 0 0 0 0 FRANCIS TRAMP 154624 0 0 0 296 0 3198 0 17961 0 176079 0 0 0 MONTY MCKINVEN 354065 0 0 0 565 0 4360 0 18047 0 377037 0 0 0 WASEEM ALOUNK 278461 0 0 0 154 0 5000 0 17594 0 301209 0 0 0 PETER DAHER MD 217225 0 0 0 151 0 0 0 17848 0 235224 0 0 0 A CITY OF ONAWA IOWA 426005064 2012-07-13 6259250 REFUND PRIOR ISSUE (06/08/05) 0 0 0 A 411780 6259250 125185 6134065 2007 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 1 1 1 0 0 0 1 A 1 SCHEDULE K, PART IV, ARBITRAGE, LINE 2C: DATE THE REBATE COMPUTATION WAS PERFORMED: 01/13/2013 NOTE REGARDING THE REBATE COMPUTATION: SINCE THE BOND PROCEEDS HAVE BEEN SPENT, A SPENDING EXCEPTION WAS MET AND THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. FORM 990, PART VI, SECTION A, LINE 6 BURGESS HEALTH CENTER HAS MEMBERS. A PERSON MAY BECOME A MEMBER IF HE OR SHE IS AT THAT TIME A RESIDENT OF THE GEOGRAPHIC AREA SERVED BY THE CORPORATION AND THEN ONLY UPON COMPLETION OF A MEMBERSHIP REGISTRATION FORM AND PAYMENT OF A LIFE MEMBERSHIP OF $10. FORM 990, PART VI, SECTION A, LINE 7B THERE IS AN ANNUAL MEETING OF THE MEMBERS. AT THE ANNUAL MEETING, THE MEMBERS RECEIVE AN ANNUAL REPORT ON THE AFFAIRS OF THE CORPORATION AND HAVE THE OPPORTUNITY TO OFFER THEIR INPUT ON ANY MATTER AFFECTING THE CORPORATION. THE MEMBERS SHALL ALSO CARRY OUT ANY DUTIES RESERVED TO MEMBERS UNDER THE IOWA NONPROFIT CORPORATION ACT. EACH MEMBER HAS ONE VOTE. THE ACT OF A MAJORITY OF MEMBERS PRESENT AND VOTING SHALL BE THE ACT OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND THE RELATED SCHEDULES ARE PRESENTED TO THE FINANCE COMMITTEE BY SHAWN GOSCH, CFO, AT THE FIRST SCHEDULED FINANCE COMMITTEE MEETING AFTER THE COMPLETION OF THE FORM 990. WITH THE EXTENSION, THE FORM 990 IS DUE FEBRUARY 15, 2014 AND WILL BE REVIEWED PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C ON A ANNUAL BASIS, ALL BOARD MEMBERS ALONG WITH THE MANAGEMENT STAFF (MANAGERS, DIRECTORS, OFFICERS) COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. THE RESULTS ARE REVIEWED AT ONE OF THE BOARD MEETINGS. FORM 990, PART VI, SECTION B, LINE 15A THE CEO SALARY IS DETERMINED BASED ON GRADE, NUMBER OF YEARS IN THE POSITION AND COMPARED TO IHA (IOWA HOSPITAL ASSOC.) DATA SHOWING MARKET RATES FOR THE BURGESS CUSTOM GROUP. THIS INFORMATION IS PASSED ON TO THE EXECUTIVE COMMITTEE OF THE BOARD WHO MAKES A RECOMMENDATION TO THE COMPLETE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINAL DECISION. FORM 990, PART VI, SECTION C, LINE 19 BURGESS HEALTH CENTER DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS CONSOLIDATED FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BURGESS FOUNDATION 1600 DIAMOND STREET ONAWA IA 51040 421188964 RAISING FUNDS FOR BURGESS HEALTH CENTER IA 501(C)(3) 11B N/A 1 BURGESS HEALTH CORP EMPLOYEE BENEFIT TRUST 1600 DIAMOND STREET ONAWA IA 51040 421320408 PROVIDE HEALTH BENFITS TO EMPLOYEES OF BURGESS HEALTH CENTER IA 501(C)(9) N/A N/A 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 BURGESS FOUNDATION C 746 BURGESS HEALTH CORP EMPLOYEE BENEFIT TRUST Q 797771