2014-11-14T17:05:33-06:00 2013-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2013-01-01 470686476 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION CHEY 3082545825 645 OSAGE SIDNEY NE 69162 KELLY UTLEY EXECUTIVE DIRECTOR 3082545825 2014-11-14 1 BARBARA J FAJEN P00400874 4023302660 2013 2015-11-30 17:44:51Z KELLY UTLEY 645 OSAGE SIDNEY NE 69162 145005 0 X WWW.SIDNEYRMC.COM X 1985 NE HEALTH CENTER FOUNDATION SUPPORTS SIDNEY REGIONAL MEDICAL CENTER IN THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICES. THROUGH OUR RESPONSIBLE DONATION MANAGEMENT, WE ARE HELPING TO ASSURE THAT OUR COMMUNITY WILL CONTINUE TO HAVE LOCAL, QUALITY HEALTH CARE AND CURRENT STATE-OF-THE-ART TECHNOLOGIES, IN A FACILITY MAINTAINED AND UPDATED TO MEET THE EMERGING AND GROWING NEEDS OF CHEYENNE COUNTY AND THE SURROUNDING REGIONS. 10 9 0 100 0 0 33503 65112 0 0 8762 15790 3095 19493 45360 100395 39133 43868 0 0 0 0 0 0 8760 13342 8760 52475 52628 -7115 47767 1537286 1624368 7609 2792 1529677 1621576 TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. 0 0 27178 27178 PROVIDE SUPPORT TO CHEYENNE COUNTY HOSPITAL ASSOCIATION (SIDNEY REGIONAL MEDICAL CENTER) TO FURTHER THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICE. 9307 9307 PROVIDE FUNDING TO SUPPORT SCHOLARSHIPS AND INTERN PROGRAMS FOR INDIVIDUALS CURRENTLY STUDYING IN THE HEALTH CARE FIELD. 7383 7383 PROVIDE FUNDING TO ASSIST WITH DENTAL PROCEDURES FOR THOSE IN NEED. 43868 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X KELLY UTLEY 3082545825 645 OSAGE SIDNEY NE 69162 X MITCH MUHS PRESIDENT 1.00 39.00 X X 0 122876 6419 KIM CASTNER VICE PRESIDENT 1.00 0.00 X X 0 0 0 MEGAN MCGOWN SECRETARY 1.00 0.00 X X 0 0 0 BILL BUTKUS TREASURER 1.00 0.00 X X 0 0 0 STAN BELIEU MEMBER 1.00 0.00 X 0 0 0 SEAN DOYLE MEMBER 1.00 0.00 X 0 0 0 GERALD BERLAGE MEMBER 1.00 0.00 X 0 0 0 SHERI EHLER MEMBER 1.00 0.00 X 0 0 0 VICKI SMITH MEMBER 1.00 0.00 X 0 0 0 JULIE WAMSLEY MEMBER 1.00 0.00 X 0 0 0 KELLY UTLEY EXECUTIVE DIRECTOR 1.00 39.00 X 0 136952 24219 0 259828 30638 0 0 1 0 0 13000 52112 65112 15790 15790 5775 6191 -416 -416 -416 58328 13000 38419 19909 19909 100395 0 0 35283 27178 27178 16690 16690 1650 1650 1525 1525 1359 1359 30 30 4064 4064 63 63 DUES & SUBSCRIPTIONS 69 69 52628 43868 0 8760 225675 0 915504 1176706 247007 50366 200705 196641 195387 251021 15 0 1537286 1624368 2571 0 5038 2792 7609 2792 X 1325652 1386370 204025 235206 1529677 1621576 1537286 1624368 47767 44132 0 X X 0 1 X 1 0 X X X 0 0 0 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER 470408242 3 1 1 1 27178 1 27178 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 144483 144483 101605 49447 52158 919 919 0 196641 DUE TO AFFILIATE 2792 2792 X PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2013, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2010. HEALTH FAIR 38207 0 38207 13468 GOLF TOURNAMENT 31010 13000 18010 18700 1633 2516 1116 1 2111 0 2111 986 71328 13000 58328 18700 1633 2516 15570 38419 19909 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 645 OSAGE STREET SIDNEY NE 69162 470480242 501(C)(3) 27178 ASSISTING CHEYENNE COUNTY HOSPITAL ASSOCIATION PROVIDE SERVICES TO THE COMMUNITY 1 0 SCHOLARSHIP AND INTERN PROGRAM 4 9306 ASSISTANCE FOR DENTAL PROCEDURES 5 7384 PART I, LINE 2: CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION PROVIDES FUNDS TO SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE FUNDS ARE UTILIZED FOR ASSET PURCHASES AND OPERATIONS OF THE HOSPITAL. THE INTERNSHIP AND SCHOLARSHIP PROGRAM GRANTS LEARNING OPPORTUNITIES TO INDIVIDUALS IN THE AREA CURRENTLY STUDYING IN THE HEALTH CARE FIELD. 0 0 0 0 0 0 0 0 0 KELLY UTLEY EXECUTIVE DIRECTOR 0 136952 0 0 0 0 0 6055 0 18164 0 161171 0 0 PART I, LINE 3 KELLY UTLEY, THE EXECUTIVE DIRECTOR OF THE FOUNDATION, IS AN EMPLOYEE OF SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE BOARD OF DIRECTORS OF THE MEDICAL CENTER REVIEWS MARKET COMPENSATION DATA FOR ALL HOSPITAL STAFF AND THE CEO OF THE MEDICAL CENTER APPROVES THE COMPENSATION FOR THE EXECUTIVE DIRECTOR. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 INFORMATION IS ACCUMULATED BY THE ACCOUNTING DEPARTMENT AND SUBMITTED TO THE INDEPENDENT PUBLIC ACCOUNTANTS FOR FURTHER REVIEW AND PREPARATION. COMMUNICATIONS BETWEEN THE INDEPENDENT PUBLIC ACCOUNTANTS AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. AFTER THE PREPARATION IS COMPLETE, THE EXECUTIVE DIRECTOR REVIEWS THE FORM 990. UPON APPROVAL, THE FORM 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE FORM 990 HAS BEEN REVIEWED BY ALL PARTIES IT WILL BE SUBMITTED TO THE IRS ON OR BEFORE THE EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AMD MADE A MATTER OF BOARD RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER ABSTAINS FROM DISCUSSION AND THE VOTE. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 15: AS THE ORGANIZATION DOES NOT HAVE ANY EMPLOYEES, THERE IS NO INDEPENDENT REVIEW AND APPROVAL OF COMPENSATION. FORM 990, PART VII, SECTION A MITCH MUHS IS A PHYSICIAN ASSISTANT AT SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. MR. MUHS' COMPENSATION IS FOR HIS SERVICES AS A PHYSICIAN ASSISTANT. HE IS NOT PAID BY SIDNEY REGIONAL MEDICAL CENTER OR CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION FOR HIS SERVICE AS A MEMBER OF THE FOUNDATION'S BOARD OF DIRECTORS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 645 OSAGE STREET SIDNEY NE 69162 470480242 PROVIDING HEALTH CARE TO THOSE IN THE COMMUNITY NE 501(C)(3) LINE 3 N/A 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0