HEALTH INC HOSPICE: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
HEALTH INC HOSPICE (EIN 38-3320710)
Tax period
2011-07-01 to 2012-06-30
Filed
2013-02-08
IRS object ID
201300399349300320
Schema version
2011v1.2
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

FieldValueIRS element (for citing)
Timestamp2013-02-08T09:54:27-06:00Timestamp
Tax Period End Date2012-06-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN481292483EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1HENJES CONNER & WILLIAMS PCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1800 FRANCES BLDGAddressLine1
CitySIOUX CITYCity
StateIAState
ZIP Code51101ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-07-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN383320710EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1HOSPICE OF SIOUXLANDBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlHOSPNameControl
Phone7122334144Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line14300 HAMILTON BLVDAddressLine1
CitySIOUX CITYCity
StateIAState
ZIP Code51104ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameDANIEL K LAUERName
TitleCHIEF FINANCIAL OFFICERTitle
Phone7122529418Phone
Date Signed2013-01-31DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameMELISSA J WILLERName
PTINP00121904PTIN
Phone7122773931Phone
Date Prepared2013-01-29DatePrepared
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonDANIEL K LAUERNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1230 NEBRASKA STAddressLine1
CitySIOUX CITYCity
StateIAState
ZIP Code51101ZIPCode
FieldValueIRS element (for citing)
Gross Receipts18718248GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.HOSPICEOFSIOUXLAND.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1982YearFormation
State Legal DomicileIAStateLegalDomicile
Activity Or Mission DescriptionPROVIDE COMFORT, SUPPORT, AND COMPASSIONATE CARE TO TERMINALLY ILL PEOPLE AND THEIR FAMILIES THAT RESPECTS THE DIGNITY OF EACH INDIVIDUAL, AND TO FOSTER COMMUNITY ACCEPTANCE THAT DYING IS AN INTEGRAL PART OF LIVING.ActivityOrMissionDescription
Nbr Voting Members Governing Body10NbrVotingMembersGoverningBody
Nbr Independent Voting Members10NbrIndependentVotingMembers
Total Nbr Employees170TotalNbrEmployees
Total Nbr Volunteers300TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year254372ContributionsGrantsPriorYear
Contributions Grants Current Year327576ContributionsGrantsCurrentYear
Program Service Revenue Prior Year13872793ProgramServiceRevenuePriorYear
Program Service Revenue CY14697167ProgramServiceRevenueCY
Investment Income Prior Year277190InvestmentIncomePriorYear
Investment Income Current Year72912InvestmentIncomeCurrentYear
Other Revenue Prior Year7507OtherRevenuePriorYear
Other Revenue Current Year66512OtherRevenueCurrentYear
Total Revenue Prior Year14411862TotalRevenuePriorYear
Total Revenue Current Year15164167TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year7063017SalariesEtcPriorYear
Salaries Etc Current Year7146055SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year131670TotalFundrsngExpCurrentYear
Other Expense Prior Year6799148OtherExpensePriorYear
Other Expenses Current Year6919259OtherExpensesCurrentYear
Total Expenses Prior Year13862165TotalExpensesPriorYear
Total Expenses Current Year14065314TotalExpensesCurrentYear
Revenues Less Expenses Prior Year549697RevenuesLessExpensesPriorYear
Revenues Less Expenses CY1098853RevenuesLessExpensesCY
Total Assets BOY8994012TotalAssetsBOY
Total Assets EOY9714868TotalAssetsEOY
Total Liabilities BOY3232049TotalLiabilitiesBOY
Total Liabilities EOY3961678TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY5761963NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY5753190NetAssetsOrFundBalancesEOY
Mission DescriptionPROVIDE COMFORT, SUPPORT, AND COMPASSIONATE CARE TO TERMINALLY ILL PEOPLE AND THEIR FAMILIES THAT RESPECTS THE DIGNITY OF EACH INDIVIDUAL, AND TO FOSTER COMMUNITY ACCEPTANCE THAT DYING IS AN INTEGRAL PART OF LIVING.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense11192764Expense
Revenue14715507Revenue
DescriptionHOSPICE OF SIOUXLAND'S MISSION IS TO PROVIDE COMFORT, SUPPORT AND COMPASSIONATE CARE TO PEOPLE WITH LIFE-LIMITING ILLNESSES AND TO THEIR FAMILIES IN A MANNER THAT RESPECTS THE DIGNITY OF EACH INDIVIDUAL AND TO FOSTER COMMUNITY ACCEPTANCE THAT DYING IS AN INTEGRAL PART OF LIVING. ALL PATIENTS WHO MEET ADMISSION CRITERIA ARE ELIGIBLE FOR HOSPICE CARE, NO MATTER WHAT THEIR FINANCIAL CIRCUMSTANCES, OR ABILITY TO PAY.Description
Total Program Service Expense11192764TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities1ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109610NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees170NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Form8899 Filed0Form8899Filed
Form1098 C Filed0Form1098CFiled
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members10NbrVotingGoverningBodyMembers
Number Independent Voting Members10NumberIndependentVotingMembers
Family Or Business Relationship1FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy0WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1DAN LAUERBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number7122529418TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1230 NEBRASKA ST PO BOX 5017AddressLine1
CitySIOUX CITYCity
StateIAState
ZIP Code51101ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (14 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationHighest Compensated EmployeeHighestCompensatedEmployee
MILT AVERY
VICE CHAIRPERSON1.00XX000
BOB PEEBLES
SECRETARY1.00XX000
PETER THOREEN
TREASURER1.00XX000
CHARESE YANNEY
CHAIRPERSON1.00XX000
MARI KAPTAIN-DAHLEN
DIRECTOR0.50X000
LYNN WOLD
DIRECTOR0.50X000
STEVE EAVENSON
DIRECTOR0.50X000
JIM GOBELL
DIRECTOR0.50X000
ELLEN KAPLAN
DIRECTOR0.50X000
DR WAYNE BARNES
DIRECTOR0.50X000
LINDA TODD
DIRECTOR OF OPERATIONS40.00X103074021951
KAREN VAN DE STEEG
EXECUTIVE DIRECTOR40.00X000
DAN LAUER
CHIEF FINANCIAL OFFICER40.00X000
DALE HOLDIMAN
MEDICAL DIRECTOR40.00208000029414X
FieldValueIRS element (for citing)
Total Reportable Comp From Org311074TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation51365TotalOtherCompensation
Number Individuals GT100 K2NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
HOSPISCRIPT SERVICES LLC
4525 EXECUTIVE PARK DR SUITE 100MONTGOMERYAL36116PRESCRIPTIONS648219
MERCY MEDICAL CENTER
801 5TH STREETSIOUX CITYIA51101INPATIENT AND OUTPATIEN HOSPITAL CHARGES502203
INVASERV LLC
2130 E UNIVERSITY DRTEMPEAZ85281MEDICAL399774
JUNE E NYLEN CANCER CENTER
230 NEBRASKA STREETSIOUX CITYIA51101MANAGEMENT FEES AND INSURANCE REBILLS389343
HOLY SPIRIT RETIREMENT HOME
1701 W 25TH STSIOUX CITYIA51103ROOM AND BOARD CHARGES327129
FieldValueIRS element (for citing)
Number Of Contractors GT100 K16NumberOfContractorsGT100K
All Other Contributions327576AllOtherContributions
Total Contributions327576TotalContributions

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionPATIENT SERVICE REVENUDescription
Business Code621610BusinessCode
Total Revenue Column14697167TotalRevenueColumn
Related Or Exempt Function Income14697167RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue14697167TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column121084TotalRevenueColumn
Exclusion$121,084ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real210268Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real190743Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real19525Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column19525TotalRevenueColumn
Related Or Exempt Function Income19525RelatedOrExemptFunctionIncome

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Securities3193780Securities
Other121386Other

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Securities3241952Securities
Other121386Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Securities-48172Securities
Other0Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column-48172TotalRevenueColumn
Related Or Exempt Function Income-48172RelatedOrExemptFunctionIncome

Other Revenue Misc OtherRevenueMisc (2 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
OTHER INCOME9000993191331913
OTHER INVESTMENT INCOM9000991507415074
FieldValueIRS element (for citing)
Total Other Revenue46987TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column15164167TotalRevenueColumn
Related Or Exempt Function Income14715507RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$121,084ExclusionAmount

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total125025Total
Management And General125025ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total5283887Total
Program Services4176496ProgramServices
Management And General1069113ManagementAndGeneral
Fundraising38278Fundraising

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total300232Total
Program Services232769ProgramServices
Management And General65330ManagementAndGeneral
Fundraising2133Fundraising

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total1055631Total
Program Services835447ProgramServices
Management And General212527ManagementAndGeneral
Fundraising7657Fundraising

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total381280Total
Program Services299044ProgramServices
Management And General79744ManagementAndGeneral
Fundraising2492Fundraising

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total6007Total
Management And General6007ManagementAndGeneral

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total49971Total
Management And General49971ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total4097994Total
Program Services3824547ProgramServices
Management And General273447ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total62133Total
Management And General62133ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total103451Total
Management And General101925ManagementAndGeneral
Fundraising1526Fundraising

Occupancy Occupancy

FieldValueIRS element (for citing)
Total252452Total
Program Services10731ProgramServices
Management And General240318ManagementAndGeneral
Fundraising1403Fundraising

Travel Travel

FieldValueIRS element (for citing)
Total436337Total
Program Services382030ProgramServices
Management And General53976ManagementAndGeneral
Fundraising331Fundraising

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total53971Total
Management And General53971ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total21838Total
Management And General21838ManagementAndGeneral

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total72801Total
Management And General72801ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total43082Total
Management And General43082ManagementAndGeneral

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneralFundraisingFundraising
MEDICAL SUPPLIES13534951353495
REPAIRS AND MAINTENANCE9413794137
OTHER COSTS79144356860610503
BAD DEBTS7817078170

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total114276Total
Management And General46929ManagementAndGeneral
Fundraising67347Fundraising

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total14065314Total
Program Services11192764ProgramServices
Management And General2740880ManagementAndGeneral
Fundraising131670Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY1124250BOY
EOY847340EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY1503733BOY
EOY2350603EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY144389BOY
EOY154960EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis2798449LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec1396713LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY99631BOY
EOY1401736EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY5063995BOY
EOY4952971EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY1058014BOY
EOY7258EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY8994012BOY
EOY9714868EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY2422049BOY
EOY3546678EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY810000BOY
EOY415000EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY3232049BOY
EOY3961678EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY5239459BOY
EOY5251866EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY22504BOY
EOY1324EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY500000BOY
EOY500000EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY5761963BOY
EOY5753190EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY8994012BOY
EOY9714868EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses1098853ReconcilationRevenueExpenses
Reconcilation Other Changes-1107626ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3XSupportingOrganization509a3
Supporting Org509a3 Type1XSupportingOrg509a3Type1
Contrib By Controlling Individual0ContribByControllingIndividual
Contribution By Related Party0ContributionByRelatedParty
Contrib By35 Controlled Entity0ContribBy35ControlledEntity

Supported Org Information SupportedOrgInformation (2 entries)

EINEINType Of OrganizationTypeOfOrganizationListed In Governing DocListedInGoverningDocSupported Organization NotifiedSupportedOrganizationNotifiedOrganized In USOrganizedInUSAmountAmount
MERCY HEALTH SERVICES
3113730803001$0
NORTHWEST IOWA HOSPITAL CORPORATION
4210198723001$0
FieldValueIRS element (for citing)
Total Number Of Supported Orgs2TotalNumberOfSupportedOrgs
Sum Of Amounts0SumOfAmounts

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule D IRS990ScheduleD

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance684578BeginningOfYearBalance
Investment Earnings Or Losses-13202InvestmentEarningsOrLosses
End Of Year Balance671376EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance558179BeginningOfYearBalance
Investment Earnings Or Losses126399InvestmentEarningsOrLosses
End Of Year Balance684578EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance491289BeginningOfYearBalance
Investment Earnings Or Losses66890InvestmentEarningsOrLosses
End Of Year Balance558179EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance0.25530BoardDesignatedEOYBalance
Permanent Endowment EOY Balance0.74470PermanentEndowmentEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs0EndowmentsHeldByRelatedOrgs

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis1671554OtherCostOrOtherBasis
Depreciation693001Depreciation
Book Value978553BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis752237OtherCostOrOtherBasis
Depreciation703712Depreciation
Book Value48525BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis374658OtherCostOrOtherBasis
Book Value374658BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings1401736TotalOfBookValueLandBuildings

Other Securities OtherSecurities (5 entries)

DescriptionDescriptionBook ValueBookValueMethod Of ValuationMethodOfValuation
MUTUAL FUNDS2456180F
U. S. GOVERNMENT SECURITIES561928F
CORPORATE SECURITIES1070612F
MORTGAGE BACKED SECURITIES154148F
CERTIFICATES OF DEPOSIT710103F
FieldValueIRS element (for citing)
Total Of Book Value Securities4952971TotalOfBookValueSecurities
Total Revenue15164167TotalRevenue
Total Expenses14065314TotalExpenses
Excess Or Deficit For Year1098853ExcessOrDeficitForYear
Net Unrealized GL On Investments-89839NetUnrealizedGLOnInvestments
Other-$1,017,787OtherAmount
Total Adjustments-1107626TotalAdjustments
Excess Or Deficit Per FS-8773ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt15215100TotRevenueEtcAuditedFinclStmt
Net Unrealized Gains Investments-89839NetUnrealizedGainsInvestments
Other Revenues190743OtherRevenues
Revenue Not Rptd F990100904RevenueNotRptdF990
Revenue Subtotal15114196RevenueSubtotal
Investment Expenses Not Included49971InvestmentExpensesNotIncluded
Revenue Not Rptd On Fin Stmt49971RevenueNotRptdOnFinStmt
Total Revenue Per Form99015164167TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt14215524TotExpensesEtcAuditedFinclStmt
Other Expenses Included200181OtherExpensesIncluded
Expenses Not Rptd F990200181ExpensesNotRptdF990
Expenses Subtotal14015343ExpensesSubtotal
Investment Expenses Not Included249971InvestmentExpensesNotIncluded2
Expenses Not Rptd On Fin Stmt49971ExpensesNotRptdOnFinStmt
Total Expenses Per Form99014065314TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X:HEALTH, INC. AND ITS SUBSIDIARIES ARE NON-PROFIT ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS SUCH, INCOME EARNED IN THE PERFORMANCE OF ITS EXEMPT PURPOSE IS NOT SUBJECT TO INCOME TAX AND ACCORDINGLY, THE FINANCIAL STATEMENTS DO NOT REFLECT A PROVISION FOR INCOME TAXES. MANAGEMENT HAS CONCLUDED THAT ANY UNCERTAIN TAX POSITIONS WOULD BE IMMATERIAL TO THE FINANCIAL STATEMENTS TAKEN AS A WHOLE. ACCORDINGLY, THE ACCOMPANYING FINANCIAL STATEMENTS DO NOT INCLUDE ANY PROVISION FOR UNCERTAIN TAX POSITIONS, AND NO RELATED INTEREST OR PENALTIES HAVE BEEN RECORDED IN THE OPERATING STATEMENT OR ACCRUED IN THE BALANCE SHEET. TAX RETURNS OF THE ENTITY ARE GENERALLY OPEN TO EXAMINATION BY THE RELEVANT TAXING AUTHORITIES FOR A PERIOD OF THREE YEARS FROM THE DATE THE RETURNS ARE FILED.
PART XI, LINE 8 - OTHER ADJUSTMENTS:PENSION ADJUSTMENT -1,008,349. LOSS ON INTERCOMPANY ACTIVITY -9,438. TOTAL TO SCHEDULE D, PART XI, LINE 8: -1,017,787.
PART XII, LINE 2D - OTHER ADJUSTMENTS:RENT EXPENSES 190,743.
PART XIII, LINE 2D - OTHER ADJUSTMENTS:LOSS ON INTERCOMPANY ACTIVITY 9,438. RENT EXPENSES 190,743.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation CommitteeXCompensationCommittee
Independent ConsultantXIndependentConsultant
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII

FieldValueIRS element (for citing)
Name PersonDALE HOLDIMANNamePerson
Base Compensation Filing Org208000BaseCompensationFilingOrg
Comp Based On Related Orgs0CompBasedOnRelatedOrgs
Bonus Filing Org0BonusFilingOrg
Bonus Related Orgs0BonusRelatedOrgs
Other Compensation Filing Org0OtherCompensationFilingOrg
Other Compensation Related Orgs0OtherCompensationRelatedOrgs
Deferred Comp Filing Org0DeferredCompFilingOrg
Deferred Comp Related Orgs0DeferredCompRelatedOrgs
Nontaxable Benefits Filing Org29414NontaxableBenefitsFilingOrg
Nontaxable Benefits Related Orgs0NontaxableBenefitsRelatedOrgs
Total Compensation Filing Org237414TotalCompensationFilingOrg
Total Compensation Related Orgs0TotalCompensationRelatedOrgs
Comp Report Prior990 Filing Org0CompReportPrior990FilingOrg
Comp Report Prior990 Related Orgs0CompReportPrior990RelatedOrgs

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (10 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 2HALF OF THE BOARD WORKS FOR NORTHWEST IOWA HOSPITAL CORPORATION OR IS ON THE NORTHWEST IOWA HOSPITAL CORPORATION BOARD AND HALF OF THE BOARD WORKS FOR MERCY HEALTH SERVICES IS ON THE MERCY HEALTH SERVICES BOARD.
FORM 990, PART VI, SECTION A, LINE 6HEALTH INC., NORTHWEST IOWA HOSPITAL CORPORATION AND SUBSIDIARIES, MERCY HEALTH SERVICES AND SUBSIDIARIES
FORM 990, PART VI, SECTION A, LINE 7ANORTHWEST IOWA HOSPITAL CORPORATION AND MERCY HEALTH SERVICES APPOINT THEIR REPRESENTATIVES TO BE ON THE BOARD
FORM 990, PART VI, SECTION A, LINE 7BTRINITY HEALTH AND IOWA HEALTH SYSTEMS HAVE TO APPROVE LARGE CAPITAL PROJECTS
FORM 990, PART VI, SECTION B, LINE 11ORGANIZATION REVIEWED AND SUBMITTED RETURN UPON COMPLETION BY PREPARER
FORM 990, PART VI, SECTION B, LINE 12CALL BOARD MEMBERS ARE REQUIRED TO COMPLETE A FORM DETAILING ANY AND ALL BUSINESS RELATIONSHIPS WITH HEALTH INC AND RELATED ENTITIES. ALL COMPLETED FORMS ARE REVIEWED AND DISCUSSED WITH THE BOARD AS APPROPRIATE.
FORM 990, PART VI, SECTION B, LINE 15TOP MANAGEMENT EMPLOYEES PROVIDE INDEPENDENT DOCUMENTATION FROM TRADE SOURCES TO SUBSTANTIATE PAY LEVELS.
FORM 990, PART VI, SECTION C, LINE 19ORGANIZATION'S DOCUMENTS ARE AVAILABLE UPON REQUEST.
FORM 990, PART XI, LINE 5:NET UNREALIZED LOSSES ON INVESTMENTS: -89,839. PENSION ADJUSTMENT -1,008,349. LOSS ON INTERCOMPANY ACTIVITY -9,438. TOTAL TO FORM 990, PART XI, LINE 5: -1,107,626.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 2CNO CHANGES

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (5 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusControlled OrgControlledOrg
HEALTH INC
230 NEBRASKA STREETSIOUX CITYIA51101311712115SERVE AS THE CENTRAL ORGANIZATION FOR OTHER 501(C) (3) ENTITIESIA501(C)(3)PF0
SIOUXLAND REGIONAL CANCER CENTER
PO BOX 5017SIOUX CITYIA51102421411233DEDICATED TO CANCER TREATMENT, RESEARCH AND EDUCATION & SERVICES ALL PATIENTIA501(C)(3)LINE 90
SIOUXLAND PARAMEDICS
1701 TERMINAL DRIVESIOUX CITYIA51105421185707MEDICAL TRANSPORTATION SERVICEIA501(C)(3)LINE 11A, I0
MERCY HEALTH SERVICES
801 5TH STREETSIOUX CITYIA51102311373080PROVIDES A FULL CONTINUUM OF WELLNESS, PRIMARY, ACUTE AND TERTIARY SERVICESIA501(C)(3)LINE 11C, III-FI0
NORTHWEST IOWA HOSPITAL CORPORATION
2720 STONE PARK BOULEVARDSIOUX CITYIA51104421019872STRIVES TO PROVIDE THE MOST PATIENT-CENTERED CARE IN SIOUXLANDIA501(C)(3)LINE 11C, III-FI0
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs1RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs1RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (7 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolved
SIOUXLAND REGIONAL CANCER CENTER
N176400
SIOUXLAND REGIONAL CANCER CENTER
O78485
SIOUXLAND PARAMEDICS
O59010
MERCY HEALTH SERVICES
O342849
NORTHWEST IOWA HOSPITAL CORPORATION
O363818
MERCY HEALTH SERVICES
J122728
NORTHWEST IOWA HOSPITAL CORPORATION
I210268

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