2013-02-08T09:54:27-06:00 2012-06-30 481292483 HENJES CONNER & WILLIAMS PC 800 FRANCES BLDG SIOUX CITY IA 51101 990 2011-07-01 383320710 HOSPICE OF SIOUXLAND HOSP 7122334144 4300 HAMILTON BLVD SIOUX CITY IA 51104 DANIEL K LAUER 7122529418 2013-01-31 1 MELISSA J WILLER P00121904 7122773931 2013-01-29 2011 2016-02-25 16:41:14Z DANIEL K LAUER 230 NEBRASKA ST SIOUX CITY IA 51101 18718248 0 X WWW.HOSPICEOFSIOUXLAND.ORG X 1982 IA PROVIDE 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. 10 10 170 300 0 0 254372 327576 13872793 14697167 277190 72912 7507 66512 14411862 15164167 0 0 0 0 7063017 7146055 0 0 131670 6799148 6919259 13862165 14065314 549697 1098853 8994012 9714868 3232049 3961678 5761963 5753190 PROVIDE 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. 0 0 11192764 14715507 HOSPICE 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. 11192764 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 10 0 170 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 0 X DAN LAUER 7122529418 230 NEBRASKA ST PO BOX 5017 SIOUX CITY IA 51101 MILT AVERY 1.00 X X 0 0 0 BOB PEEBLES 1.00 X X 0 0 0 PETER THOREEN 1.00 X X 0 0 0 CHARESE YANNEY 1.00 X X 0 0 0 MARI KAPTAIN-DAHLEN 0.50 X 0 0 0 LYNN WOLD 0.50 X 0 0 0 STEVE EAVENSON 0.50 X 0 0 0 JIM GOBELL 0.50 X 0 0 0 ELLEN KAPLAN 0.50 X 0 0 0 DR WAYNE BARNES 0.50 X 0 0 0 LINDA TODD 40.00 X 103074 0 21951 KAREN VAN DE STEEG 40.00 X 0 0 0 DAN LAUER 40.00 X 0 0 0 DALE HOLDIMAN 40.00 X 208000 0 29414 311074 0 51365 2 0 1 0 HOSPISCRIPT SERVICES LLC 4525 EXECUTIVE PARK DR SUITE 100 MONTGOMERY AL 36116 PRESCRIPTIONS 648219 MERCY MEDICAL CENTER 801 5TH STREET SIOUX CITY IA 51101 INPATIENT AND OUTPATIEN HOSPITAL CHARGES 502203 INVASERV LLC 2130 E UNIVERSITY DR TEMPE AZ 85281 MEDICAL 399774 JUNE E NYLEN CANCER CENTER 230 NEBRASKA STREET SIOUX CITY IA 51101 MANAGEMENT FEES AND INSURANCE REBILLS 389343 HOLY SPIRIT RETIREMENT HOME 1701 W 25TH ST SIOUX CITY IA 51103 ROOM AND BOARD CHARGES 327129 16 327576 327576 PATIENT SERVICE REVENU 621610 14697167 14697167 14697167 121084 121084 210268 190743 19525 19525 19525 3193780 121386 3241952 121386 -48172 0 -48172 -48172 OTHER INCOME 900099 31913 31913 OTHER INVESTMENT INCOM 900099 15074 15074 46987 15164167 14715507 0 121084 125025 125025 5283887 4176496 1069113 38278 300232 232769 65330 2133 1055631 835447 212527 7657 381280 299044 79744 2492 6007 6007 49971 49971 4097994 3824547 273447 62133 62133 103451 101925 1526 252452 10731 240318 1403 436337 382030 53976 331 53971 53971 21838 21838 72801 72801 43082 43082 MEDICAL SUPPLIES 1353495 1353495 REPAIRS AND MAINTENANCE 94137 94137 OTHER COSTS 79144 35 68606 10503 BAD DEBTS 78170 78170 114276 46929 67347 14065314 11192764 2740880 131670 1124250 847340 1503733 2350603 144389 154960 2798449 1396713 99631 1401736 5063995 4952971 1058014 7258 8994012 9714868 2422049 3546678 810000 415000 3232049 3961678 X 5239459 5251866 22504 1324 500000 500000 5761963 5753190 8994012 9714868 X 1098853 -1107626 X X 0 1 1 X 0 X X 0 0 0 MERCY HEALTH SERVICES 311373080 3 0 0 1 0 NORTHWEST IOWA HOSPITAL CORPORATION 421019872 3 0 0 1 0 2 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 684578 -13202 671376 558179 126399 684578 491289 66890 558179 0.25530 0.74470 0 0 1671554 693001 978553 752237 703712 48525 374658 374658 1401736 MUTUAL FUNDS 2456180 F U. S. GOVERNMENT SECURITIES 561928 F CORPORATE SECURITIES 1070612 F MORTGAGE BACKED SECURITIES 154148 F CERTIFICATES OF DEPOSIT 710103 F 4952971 15164167 14065314 1098853 -89839 -1017787 -1107626 -8773 15215100 -89839 190743 100904 15114196 49971 49971 15164167 14215524 200181 200181 14015343 49971 49971 14065314 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. X X X X 0 0 0 0 0 0 0 0 0 DALE HOLDIMAN 208000 0 0 0 0 0 0 0 29414 0 237414 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 HALF 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 6 HEALTH INC., NORTHWEST IOWA HOSPITAL CORPORATION AND SUBSIDIARIES, MERCY HEALTH SERVICES AND SUBSIDIARIES FORM 990, PART VI, SECTION A, LINE 7A NORTHWEST IOWA HOSPITAL CORPORATION AND MERCY HEALTH SERVICES APPOINT THEIR REPRESENTATIVES TO BE ON THE BOARD FORM 990, PART VI, SECTION A, LINE 7B TRINITY HEALTH AND IOWA HEALTH SYSTEMS HAVE TO APPROVE LARGE CAPITAL PROJECTS FORM 990, PART VI, SECTION B, LINE 11 ORGANIZATION REVIEWED AND SUBMITTED RETURN UPON COMPLETION BY PREPARER FORM 990, PART VI, SECTION B, LINE 12C ALL 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 15 TOP MANAGEMENT EMPLOYEES PROVIDE INDEPENDENT DOCUMENTATION FROM TRADE SOURCES TO SUBSTANTIATE PAY LEVELS. FORM 990, PART VI, SECTION C, LINE 19 ORGANIZATION'S DOCUMENTS ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: 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. FORM 990, PART XI, LINE 2C NO CHANGES HEALTH INC 230 NEBRASKA STREET SIOUX CITY IA 51101 311712115 SERVE AS THE CENTRAL ORGANIZATION FOR OTHER 501(C) (3) ENTITIES IA 501(C)(3) PF 0 SIOUXLAND REGIONAL CANCER CENTER PO BOX 5017 SIOUX CITY IA 51102 421411233 DEDICATED TO CANCER TREATMENT, RESEARCH AND EDUCATION & SERVICES ALL PATIENT IA 501(C)(3) LINE 9 0 SIOUXLAND PARAMEDICS 1701 TERMINAL DRIVE SIOUX CITY IA 51105 421185707 MEDICAL TRANSPORTATION SERVICE IA 501(C)(3) LINE 11A, I 0 MERCY HEALTH SERVICES 801 5TH STREET SIOUX CITY IA 51102 311373080 PROVIDES A FULL CONTINUUM OF WELLNESS, PRIMARY, ACUTE AND TERTIARY SERVICES IA 501(C)(3) LINE 11C, III-FI 0 NORTHWEST IOWA HOSPITAL CORPORATION 2720 STONE PARK BOULEVARD SIOUX CITY IA 51104 421019872 STRIVES TO PROVIDE THE MOST PATIENT-CENTERED CARE IN SIOUXLAND IA 501(C)(3) LINE 11C, III-FI 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 SIOUXLAND REGIONAL CANCER CENTER N 176400 SIOUXLAND REGIONAL CANCER CENTER O 78485 SIOUXLAND PARAMEDICS O 59010 MERCY HEALTH SERVICES O 342849 NORTHWEST IOWA HOSPITAL CORPORATION O 363818 MERCY HEALTH SERVICES J 122728 NORTHWEST IOWA HOSPITAL CORPORATION I 210268