2013-11-14T09:27:28-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 911772474 FAITH REGIONAL HEALTH SERVICES FOUNDATION FAIT 4026447301 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 JOHN WILKER 4026447301 2013-11-11 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-02-24 21:20:13Z JOHN WILKER 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 2115894 0 X WWW.FRHS.ORG X 1996 NE TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES, AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE, PREVENTIVE, AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATES AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION, OR DIAGNOSIS. 17 16 0 26 0 0 630319 1859393 0 0 159888 90432 78176 48548 868383 1998373 1089050 1001338 0 0 0 0 0 0 21155 17506 34573 1106556 1035911 -238173 962462 8690714 10042900 124080 99433 8566634 9943467 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFITS OF FRHS OR ITS PROGRAMS AND SERVICES. 0 0 1001338 1001338 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANT DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE PREVENTATIVE AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION OR DIAGNOSIS. 1001338 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 3 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 17 16 1 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JOHN WILKER 4026447249 2700 WEST NORFOLK AVE STE 200 NORFOLK NE 68701 JOHN SEHI 1.00 0.00 X X 0 0 0 TODD WRAGGE MD 1.00 0.00 X X 0 0 0 GORDON ADAMS MD 1.00 0.00 X X 0 0 0 RUSS MCKILLIP 1.00 0.00 X X 0 0 0 DONNA HERRICK 1.00 1.00 X 0 0 0 JIM SCHEER 1.00 1.00 X 0 0 0 DONALD BELL MD 1.00 0.00 X 0 0 0 ALAN COLLISON 1.00 0.00 X 0 0 0 JACQUE COLLISON 1.00 0.00 X 0 0 0 BRANDON DOKE 1.00 0.00 X 0 0 0 VIRGIL FROEHLICH 1.00 0.00 X 0 0 0 RICK HIGGINS 1.00 0.00 X 0 0 0 PAT HUGHES 1.00 0.00 X 0 0 0 ELEANOR MCINTOSH 1.00 0.00 X 0 0 0 PAUL J MCINTOSH 1.00 0.00 X 0 0 0 HARRIET STUDEBAKER 1.00 0.00 X 0 0 0 TIMOTHY TIGHE 1.00 0.00 X 0 0 0 JAMES SINEK 1.00 39.00 X 0 481208 32257 DOUGLAS WISMER 1.00 39.00 X 0 50821 2229 JOHNATHAN WILKER 1.00 39.00 X 0 68385 4517 BILL LUKE 1.00 39.00 X 0 151913 0 JAKE CLAUSSEN 20.00 20.00 X 0 73182 5683 0 825509 44686 0 0 1 0 0 107480 1751913 49516 1859393 90432 90432 166069 107480 117521 48548 48548 1998373 0 0 138980 1001338 1001338 13418 13418 1712 1712 DREAM TEAM EXPENSE 15612 15612 CHILD ADVOCACY 3831 3831 1035911 1001338 13418 21155 1011 5334 4828231 5117029 169570 93614 3636704 4826923 55198 0 8690714 10042900 26359 1712 97721 97721 124080 99433 X 1352860 1667972 1837912 2887619 5375862 5387876 8566634 9943467 8690714 10042900 962462 414371 0 X X 0 1 X 1 0 X X X 0 0 0 FAITH REGIONAL HEALTH SERVICES 470796875 3 1 1 1 1001338 1 1001338 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5578113 12162 444388 10092 6024571 5670101 13321 -38571 66738 5578113 5188508 2727 517780 38914 5670101 4493972 6814 721427 33705 5188508 5706317 4188 -1145496 71037 4493972 0.00000 1.00000 0.00000 0 0 0 ANNUITY PAYABLE 97721 97721 X 2519353 414371 2506 117521 534398 1984955 13418 13418 1998373 1142520 2506 117521 120027 1022493 13418 13418 1035911 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S (FRHS) CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FRHS'S CHILDREN'S CARE FUND. DONORS CAN SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: FAITH REGIONAL HEALTH SERVICES (FRHS) AND FAITH REGIONAL HEALTH SERVICES FOUNDATION (THE FOUNDATION) ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C) (3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND NEBRASKA STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. FAITH REGIONAL PHYSICIAN SERVICES (FRPS) IS A LIMITED LIABILITY COMPANY WHOLLY OWNED BY FRHS. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE FRHS AND THE FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. FAITH ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012 AND 2011, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, FAITH IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2009. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 117,521. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 117,521. GOLF TOURNAMENT 42797 21395 21402 4175 810 4777 4578 12389 WINTER GALA 230752 86085 144667 855 780 1150 16171 71836 273549 107480 166069 5030 1590 5927 20749 84225 117521 48548 1 FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 847707 FUNDING FOR PURCHASE OF LINAC-CT UPGRADES FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 71986 FUNDING FOR PURCHASE OF CANCER CENTER VANS FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 20077 FUNDING FOR PURCHASE OF PEDIATRIC EQUIPMENT '11 WINTER GALA FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 17158 FUNDING FOR PURCHASE OF PATIENT ROOM WHITEBOARDS FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 12268 FUNDING FOR PURCHASE OF ZOOM CART FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 12223 FUNDING FOR PURCHASE OF WIRELESS EKG FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 6000 FUNDING FOR NURSE LEARNING EXPERIENCE FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 5322 FUNDING FOR PURCHASE OF CARDIAC REHAB STAIRMASTER FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 3753 FUNDING FOR SUPPORT OF INTERNSHIP PROGRAM FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 2075 FUNDING FOR PURCHASE OF TWO BARIATRIC WHEEL CHAIRS. FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 1201 FUNDING FOR PURCHASE OF APPEARANCE PRODUCTS FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 507 FUNDING FOR PURCHASE OF DOPPLER EQUIPMENT FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 500 FUNDING FOR DR. JOSEPH DAVID SCHOLARSHIPS FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 255 FUNDING FOR CARSON CANCER CENTER FBLA SNACKS FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 155 FUNDING FOR DEVELOPMENT OF CARSON CANCER CENTER STAR PROGRAM FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 101 FUNDING FOR FUNDING OF ST. JOSEPH'S CASINO DAY FAITH REGIONAL HEALTH SERVICES 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 50 FUNDING FOR CARSON CANCER CENTER SNACKS 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: FAITH REGIONAL HEALTH SERVICES FOUNDATION PROVIDES GRANT MONEY TO FAITH REGIONAL HEALTH SERVICES, A RELATED 501(C)(3) ORGANIZATION. FAITH REGIONAL HEALTH SERVICES PROVIDES HEALTH CARE SERVICES TO INDIVIDUALS IN NORTHEAST NEBRASKA. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 JAMES SINEK 0 481208 0 0 0 0 0 7500 0 24757 0 513465 0 0 BILL LUKE 0 151913 0 0 0 0 0 0 0 0 0 151913 0 0 PART I, LINE 1A JAMES J. SINEK'S YMCA MEMBERSHIP AND COUNTRY CLUB DUES ARE PAID BY FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. THE AMOUNTS PAID FOR THESE ITEMS ARE ADDED TO MR. SINEK'S W-2 AS WAGES. SUPPLEMENTAL INFORMATION PART III PART II: COMPENSATION REPORTED FOR BILL LUKE IS COMPENSATION RECEIVED SOLELY FROM FRHS, A RELATED ORGANIZATION. BILL LUKE ALSO RECEIVED COMPENSATION FROM LUKE AND ASSOCIATES, INC., AN UNRELATED BUSINESS. MR. LUKE'S SERVICES FOR LUKE AND ASSOCAITES, INC. ARE NOT RELATED TO FRHS, AND ARE IS NOT REPORTED IN THIS FORM 990. DIVOTS CONFERENCE CENTER DONNA HERRICK IS A FRHS BOARD REPRESENTATIVE AND OWNER/PRESIDENT OF DIVOTS 18446 PROVIDES SERVICES TO THE FOUNDATION FOR THE WINTER GALA EVENT FOR FOOD AND BEVERAGES 0 X 5 700 FMV X 7990 FMV X 20 3592 FMV X 13 2476 FMV X GIFT CERTIFICATES 54 9433 GIFT CERTIFICATE VALUE X TICKETS 8 870 FMV X RECREATION TRIPS 7 10400 FMV X ELECTRONICS 9 2775 FMV X SPORTING EQUIPMENT 5 1005 FMV X GIFT BASKETS 14 1638 FMV X EYEWARE 3 1846 FMV X OTHER MISCELLANEOUS ITEMS 30 6791 FMV 0 1 0 FORM 990, PART VI, SECTION A, LINE 2 JACQUE COLLISON AND ALAN COLLISON, BOTH BOARD MEMBERS, HAVE A FAMILY RELATIONSHIP. FURTHERMORE, BOARD MEMBERS ELEANOR MCINTOSH AND J. PAUL MCINTOSH, HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 7A FAITH REGIONAL HEALTH SERVICES FOUNDATION'S BYLAWS STATE ALL DIRECTORS SHALL BE APPOINTED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B BOARD MEMBER APPOINTMENT AND RETENTION DECISIONS MADE BY THE FOUNDATION BOARD ARE APPROVED BY THE FAITH REGIONAL HEALTH SERVICES BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND ALL APPLICABLE SCHEDULES WERE PREPARED AND SIGNED BY SEIM JOHNSON, LLP IN OMAHA, NEBRASKA. COPIES OF THE COMPLETED RETURN WERE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL HEALTH SERVICES FOUNDATION BOARD MEMBERS COMPLETE A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. THESE STATEMENTS ARE REVIEWED BY A DIRECTOR OF THE FOUNDATION. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST STATEMENT, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XII, LINE 2C: FAITH REGIONAL HEALTH SERVICES FOUNDATION HAS AN AUDIT COMPLETED ON A CONSOLIDATED BASIS WITH FAITH REGIONAL HEALTH SERVICES AND FAITH REGIONAL PHYSICIAN SERVICES, LLC. THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THERE HAVE BEEN NO CHANGES IN THE PROCESSES SINCE LAST YEAR. FORM 990, PART VI, SECTION B, LINE 15: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT PAY COMPENSATION TO A CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OFFICERS OR KEY EMPLOYESS OF THE OGANIZATION. THEREFORE, QUESTION 15A AND 15B ARE ANSWERED NO. FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVE NORFOLK NE 68701 470769875 PROVIDE HEALTHCARE SERVICES TO THE NORTHEAST NEBRASKA REGION NE 501(C)(3) 3 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 0 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 3 N/A 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0