2013-05-14T10:29:50-05:00 2012-06-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-07-01 420890973 OSCEOLA COMMUNITY HOSPITAL INC OSCE 7127542574 600 9TH AVENUE NORTH SIBLEY IA 51249 JANET DYKSTRA 7127542574 2013-05-13 1 ROB SCHILE P00068340 6123764500 2011 2016-02-24 21:20:13Z JANET DYKSTRA 600 9TH AVENUE NORTH SIBLEY IA 51249 10674286 0 X WWW.OSCEOLACOMMUNITYHOSPITAL.ORG X 1960 IA TO PROVIDE HEALTHCARE TO THE CITIZENS OF OSCEOLA COUNTY AND THE SURROUNDING AREA. 9 9 127 57 391798 -134732 302248 338451 6798646 9529270 50441 101797 446275 704768 7597610 10674286 0 24893 0 0 3636485 4729193 0 0 0 3934544 5590602 7571029 10344688 26581 329598 20198257 20565655 7326166 7475748 12872091 13089907 X IT IS THE MISSION OF THE OSCEOLA COMMUNITY HOSPITAL TO ENHANCE AND IMPROVE THE QUALITY OF LIFE OF THE POPULATION IT SERVES, TO BE THE AREA'S PREMIER HEALTH CARE SERVICE PROVIDER, AND TO HAVE A POSITIVE IMPACT ON THE LIVES OF THE PEOPLE AND COMMUNITY IT SERVES. 0 0 8944864 0 9628485 OSCEOLA COMMUNITY HOSPITAL PROVIDED NURSING SERVICES, LAB, RADIOLOGY AND OTHER RELATED HOSPITAL FUNCTIONS TO RESIDENTS OF OSCEOLA COUNTY, IOWA AND NEARBY COUNTIES. IN ADDITION THE HOSPITAL ALSO PROVIDES HOME HEALTH, INDEPENDANT/ASSISTED LIVING, AND DAY CARE TO THE COMMUNITY. HEALTH SCREENINGS SUCH AS CHOLOSTERAL AND CARDIAC ARE PROVIDED AS WELL. THE HOSPITAL WORKS HARD TO BRING OUTREACH SPECIALISTS TO THE FACILITY TO MAKE THESE SERVICES AVAILABLE TO THOSE THAT FIND IT DIFFICULT TO TRAVEL. WE NOW HAVE CATARAC SURGERY AVAILABLE AT OUR SITE. THE FACILITY'S WELLNESS CENTER PROVIDES PROGRAMS TO THE LOCAL SCHOOL SYSTEM AND NURSING HOME FACILITIES. DURING THE YEAR THE HOSPITAL PROVIDED $76,714 OF CHARITY CARE TO VARIOUS INDIVIDUALS, WITHOUT REIMBURSEMENT, FOR THE YEAR ENDING JUNE 30, 2012. WE ALLOW LOWER INCOME PATIENTS TO SET UP PAYMENTS ACCORDING TO THEIR FINANCIAL ABILITY WITH INTEREST FORGIVENESS. 8944864 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 46 0 127 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IA X GERALDINE PALSROK 7127542574 600 9TH AVE NORTH SIBLEY IA 51249 X SUE ELLEN SCHUTTE 1.00 X X 0 0 0 KAREN GLADE 1.00 X X 0 0 0 DARYL BOSMA 1.00 X X 0 0 0 PAUL HIBMA 1.00 X X 0 0 0 BRIAN MINO 1.00 X 0 0 0 DEB KOHN 1.00 X 0 0 0 BOB HANSEN 1.00 X 0 0 0 JOHN VANDIEPEN 1.00 X 0 0 0 DENNIS CLARK 1.00 X 0 0 0 SHIRLEY CHRISTIANS 1.00 X 0 0 0 JANET DYKSTRA 40.00 X 118367 0 15266 JULIE SCHRODER 40.00 X 79082 0 8776 JERRI GERALDINE PALSROK 40.00 X 55161 0 11550 252610 0 35592 1 0 0 0 AVERA MCKENNAN 800 E 21ST STREET SIOUX FALLS SD 57117 ADMINISTRATIVE & IT SERVICES 456956 SANFORD USD MEDICAL CENTER PO BOX 5074 SIOUX FALLS SD 57117 CRNA SERVICES 188806 ROBERT THROBROGGER 24376 140TH STREET SPIRIT LAKE IA 51360 RADIOLOGIST SERVICES 169622 GREAT LAKE PT LLP 5670 CENTER LAKE SPIRIT LAKE IA 51360 PHYSICAL THERAPY SERVICES 138744 DELTA LOCAL TENANS LP 1755 WITTINGTON PLACE SUITE 175 DALLAS TX 75320 LOCAL TENENS & PHYSICIAN SEARCH SERVICES 117130 7 125505 212946 338451 PATIENT REVENUE 621400 9434257 9434257 OTHER REVENUE 621400 95013 95013 9529270 22430 22430 82743 0 82743 82743 82743 77883 1484 0 0 77883 1484 79367 79367 99215 0 99215 99215 DAYCARE REVENUE 624410 311259 311259 0 MEALS AND VENDING REV 621400 89187 89187 WELLNESS CENTER REV 713940 80539 80539 41825 41825 522810 10674286 9628485 391798 315552 24893 24893 276522 276522 3034335 2808940 225395 80691 66115 14576 1105583 889203 216380 232062 196602 35460 58401 58401 7395 7395 103572 103572 1459240 1459240 68858 482 68376 80513 34956 45557 90660 90660 471928 333683 138245 40928 38193 2735 305220 305220 1094140 1094140 70669 11083 59586 DRUG COST 676700 676700 MEDICAL SUPPLIES 577491 558187 19304 FOOD COST 103902 103678 224 BAD DEBTS EXPENSE 100000 100000 280985 243549 37436 10344688 8944864 1399824 0 624730 1092556 2568565 2266784 206783 146609 2049050 2589164 87500 278488 279789 31466 37819 19425611 8529652 11174455 10895959 2770378 2738076 494342 431399 20198257 20565655 894954 951372 4710000 5620454 1721212 903922 7326166 7475748 X 11562996 12872873 1309095 217034 12872091 13089907 20198257 20565655 X 329598 -111782 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 274148 274148 12817032 4285358 8531674 5770403 3863496 1906907 564028 380798 183230 10895959 INVESTMENT IN COUNTRY VIEW MANOR, INC 77664 F NORTHWEST IOWA CO-OP ALLOCATED PATRONAGE DIVIDENDS 780 F AVERA FOUNDATION POOLED INVESTMENT 2218832 F US BANK INVESTMENT ACCOUNT 10660 F BOND SINKING FUND 74967 F DEBT RESERVE FUND 355173 F 2738076 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME TAXES THE HOSPOTAL AND AFFILIATE HAVE BEEN GRANTED EXEMPT STATUS RELATIVE TO INTERNAL REVENUE SERVICE CODE SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, THUS THERE IS NO PROVISION FOR INCOME TAXES AT JUNE 30, 2012 AND 2011. THE HOSPITAL AND AFFILIATE HAVE ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE HOSPITAL AND AFFILIATE FOLLOW THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT ON THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL AND AFFILIATE'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE TAX RETURNS FOR YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 X 1 X 133.000000000000 1 X 185.000000000000 1 1 0 54662 54662 0.00530 320355 229072 91283 0.00880 375017 229072 145945 0.01410 227829 13750 214079 0.02070 32719 32719 0.00320 105034 105034 0.01020 365582 13750 351832 0.03410 740599 242822 497777 0.04820 125013 125013 0.01210 4784 4784 0.00050 129797 129797 0.01260 1 100000 50000 3437321 3408310 29011 X 1 1 OSCEOLA COMMUNITY HOSPITAL

600 NINTH AVENUE NORTH SIBLEY IA 51249

X X OSCEOLA COMMUNITY HOSPITAL 2 1 1 133.000000000000 1 185.000000000000 1 X X X X X X X 1 1 X X 1 0 1 X 0 0 PART I, LINE 7: COSTING METHODOLOGY:A COST-TO-CHARGE RATIO WAS USED TO REPORT BAD DEBT FIGURES IN PART III, SECTION A. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE IRS INSTRUCTIONS FOR SCHEDULE H, WORKSHEET 2. PART I, L7 COL(F): THERE WAS $100,000 OF BAD DEBT EXPENSE THAT WAS EXCLUDED BEFORE ARRIVING AT TOTAL EXPENSES FOR CALCULATING PERCENTAGE OF COMMUNITY BENEFIT PART II: APPROXIMATELY 80% OF THE ACTIVITY REPORTED IN PART II AS COMMUNITY BUILDING ACTIVITIES RELATES TO CHILD CARE PROVIDED BY THE ORGANIZATION THAT IS MADE AVAILABLE TO VULNERABLE POPULATIONS. THIS COMMUNITY SUPPORT ACTIVITY PROMOTES THE HEALTH OF THE COMMUNITIES IT SERVES BY PROVIDING THE COMMUNITY WITH A HEALTHY, SAFE ENVIRONMENT FOR CHILDREN TO DEVELOP IN WHILE THEIR PARENTS ARE WORKING OR UNABLE TO CARE FOR THEM.THE ORGANIZATION ALSO INCLUDES ACTIVITY RELATED TO NEIGHBORHOOD SUPPORT GROUPS. THESE PROGRAMS PROMOTE THE HEALTH OF THE COMMUNITY BY ESTABLISHING SOCIAL NETWORKS FOR ITS RESIDENTS THAT PROVIDE THEM WITH; A NETWORK OF SIMILAR EXPERIENCES, SYMPATHETIC AND UNDERSTANDING MEMBERS, EMOTIONAL COMFORT, AND MORAL SUPPORT. ALL OF THESE CAN LEAD TO A REDUCTION IN STRESS AND ANXIETY. PART III, LINE 4: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIONS CHARITY CARE POLICY IS 50%. THIS IS BASED ON RECORD REVIEWS AND ANALYSIS OF DEMOGRAPHICS.FINANCIAL STATEMENT BAD DEBT EXPENSE FOOTNOTE:ACCOUNT RECEIVABLE ARE SHOWN AT THE AMOUNT EXPECTED TO BE COLLECTED AFTER DETERMINING THAT ALLOWANCE FOR DOUBTFUL ACCOUNTS AND CONTRACTUAL ADJUSTMENTS FROM THIRD-PARTY PAYORS. THE HOSPITAL PROVIDES AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON MANAGEMENT'S JUDGMENT. PATIENTS ARE NOT REQUIRED TO PROVIDE COLLATERAL FOR SERVICES RENDERED. PAYMENT FOR SERVICES IS REQUIRED WITHIN 30 DAYS OF RECEIPT OF INVOICE OR CLAIM SUBMITTED. ACCOUNTS OVER 125 DAYS PAST DUE ARE TURNED OVER TO COLLECTION AGENTS OR FILED TO SMALL CLAIMS COURT. IN ADDITION, AN ALLOWANCE IS ESTIMATED FOR OTHER ACCOUNTS BASED ON HISTORICAL EXPERIENCE WITH THE HOSPITAL. PART III, LINE 8: THERE WASNT A MEDICARE SHORTFALL REPORTED IN PART III, LINE 8. THE SURPLUS APPEARS REASONABLE AS THE HOSPITAL IS A CRITICAL ACCESS HOSPITAL AND IS REIMBURSED AT 101% OF COST. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 13G: IF THE PATIENTS ARE UNINSURED OR HAVE A LARGE DEDUCTIBLE OR CO-PAY, OCH WILL TRY TO CONTACT THE PATIENT PRIOR TO DISCHARGE AND INFORM THEM OF THE FINANCIAL ASSISTANCE POLICY. IF THE PATIENT HAS ALREADY BEEN DISCHARGED, OCH WILL CONTACT THEM VIA PHONE OR LETTER TO INFORM THEM OF THE FINANCIAL ASSISTANCE POLICY. OSCEOLA COMMUNITY HOSPITAL PART V, SECTION B, LINE 19D: THE HOSPITAL UTILIZES THE SAME METHOD FOR BILLING PATIENTS FOR EMERGENCY AND NON-EMERGENCY CARE. THE DISCOUNTED OR FREE CARE IS DETERMINED THROUGH THE FINANCIAL ASSISTANCE POLICIES THAT ARE DEPENDENT UPON THE PATIENT'S INCOME AND THE FPG LEVELS. PART VI, LINE 2: THE HOSPITAL ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY THROUGH FORMAL PROCESSES THAT INCLUDE, MEETINGS, SURVEY AND COMMUNITY INPUT PRIOR TO UNDERTAKING ANY LARGE PROJECTS. THROUGHOUT THE YEAR, COMMUNITY NEEDS ARE ASSESSED INFORMALLY AT VARIOUS COMMUNITY MEETINGS AND THROUGH PATIENT SURVEYS. THE ORGANIZATION ALSO ASSISTS THE HOME HEALTH DEPARTMENT/PUBLIC HEALTH WITH A COMMUNITY NEEDS ASSESSMENT INFORMATION FROM THE CHNA IS UTILIZED TO HELP PLAN SERVICES THE ORGANIZATION OFFERS. PART VI, LINE 3: DURING THE COURSE OF PRE-REGISTRATION A MODE OF PAYMENT IS RECORDED ON THE ADMISSION FORM. IF INSURANCE IS INDICATED, BENEFITS ARE REQUEST FROM THE INSURANCE COMPANY. IF IT IS NOTED THAT THE ACCOUNT HAS A LARGE DEDUCTIBLE OR IS SELF PAY, THE INFORMATION IS FORWARDED TO THE COLLECTION STAFF AND SOCIAL SERVICES. OPTIONS FOR HANDLING PAYMENT OF THE ACCOUNT ARE THEN DISCUSSED WITH THE PATIENT OR THE RESPONSIBLE PARTY. IF THE PATIENT OR RESPONSIBLE PARTY IS NOT AVAILABLE AT THE TIME THE INFORMATION IS RECEIVED BY THE BUSINESS OFFICE OR SOCIAL SERVICE STAFF, EFFORTS TO CONTACT THEM INCLUDE PHONE AND WRITTEN CORRESPONDENCE. IF THE PARTY DOES NOT RESPOND, THE ACCOUNT IS HANDED OVER TO THE COLLECTION AREA. THIS PROCESS OFTEN REQUIRES A COMBINATION OF BUSINESS OFFICE AND SOCIAL SERVICE STAFF WORKING TOGETHER. OPTIONS FOR ANY SELF PAY OBLIGATIONS INCLUDE PAYMENT IN FULL, PAYMENT PLANS, VARIOUS ASSISTANCE PROGRAMS, AND THE FINANCIAL ASSISTANCE OFFERED BY OSCEOLA COMMUNITY HOSPITAL'S CHARITY CARE. INFORMATION REGARDING THESE OPTIONS IS MADE AVAILABLE AT THIS TIME. DURING THE DISCUSSIONS, INFORMATION IS REQUESTED TO ASSESS AND PROVE FINANCIAL STATUS IF PAYMENTS, PROGRAM APPLICATION, OR CHARITY ARE INDICATED. ASSISTANCE IS OFFERED FOR COMPLETION OF APPLICATIONS AND INSTRUCTIONS ARE GIVEN FOR COMPLETION OF FINANCIAL ASSESSMENTS. ATTENTION TO PARTICULAR ACCOUNTS MAY ALSO BE BROUGHT TO THE ATTENTION OF THE BUSINESS OFFICE OR SOCIAL SERVICES BY THE COLLECTIONS STAFF, PATIENTS THEMSELVES, OR RELATIVES OF PATIENTS. THIS USUALLY OCCURS WHEN THE CIRCUMSTANCES OF THE PATIENT CHANGES AFTER A TIME PERIOD HAS PASSED. WHEN NOTIFICATION IS RECEIVED, THESE CASES ARE REASSESSED. PART VI, LINE 4: OSCEOLA COMMUNITY HOSPITAL'S PRIMARY SERVICE AREA INCLUDES THE CITIZENS OF OSCEOLA COUNTY, IOWA. THE SECONDARY SERVICE AREA INCLUDES THE SURROUNDING COUNTIES OF NOBLES (MN), JACKSON (MN), DICKINSON (IA), O'BRIEN (IA), AND LYON (IA). ACCORDING TO THE 2000 AND 2010 CENSUS, THE POPULATION HAS DECREASED 8% OVER THE PREVIOUS 10 YEARS. THE MEDIAN AGE OF THE POPULATION WAS 40 AND WAS MADE UP OF 98% CAUCASIANS. THE MEDIAN HOUSEHOLD INCOME WAS $34,274 WITH AN AVERAGE HOUSEHOLD OF 2.5. PART VI, LINE 6: THE HOSPITAL IS A MEMBER OF AVERA HEALTH. 0 YMCA 2721 W 41ST ST PLAZA 41 SIOUX FALLS SD 57104 460452300 24893 GENERAL SUPPORT 1 0 CITY OF SIBLEY IOWA 426005203 825759AM5 2007-12-01 4800000 CAPITAL PROJECTS 0 0 0 CITY OF SIBLEY IOWA 426005203 2007-12-14 1000000 CAPITAL PROJECTS 0 0 0 90000 4800000 88603 142554 4657446 0 0 1 1 56519 1000000 21463 978537 0 0 1 1 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 BONDS A AND B DESCRIPTION OF PROJECT: THE PROJECT CONSISTS OF EXPANDING AND RENOVATING BORROWER'S EXISTING HOSPITAL FACILITIES, AND ACQUIRING MAJOR MEDICAL EQUIPMENT, INCLUDING WITHOUT LIMITAION, A NEW OPERATING ROOM, NEW PATIENT ROOMS, A RENOVATED AND EXPANDED EMERGENCY ROOM, AN EXPANDED WELLNESS AREA, NEW EXAM ROOMS, NEW SUPPORT AREAS, A NEW NURSING STATION, AND NEW NURSERY OBSTETRICAL SUITES FOR USE AT THE BORROWER'S EXISTING HOSPITAL FACILITIES AT 600 9TH AVENUE NORTH IN SIBLEY, IOWA. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE ORGANIZATION. THE PRESIDENT SHALL SERVE AS THE CHAIR OF THE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINSS OF THE ORGANIZATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD OF TRUSTEES, PROVIDED THAT ANY ACTION WHICH IT MAY TAKE SHALL NOT CONFLICT WITH THE POLICIES AND EXPRESSED WISHES OF THE BOARD OF TRUSTEES, AND THAT IT SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 REGULAR MEMBERS ARE THOSE PERSONS, CORPORATIONS, ASSOCIATIONS OR PARTNERSHIPS WHO HAVE CONTRIBUTED AND PAID INTO THE CORPORATION A MINIMUM OF $75 OR MORE TO FURTHER THE OBJECTIVES OF THE CORPORATION. MEMBERSHIP SHALL BE LIFELONG AND NONTRANSFERABLE. EACH MEMBER WHOSE NAME IS ENDORSED ON THE MEMBERSHIP CERTIFICATES SHALL BE QUALIFIED TO ORIGINATE AND TAKE PART IN THE DISCUSSION OF ANY SUBJECT THAT MAY PROPERLY COME BEFORE THE ANNUAL MEETING OF THE CORPORATION, TO VOTE ON SUCH SUBJECTS, AND TO HOLD ANY OFFICE TO WHICH THE MEMBER MAY BE ELECTED OR APPOINTED. NO EMPLOYEE OR EMPLOYEE'S SPOUSE OF THE CORPORATION MAY BE ELECTED TO THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF TRUSTEES ARE ELECTED FROM THE MEMBERS AT THE ANNUAL MEETING OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE MANAGEMENT OF THE ORGANIZATION REVIEWS THE FORM 990 PRIOR TO FILING. THE BOARD OF DIRECTORS REVIEW THE 990 SUBSEQUENT TO FILING. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR/TRUSTEE, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A CONFLICT OF INTEREST STATEMENT. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF A FINANCIAL INTEREST AND ALL MATERIAL FACTS TO THE DIRECTORS/TRUSTEES AND MEMBERS OF COMMITTEES WITH BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER THE INTERESTED PERSON LEAVES THE MEETING, THE REMAINING BOARD OR COMMITTEE MEMBERS WILL DISCUSS AND VOTE UPON WHETHER A CONFLICT OF INTEREST EXISTS. ALSO, IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE A DIRECTOR, TRUSTEE, OR MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM SUCH PERSON OF THE BASIS FOR SUCH BELIEF AND AFFORD THE PERSON AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION SHALL BE TAKEN IF NECESSARY. FORM 990, PART VI, SECTION B, LINE 15 A COMPENSATION SPECIALIST FROM AN AFFILIATE ORGANIZATION REVIEWS THE COMPENSATION WITH THE BOARD OF TRUSTEES ANNUALLY. THE SPECIALIST REVIEWS MARKET VALUE AND PRESENTS A RECOMMENDATION TO THE BOARD OF TRUSTEES. THE BOARD MAKES THEIR DECISION ON THE INFORMATION PRESENTED. THE MOST RECENT PROCESS WAS COMPLETED IN MAY 2012 FOR ALL OFFICERS AND TOP MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST AND THE FORM 990 AND 990T ARE AVAILABLE AT THE ANNUAL MEETING AND UPON REQUEST. ALLOCATION OF HOURS FORM 990, PART VII JANET DYKSTRA SERVES AS THE CEO OF OSCEOLA COMMUNITY HOSPITAL AND A BOARD MEMBER OF ITS RELATED ORGANIZATION, HEARTWOOD HEIGHTS. SHE SPENDS APPROXIMATELY 40 HOURS PER WEEK WORKING FOR OSCEOLA COMMUNITY HOSPITAL AND 1 HOUR PER WEEK FOR HEARTWOOD HEIGHTS. BRIAN MINO, DARRYL BOSMA, AND DEB KOHN EACH SERVE ON THE BOARD OF OSCEOLA COMMUNITY HOSPITAL AND ITS RELATED ORGANIZATION, HEARTWOOD HEIGHTS. EACH INDIVIDUAL SPENDS APPROXIMATELY 1 HOUR PER WEEK WORKING FOR EACH OF THE ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: DONATED SERVICES AND USE OF FACILITIES: -19,994. PRIOR PERIOD ADJUSTMENTS: 29,404. UNRESTRICTED:NET ASSETS RELEASED FROM RESTRICTIONS FOR CAPITAL EXPENDITURES 1,212,243. TEMP REST: NET ASSETS RELEASED FROM RESTRICTIONS FOR CAPITAL EXPENDITURES -1,224,818. CHANGE IN UNREALIZED GAINS -108,617. TOTAL TO FORM 990, PART XI, LINE 5: -111,782. HEARTWOOD HEIGHTS 409 9TH AVE NORTH SIBLEY IA 51249 421495686 INDEPENDENT/ASSISTED LIVING COMPLEX IA 501(C)(3) PF OSCEOLA COMMUNITY HOSPITAL 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 HEARTWOOD HEIGHTS N 168727 ACTUAL COST