2013-05-15T08:09:22-05:00 2012-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 55402 990 2011-07-01 450344371 F-M Ambulance Service Inc F-MA 7012342000 2215 18th Street South Fargo ND 58103 JoAnn Kunkel 6053331000 2013-05-15 1 Kristina Rasmussen P00143920 6123974000 2011 2016-02-24 21:20:13Z Kelby K Krabbenhoft 1305 W 18th St Sioux Falls SD 57117 11967696 0 X www.FMAmbulance.com X 1978 ND Dedicated to the work of health and healing 16 7 164 0 0 0 103085 15300 11257992 11847776 20202 21109 122544 37880 11503823 11922065 50 0 0 0 5332996 5173641 0 0 0 4194174 4618426 9527220 9792067 1976603 2129998 6188786 7048918 1081031 945834 5107755 6103084 X The Mission of F-M Ambulance, "Dedicated to the Work of Health and Healing" and the vision "Improving the Human Condition through Exceptional Care, Innovation and Discovery", is the constant force that drives our plans, decisions and actions. 0 0 8377880 0 11847776 As part of the Sanford integrated delivery system, F-M Ambulance provides emergency medical and special transportation services to the Fargo, North Dakota/Moorhead, Minnesota metro area and other surrounding communities. F-M Ambulance is the largest advanced life support ground ambulance provider in North Dakota and serves as a resource to rescue and ambulance providers throughout the state. F-M Ambulance works closely with the local volunteer service to coordinate the delivery of emergency medical care to the communities in its service area and is a leader in Homeland Defense Preparedness by serving as a regional training, resources partner and responder.Through its Ready Wheels operations, F-M Ambulance provides local and long distance transportation for individuals using wheelchairs. This special transportation service is available 24 hours a day, seven days a week to provide door-to-door wheelchair service. These services allow individuals in the community to access transportation services that accommodate unique individual needs due to health conditions.Education and other services:F-M Ambulance also engages in various activities that promote the health of the community, including providing medical and safety education. F-M Ambulance provides educational programs for members of the community including first aid, automated external defibrillator, CPR and other courses. In addition, F-M Ambulance operates an on-site bookstore that is open to the public. The store sells education texts and reference books, trauma bags, first aid kits and supplies, medical supplies used in delivering emergency medical service outside the hospital and logo wear.F-M Ambulance also works with other organizations in the community to prepare for medical situations by having customized first aid supplies available to respond to workplace medical needs. These services help improve the health and well being of the community at large. F-M Ambulance is also very involved in numerous community activities that help promote health including participation in the national safe kids campaign, participating in bicycle safety helmet programs and providing non-dedicated stand-bys for community events. 8377880 0 0 0 0 0 0 0 0 0 1 0 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 1 0 0 1 0 0 164 1 0 0 0 0 1 1 0 X 16 7 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JoAnn Kunkel CFO 6053331000 1305 West 18th Street Sioux Falls SD 57117 X Barb Everist 0.50 X 0 0 0 Barbara Stork 0.50 X 0 0 0 Barry Martin 0.50 X 0 0 0 Brent Teiken 0.50 X 0 0 0 David Beito 0.50 X 0 0 0 Don Morton 0.50 X 0 0 0 Jerome Feder 0.50 X 0 0 0 Jim Entenman 0.50 X 0 0 0 John C Vanderwoude 60.00 X 0 1183385 28640 John Jambois 0.50 X 0 0 0 Lauris Molbert 0.50 X 0 0 0 Mark Paulson MD 60.00 X 0 268151 30760 Michael L Olson 60.00 X 0 572221 6711 Michael L Olson Deferred Comp 60.00 X 0 0 49282 Mikal Claar 0.50 X 0 0 0 Pamela Anderson 0.50 X 0 0 0 Richard D Hardie 60.00 X 0 566503 24244 Ronald Moquist 0.50 X 0 0 0 Terrence Grimm MD thru Feb12 60.00 X 0 557673 26124 Terry Baloun 0.50 X 0 0 0 Thomas Hruby 0.50 X 0 0 0 Kelby K Krabbenhoft 60.00 X X 0 1484297 21738 Kelby K Krabbenhoft Deferred Comp 60.00 X X 0 0 565035 Lisa Carlson 60.00 X 0 717737 31290 Dennis Millirons 60.00 X 0 666051 26514 Tiffany Lawrence 60.00 X 0 271463 28534 Linda O'Halloran 60.00 X 0 435150 19026 Dean Lampe 60.00 X 117512 0 85 Roger Gilbertson MD 60.00 X 0 501987 0 117512 7224618 857983 1 1 1 0 0 14600 700 15300 Emergency Medical Serv 621910 10945116 10945116 Education 900099 708527 708527 Special Transportation 621910 194133 194133 11847776 164 164 12780 0 12780 12780 12780 21000 55 20945 20945 20945 70676 45576 25100 25100 11922065 11847776 0 58989 55529 55529 4064935 3724444 340491 190680 165354 25326 495493 422228 73265 367004 283006 83998 26227 26227 48499 25875 22624 20608 13735 6873 246388 123922 122466 94936 49035 45901 160838 86999 73839 361243 347766 13477 55583 54946 637 19140 17727 1413 553614 436290 117324 201605 733 200872 Bad Debt 2319572 2317899 1673 Medical Supplies 223570 221548 2022 Intercompany Purchased 200711 28263 172448 Miscellaneous Expense 85892 58110 27782 9792067 8377880 1414187 0 1248808 1805998 71764 51392 46202 28958 8066153 4296665 3428930 3769488 1393082 1393082 6188786 7048918 583839 579367 21813 44887 475379 321580 1081031 945834 X 5107755 6103084 5107755 6103084 6188786 7048918 X 2129998 -1134669 X 0 1 1 X 0 481239 481239 2762068 893836 1868232 135053 55528 79525 2213043 1783582 429461 2474750 1563719 911031 3769488 Description of Uncertain Tax Positions Under FIN 48: Part X: Certain controlled organizations are subject to income taxes. Deferred income tax assets and liabilities are recognized for the differences between the financial and income tax reporting basis of assets and liabilities based on enacted tax rates and laws. A tax benefit from an uncertain tax position may be recognized when it is more likely than not that the position will be sustained upon examination. The deferred income tax provision or benefit generally reflects the net change in deferred income tax assets and liabilities during the year. The current income tax provision reflects the tax consequences of revenues and expenses currently taxable or deductible on various income tax returns for the year reported. F-M Ambulance Service, Inc did not have an income tax liability at June 30, 2012; some related organizations have established reserves. 1 1 0 0 0 0 1 0 0 John C Vanderwoude 0 1000000 0 0 0 183385 0 4900 0 23740 0 1212025 0 0 Mark Paulson MD 0 236419 0 0 0 31732 0 12250 0 18510 0 298911 0 0 Michael L Olson 0 563933 0 0 0 8288 0 0 0 6711 0 578932 0 0 Michael L Olson Deferred Comp 0 0 0 0 0 0 0 49282 0 0 0 49282 0 0 Richard D Hardie 0 562511 0 0 0 3992 0 7350 0 16894 0 590747 0 0 Terrence Grimm MD thru Feb12 0 500004 0 0 0 57669 0 12250 0 13874 0 583797 0 0 Kelby K Krabbenhoft 0 913461 0 0 0 570836 0 0 0 21738 0 1506035 0 0 Kelby K Krabbenhoft Deferred Comp 0 0 0 0 0 0 0 565035 0 0 0 565035 0 0 Lisa Carlson 0 500321 0 0 0 217416 0 12250 0 19040 0 749027 0 0 Dennis Millirons 0 465027 0 0 0 201024 0 12250 0 14264 0 692565 0 0 Tiffany Lawrence 0 250890 0 0 0 20573 0 12145 0 16390 0 299998 0 0 Linda O'Halloran 0 387487 0 0 0 47663 0 12250 0 6776 0 454176 0 0 Roger Gilbertson MD 0 501987 0 0 0 0 0 0 0 0 0 501987 0 0 Part I, Line 1a On Part I, Questions Regarding Compensation, Sanford checked several of the items as provided to listed persons: First Class or Charter Travel - Charter travel for business purposes is provided for individuals as needed and as cost appropriate. These costs are not included in the W-2's of the individuals as they are incurred for business purposes of Sanford. Travel for Companions - Limited travel for companions is required for certain annual meetings. These costs are not included in the W-2's of the individuals as they are incurred for business purposes of Sanford. Tax Indemnification and gross-up payments - Certain compensation may be grossed up to include appropriate tax amounts. Health or social club dues or initiation fees - All Sanford employees are eligible for discounted wellness memberships, a portion of these discounts and other club dues are included as fringe benefits, and taxed as such. Personal services - Individuals may have benefits which include tax preparation or planning, this benefit is included in income and taxed. Part I, Line 3: The Sanford Board of Trustees directly engages a nationally recognized independent compensation consulting firm to annually review the total compensation of arrangements of the officers of the organization, and to report findings and recommendations to the Sanford Board of Trustees for deliberation and action. The most recent study was completed in 2012. Part I, Lines 4a-b Part I, Lines 4a-b: Roger Gilbertson, former MeritCare President and CEO, received a payment of $501,987 upon his retirement, per employment contract. Part I, Line 4b/Schedule J, Part II, Column C: In addition to employer contributions to pension plans, amounts representing increases and decreases in actuarial value (actuarial value factors include age, tenure and salary) of defined contribution and defined benefit SERP Plans are included in Column C. Participants and changes in values include: Kelby Krabbenhoft $418,302 Part I, Line 6 Sanford physicians are compensated based on the professional services they perform within the clinic in which they provide care. Generally, the model is revenues less expenses. Physicians listed that were paid on this model include: Michael L Olson Richard Hardie Supplemental Information Part III Compensation reported on Schedule J, Part II includes: (B)(i) Base compensation - salaries are based on the experience and performance of each executive and bench-marked using independent compensation survey information. (B)(ii) Bonus & incentive compensation - as part of executive compensation, individuals may be eligible for incentive performance compensation, however if the organization does not make its financial targets, incentive payments are not paid regardless of performance. (B)(iii) Other Reportable Compensation - generally includes taxable executive benefits. (C) Deferred Compensation includes employer contributions to pension plans and the increase (or decrease) in the actuarial value (actuarial value factors include age, tenure and salary) of the benefit plans. (D) Nontaxable Benefits generally includes health insurance premiums. Supplemental Information Part III A memo regarding executive compensation, written by the Chairman of the Sanford Board of Trustees, is on file and available upon request. Supplemental Information Part III Compensation paid to trustees is for full-time professional responsibilities as physicians, administrators or employees of the organization. The total compensation paid to Kelby Krabbenhoft of $1,484,297 is comprised of Base salary of $913,461, and Other Taxable Earnings of $570,836. In addition, an amount of $565,035 has been reported for the estimated amount of ratable increase in value of the defined benefit pension plan, defined benefit SERP and a Gift Agreement Management Continuity Retention plan. Form 990, Part VI, Section A, line 2 Pamela Anderson, Trustee, and Lisa Carlson, CFO, have a business relationship. The following officers, board members, and key employees are employees of Sanford or its related organizations. Many of these employees also serve on other related Sanford boards, or have business relationships with each other that span the organization as a whole: John Vanderwoude Mark Paulson Michael Olson Richard Hardie Terrence Grimm Kelby Krabbenhoft Lisa Carlson Tiffany Lawrence Dennis Millirons Linda O'Halloran Form 990, Part VI, Section A, line 6 Sanford North is the sole stockholder of F-M Ambulance. Form 990, Part VI, Section A, line 7a Board members are appointed by the President and CEO of Sanford North. Form 990, Part VI, Section A, line 7b Sanford North must approve the following actions: * Modifying the purpose of the Corporation * Unbudgeted capital expenses in excess of 1/2 of 1% of approved operating budgets *Adoption of capital and operating budgets *Acquisition, sale, lease, disposition, or mortgaging of real property *Guarantee of debts or obligations of any other person, firm, corporation, partnership, association, or other entity which if held in deafult would obligate the corporation to an aggregate amount in excess of $100,000 *Merger or consolidation of the Corporation *Incurring a loan or other obligation in an agreement in excess of $500,000 for more than 60 days *Making of a gift, grant or other donation in an amount in excess of $5,000 to an organization not related to the Corporation or Member *Member has the authority to direct the Corporation regardless of the vote by the Corporation's Board of Directors to transger assets and/or funds to the health system to satisfy obligations of the health system. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by the finance department and reviewed by executive management. An external accounting firm reviews the return prior to filing and prepares return highlights and key disclosures for the Audit Committee prior to the return filing date. Before the return is filed, a complete copy is made available to the current Board of Trustees. Form 990, Part VI, Section B, line 12c The annual Conflict of Interest disclosure process is managed by the Chief Compliance Officer (CCO). The CCO is responsible for assuring that all completed forms are returned in a timely and complete manner. Conflict of Interest questionnaires are sent to System Trustees, members of the governing boards for subsidiary entities, officers, and key employees for all entities subject to the IRS Form 990 filings. The disclosures are summarized for review by the executive committee of the Board of Trustees, pursuant to policy. This review allows: 1) The Board to acquire an awareness of financial relationships of board members and key management employees and can invoke the recusal process on a case-by-case basis when potential conflicts are implicated in Board decisions and deliberations, and, 2) Gives the Board the opportunity to seek additional information and clarification about disclosures to determine potential conflicts of interest and how to manage such. Form 990, Part VI, Section B, line 15 The Sanford Board of Trustees directly engages a nationally recognized independent compensation consulting firm to annually review the total compensation arrangements of the officers and operating unit executives of the organization, including the CEO, and to report the findings and recommendations to them for deliberation and action. The deliberations and actions are recorded in the minutes of the Sanford Board of Trustees. The most recent study was completed in 2012. Additionally, Sanford periodically engages an independent compensation consultant to review and issue a report regarding the reasonableness of the total compensation arrangements of all physicians employed by the organization. The most recent study of physician total compensation arrangements was completed in 2009. Form 990, Part VI, Section C, line 19 Although the organization does not maintain a website where the public can access these documents, it would respond individually to any requests or inquiries from the public for these documents. Form 990, Part VII Sanford Trustees provide services to Sanford and its subsidiaries. Hours reported for each individual reflect the time spent on work related to either the filing organization or a related organization. Sanford Board of Trustees has ultimate governance responsibilities for each entity within the Sanford system. In addition, a Board of Directors is established for each entity, which has specific delegated responsibilities from the Board of Trustees related to the oversight of day to day operations of that entity. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net Asset Transfers (AP Intercompany) -1,134,669. Total to Form 990, Part XI, Line 5: -1,134,669. Sanford Health 1305 West 18th Street Sioux Falls SD 57117 311527032 Supporting Organization SD 501(c)(3) 11-II Sanford 1 Sanford Health Foundation 1305 West 18th Street Sioux Falls SD 57117 363297853 Supporting Organization SD 501(c)(3) 11-II Sanford Health 1 Sanford 801 Broadway Drive Fargo ND 58122 271218956 Supporting Organization ND 501(c)(3) 11-II 0 Sanford North PO Box 2010 Fargo ND 58122 450385890 Supporting Organization ND 501(c)(3) 11-II Sanford 1 Sanford Medical Center Fargo PO Box 2010 Fargo ND 58122 450226909 Hospital ND 501(c)(3) 3 Sanford North 1 Sanford Clinic North PO Box 2010 Fargo ND 58122 911770748 Clinics ND 501(c)(3) 9 Sanford North 1 Sanford Health Network North PO Box 2010 Fargo ND 58122 450409348 Hospitals/Clinics ND 501(c)(3) 11-II Sanford North 1 Sanford Medical Center Wheaton 401 12th Street North Wheaton MN 56296 272042143 Hospital/Clinic MN 501(c)(3) 3 Sanford North 1 Sanford Health Foundation North PO Box 2010 Fargo ND 58122 450398104 Fundraising ND 501(c)(3) 7 Sanford North 1 Sanford Medical Center Thief River Falls 120 Labree Ave S Thief River Falls MN 56701 410709579 Hospital MN 501(c)(3) 3 Sanford North 1 Sanford Medical Center Mayville 42 6th Ave SE Mayville ND 58257 450228899 Hospital ND 501(c)(3) 3 Sanford North 1 MeritCare Minnesota 1720 South Highway 59 Thief River Falls MN 56701 261530302 Promotion of health MN 501(c)(3) 3 Sanford North 1 Agassiz Assurance Company 100 Bank Street Suite 610 Burlington VT 05401 743121855 Insurance VT 501(c)(3) 11-II Sanford North 1 MeritCare Health Enterprises Inc PO Box 2010 Fargo ND 58122 450359785 Prescription drugs ND 501(c)(4) Sanford North 1 Sanford Health of Northern Minnesota 1300 Anne St NW Bemidji MN 56601 411266009 Hospital MN 501(c)(3) 3 Sanford North 1 Baker Park Inc 803 Dewey Ave NW Bemidji MN 56601 411372480 Low Income Senior Housing MN 501(c)(3) 9 Sanford Health of Northern Minnesota 1 Sanford Health Foundation of Northern Minnesota 1300 Anne St NW Bemidji MN 56601 411389317 Fundraising - Support MN 501(c)(3) 11-II Sanford Health of Northern Minnesota 1 North Country Medical Clinic 1300 Anne St NW Bemidji MN 56601 411753855 Family Practice Medical Clinic MN 501(c)(3) 3 Sanford Health of Northern Minnesota 1 Sanford ResearchUSD 1305 West 18th Street PO Box 5039 Sioux Falls SD 571175039 460450378 Research SD 501(c)(3) 3 Sanford Health 1 Sanford USD Medical Center 1305 West 18th Street PO Box 5039 Sioux Falls SD 571175039 460227855 Hospital SD 501(c)(3) 3 Sanford Health 1 Sanford Clinic 1305 West 18th Street PO Box 5039 Sioux Falls SD 571175039 460447693 Clinical Services SD 501(c)(3) 3 Sanford Health 1 Sanford Health Network 1305 West 18th Street PO Box 5039 Sioux Falls SD 571175039 460388596 Hospitals/Clinics SD 501(c)(3) 11-II Sanford Health 1 Sanford Home Health 1305 West 18th Street PO Box 5039 Sioux Falls SD 571175039 460282134 Home Health Services SD 501(c)(3) 9 Sanford Health 1 MeritCare Health Enterprises Inc 201 Fifth Street North 14 Floor Fargo ND 58102 453788040 Prescription drugs PA 501(c)(4) Sanford North 1 Edith Sanford Breast Cancer Foundation 2301 E 60th Street N Sioux Falls SD 57104 450404126 Foundation ND 501(c)(3) 11-II Sanford Health 1 Sanford World Clinics 1305 West 18th Street Sioux Falls SD 57117 262707628 Healthcare SD 501(c)(3) 3 Sanford Health 1 National Student Housing - South Dakota LLC 100 S Phillips Ave Sioux Falls SD 57104 202129839 Investment SD N/A RAC Rentals LLC 100 S Phillips Ave Sioux Falls SD 57104 261961077 Investment SD N/A Sanford Home Medical Equipment Inc 2710 W 12th Street Sioux Falls SD 57105 460388597 Healthcare Equipment SD N/A C Sanford Health Plan 300 Cherapa Place Sioux Falls SD 57103 911842494 Insurance SD N/A C Sanford Health Plan of MN 300 Cherapa Place Sioux Falls SD 57103 460445852 Insurance MN N/A C Bemidji Medical Equipment Inc 1300 Anne St NW Bemidji MN 56601 411551725 Retail Sales of DME MN N/A C North Country Management Inc 1300 Anne St NW Bemidji MN 56601 411820025 Management Services MN N/A C Sanford Frontiers 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 455436599 Weight Loss Management SD N/A C 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0