2013-11-11T08:55:40-06:00 2012-12-31 481026809 Wendling Noe Nelson & Johnson LLC 534 S Kansas Ave Suite 1500 Topeka KS 666033491 990 2012-01-01 481112955 Citizens Foundation CITI 7854627511 100 E College Drive Colby KS 67701 Kevan Trenkle 7854627511 2013-11-07 1 Derek H Hart P01054116 7852334226 2013-11-07 2012 2016-02-24 21:20:13Z Kevan Trenkle 100 E College Drive Colby KS 67701 794608 0 X www.nwkshealthcare.com/foundation X 1991 KS Fundraising for the benefit of Citizens Medical Center, Inc. 7 7 0 15 0 0 102939 714025 0 0 87702 40412 0 0 190641 754437 5500 26807 0 0 0 0 0 20614 29750 233512 17218 239012 64639 -48371 689798 1668290 2358293 118 323 1668172 2357970 X To support health care, treatment, health related education, as well as the promotion of health and wellness for northwest Kansas. To promote health and well being of people through the development, promotion, improvement, and support of all forms of healthcare service and means for the delivery of such service as well as the support and enhancement of existing health care treatment facilities. 0 0 5500 5500 Provide scholarships according to the restricted endowment fund guidelines. 20000 20000 Provide support for health care services in the community. 1307 1307 Provide coats for needy children in the community. 26807 1 1 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 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 1 0 0 X 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 0 0 0 0 X Kevan Trenkle 7854627511 100 E College Drive Colby KS 67701 X Sue Evans 1.00 X X 0 0 0 Kathy Kersenbrock-Ostmeyer 1.00 X X 0 0 0 Vern Schwanke 1.00 X X 0 0 0 Ken Frahm 1.00 X X 0 0 0 Sean Hankin 1.00 X 0 0 0 Kasiah Rothchild 1.00 X 0 0 0 Pat Mallory 1.00 X 0 0 0 0 0 0 0 0 0 0 0 25780 688245 250833 714025 40412 40412 40171 25780 40171 0 754437 0 0 40412 20000 20000 6807 6807 20614 20614 4893 4893 4409 4409 2945 2945 244 244 Uncollected pledges 4727 4727 64639 26807 8082 29750 6994 16080 904052 1521446 79709 28878 4204 728313 736847 53 7 1668290 2358293 118 323 118 323 X 1298177 1322928 665047 369995 369995 1668172 2357970 1668290 2358293 689798 0 X 0 0 0 X 1103143 49148 102514 27744 714025 1996574 1103143 49148 102514 27744 714025 1996574 1996574 19327 3693 44541 87702 40412 195675 2192249 848984 0.91070 0.88370 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1268240 35481 4784 1672 1297265 726432 516260 27145 1597 1268240 621836 99940 6195 1539 726432 263408 332872 27773 1000 1217 621836 200012 55000 13476 4000 1080 263408 0.20000 0.29000 0.51000 1 0 0 Description of Intended Use of Endowment Funds: Part V, Line 4: Endowment funds are restricted for healthcare education scholarships and for capital improvements to Citizens Medical Center and its physician clinic. X X X X X X 1 Virgil Scott 4657 Rabbit Mountain Road Broomfield CO 80020 Consultation on fundraising related to expansion of the FCHC 0 665046 20614 644432 665046 20614 644432 Harvest for Health Golf Tournament 20982 13140 7842 3932 3910 Scrub sales 24243 3561 20682 20682 3 20726 9079 11647 11647 65951 25780 40171 3932 36239 40171 0 1 Citizens Medical Center 100 E College Drive Colby KS 67701 480892178 501(c)(3) 20000 FMV Medical equipment 1 Scholarships for health care education 4 5500 FMV Coats for needy children 42 1307 FMV Winter coats Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Enrollment in secondary education is verified prior to disbursing scholarship funds. Coats are given directly to needy children in the community. X Grain 2 250833 Market price on date of donation 0 0 0 Method for Determining Number of Contributors: Part I, Column (b): The number of contributions is reported. Form 990, Part VI, Section A, line 6 The organization had 7 members on the Board of Directors and 24 voting members as of 12/31/2012. The voting members elect the members of the Board of Directors and vote on such other matters as are submitted to a vote. Form 990, Part VI, Section A, line 7a Citizens Foundation has 24 voting members responsible for electing and overseeing the governing body, known as the Board of Directors. The Board of Directors is responsible for managing the affairs of the Foundation. The Board of Directors may submit other matters to the voting members for a vote. Form 990, Part VI, Section B, line 11 Form 990 is provided to the governing body and reviewed prior to filing. Form 990, Part VI, Section B, line 12c A conflict of interest disclosure form is provided with a copy of the current conflict of interest policy. This disclosure form is completed by each Member upon election and annually thereafter. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon written request. Citizens Medical Center Inc 100 E College Drive Colby KS 67701 480892178 Hospital KS 501(c)(3) Line 3 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0