2013-08-01T14:11:26-05:00 2012-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2012-01-01 742358522 NCMC INC NCMC 9703506052 1801 16TH STREET GREELEY CO 80631 ROBERT E MURPHY 9703506052 2013-08-01 1 LISA CHAFFEE CPA P00193453 7012398500 2013-08-01 2012 2016-02-24 21:20:13Z KEN SCHULTZ 1801 16TH STREET GREELEY CO 80631 126087448 0 X N/A X 1984 CO LEASING OF HOSPITAL FACILITIES TO ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE IRS CODE FOR THE PROVISION OF HEALTH CARE SERVICES TO THE COMMUNITY. 10 10 0 10 0 0 602257 4029042 32193801 30911590 8991371 9153925 297216 247204 42084645 44341761 3944150 2475000 0 0 1459420 3414007 0 0 0 30983915 30228187 36387485 36117194 5697160 8224567 412072198 489930200 203362140 261474188 208710058 228456012 TO PROVIDE QUALITY HEALTHCARE AT A REASONABLE COST TO THE NCMC SERVICE COMMUNITY. 0 0 34685350 2475000 30911590 NCMC, INC OWNS A HOSPITAL BUILDING WHICH IT LEASES TO BANNER HEALTH SYSTEM (AN ARIZONA 501(C)(3) ORGANIZATION), WHO OPERATES THE HOSPITAL IN A CHARITABLE FASHION. NCMC, INC IS RESPONSIBLE FOR MAINTAINING THE PROPERTY AND EQUIPMENT FOR ITS USE BY BANNER HEALTH (NORTH COLORADO MEDICAL CENTER) TO PROVIDE ACUTE MEDICAL SERVICES. 34685350 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 1 16 0 1 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 0 1 0 0 0 X KEN SCHULTZ 9703506052 1801 16TH STREET GREELEY CO 80631 X AL DOMINGUEZ 1.00 X X 0 0 0 ROBERT NOFFSINGER 1.00 X X 0 0 0 ROBERT E MURPHY 1.00 X X 0 0 0 BRANDON HOUTCHENS 1.00 X X 0 0 0 LINDA WINTER 1.00 X 0 0 0 KAY KOSMICKI 1.00 X 0 0 0 JEFFREY CARLSON 1.00 X 0 0 0 VICKI WILSON PHD RN 1.00 X 0 0 0 MICHAEL J GEILE 1.00 X 0 0 0 DAVE OWEN 1.00 X 0 0 0 KEN SCHULTZ 40.00 X 0 0 0 0 0 0 0 0 0 0 HENSEL PHELPS CONSTRUCTION 420 6TH AVE GREELEY CO 80632 CONSTRUCTION CONTRACTOR 3410463 JE DUNN CONSTRUCTION 1001 LOCUST KANSAS CITY MO 64106 CONSTRUCTION CONTRACTOR 1641327 EMPIRE ELECTRIC INC 10575 W 120TH AVE BROOMFIELD CO 80021 CONSTRUCTION CONTRACTOR 1294178 UBS FINANCIAL SERVICES INC 1901 56TH AVE SUITE 300 GREELEY CO 806342950 INVESTMENT MANAGEMENT 774133 WHEELER MANAGEMENT GROUP INC 1130 38TH AVE SUITE B GREELEY CO 806342580 REAL ESTATE MANAGEMENT FEES 316356 10 3821031 208011 4029042 HOSPITAL FACILITY RENT 532000 30902434 30902434 9156 9156 30911590 8779396 8779396 484956 237752 247204 247204 247204 81882464 81366612 141323 515852 -141323 374529 374529 44341761 30911590 0 9401129 2475000 2475000 3414007 3414007 171808 12558 159250 54347 54347 31700 31700 1134268 1134268 44190 44190 11380 3291 8089 152788 152788 500 500 1036 1036 7867833 7867833 19757282 19757282 BOND FEES 843909 843909 157146 157146 36117194 34685350 1431844 0 3754142 12611333 114982 47802 27625 0 415865477 243824500 175478092 172040977 227323053 268527776 24045297 201438 3670929 5172866 8986086 412072198 489930200 13720151 18898219 177097520 230087928 12544469 12488041 203362140 261474188 X 208710058 228456012 208710058 228456012 412072198 489930200 X 8224567 15512202 -3990815 X 0 1 X 1 0 X X X 0 0 0 NCMC BOARD OF TRUSTEES 846000813 6 1 1 1 31260792 1 31260792 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7964976 7964976 13351576 242160043 123170514 132341105 149068882 120653986 28414896 3320000 3320000 172040977 INTEREST RATE SWAP 12488041 12488041 X 55030695 15512202 -4990815 10521387 44509308 -167547 -167547 44341761 35284741 167547 167547 35117194 1000000 1000000 36117194 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: NCMC, INC. IS A COLORADO NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) OF THE CODE, AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 509(A)(3) OF THE CODE. NCMC, INC. IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE CORPORATION MAY BE SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. NORMEDCO CARE, LLC; SOUTHSIDE INVESTMENTS, LLC; AND SHEEP DRAW FARMS, LLC ARE LIMITED LIABILITY CORPORATIONS FOR WHICH THE INCOME IS ALLOCATED TO THE SOLE MEMBER (NCMC) IN ITS TAX RETURN AND, THEREFORE, NO INCOME TAX EXPENSE HAS BEEN RECORDED IN THE CONSOLIDATED FINANCIAL STATEMENTS. NCMC BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS AND, AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. NCMC WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE, IF SUCH INTEREST AND PENALTIES ARE INCURRED. NCMC'S HISTORICAL FEDERAL AND STATE TAX RETURNS ARE SUBJECT TO EXAMINATIONS BY TAX AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHARITY CARE GRANT TO BANNER HEALTH SYSTEM -1,000,000. INCREASE IN FAIR VALUE OF INTEREST RATE SWAP 56,428. PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -4,047,243. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED IN REVENUES -167,547. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED IN REVENUES 167,547. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHARITY CARE GRANT TO BANNER HEALTH SYSTEM 1,000,000. 1 BANNER HEALTH SYSTEM 1801 16TH STREET GREELEY CO 80631 450233470 501(C)(3) 1000000 CHARITY CARE NCMC FOUNDATION 1801 16TH STREET GREELEY CO 80631 840718355 501(C)(3) 1475000 OPERATIONAL ASSISTANCE AND DONATION 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THERE IS CURRENTLY NO PROCESS IN PLACE THAT MONITORS THE USE OF GRANT FUNDS BY THE RECIPIENTS. MOST CHARITABLE CONTRIBUTIONS ARE MADE THROUGH NCMC INC'S DONOR ADVISED FUND AT NCMC FOUNDATION WHICH DOES VET RECIPIENTS PRIOR TO MAKING GRANTS, AND ALSO MONITORS THE USE OF PROCEEDS. A COLORADO HEALTH FACILITIES AUTHORITY 840752932 196474K25 2003-11-13 98000000 PARTIAL REFUND SERIES 1993,RENOVATE HOSPITAL & PAY 2003 ISSUANCE COSTS. 0 0 0 B COLORADO HEALTH FACILITIES AUTHORITY 840752932 19648AMY8 2008-10-27 55515000 REFUND SERIES 1993 BONDS, FD IMPROVEMENT TO HOSPITAL FACILITY 0 0 0 C COLORADO HEALTH FACILITIES AUTHORITY 840752932 19648ARR8 2009-11-17 44800000 REFUND ALL OUTSTANDING SERIES 2005 BONDS. 0 0 0 D COLORADO HEALTH FACILITIES AUTHORITY 840752932 2012-07-31 60000000 FUND MCP PROJECT AND ROUTINE CAPEX 0 0 0 A 13570000 98000000 884500 3759456 76964179 16391865 2006 1 0 1 1 B 8230000 55515000 585244 25000000 29929756 2011 1 0 1 1 C 6020000 44800000 437252 44362748 2009 1 0 1 1 D 820000 60000000 25599 595000 10868353 48511048 0 0 0 0 A 0 1 0 0 0.00030 0.00000 0.00030 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 1 FSA CAPITAL MANAGEMENT SERVICES 2.000000000000 1 0 1 B 0 1 0 0 1 1 CITIBANK NA 21.500000000000 1 1 0 0 1 C 0 1 0 0 1 1 CITIBANK NA 14.500000000000 1 1 0 0 1 D 0 1 0 0 0 0 0 0 1 A 1 B 1 C 1 D 1 SCHEDULE K PART IV, ARBITRAGE, LINE 2C DATE REBATE COMPUTATION PERFORMED ISSUER NAME: COLORADO HEALTH FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 07/29/2009 THE AMOUNT REPORTED ON SCHEDULE K, PART II, LINE 11, COLUMN A, B AND C IS THE AMOUNT OF BOND PROCEEDS USED TO REFUND THE PRIOR BONDS ISSUED. KEN SCHULTZ KEN IS NCMC INC. BOARD EXECUTIVE AND 33.33% OWNER OF NORTHSTAR MGMT 159250 PAYMENTS MADE TO NORTHSTAR MANAGEMENT GROUP, INC IN 2012 WERE $159,250. 0 X 1 3821032 NET BOOK VALUE 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE ORGANIZATION HAS AN EXECUTIVE COMMITTEE WHICH IS ABLE TO EXERCISE AUTHORITY OF THE BOARD WHEN THE BOARD IS NOT IN SESSION EXCEPT AS SUCH AUTHORITY IS LIMITED BY STATUTE OR BY RESOLUTION CREATING OR OTHERWISE CONTROLLING THE EXECUTIVE COMMITTEE. THE MEMBERSHIP OF THE EXECUTIVE COMMITTEE INCLUDES THE CHAIR AND PRESIDENT OF THE BOARD OF THE CORPORATION, THE CHAIR OF THE FINANCE COMMITTEE, THE CHAIR OF THE OPERATIONS COMMITTEE AND THE VICE CHAIR OF THE BOARD. THE CHAIR AND PRESIDENT OF THE BOARD OF THE CORPORATION SHALL SERVE AS CHAIR OF THE COMMITTEE. THE EXECUTIVE COMMITTEE DOES NOT HAVE THE AUTHORITY OF THE BOARD IN REFERENCE TO: 1) APPOINTING, REMOVING OR FILLING VACANCIES IN THE MEMBERSHIP OF THE BOARD, BOARD COMMITTEES OR OFFICERS OF THE CORPORATION; 2) AMENDING THE ARTICLES OF INCORPORATION; 3) RESTATING THE ARTICLES OF INCORPORATION; 4) ADOPTING A PLAN OF MERGER OR CONSOLIDATION WITH ANOTHER CORPORATION; 5) AUTHORIZING THE SALE, LEASE, EXCHANGE OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY AND ASSETS OF THE CORPORATION (EXCEPT FOR THE ISSUANCE OF TAX EXEMPT DEBT AND APPROVING RELATED DOCUMENTS); 6) AUTHORIZING THE VOLUNTARY DISSOLUTION OF THE CORPORATION OR REVOKING PROCEEDINGS THEREFOR; 7) ADOPTING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF THE CORPORATION OR 8) AMENDING, ALTERING OR REPEALING ANY RESOLUTION OF THE BOARD WHICH BY ITS TERMS PROVIDES THAT IT SHALL NOT BE AMENDED, ALTERED OR REPEALED BY SUCH COMMITTEE. FORM 990, PART VI, SECTION A, LINE 3 NORTHSTAR MANAGEMENT GROUP INC. IS THE MANAGEMENT COMPANY. KEN SCHULTZ IS A 33.33% OWNER OF THE MANAGEMENT COMPANY AND SUPERVISES ALL OF THE OPERATIONS OF NCMC, INC. FORM 990, PART VI, SECTION A, LINE 7A THE NCMC BOARD OF TRUSTEES IS ELIGIBLE TO APPOINT 3 OF THE BOARD MEMBERS OF NCMC, INC. NCMC, INC. IS A SUPPORTING ORGANIZATION OF NCMC BOARD OF TRUSTEES. NCMC BOARD OF TRUSTEES IS A GOVERNMENT BODY APPOINTED BY THE COUNTY COMMISSIONERS. WELD COUNTY OWNS THE LAND THAT THE HOSPITAL SITS ON. FORM 990, PART VI, SECTION B, LINE 11 KEN SCHULTZ AND THE FINANCE COMMITTEE WILL REVIEW A COPY OF THE DRAFT FORM 990 AND THEN PRESENT IT TO FULL BOARD FOR APPROVAL PRIOR TO FILING THE FINAL COPY. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS RECEIVES THE CONFLICT OF INTEREST POLICY AT THE ANNUAL MEETING. KEN SCHULTZ RECEIVES THE RESPONSES AND FORWARDS THEM TO THE GENERAL COUNSEL OF THE BOARD. IF THERE ARE ANY ITEMS THAT COME UP FOR DISCUSSION IN WHICH A CONFLICT OF INTEREST IS PRESENT, THE BOARD MEMBER EXCUSES HIM OR HERSELF AND ABSTAINS FROM VOTING. THE BOARD HAS THE OPTION TO ALLOW THE MEMBER TO BE PART OF THE DISCUSSION. FORM 990, PART VI, SECTION C, LINE 19 THE GENERAL PUBLIC IS ALLOWED TO VIEW THE DOCUMENTS BUT NOT ALLOWED TO MAKE COPIES AND TAKE THEM OFF OF THE PREMISES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: REDUCTION IN FAIR VALUE OF INTEREST RATE SWAPS 56,428. PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -4,047,243. FORM 8621 NCMC, INC. IS FILING FORM 8621 AS A SHAREHOLDER IN VARIOUS FOREIGN FUNDS AS THEY ARE CONSIDERED TO BE PASSIVE FOREIGN INVESTMENT COMPANIES. THE DISTRIBUTIONS FROM THESE FUNDS TO NCMC, INC. ARE NOT TAXABLE AND THEREFORE NOT INCLUDED ON PART IV OF FORM 8621. THE FUNDS ARE IDENTIFIED BELOW: -AURORA OFFSHORE FUND LTD. -PINEHEARST INSTITUTIONAL, LTD. SHEEP DRAW FARMS LLC 1801 16TH STREET GREELEY CO 80631 680540676 HOLDS TITLE TO FARM RENT INCOME CO 4000 5786414 NCMC INC SOUTHSIDE INVESTMENTS 1801 16TH STREET GREELEY CO 80631 680611503 OWNS HOUSES ADJACENT TO THE HOSPITAL CO 67095 1194707 NCMC INC NORMEDCO CARE LLC 1801 16TH STREET GREELEY CO 80631 742354112 OWNS FACILITY LEASED TO A FEDERALLY QUALIFIED HEALTH CENTER FOR $1 PER YEAR CO 1 3540578 NCMC INC NCMC BOARD OF TRUSTEES 1801 16TH STREET GREELEY CO 80631 846000813 GOVERNMENTAL ACTIVITY - HOSPITAL CO GOVERNMENTAL UNIT 6 WELD COUNTY BOARD OF COUNTY COMMISSIONERS 0 NCMCBH GREELEY I LLC 1801 16TH STREET GREELEY CO 80631 900824175 LAND INVESTMENT CO NCMC INC RELATED 2274755 0 0 0.50000 NCMCBH GREELEY II LLC 1801 16TH STREET GREELEY CO 80631 900824173 LAND INVESTMENT CO NCMC INC RELATED 1199920 0 0 0.50000 NMSI DBA NORTHCARE 1801 16TH STREET GREELEY CO 80634 742354291 MEDICAL CLAIMS PROCESSING CO NCMC INC C 14458 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0