2013-11-14T15:03:50-06:00 2012-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-01-01 470686476 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION CHEY 3082545825 645 OSAGE SIDNEY NE 69162 KELLY UTLEY 3082545825 2013-11-13 1 BARBARA J FAJEN P00400874 4023302660 2012 2016-02-25 16:41:14Z KELLY UTLEY 645 OSAGE SIDNEY NE 69162 51957 0 X WWW.SIDNEYRMC.COM X 1985 NE HEALTH CENTER FOUNDATION SUPPORTS SIDNEY REGIONAL MEDICAL CENTER IN THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICES. THROUGH OUR RESPONSIBLE DONATION MANAGEMENT, WE ARE HELPING TO ASSURE THAT OUR COMMUNITY WILL CONTINUE TO HAVE LOCAL, QUALITY HEALTH CARE AND CURRENT STATE-OF-THE-ART TECHNOLOGIES, IN A FACILITY MAINTAINED AND UPDATED TO MEET THE EMERGING AND GROWING NEEDS OF CHEYENNE COUNTY AND THE SURROUNDING REGIONS. 12 11 0 109 0 0 57034 33503 0 0 9065 8762 2094 3095 68193 45360 57330 39133 0 0 0 0 0 0 13342 14776 13342 72106 52475 -3913 -7115 1528260 1537286 18039 7609 1510221 1529677 TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. 0 0 26196 26196 SUPPORT OF CHEYENNE COUNTY HOSPITAL ASSOCIATION 7932 7932 SUPPORT FOR SCHOLARSHIP AND INTERN PROGRAMS 5005 5005 ASSISTANCE FOR DENTAL PROCEDURES 39133 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 X KELLY UTLEY 3082545825 645 OSAGE SIDNEY NE 69162 X MITCH MUHS 1.00 39.00 X X 0 95587 3752 KIM CASTNER 1.00 0.00 X X 0 0 0 MEGAN MCGOWN 1.00 0.00 X X 0 0 0 BILL BUTKIS 1.00 0.00 X X 0 0 0 STAN BELIEU 1.00 0.00 X 0 0 0 SEAN DOYLE 1.00 0.00 X 0 0 0 GERALD BERLAGE 1.00 0.00 X 0 0 0 SHERI EHLER 1.00 0.00 X 0 0 0 VICKI SMITH 1.00 0.00 X 0 0 0 MERRY JEAN MILLER 1.00 0.00 X 0 0 0 LEASA HLAVINKA 1.00 0.00 X 0 0 0 ROB ROBINSON 1.00 0.00 X 0 0 0 KELLY UTLEY 1.00 39.00 X 0 121816 26510 0 217403 30262 0 0 0 0 0 33503 33503 8762 8762 5775 6181 -406 -406 -406 3917 416 3501 3501 45360 0 0 11857 26196 26196 12937 12937 8069 8069 988 988 4064 4064 MISCELLANEOUS 221 221 52475 39133 0 13342 229396 225675 926360 915504 3060 0 247007 46302 204769 200705 164675 195387 0 15 1528260 1537286 18039 2571 0 5038 18039 7609 X 1330449 1325652 179772 204025 1510221 1529677 1528260 1537286 -7115 26571 0 X X 0 1 X 1 0 X X X 0 0 0 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER 470408242 3 1 1 1 26196 1 26196 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 144483 144483 101605 45383 56222 919 919 0 200705 DUE TO AFFILIATE 5038 5038 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: SIDNEY REGIONAL MEDICAL CENTER AND CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION ARE EXEMPT FROM INCOME TAXES UNDER SECTION 501(A) OF THE CODE AND A SIMILAR PROVISION OF STATE LAW. HOWEVER, THEY ARE SUBJECT TO FEDERAL INCOME TAX ON ANY UNRELATED BUSINESS TAXABLE INCOME. THE SYSTEM ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE SYSTEM RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2012, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY U.S. FEDERAL, STATE, OR LOCAL AUTHORITIES FOR YEARS BEFORE 2009. 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 645 OSAGE STREET SIDNEY NE 69162 470480242 501(C)(3) 26196 ASSISTING CHEYENNE COUNTY HOSPITAL ASSOCIATION PROVIDE SERVICES TO THE COMMUNITY 1 0 SCHOLARSHIP AND INTERN PROGRAM 2 7932 ASSISTANCE FOR DENTAL PROCEDURES 3 5005 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION PROVIDES FUNDS TO SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE FUNDS ARE UTILIZED FOR ASSET PURCHASES AND OPERATIONS OF THE HOSPITAL. THE INTERNSHIP AND SCHOLARSHIP PROGRAM GRANTS GIFTS TO INDIVIDUALS IN THE AREA CURRENTLY STUDYING IN THE HEALTH CARE FIELD. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 INFORMATION IS ACCUMULATED BY THE ACCOUNTING DEPARTMENT AND SUBMITTED TO THE INDEPENDENT PUBLIC ACCOUNTANTS FOR FURTHER REVIEW AND PREPARATION. COMMUNICATIONS BETWEEN THE INDEPENDENT PUBLIC ACCOUNTANTS AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. AFTER THE PREPARATION IS COMPLETE, THE EXECUTIVE DIRECTOR REVIEWS THE FORM 990. UPON APPROVAL, THE FORM 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE FORM 990 HAS BEEN REVIEWED BY ALL PARTIES IT WILL BE SUBMITTED TO THE IRS ON OR BEFORE THE EXTENDED DUE DATE. FORM 990, PART VI, SECTION B, LINE 12C EACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AMD MADE A MATTER OF PUBLIC RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER ABSTAINS FROM DISCUSSION AND THE VOTE. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VI, SECTION B, LINE 13: THE ORGANIZATION DOES NOT HAVE A FORMAL WHISTLEBLOWER POLICY, BUT IT IS IN THE PROCESS OF ADOPTING SUCH POLICY. FORM 990, PART VI, SECTION B, LINE 14: THE ORGANIZATION DOES NOT HAVE A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY, BUT IT IS IN THE PROCESS OF ADOPTING SUCH POLICY. FORM 990, PART VI, SECTION B, LINE 15: AS THE ORGANIZATION DOES NOT HAVE ANY EMPLOYEES, THERE IS NO INDEPENDENT REVIEW AND APPROVAL OF COMPENSATION. BOARD MEMBER COMPENSATION FORM 990, PART VII, SECTION A MITCH MUHS IS A PHYSICIAN ASSISTANT AT SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. MR. MUHS' COMPENSATION IS FOR HIS SERVICES AS A PHYSICIAN ASSISTANT. HE IS NOT PAID BY SIDNEY REGIONAL MEDICAL CENTER OR CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION FOR HIS SERVICE AS A MEMBER OF THE FOUNDATION'S BOARD OF DIRECTORS. CHEYENNE COUNTY HOSPITAL ASSOCIATION INC 645 OSAGE STREET SIDNEY NE 69162 470480242 PROVIDING HEALTH CARE TO THOSE IN THE COMMUNITY NE 501(C)(3) 3 N/A 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0