2012-11-14T07:55:06-06:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 911772474 FAITH REGIONAL HEALTH SERVICES FOUNDATION FAIT 4026447301 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 JOHN WILKER 4026447301 2012-11-09 1 P GREG DONDELINGER P00400863 4023302660 2011 2016-02-24 21:20:13Z JOHN WILKER 2700 WEST NORFOLK AVENUE NO 200 NORFOLK NE 68701 989187 0 X WWW.FRHS.ORG X 1996 NE TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES, AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE, PREVENTIVE, AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATES AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION, OR DIAGNOSIS. 17 16 0 20 0 0 715997 630319 0 0 146600 159888 -975 78176 861622 868383 878272 1089050 0 0 0 0 0 0 17506 50676 17506 928948 1106556 -67326 -238173 8953529 8690714 10671 124080 8942858 8566634 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANTS, DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFITS OF FRHS OR ITS PROGRAMS AND SERVICES. 0 0 1089050 1089050 TO AID FAITH REGIONAL HEALTH SERVICES (FRHS) BY THE SOLICITATION OF GIFTS, GRANT DEVICES AND BEQUESTS EXCLUSIVELY FOR THE USE AND BENEFIT OF FRHS OR ITS PROGRAMS AND SERVICES. FRHS PROVIDES ACUTE PREVENTATIVE AND OTHER HEALTHCARE SERVICES TO THE REGION WHILE ENCOURAGING EDUCATIONAL AND CLINICAL RESEARCH. FRHS SERVES ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY AND DOES NOT LIMIT ITS SERVICES OR DISCRIMINATE AGAINST ANYONE ON THE BASIS OF RACE, SEX, NATIONAL ORIGIN, RELIGION OR DIAGNOSIS. 1089050 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 4 0 1 0 0 0 0 0 0 1 0 0 0 0 0 X 17 16 1 0 1 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X JOHN WILKER 4026447249 2700 WEST NORFOLK AVE STE 200 NORFOLK NE 68701 X JOHN SEHI 1.00 X X 0 0 0 TODD WRAGGE MD 1.00 X X 0 0 0 GORDON ADAMS MD 1.00 X X 0 0 0 RUSS MCKILLIP 1.00 X X 0 0 0 DONNA HERRICK 1.00 X 0 0 0 JIM SCHEER 1.00 X 0 0 0 DONALD BELL MD 1.00 X 0 0 0 JACK BOESCH 1.00 X 0 0 0 AL COLLISON 1.00 X 0 0 0 JACQUE COLLISON 1.00 X 0 0 0 VIRGIL FROEHLICH 1.00 X 0 0 0 RICK HIGGINS 1.00 X 0 0 0 PAT HUGHES 1.00 X 0 0 0 J PAUL MCINTOSH 1.00 X 0 0 0 ELEANOR MCINTOSH 1.00 X 0 0 0 HARRIET STUDEBAKER 1.00 X 0 0 0 TIMOTHY TIGHE 1.00 X 0 0 0 JAMES SINEK 1.00 X 0 476500 27240 BARRY SPEAR 16.00 X 0 172013 12062 DOUGLAS WISMER 1.00 X 0 180391 14727 DIANE MOUCHKA 40.00 X 0 87610 9969 JAKE CLAUSSEN 20.00 X 0 61453 1579 0 977967 65577 0 0 1 0 0 116288 514031 3627 630319 160044 160044 156 -156 -156 -156 198824 116288 120648 78176 78176 868383 0 0 238064 1089050 1089050 1160 1160 DREAM TEAM EXPENSE 9274 9274 CHILD ADVOCACY 4072 4072 EMPLOYEE GIVING CAMPAIG 3000 3000 1106556 1089050 0 17506 43 1011 4603881 4828231 383852 169570 3934910 3636704 30843 55198 8953529 8690714 347 26359 10324 97721 10671 124080 X 1134240 1352860 2446077 1837912 5362541 5375862 8942858 8566634 8953529 8690714 X -238173 -138051 X X 0 1 1 X 0 X X X 0 0 0 FAITH REGIONAL HEALTH SERVICES 470796875 3 1 1 1 1089050 1 1089050 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5670101 13321 -38571 66738 5578113 5188508 2727 517780 38914 5670101 4493972 6814 721427 33705 5188508 5706317 4188 -1145496 71037 4493972 0.00000 1.00000 0.00000 0 0 0 ANNUITY PAYABLE 97721 97721 868383 1106556 -238173 -138051 -138051 -376224 850980 -138051 120648 -17403 868383 0 868383 1227204 120648 120648 1106556 0 1106556 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CARSON CANCER CENTER ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATIONS OF THE CARSON REGIONAL CANCER CENTER. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. GENERAL ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS. INVESTMENT EARNINGS ON THESE FUNDS ARE NOT RESTRICTED AS TO USE. THE HOSPICE ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT THE HOSPICE PROGRAM AND ITS PATIENTS. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. THE CARDIAC SERVICES ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO FUND FAITH REGIONAL HEALTH SERVICE'S CARDIAC PROGRAM CAPITAL AND/OR OPERATIONAL EXPENSES. THE EDUCATION ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S EDUCATION PROGRAMS AND ITS EFFORTS TO RECRUIT AND RETAIN EMPLOYEES. INVESTMENT INCOME ON THESE FUNDS IS TEMPORARILY RESTRICTED AS TO USE. ST. JOSEPH'S NURSING HOME/SKYVIEW VILLA ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BE USED TO FUND CAPITAL EQUIPMENT PURCHASES AND/OR OPERATION OF ST. JOSEPH'S NURSING HOME AND SKYVIEW VILLA. INVESTMENT EARNINGS ON THESE FUNDS ARE TEMPORARILY RESTRICTED AS TO USE. THE PEDIATRIC ENDOWMENT FUNDS ARE PERMANENTLY SET ASIDE TO GENERATE INVESTMENT EARNINGS TO BENEFIT FAITH REGIONAL HEALTH SERVICE'S CHILDREN'S CARE FUND. DONORS CAN SPECIFY CONTRIBUTIONS TO ANY OF THE ENDOWMENT FUNDS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FRHS AND THE FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C) (3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND NEBRASKA STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. FRPS IS A LIMITED LIABILITY COMPANY WHOLLY OWNED BY FAITH. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE FRHS AND THE FOUNDATION TO MEET A COMMUNITY BENEFIT STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. FRHS ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. FAITH RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2011 AND 2010, FAITH HAD NO UNCERTAIN TAX POSITIONS ACCRUED. OPEN TAX YEARS FOR FAITH INCLUDE 2011, 2010 AND 2009. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 120,648. PART XIII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 120,648. GOLF TOURNAMENT 46743 20700 26043 4699 3397 4967 13250 WINTER GALA 236429 63648 172781 1000 14514 78821 283172 84348 198824 4699 4397 19481 92071 120648 78176 1 FAITH REGIONAL HEALTH SERVICES - CT SCANNER 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 800000 FUNDING FOR PURCHASE OF CT SCANNER FAITH REGIONAL HEALTH SERVICES - METIMAN SIMULATOR 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 85349 FUNDING FOR PURCHASE OF METIMAN SIMULATOR FAITH REGIONAL HEALTH SERVICES - INVESTMENT POLICY GRANT 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 66738 INVESTMENT POLICY GRANT FAITH REGIONAL HEALTH SERVICES - PEDIATRIC EQUIPMENT '11 WINTER GALA 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 54395 FUNDING FOR PURCHASE OF PEDIATRIC EQUIPMENT '11 WINTER GALA FAITH REGIONAL HEALTH SERVICES - BRADFORD SPIRITUAL GARDEN 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 25000 FUNDING FOR CONSTRUCTION OF BRADFORD SPIRITUAL GARDEN FAITH REGIONAL HEALTH SERVICES - CARSON CANCER CENTER STAR PROGRAM 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 22626 FUNDING FOR DEVELOPMENT OF CARSON CANCER CENTER STAR PROGRAM FAITH REGIONAL HEALTH SERVICES - SALTER HALL OF GENEROSITY SIGNAGE 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 8686 FUNDING FOR PURCHASE OF SALTER HALL OF GENEROSITY SIGNAGE FAITH REGIONAL HEALTH SERVICES - STETHOSCOPE 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 8507 FUNDING FOR PURCHASE OF STETHOSCOPE FAITH REGIONAL HEALTH SERVICES - CANCER CENTER NASOLARYNGO SC 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 5370 FUNDING FOR PURCHASE OF CANCER CENTER NASOLARYNGO SC FAITH REGIONAL HEALTH SERVICES - INTERNSHIP PROGRAM 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 4319 FUNDING FOR SUPPORT OF INTERNSHIP PROGRAM FAITH REGIONAL HEALTH SERVICES - CANCER CENTER WORKSTATION 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 2184 FUNDING FOR PURCHASE OF CANCER CENTER WORKSTATION FAITH REGIONAL HEALTH SERVICES - CANCER CENTER BPPULSE UNIT 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 1900 FUNDING FOR PURCHASE OF CANCER CENTER BP/PULSE UNIT FAITH REGIONAL HEALTH SERVICES - PEDIATRIC WAGONS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 900 FUNDING FOR PURCHASE OF PEDIATRIC WAGONS FAITH REGIONAL HEALTH SERVICES - CHEMOTHERAPY CHAIRS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 739 FUNDING FOR PURCHASE OF CHEMOTHERAPY CHAIRS FAITH REGIONAL HEALTH SERVICES - PEDIATRIC TOYS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 661 FUNDING FOR PURCHASE OF PEDIATRIC TOYS FAITH REGIONAL HEALTH SERVICES - DIALYSIS UNIT BENCH 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 563 FUNDING FOR PURCHASE OF DIALYSIS UNIT BENCH FAITH REGIONAL HEALTH SERVICES - CANCER CENTER DVDS & PLAYER 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 322 FUNDING FOR PURCHASE OF CANCER CENTER DVDS & PLAYER FAITH REGIONAL HEALTH SERVICES - HOSPICE BEREAVEMENT BOOKS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 255 FUNDING FOR PURCHASE OF HOSPICE BEREAVEMENT BOOKS FAITH REGIONAL HEALTH SERVICES - ICU COFFEE MAKERS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 240 FUNDING FOR PURCHASE OF ICU COFFEE MAKERS FAITH REGIONAL HEALTH SERVICES - BEFRIENDER MINISTRY CONFERENCE 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 126 FUNDING FOR SPIRITUAL CARE CONFERENCE FAITH REGIONAL HEALTH SERVICES - CANCER CENTER FBLA SNACKS 2700 WEST NORFOLK AVENUE NORFOLK NE 68701 470796875 501(C)(3) 170 FUNDING FOR CARSON CANCER CENTER SNACKS 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: FAITH REGIONAL HEALTH SERVICES FOUNDATION PROVIDES GRANT MONEY TO FAITH REGIONAL HEALTH SERVICES, A RELATED 501(C)(3) ORGANIZATION. FAITH REGIONAL HEALTH SERVICES PROVIDES HEALTH CARE SERVICES TO INDIVIDUALS IN NORTHEAST NEBRASKA. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 JAMES SINEK 0 457978 0 0 0 18522 0 7350 0 19890 0 503740 0 0 BARRY SPEAR 0 161231 0 0 0 10782 0 4875 0 7187 0 184075 0 0 DOUGLAS WISMER 0 166600 0 0 0 13791 0 6701 0 8026 0 195118 0 0 PART I, LINE 1A JAMES J. SINEK'S YMCA MEMBERSHIP AND COUNTRY CLUB DUES ARE PAID BY FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. THE AMOUNTS PAID FOR THESE ITEMS ARE ADDED TO MR. SINEK'S W-2 AS WAGES. BARRY SPEAR'S YMCA MEMBERSHIP AND COUNTRY CLUB DUES ARE PAID BY FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. THE AMOUNT PAID IS ADDED TO MR. SPEARS' W-2 AS WAGES. DIVOTS CONFERENCE CENTER DONNA HERRICK IS A FRHS BOARD REPRESENTATIVE AND OWNER/PRESIDENT OF DIVOTS 19202 PROVIDES SERVICES TO THE FOUNDATION FOR THE WINTER GALA EVENT FOR FOOD AND BEVERAGES 0 FORM 990, PART VI, SECTION A, LINE 2 JACQUE COLLISON AND ALAN COLLISON, BOTH BOARD MEMBERS, HAVE A FAMILY RELATIONSHIP. FURTHERMORE, BOARD MEMBERS ELEANOR MCINTOSH AND J. PAUL MCINTOSH, HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 4 IN 2011, THE FAITH REGIONAL HEALTH SERVICES FOUNDATION BY-LAWS WERE AMENDED TO ELIMINATE THE PROVISION REQUIRING A ONE YEAR ABSENCE BETWEEN THE SECOND AND THIRD CONSECUTIVE TERMS FOR BOARD MEMBERS AND ALSO ADDED AN ADDITIONAL VOTING MEMBER TO THE FOUNDATION BOARD, REPRESENTED BY A MEMBER OF THE LUTHERAN COMMUNITY HOSPITAL ASSOCIATION BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A FAITH REGIONAL HEALTH SERVICES FOUNDATION'S BYLAWS STATE ALL DIRECTORS SHALL BE APPOINTED BY FAITH REGIONAL HEALTH SERVICES' BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B BOARD MEMBER APPOINTMENT AND RETENTION DECISIONS MADE BY THE FOUNDATION BOARD ARE APPROVED BY THE FAITH REGIONAL HEALTH SERVICES BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND ALL APPLICABLE SCHEDULES WERE PREPARED AND SIGNED BY SEIM JOHNSON, LLP IN OMAHA, NEBRASKA. COPIES OF THE COMPLETED RETURN WERE DISTRIBUTED TO THE BOARD MEMBERS FOR REVIEW PRIOR TO SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C FAITH REGIONAL HEALTH SERVICES FOUNDATION BOARD MEMBERS COMPLETE A CONFLICT OF INTEREST STATEMENT AND DISCLOSURE ANNUALLY. THESE STATEMENTS ARE REVIEWED BY A DIRECTOR OF THE FOUNDATION. FORM 990, PART VI, SECTION C, LINE 19 FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST STATEMENT, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART VII, SECTION A, LINE 1A: JAMES SINEK, CEO, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. DOUGLAS WISMER, CFO, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. BARRY SPEAR, VP GROWTH & DEVELOPMENT, DEVOTES AN AVERAGE OF 24.00 HOURS PER WEEK TO FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. DONNA HERRICK, FAITH REGIONAL HEALTH SERVICES BOARD REPRESENTATIVE, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO FAITH REGIONAL HEALTH SERVICES, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -138,051. FORM 990, PART XII, LINE 2C: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES HAVE AN AUDIT COMPLETED ON A CONSOLIDATED BASIS WITH FAITH REGIONAL HEALTH SERVICES AND FAITH REGIONAL PHYSICIAN SERVICES, LLC. THE BOARD OF DIRECTORS OF FAITH REGIONAL HEALTH SERVICES ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THERE HAS BEEN NO CHANGE IN THE PROCESSES SINCE LAST YEAR. FORM 990, PART VI, SECTION B, LINE 15: FAITH REGIONAL HEALTH SERVICES FOUNDATION DOES NOT PAY COMPENSATION TO A CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OFFICERS OR KEY EMPLOYESS OF THE OGANIZATION. THEREFORE, QUESTION 15A AND 15B ARE ANSWERED NO. FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVE NORFOLK NE 68701 470769875 PROVIDE HEALTHCARE SERVICES TO THE NORTHEAST NEBRASKA REGION NE 501(C)(3) 3 N/A 0 LUTHERAN COMMUNITY HOSPITAL ASSOCIATION 2700 W NORFOLK AVE NORFOLK NE 68701 470396139 SUPPORT FAITH REGIONAL HEALTH SERVICES NE 501(C)(3) 3 N/A 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0