CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION: Form 990, tax year 2011
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- Organization
- CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION (EIN 47-0686476)
- Tax period
- 2011-01-01 to 2011-12-31
- Filed
- 2012-11-14
- IRS object ID
- 201243199349305879
- Schema version
- 2011v1.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-11-14T15:57:12-06:00 | Timestamp |
| Tax Period End Date | 2011-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 476097913 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 680224722 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470686476 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL & HEALTH CENTER | BusinessNameLine1 |
| Business Name Line2 | FOUNDATION | BusinessNameLine2 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | CHEY | NameControl |
| Phone | 3082545825 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | KELLY UTLEY | Name |
| Title | CFO | Title |
| Phone | 3082545825 | Phone |
| Date Signed | 2012-11-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | BARBARA J FAJEN | Name |
| PTIN | P00400874 | PTIN |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | KELLY UTLEY | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 77401 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.MEMORIALHEALTHCENTER.ORG/FOUND.HTML | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1985 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | HEALTH CENTER FOUNDATION SUPPORTS MEMORIAL HEALTH 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. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 16 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 16 | NbrIndependentVotingMembers |
| Total Nbr Employees | 0 | TotalNbrEmployees |
| Total Nbr Volunteers | 85 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 71348 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 57034 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 0 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 0 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 11567 | InvestmentIncomePriorYear |
| Investment Income Current Year | 9065 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -2013 | OtherRevenuePriorYear |
| Other Revenue Current Year | 2094 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 80902 | TotalRevenuePriorYear |
| Total Revenue Current Year | 68193 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 36615 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 57330 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 0 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 0 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 14776 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 13989 | OtherExpensePriorYear |
| Other Expenses Current Year | 14776 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 50604 | TotalExpensesPriorYear |
| Total Expenses Current Year | 72106 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 30298 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -3913 | RevenuesLessExpensesCY |
| Total Assets BOY | 1536186 | TotalAssetsBOY |
| Total Assets EOY | 1528260 | TotalAssetsEOY |
| Total Liabilities BOY | 11394 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 18039 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 1524792 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 1510221 | NetAssetsOrFundBalancesEOY |
| Mission Description | TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 36104 | Expense |
| Grants | 36104 | Grants |
| Description | SUPPORT OF CHEYENNE COUNTY HOSPITAL ASSOCIATION | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 8671 | Expense |
| Grants | 8671 | Grants |
| Description | SUPPORT FOR SCHOLARSHIP AND INTERN PROGRAMS | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 12555 | Expense |
| Grants | 12555 | Grants |
| Description | ASSISTANCE FOR DENTAL PROCEDURES | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 57330 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 0 | Hospital |
| Grants To Organizations | 1 | GrantsToOrganizations |
| Grants To Individuals | 1 | GrantsToIndividuals |
| Schedule J Required | 0 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 0 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 0 | NumberOfEmployees |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 1 | QuidProQuoContributions |
| Quid Pro Quo Disclosure | 1 | QuidProQuoDisclosure |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 16 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 16 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 0 | WhistleblowerPolicy |
| Document Retention Policy | 0 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | KELLY UTLEY | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 3082545825 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (19 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| BETH FIEGENSCHUH | ||||||
| PRESIDENT | 1.00 | X | X | 0 | 0 | 0 |
| BILL BUTKUS | ||||||
| VICE PRESIDENT | 1.00 | X | X | 0 | 0 | 0 |
| MEGAN MCGOWN | ||||||
| SECRETARY | 1.00 | X | X | 0 | 0 | 0 |
| WENDALL GASTON | ||||||
| TREASURER | 1.00 | X | X | 0 | 0 | 0 |
| TERRY AKESON | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| STAN BELIEU | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| TOM BIRNER | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| KIM CASTNER | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| SEAN DOYLE | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| SHERI EHLER | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| MITCH MUHS | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| DAVID PECKHAM | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| ROB ROBINSON | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| CLEM SCHUMACHER | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| PAUL SHEAMAN | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| VICKI SMITH | ||||||
| MEMBER | 1.00 | X | 0 | 0 | 0 | |
| EVETTE PARSONS | ||||||
| INTERIM DIRECTOR (3/11-PRESENT) | 1.00 | X | 0 | 49250 | 2542 | |
| JIM HANSEL | ||||||
| DIRECTOR (1/11 - 2/11) | 1.00 | X | 0 | 16785 | 874 | |
| KELLY UTLEY | ||||||
| MHC- CFO | 1.00 | X | 0 | 112932 | 5941 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 0 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 178967 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 9357 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 0 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Fundraising Events | 13650 | FundraisingEvents |
| All Other Contributions | 43384 | AllOtherContributions |
| Total Contributions | 57034 | TotalContributions |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 9065 | TotalRevenueColumn |
| Exclusion | $9,065 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 5775 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 6653 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -878 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -878 | TotalRevenueColumn |
| Exclusion | -$878 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 5527 | GrossIncomeFundraisingEvents |
| Cntrbtns Rprtd Fundraising Events | 13650 | CntrbtnsRprtdFundraisingEvents |
| Fundraising Direct Expenses | 2555 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 2972 | TotalRevenueColumn |
| Exclusion | $2,972 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 68193 | TotalRevenueColumn |
| Related Or Exempt Function Income | 0 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $11,159 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 36104 | Total |
| Program Services | 36104 | ProgramServices |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 21226 | Total |
| Program Services | 21226 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9027 | Total |
| Fundraising | 9027 | Fundraising |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1023 | Total |
| Fundraising | 1023 | Fundraising |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4064 | Total |
| Fundraising | 4064 | Fundraising |
Other Expenses OtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | MISCELLANEOUS | Description |
| Total | 662 | Total |
| Fundraising | 662 | Fundraising |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 72106 | Total |
| Program Services | 57330 | ProgramServices |
| Management And General | 0 | ManagementAndGeneral |
| Fundraising | 14776 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 292820 | BOY |
| EOY | 229396 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 857335 | BOY |
| EOY | 926360 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1524 | BOY |
| EOY | 3060 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 247007 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 42238 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 208833 | BOY |
| EOY | 204769 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 172464 | BOY |
| EOY | 164675 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3210 | BOY |
| EOY | 0 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1536186 | BOY |
| EOY | 1528260 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11394 | BOY |
| EOY | 18039 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11394 | BOY |
| EOY | 18039 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1342436 | BOY |
| EOY | 1330449 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 182356 | BOY |
| EOY | 179772 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1524792 | BOY |
| EOY | 1510221 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1536186 | BOY |
| EOY | 1528260 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | -3913 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | -10658 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Supporting Organization509a3 | X | SupportingOrganization509a3 |
| Supporting Org509a3 Type3 Func Int | X | SupportingOrg509a3Type3FuncInt |
| Certification Checkbox | X | CertificationCheckbox |
| Contrib By Controlling Individual | 0 | ContribByControllingIndividual |
| Contribution By Related Party | 0 | ContributionByRelatedParty |
| Contrib By35 Controlled Entity | 0 | ContribBy35ControlledEntity |
Supported Org Information SupportedOrgInformation
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL & HEALTH CENTER | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470408242 | EIN |
| Type Of Organization | 3 | TypeOfOrganization |
| Listed In Governing Doc | 1 | ListedInGoverningDoc |
| Supported Organization Notified | 1 | SupportedOrganizationNotified |
| Organized In US | 1 | OrganizedInUS |
| Amount | $36,104 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Number Of Supported Orgs | 1 | TotalNumberOfSupportedOrgs |
| Sum Of Amounts | 36104 | SumOfAmounts |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 144483 | OtherCostOrOtherBasis |
| Book Value | 144483 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 101605 | OtherCostOrOtherBasis |
| Depreciation | 41319 | Depreciation |
| Book Value | 60286 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 919 | OtherCostOrOtherBasis |
| Depreciation | 919 | Depreciation |
| Book Value | 0 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 204769 | TotalOfBookValueLandBuildings |
| Total Revenue | 68193 | TotalRevenue |
| Total Expenses | 72106 | TotalExpenses |
| Excess Or Deficit For Year | -3913 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | -10658 | NetUnrealizedGLOnInvestments |
| Total Adjustments | -10658 | TotalAdjustments |
| Excess Or Deficit Per FS | -14571 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 66743 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | -10658 | NetUnrealizedGainsInvestments |
| Other Revenues | 9208 | OtherRevenues |
| Revenue Not Rptd F990 | -1450 | RevenueNotRptdF990 |
| Revenue Subtotal | 68193 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 68193 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 81314 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 9208 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 9208 | ExpensesNotRptdF990 |
| Expenses Subtotal | 72106 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 72106 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (3 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X: | WESTERN NEBRASKA HEALTH SYSTEMS, CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC., CHEYENNE COUNTY WESTERN NEBRASKA HEALTH SYSTEMS, CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC., CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION, AND HIGH PLAINS MEDICAL 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, 2011, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 2,555. REAL ESTATE TAXES 6,653. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | FUNDRAISING EXPENSES 2,555. REAL ESTATE TAXES 6,653. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | GOLF TOURNAMENT | NameOfEvent1 |
| Gross Receipts Event1 | 16764 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 13650 | CharitableContributionsEvent1 |
| Gross Revenue Event1 | 3114 | GrossRevenueEvent1 |
| Cash Prizes Event1 | 0 | CashPrizesEvent1 |
| Non Cash Prizes Event1 | 432 | NonCashPrizesEvent1 |
| Rent Facility Costs Event1 | 895 | RentFacilityCostsEvent1 |
| Food And Beverage Event1 | 430 | FoodAndBeverageEvent1 |
| Other Direct Expenses Event1 | 56 | OtherDirectExpensesEvent1 |
| Name Of Event2 | BAZAAR | NameOfEvent2 |
| Gross Receipts Event2 | 2413 | GrossReceiptsEvent2 |
| Charitable Contributions Event2 | 0 | CharitableContributionsEvent2 |
| Gross Revenue Event2 | 2413 | GrossRevenueEvent2 |
| Other Direct Expenses Event2 | 742 | OtherDirectExpensesEvent2 |
| Gross Receipts Total | 19177 | GrossReceiptsTotal |
| Charitable Contributions Total | 13650 | CharitableContributionsTotal |
| Gross Revenue Total Events | 5527 | GrossRevenueTotalEvents |
| Non Cash Prizes Total Events | 432 | NonCashPrizesTotalEvents |
| Rent Facility Costs Total Events | 895 | RentFacilityCostsTotalEvents |
| Food And Beverage Total Events | 430 | FoodAndBeverageTotalEvents |
| Other Direct Expenses Total Events | 798 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 2555 | DirectExpenseSummaryEvents |
| Net Income Summary | 2972 | NetIncomeSummary |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Records Maintained | 1 | RecordsMaintained |
Recipient Table RecipientTable
Recipient Name Business RecipientNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN Of Recipient | 470480242 | EINOfRecipient |
| IRC Section | 501(C)(3) | IRCSection |
| Amount Of Cash Grant | 36104 | AmountOfCashGrant |
| Purpose Of Grant | ASSISTING CHEYENNE COUNTY HOSPITAL ASSOCIATION PROVIDE SERVICES TO THE COMMUNITY | PurposeOfGrant |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Nbr Of501 C3 And Govt Grants | 1 | TotalNbrOf501C3AndGovtGrants |
| Total Nbr Of Other Organizations | 0 | TotalNbrOfOtherOrganizations |
Form990 Schedule I Part III Form990ScheduleIPartIII (2 entries)
| Type Of GrantTypeOfGrant | Number Of RecipientsNumberOfRecipients | Amount Of Cash GrantAmountOfCashGrant |
|---|---|---|
| SCHOLARSHIP AND INTERN PROGRAM | 4 | 8671 |
| ASSISTANCE FOR DENTAL PROCEDURES | 10 | 12555 |
Form990 Schedule I Part IV Form990ScheduleIPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | PROCEDURE FOR MONITORING GRANTS IN THE U.S.: | Identifier |
| Return Reference | PART I, LINE 2: | ReturnReference |
| Explanation | SCHEDULE I, PART I, LINE 2: CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION PROVIDES FUNDS TO MEMORIAL HEALTH 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 COMMUNITY GAINING HIGHER EDUCATION IN THE HEALTH CARE FIELD. | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| 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 CEO AND CFO REVIEW THE FORM 990. UPON THEIR 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 | 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 SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. | |
| 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. | |
| FORM 990, PART VII, SECTION A, LINE 1A: | STAN BELIEU, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL HEALTH CENTER, A RELATED ORGANIZATION. ROB ROBINSON, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL HEALTH CENTER, A RELATED ORGANIZATION. EVETTE PARSONS, ASSISTANT DIRECTOR DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL HEALTH CENTER, A RELATED ORGANIZATION. KELLY UTLEY, CFO, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC. D/B/A SIDNEY REGIONAL HEALTH CENTER, A RELATED ORGANIZATION. | |
| FORM 990, PART XI, LINE 5: | NET UNREALIZED LOSSES ON INVESTMENTS: -10,658. | CHANGES IN NET ASSETS OR FUND BALANCES: |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHEYENNE COUNTY HOSPITAL ASSOCIATION INC | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 645 OSAGE STREET | AddressLine1 |
| City | SIDNEY | City |
| State | NE | State |
| ZIP Code | 69162 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470480242 | EIN |
| Primary Activities | PROVIDING HEALTH CARE TO THOSE IN THE COMMUNITY | PrimaryActivities |
| Legal Domicile State | NE | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | 3 | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Controlled Org | 0 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 1 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 1 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
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