2012-11-14T15:57:12-06:00 2011-12-31 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2011-01-01 470686476 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION CHEY 3082545825 645 OSAGE SIDNEY NE 69162 KELLY UTLEY 3082545825 2012-11-14 1 BARBARA J FAJEN P00400874 4023302660 2011 2016-02-24 21:20:13Z KELLY UTLEY 645 OSAGE SIDNEY NE 69162 77401 0 X WWW.MEMORIALHEALTHCENTER.ORG/FOUND.HTML X 1985 NE 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. 16 16 0 85 0 0 71348 57034 0 0 11567 9065 -2013 2094 80902 68193 36615 57330 0 0 0 0 0 0 14776 13989 14776 50604 72106 30298 -3913 1536186 1528260 11394 18039 1524792 1510221 TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. 0 0 36104 36104 SUPPORT OF CHEYENNE COUNTY HOSPITAL ASSOCIATION 8671 8671 SUPPORT FOR SCHOLARSHIP AND INTERN PROGRAMS 12555 12555 ASSISTANCE FOR DENTAL PROCEDURES 57330 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 X 16 16 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 BETH FIEGENSCHUH 1.00 X X 0 0 0 BILL BUTKUS 1.00 X X 0 0 0 MEGAN MCGOWN 1.00 X X 0 0 0 WENDALL GASTON 1.00 X X 0 0 0 TERRY AKESON 1.00 X 0 0 0 STAN BELIEU 1.00 X 0 0 0 TOM BIRNER 1.00 X 0 0 0 KIM CASTNER 1.00 X 0 0 0 SEAN DOYLE 1.00 X 0 0 0 SHERI EHLER 1.00 X 0 0 0 MITCH MUHS 1.00 X 0 0 0 DAVID PECKHAM 1.00 X 0 0 0 ROB ROBINSON 1.00 X 0 0 0 CLEM SCHUMACHER 1.00 X 0 0 0 PAUL SHEAMAN 1.00 X 0 0 0 VICKI SMITH 1.00 X 0 0 0 EVETTE PARSONS 1.00 X 0 49250 2542 JIM HANSEL 1.00 X 0 16785 874 KELLY UTLEY 1.00 X 0 112932 5941 0 178967 9357 0 0 0 0 0 13650 43384 57034 9065 9065 5775 6653 -878 -878 -878 5527 13650 2555 2972 2972 68193 0 0 11159 36104 36104 21226 21226 9027 9027 1023 1023 4064 4064 MISCELLANEOUS 662 662 72106 57330 0 14776 292820 229396 857335 926360 1524 3060 247007 42238 208833 204769 172464 164675 3210 0 1536186 1528260 11394 18039 11394 18039 X 1342436 1330449 182356 179772 1524792 1510221 1536186 1528260 X -3913 -10658 X X 0 1 1 X 0 X X X 0 0 0 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER 470408242 3 1 1 1 36104 1 36104 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 144483 144483 101605 41319 60286 919 919 0 204769 68193 72106 -3913 -10658 -10658 -14571 66743 -10658 9208 -1450 68193 0 68193 81314 9208 9208 72106 0 72106 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. GOLF TOURNAMENT 16764 13650 3114 0 432 895 430 56 BAZAAR 2413 0 2413 742 19177 13650 5527 432 895 430 798 2555 2972 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 645 OSAGE STREET SIDNEY NE 69162 470480242 501(C)(3) 36104 ASSISTING CHEYENNE COUNTY HOSPITAL ASSOCIATION PROVIDE SERVICES TO THE COMMUNITY 1 0 SCHOLARSHIP AND INTERN PROGRAM 4 8671 ASSISTANCE FOR DENTAL PROCEDURES 10 12555 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 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. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -10,658. 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 1 0 0 1 1 1 1 0 0