2011-11-15T15:43:50-06:00 2010-12-31 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2010-01-01 470686476 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION CHEY 3082545825 645 OSAGE SIDNEY NE 69162 KELLY UTLEY 3082545825 2011-11-11 1 BARBARA J FAJEN 4023302660 2010 2016-03-07 17:11:31Z KELLY UTLEY 645 OSAGE SIDNEY NE 69162 91841 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. 15 12 0 10 0 0 45501 71348 0 0 20402 11567 835 -2013 66738 80902 96217 36615 0 0 0 0 0 0 9616 10014 13989 106231 50604 -39493 30298 1486280 1536186 7007 11394 1479273 1524792 TO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY. 0 0 16533 16533 SUPPORT OF CHEYENNE COUNTY HOSPITAL ASSOCIATION 8567 8567 SUPPORT FOR SCHOLARSHIP AND INTERN PROGRAMS 11515 11515 OTHER PROGRAMS 36615 1 1 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 1 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 15 12 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 X KELLY UTLEY 3082545825 645 OSAGE SIDNEY NE 69162 X BETH FIEGENSCHUH 1.00 X X 0 0 0 TOM BIRNER 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 CLEM SCHUMACHER 1.00 X 0 0 0 PAUL SHEAMAN 1.00 X 0 0 0 TERRY AKESON 1.00 X 0 0 0 DAVID PECKHAM 1.00 X 0 0 0 ROB ROBINSON 1.00 X 0 0 0 MITCH MUHS 1.00 X 0 0 0 STAN BELIEU 1.00 X 0 0 0 JIM HANSEL 1.00 X X 0 101645 5305 EVETTE PARSONS 1.00 X 0 47872 764 DANIELLE GEARHART 1.00 X X 0 133157 5326 KELLY UTLEY 1.00 X X 0 98875 5168 JOYCE HEIN 1.00 X X 0 30000 1200 0 411549 17763 0 0 0 1 0 20115 51233 71348 11567 11567 5075 5604 -529 -529 -529 3841 20115 5335 -1494 -1494 MISCELLANEOUS 999999 10 10 10 80902 0 0 9554 16533 16533 20082 20082 4373 4373 320 320 4875 4875 357 357 4064 4064 50604 36615 4373 9616 296090 292820 822661 857335 1524 247007 38174 212897 208833 154632 172464 3210 1486280 1536186 7007 11394 7007 11394 X 1296973 1342436 182300 182356 1479273 1524792 1486280 1536186 X 30298 15221 X X 0 1 1 X 0 X X X 0 0 0 CHEYENNE COUNTY HOSPITAL & HEALTH CENTER 470408242 3 1 1 1 16533 1 16533 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 144483 144483 101605 37255 64350 919 919 0 208833 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, 2010, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED. GOLF TOURNAMENT 22170 20115 2055 295 2005 1193 1135 BAZAAR 1786 1786 707 23956 20115 3841 295 2005 1193 1842 5335 -1494 1 CHEYENNE COUNTY HOSPITAL ASSOCIATION 645 OSAGE STREET SIDNEY NE 69162 470480242 501(C)(3) 16533 ASSISTING CHEYENNE COUNTY HOSPITAL ASSOCIATION PROVIDE SERVICES TO THE COMMUNITY 1 0 SCHOLARSHIP AND INTERN PROGRAM 3 8567 ASSISTANCE FOR DENTAL PROCEDURES 7 11515 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. X X X X 0 0 0 0 0 0 0 0 0 DANIELLE GEARHART 0 133157 0 0 0 0 0 5326 0 0 0 138483 0 0 JOYCE HEIN 0 30000 0 0 0 0 0 1200 0 0 0 31200 0 0 SUPPLEMENTAL INFORMATION PART III DANIELLE GEARHART AND JOYCE REIN RECEIVES COMPENSATION FROM AN UNRELATED ORGANIZATION, QUORUM HEALTH RESOURCES, WHICH PROVIDES MANAGEMENT SERVICES TO ITS CLIENTS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED 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 990 TAX RETURN. UPON THEIR APPROVAL, THE FORM 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE 990 RETURN HAS BEEN REVIEWED BY ALL PARTIES IT WILL BE SUBMITTED TO THE IRS ON OR BY NOVEMBER 15. FORM 990, PART VI, SECTION B, LINE 12 THE ORGANIZATION DOES NOT HAVE A CONFLICT OF INTEREST POLICY, BUT THE ORGANIZATION IS IN THE PROCESS OF ADOPTING THIS POLICY. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. AVERAGE HOURS PER WEEK DEVOTED TO A RELATED ORGANIZATION FORM 990, PART VII, SECTION A, LINE 1A: DANIELLE GEARHART, CEO, DEVOTED AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. JOYCE HEIN, INTERIM CEO, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. JIM HANSEL, DIRECTOR, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. KELLY UTLEY, CFO, DEVOTES AN AVERAGE OF 39.00 HOURS PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. ROB ROBINSON, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. STAN BELIEU, BOARD MEMBER, DEVOTES AN AVERAGE OF 1.00 HOUR PER WEEK TO CHEYENNE COUNTY HOSPITAL ASSOCIATION D/B/A MEMORIAL HEALTH CENTER, A RELATED ORGANIZATION. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 15,221. COMMITTEE OVERSIGHT OF THE AUDIT FORM 990, PART XI, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. FORM 990, PART VI, SECTION A, LINE 3: QUORUM HEALTH RESOURCES, QHR, CURRENTLY EMPLOYS THE CHIEF EXECUTIVE OFFICER FOR MEMORIAL HEALTH CENTER. QHR IS AN UNRELATED ENTITY TO THE FOUNDATION. 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 VI, LINE 13: THE ORGANIZATION DOES NOT HAVE A FORMAL WHISTLEBLOWER POLICY, BUT IT IS IN THE PROCESS ADOPTING SUCH POLICY. FORM 990, PART VI, LINE 14: THE ORGANIZATION DOES NOT HAVE A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY, BUT IT IS IN THE PROCESS ADOPTING SUCH POLICY. CHEYENNE COUNTY HOSPITAL ASSOCIATION 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 0 0 1 1 1 0 0 0