ANTELOPE MEMORIAL HOSPITAL: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- ANTELOPE MEMORIAL HOSPITAL (EIN 47-0393176)
- Tax period
- 2009-07-01 to 2010-06-30
- Filed
- 2011-02-03
- IRS object ID
- 201110349349300831
- Schema version
- 2009v1.7
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule M
- Schedule O
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-02-03T14:46:15-06:00 | Timestamp |
| Tax Period End Date | 2010-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON SESTAK & QUIST LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 8807 INDIAN HILLS DRIVE SUITE 300 | AddressLine1 |
| City | OMAHA | City |
| State | NE | State |
| ZIP Code | 681144123 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 470393176 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | ANTE | NameControl |
| Phone | 4028874151 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JACK W GREEN | Name |
| Title | ADMINISTRATOR | Title |
| Phone | 4028874151 | Phone |
| Date Signed | 2011-01-27 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Julie M Gerken | Name |
| Phone | 4023302660 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | JACK W GREEN | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 12107758 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.amhne.org | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1974 | YearFormation |
| State Legal Domicile | NE | StateLegalDomicile |
| Activity Or Mission Description | TO BUILD, ERECT, MAINTAIN, EXPAND, EQUIP, MANAGE AND OPERATE A HOSPITAL AND AFFILIATED INSTITUTIONS IN THE COUNTY OF ANTELOPE, NEBRASKA FOR THE CARE AND TREATMENT OF SICK AND INFIRM PEOPLE, REGARDLESS OF RACE, CREED, COLOR AND RESIDENCE. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 8 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 8 | NbrIndependentVotingMembers |
| Total Nbr Employees | 171 | TotalNbrEmployees |
| Total Nbr Volunteers | 10 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 59464 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 120175 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 11339460 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 11826962 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 87992 | InvestmentIncomePriorYear |
| Investment Income Current Year | 98622 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 69054 | OtherRevenuePriorYear |
| Other Revenue Current Year | 61869 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 11555970 | TotalRevenuePriorYear |
| Total Revenue Current Year | 12107628 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 5985006 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 6206295 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 4741198 | OtherExpensePriorYear |
| Other Expenses Current Year | 5124773 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 10726204 | TotalExpensesPriorYear |
| Total Expenses Current Year | 11331068 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 829766 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 776560 | RevenuesLessExpensesCY |
| Total Assets BOY | 14582916 | TotalAssetsBOY |
| Total Assets EOY | 15120132 | TotalAssetsEOY |
| Total Liabilities BOY | 6104863 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 5830885 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 8478053 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 9289247 | NetAssetsOrFundBalancesEOY |
| Mission Description | MAKING A DIFFERENCE IN PEOPLE'S LIVES THROUGH EXCELLENT PATIENT CARE. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 10222740 | Expense |
| Revenue | 11826962 | Revenue |
| Description | ANTELOPE MEMORIAL HOSPITAL IS A 25-BED CRITICAL ACCESS HOSPITAL IN NELIGH, NE. IT PROVIDES QUALITY HEALTH CARE REGARDLESS OF RACE, CREED, COLOR, NATIONAL ORIGIN, AGE, GENDER, HANDICAP, OR ABILITY TO PAY. THE HOSPITAL IS A FAMILY-CENTERED, COMMUNITY-ORIENTED HOSPITAL, OFFERING COMPREHENSIVE MEDICAL SERVICES, INCLUDING A FULL-TIME EMERGENCY ROOM. | Description |
| Total Program Service Expense | 10222740 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | 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 | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| 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 | 1 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 11 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 171 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| 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 | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 8 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 8 | 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 | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | 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 | MARTHA NELSON | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 4028876282 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 229 | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (13 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| John Mlnarik | |||||||
| President | 4.00 | X | X | 0 | 0 | 0 | |
| James Blackburn | |||||||
| Vice President | 4.00 | X | X | 0 | 0 | 0 | |
| James Meuret | |||||||
| Member | 2.00 | X | 0 | 0 | 0 | ||
| David Sullivan | |||||||
| Member | 2.00 | X | 0 | 0 | 0 | ||
| Joe Knight | |||||||
| Secretary/Treasurer | 4.00 | X | X | 0 | 0 | 0 | |
| Philip Kluthe | |||||||
| Member | 2.00 | X | 0 | 0 | 0 | ||
| Gordon Shrader | |||||||
| Member | 2.00 | X | 0 | 0 | 0 | ||
| Christopher Twibell | |||||||
| Member | 2.00 | X | 0 | 0 | 0 | ||
| Jack Green | |||||||
| CEO | 40.00 | X | 136714 | 0 | 10145 | ||
| Martha Nelson | |||||||
| CFO | 36.00 | X | 87271 | 0 | 8082 | ||
| Douglas Dilly | |||||||
| Physician | 40.00 | 237152 | 0 | 16448 | X | ||
| Troy Dawson | |||||||
| Physician | 40.00 | 254139 | 0 | 17133 | X | ||
| Roger Rudloff | |||||||
| Physician | 40.00 | 272182 | 0 | 17137 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 987458 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 68945 | TotalOtherCompensation |
| Number Individuals GT100 K | 4 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (3 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| Overland Rehab Services | |||||
| PO Box 298 | Osmond | NE | 68765 | Physical Therapy Services | 246806 |
| North Central Anesthesia Services | |||||
| PO Box 359 | ONeill | NE | 68756 | Anesthesia Services | 234936 |
| MedType Transcription Inc | |||||
| 404 North 28th St | Norfolk | NE | 68701 | Transcription Services | 102622 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 3 | NumberOfContractorsGT100K |
| All Other Contributions | 120175 | AllOtherContributions |
| Noncash Contributions | 27457 | NoncashContributions |
| Total Contributions | 120175 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (5 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| MEDICARE/MEDICAID PAYM | 621400 | 7199436 | 7199436 |
| OTHER PATIENT SERVICE | 621400 | 4588914 | 4588914 |
| LIFELINE | 621990 | 26970 | 26970 |
| LABORATORY | 621990 | 6242 | 6242 |
| AMBULANCE | 621910 | 5400 | 5400 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 11826962 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 84277 | TotalRevenueColumn |
| Exclusion | $84,277 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 14475 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 130 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 14345 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 14345 | TotalRevenueColumn |
| Exclusion | $14,345 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | ExclusionExclusionAmount |
|---|---|---|---|
| MISCELLANEOUS REVENUE | 900099 | 34050 | $34,050 |
| CAFETERIA | 900099 | 27819 | $27,819 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 61869 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 12107628 | TotalRevenueColumn |
| Related Or Exempt Function Income | 11826962 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $160,491 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 242212 | Total |
| Management And General | 242212 | ManagementAndGeneral |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 65060 | Total |
| Program Services | 65060 | ProgramServices |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4723446 | Total |
| Program Services | 4253481 | ProgramServices |
| Management And General | 469965 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 154606 | Total |
| Program Services | 139345 | ProgramServices |
| Management And General | 15261 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 673058 | Total |
| Program Services | 589438 | ProgramServices |
| Management And General | 83620 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 347913 | Total |
| Program Services | 299746 | ProgramServices |
| Management And General | 48167 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7981 | Total |
| Management And General | 7981 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 33771 | Total |
| Management And General | 33771 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1416814 | Total |
| Program Services | 1311525 | ProgramServices |
| Management And General | 105289 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 37651 | Total |
| Program Services | 10868 | ProgramServices |
| Management And General | 26783 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1568162 | Total |
| Program Services | 1520823 | ProgramServices |
| Management And General | 47339 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 217734 | Total |
| Program Services | 217734 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 38139 | Total |
| Program Services | 34527 | ProgramServices |
| Management And General | 3612 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 8996 | Total |
| Program Services | 7751 | ProgramServices |
| Management And General | 1245 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 213923 | Total |
| Program Services | 213923 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 857582 | Total |
| Program Services | 857582 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 169686 | Total |
| Program Services | 169686 | ProgramServices |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| BAD DEBT | 498055 | 498055 | |
| DUES & SUBSCRIPTIONS | 27562 | 27562 | |
| LICENSES | 16658 | 2628 | 14030 |
| MISCELLANEOUS EXPENSES | 9053 | 9053 | |
| WELLNESS | 3006 | 3006 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 11331068 | Total |
| Program Services | 10222740 | ProgramServices |
| Management And General | 1108328 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1205338 | BOY |
| EOY | 1192756 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3598905 | BOY |
| EOY | 3842605 | EOY |
Pledges And Grants Receivable PledgesAndGrantsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 62658 | BOY |
| EOY | 40302 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1186692 | BOY |
| EOY | 1410822 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 425 | BOY |
| EOY | 14130 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 340817 | BOY |
| EOY | 351799 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 20468 | BOY |
| EOY | 23143 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 14459608 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 6730660 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7667226 | BOY |
| EOY | 7728948 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 365336 | BOY |
| EOY | 395916 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 135051 | BOY |
| EOY | 119711 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14582916 | BOY |
| EOY | 15120132 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1399956 | BOY |
| EOY | 1534770 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4170000 | BOY |
| EOY | 3990000 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 534907 | BOY |
| EOY | 306115 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6104863 | BOY |
| EOY | 5830885 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8477053 | BOY |
| EOY | 9258532 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1000 | BOY |
| EOY | 30715 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8478053 | BOY |
| EOY | 9289247 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 14582916 | BOY |
| EOY | 15120132 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 0 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
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 C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $1,209 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 1209 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Part II-B, Line 1i: | Identifier |
| Return Reference | Explanation of Other Lobbying Activities: | ReturnReference |
| Explanation | PAID NEBRASKA HOPSITAL ASSOCIATION AND AMERICAN HOSPITAL ASSOCIATION DUES GOING TO LOBBYING ACTIVITIES OF $409 AND $800, RESPECTIVELY. | Explanation |
Schedule D IRS990ScheduleD
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 63764 | OtherCostOrOtherBasis |
| Book Value | 63764 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 4592627 | OtherCostOrOtherBasis |
| Depreciation | 2119519 | Depreciation |
| Book Value | 2473108 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 8110881 | OtherCostOrOtherBasis |
| Depreciation | 4207363 | Depreciation |
| Book Value | 3903518 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1692336 | OtherCostOrOtherBasis |
| Depreciation | 403778 | Depreciation |
| Book Value | 1288558 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 7728948 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | ESTIMATED THIRD PARTY PAYORS | Description |
| Amount | $306,115 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 306115 | TotalOfAmounts |
| Total Revenue | 12107628 | TotalRevenue |
| Total Expenses | 11331068 | TotalExpenses |
| Excess Or Deficit For Year | 776560 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 34634 | NetUnrealizedGLOnInvestments |
| Total Adjustments | 34634 | TotalAdjustments |
| Excess Or Deficit Per FS | 811194 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 12142262 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | 34634 | NetUnrealizedGainsInvestments |
| Revenue Not Rptd F990 | 34634 | RevenueNotRptdF990 |
| Revenue Subtotal | 12107628 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 12107628 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 11331068 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 11331068 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 11331068 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part V, Line 4: | Description of Intended Use of Endowment Funds: | The $1,000 restriction is for an MRI unit. |
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | The Hospital is a not-for-profit corporation as described in Section 501(c)(3) of the Code and has received a determination letter that it is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Internal Revenue Service has established standards to be met to maintain the Hospitals tax exempt status. In general, such standards require the Hospital to meet a community benefits standard and comply with various laws and regulations. The Hospital accounts for uncertainties in accounting for income tax assets and liabilities using guidance included in FASB ASC 740, Income Taxes. The Hospital recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. At June 30, 2010, the Hospital had no uncertain tax positions accrued. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCare |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 18272 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 18272 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00170 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 788222 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 601559 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 186663 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01720 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 0 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 806494 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 601559 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 204935 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01890 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 24807 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 9903 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 14904 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00140 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 4000 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 4000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00040 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 637022 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 362857 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 274165 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02530 | PercentOfTotalExpense |
Research Research
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 0 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1514 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1514 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 667343 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 372760 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 294583 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02720 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1473837 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 974319 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 499518 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04610 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $348,686 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 6153236 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 6215393 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -62157 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 0 | ProvisionForCharityCare |
Form990 Schedule H Part V Form990ScheduleHPartV
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | ANTELOPE MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 102 WEST 9TH STREET | AddressLine1 |
| City | NELIGH | City |
| State | NE | State |
| ZIP Code | 68756 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Income Based Criteria | Part I, Line 3c: NOT APPLICABLE | IncomeBasedCriteria |
| Annual Community Benefit Expln | Part I, Line 6a: ANTELOPE MEMORIAL HOSPITAL'S COMMUNITY BENEFIT REPORT IS NOT PREPARED BY A RELATED ORGANIZATION. | AnnualCommunityBenefitExpln |
| Costing Method Used | Part I, Line 7: THE COSTING METHOD IS AS FOLLOWS: (TOTAL EXPENSES - BAD DEBT) / GROSS PATIENT SERVICE REVENUE = PERCENTAGE OF COST TO CHARGE. | CostingMethodUsed |
| Subsidized Health Services Expln | Part I, Line 7g: THERE ARE NO COSTS ATTRIBUTABLE TO A PHYSICIAN CLINIC INCLUDED ON LINE 7G. | SubsidizedHealthServicesExpln |
| Percent Of Total Expense Expln | Part I, Line 7f: THE COST OF BAD DEBT THAT HAS BEEN SUBTRACTED FROM TOTAL EXPENSES TO DETERMINE THE DENOMINATOR IN THE PERCENTAGES FOR COLUMN (F) IS $498,055. | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: Payment for services is expected within thirty days of initial billing. Accounts considered past due are sent to collection agencies when internal collection efforts have been unsuccessful. Any amounts deemed uncollectible are written off on a monthly basis. The Hospital does not charge interest on outstanding balances owed. The Hospital also maintains a charity care policy.PART III, SECTION A, LINE 2 WAS CALCULATED AS FOLLOWS:[(OPERATING EXPENSES - BAD DEBT) / (GROSS PATIENT SERVICE REVENUE + OTHER REVENUE)] X BAD DEBT.[(11,331,068 - 498,055) / 15,351,867 + 121,752] X 498,055 = 348,686.ALL INFORMATION IS FROM THE AUDITED FINANCIAL STATEMENTS. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: PART III, SECTION B, LINES 5 & 6: THE INFORMATION IS DERIVED FROM THE MEDICARE COST REPORT D, E, H & M WORKSHEETS. IT DOES NOT INCLUDE ALL OF THE MEDICARE REVENUES AND COSTS. IF ALL OF THE MEDICARE REVENUES AND COSTS WERE INCLUDED, THE SHORTFALL WOULD BE GREATER THAN THAT SHOWN ON LINE 7. THE SHORTFALL REPRESENTS ACTUAL UNREIMBURSED COSTS INCURRED BY ANTELOPE MEMORIAL HOSPITAL IN PROVIDING SERVICES TO INDIVIDUALS ELIGIBLE FOR MEDICARE. THE COMMUNITY BENEFITS BECAUSE THE HOSPITAL APPLIES OTHER REVENUES TO COVER THE COSTS OF CARING FOR MEDICARE PATIENTS. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: THE COLLECTION POLICY INCLUDES AN EXPLANATION OF ANTELOPE MEMORIAL HOSPITAL'S CHARITY CARE PROGRAM. THE PROGRAM IS CONSIDERED A "LAST RESORT FOR PATIENTS MAKING A GENUINE EFFORT TO PAY THEIR BILLS. ALL OTHER AVENUES FOR PAYMENT MUST BE EXHAUSTED (SUCH AS MEDICAID, DISABILITY, KID'S CONNECTION) BEFORE THIS PROGRAM APPLIES." REGULAR COLLECTION EFFORTS WILL BE FOLLOWED UNTIL A DETERMINATION IS MADE FROM A COMPLETED ASSISTANCE APPLICATION THAT A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE. | DebtCollectionPolicy |
| Number Of Facility Type Expln | Part V: ALL FACILITY INFORMATION IS ADEQUATELY ADDRESSED IN PART V. | NumberOfFacilityTypeExpln |
| General Explanation | PART VI, LINE 8: NEBRASKA DOES NOT REQUIRE THE FILING OF A COMMUNITY BENEFIT REPORT WITH THE STATE. A COMMUNITY BENEFIT REPORT IS FILED ANNUALLY WITH THE NEBRASKA HOSPITAL ASSOCIATION. ALSO, A MEDICARE COST REPORT IS FILED ANNUALLY WITH NEBRASKA. | GeneralExplanation |
| Needs Assessment | Part VI, Line 2: CURRENTLY, ANTELOPE MEMORIAL HOSPITAL DOES NOT PERFORM ANY PROCEDURES TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: ANTELOPE MEMORIAL HOSPITAL includes ITS payment policy with all statements sent to patients. This policy explains our charity care program and gives instructions for the application process. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: The hospitals primary service area is Antelope County. Patients from the primary service area account for 84% of the Hospital's admissions. Currently there are two hospitals providing acute care services within Antelope County. Based on licensed beds, the Hospital is the largest acute care facility in Antelope County. The hospital's secondary service area encompasses the following five Nebraska counties: Boone, Holt, Knox, Madison, AND Pierce. In 2009, approximately 15% of the Hospitals patients were residents of the counties included in the secondary service area. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: CURRENTLY, THERE ARE NO COMMUNITY BUILDING ACTIVITIES CONDUCTED BY ANTELOPE MEMORIAL HOSPITAL. | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: THERE ARE NO OTHER ACTIVITIES THAT FURTHER THE PROMOTION OF THE HEALTH OF THE COMMUNITY. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: ANTELOPE MEMORIAL HEALTH SYSTEM IS NOT PART OF AN AFFILIATED HEALTH CARE ORGANIZATION. | AffiliatedHealthCareSystem |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Independent Consultant | X | IndependentConsultant |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 1 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (3 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Douglas Dilly | |||||||||||||
| 237152 | 0 | 0 | 0 | 0 | 0 | 10814 | 0 | 5634 | 0 | 253600 | 0 | 0 | 0 |
| Troy Dawson | |||||||||||||
| 238083 | 0 | 16056 | 0 | 0 | 0 | 11496 | 0 | 5637 | 0 | 271272 | 0 | 0 | 0 |
| Roger Rudloff | |||||||||||||
| 267182 | 0 | 5000 | 0 | 0 | 0 | 11496 | 0 | 5641 | 0 | 289319 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | Part I, Line 5 | ReturnReference |
| Explanation | PROFESSIONAL EMPLOYMENT AGREEMENTS ENTERED INTO BETWEEN THE HOSPITAL AND PHYSICIANS PROVIDES FOR AN ANNUAL INCENTIVE PAY IN WHICH THE RESPECTIVE PHYSICIAN RECEIVES A PERCENTAGE OF THE COLLECTIVE GROSS RECEIPTS FOR SERVICES PERSONALLY PERFORMED BY THAT PHYSICIAN AS LONG AS THE COLLECTIVE GROSS FEES EXCEED A SPECIFIED AMOUNT. | Explanation |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HOSPITAL AUTHORITY NO 1 OF ANTELOPE CO NEBRASKA HOSPITAL REV BONDS 2004 | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 900198231 | IssuerEIN |
| CUSIP Number | 03665RAR1 | CUSIPNumber |
| Date Issued | 2004-07-01 | DateIssued |
| Issue Price | 4787394 | IssuePrice |
| Description Of Purpose | HOSPITAL ADDITION | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Proceeds | 4860750 | TotalProceeds |
| Amount In Reserve Fund | 404835 | AmountInReserveFund |
| Issuance Costs From Proceeds | 84438 | IssuanceCostsFromProceeds |
| Capital Expenditures | 4371478 | CapitalExpenditures |
| Year Of Subst Completion | 2005 | YearOfSubstCompletion |
| Current Refunding | 0 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 1 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 1 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Bond Counsel Routinely Engaged | 1 | BondCounselRoutinelyEngaged |
| Prcntge Prvt Business Use By Others | 0.02900 | PrcntgePrvtBusinessUseByOthers |
| Percentage Of Prvt Business Re UBI | 0.00000 | PercentageOfPrvtBusinessReUBI |
| Total Private Business Use | 0.02900 | TotalPrivateBusinessUse |
| Post Issuance Compliance Procdrs | 1 | PostIssuanceComplianceProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8038 T Filed | 0 | Form8038TFiled |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Exception To Rebate | 1 | ExceptionToRebate |
Schedule M IRS990ScheduleM
Other Non Cash Contributions Table OtherNonCashContributionsTable (2 entries)
| Non Cash CheckboxNonCashCheckbox | DescriptionDescription | Number Of ContributionsNumberOfContributions | Noncash Contribs Rptd F990NoncashContribsRptdF990 | Method Of Determining RevenuesMethodOfDeterminingRevenues |
|---|---|---|---|---|
| X | TRANSFORMER | 1 | 14108 | FAIR MARKET VALUE |
| X | POLARIS RANGER | 1 | 13349 | FAIR MARKET VALUE |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Any Property That Must Be Held | 0 | AnyPropertyThatMustBeHeld |
| Review Process Unusual NC Gifts | 0 | ReviewProcessUnusualNCGifts |
| Third Parties Used | 0 | ThirdPartiesUsed |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| Form 990, Part VI, Section B, line 11 | THE FORM 990 IS PREPARED BY A CERTIFIED PUBLIC ACCOUNTANT AND DELIVERED TO THE CHIEF FINANCIAL OFFICER. THE CFO REVIEWS FORM 990 AND PRESENTS IT AT A MONTHLY BOARD MEETING, PRIOR TO FILING. | |
| Form 990, Part VI, Section B, line 12c | All Officers, Directors, committee members, and Key Employees shall review the conflict of interest policy and complete a conflict of interest questionnaire and certification upon initial affiliation with the Corporation and on an annual basis thereafter. | |
| Form 990, Part VI, Section B, line 15a | Salary comparison data from the Nebraska Hospital Association is used to compare Administrator salary with that of other Nebraska critical access hospitals. The Chief Executive Officer and Chief Financial Officer salaries are determined using the Nebraska Hospital Association salary surveys and are then set by the Board of Directors. THE BOARD MINUTES DOCUMENT THE DELIBERATIONS AND SALARY DECISIONS. | |
| Form 990, Part VI, Section C, line 19 | THE EXEMPT ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC. | |
| FORM 990, PART XI, LINE 2C | The full Board of Directors oversees SELECTION OF AN INDEPENDENT ACCOUNTANT AND the audit of the ANTELOPE MEMORIAL HOSPITAL's financial statements. | OVERSIGHT OF AUDIT |
| SCHEDULE K, PART III, #3A MANAGEMENT OR SERVICE CONTRACTS During the applicable tax year, the organization was party to an agreement (the Agreement) with a group of anesthesiologists (the Physician Group). The Agreement permits members of the Physician Group to utilize certain portions of the surgery area of the organizations hospital facilities, which, in whole or in part, were financed with the proceeds of tax-exempt bonds. Although the terms of the Agreement may be subject to multiple interpretations, the Agreement did not fall clearly within the safe harbors provided under Revenue Procedure 97-13. Assuming that the Agreement is a management contract that gives rise to private business use of bond-financed facilities, the organization believes that the Agreement did not give rise to an impermissible level of private use, in that the Agreement (1) only relates to the use of approximately 750 square feet of bond-financed property out of a total of more than 25,800 square feet (resulting in use of less than three percent of the bond financed facility), (2) was only in effect for a portion of the time that the referenced bonds were outstanding, and (3) use by the Physician Group is not exclusive and is in common with the organizations employees and other users. In addition, it should be noted that the Agreement expired at the end of calendar 2010 and has since been replaced with a contract the terms of which are believed by the organization to fall within an applicable safe harbor of Revenue Procedure 97-13. | ||
| SCHEDULE K, PART III, #7 MANAGEMENT PRACTICES AND PROCEDURES During the applicable tax year, the organization considered its transcript documentation (including the applicable tax regulatory agreement) as its management practices and procedures relating to post-issuance compliance. |
Comments