2011-05-13T15:23:49-05:00 2010-06-30 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 55402 990 2009-07-01 450344371 F-M Ambulance Service Inc F-MA 7012342000 2215 18th Street South Fargo ND 58103 Lisa M Carlson 7012344811 2011-05-13 1 6123974000 2011-05-12 2009 2016-02-24 21:20:13Z Kelby K Krabbenhoft 1305 W 18th St Sioux Falls SD 57117 10553940 0 X WWW.FMAmbulance.com X 1978 ND Dedicated to the work of health and healing 15 10 198 0 40913 -37274 325997 101689 9511671 10014992 -34831 5244 167629 122176 9970466 10244101 150 0 4874401 5130151 0 0 4304441 3907862 9178842 9038163 791624 1205938 8467475 9370073 1779991 1476651 6687484 7893422 The Mission of F-M Ambulance, "Dedicated to the Work of Health and Healing" and the vision "Improving the Human Condition through Exceptional Care, Innovation and Discovery", is the constant force that drives our plans, decisions and actions. 0 0 7591495 150 10081908 As part of the Sanford integrated delivery system, F-M Ambulance provides emergency medical and special transportation services to the Fargo, North Dakota/Moorhead, Minnesota metro area and other surrounding communities. F-M Ambulance is the largest advanced life support ground ambulance provider in North Dakota and serves as a resource to rescue and ambulance providers throughout the state. F-M Ambulance works closely with the local volunteer service to coordinate the delivery of emergency medical care to the communities in its service area and is a leader in Homeland Defense Preparedness by serving as a regional training, resources partner and responder.See Continuation on Schedule OThrough its Ready Wheels operations, F-M Ambulance provides local and long distance transportation for individuals using wheelchairs. This special transportation service is available 24 hours a day, seven days a week to provide door-to-door wheelchair service. These services allow individuals in the community to access transportation services that accommodate unique individual needs due to health conditions.Education and other services:F-M Ambulance also engages in various activities that promote the health of the community, including providing medical and safety education. F-M Ambulance provides educational programs for members of the community including first aid, automated external defibrillator, CPR and other courses. In addition, F-M Ambulance operates an on-site bookstore that is open to the public. The store sells education texts and reference books, trauma bags, first aid kits and supplies, medical supplies used in delivering emergency medical service outside the hospital and logo wear.F-M Ambulance also works with other organizations in the community to prepare for medical situations by having customized first aid supplies available to respond to workplace medical needs. These services help improve the health and well being of the community at large. F-M Ambulance is also very involved in numerous community activities that help promote health including participation in the national safe kids campaign, participating in bicycle safety helmet programs and providing non-dedicated stand-bys for community events. 7591495 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 12 0 1 198 1 1 1 0 0 0 1 1 0 0 15 10 1 0 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X Tiffany Lawrence 7012342000 PO Box 2010 Fargo ND 58122 Kelby Krabbenhoft 60.00 X X 0 1123846 748719 Roger Gilbertson MD 60.00 X X 0 1004743 989160 Ronald Moquist 0.50 X X 0 0 0 Lauris Molbert 0.50 X X 0 0 0 Barbara Stork 0.50 X X 0 0 0 David Beito 0.50 X X 0 0 0 Ellen-Earle Chaffee PhD 0.50 X X 0 0 0 Judy Green 0.50 X X 0 0 0 John Jambois 0.50 X 0 0 0 Pamela Anderson 0.50 X 0 0 0 Terrence Grimm MD 60.00 X 0 607209 41089 Mark Paulson MD 60.00 X 0 225981 43832 Terry Baloun 0.50 X 0 0 0 Michael Olson MD 60.00 X 0 561750 53780 Barry Martin 0.50 X 0 0 0 James Entenman 0.50 X 0 0 0 John Vander Woude Jr MD 60.00 X 0 2134556 29404 Jerome Feder 0.50 X X 0 0 0 Ann Christenson 0.50 X 0 0 0 Kushal Handa MD 60.00 X 0 561777 46657 Don Morton 0.50 X 0 0 0 Roxanne Newman MD 60.00 X 0 1177119 39121 Jack Reynolds PhD 0.50 X 0 0 0 Brent Teiken 0.50 X 0 0 0 Tony Treuer PhD 0.50 X 0 0 0 David Wilcox MD 0.50 X 0 226474 46961 Lisa Carlson 60.00 X 0 294054 49603 Michael Gibbs 60.00 X 0 259344 13836 Linda O'Halloran 60.00 X 0 258830 5116 Dean Lampe 60.00 X 104510 0 7702 Roger Lee 60.00 X 0 141381 24886 Bruce Pitts MD 60.00 X 0 439889 49257 Paul Richard 60.00 X 0 286282 49603 Gregory Post MD 60.00 X 0 560576 43573 Rhonda Ketterling MD 60.00 X 0 304532 45498 Jeffrey Hoss 60.00 X 0 255549 50245 Evelyn Quigley 60.00 X 0 176638 40857 Douglas Vang 60.00 X 0 285002 48657 104510 10885532 2467556 1 1 1 0 0 95529 6160 101689 Emergency Medical Serv 621910 9044428 9044428 Education 900099 745828 745828 Special Transportation 621910 224736 224736 10014992 2188 2188 15400 1053 14347 14347 14347 12500 9444 3056 3056 3056 407171 299342 107829 66916 40913 10244101 10081908 40913 19591 150 150 119698 119698 3954122 3529007 425115 152802 133130 19672 482667 417277 65390 420862 264867 155995 2000 2000 69368 63125 6243 20493 18036 2457 485760 355197 130563 108129 61032 47097 117262 45646 71616 310248 268038 42210 45350 39739 5611 34992 26609 8383 792674 664358 128316 197861 197861 Bad Debts 1679106 1679106 Miscellaneous Expenses 23766 11497 12269 Intercompany Charges 11095 4923 6172 Provider Tax 9758 9758 9038163 7591495 1446668 0 1366887 3161192 1774088 1399493 146455 119499 123105 112474 6959206 3774873 3486958 3184333 1569982 1393082 8467475 9370073 627798 600103 16025 23592 1121967 802920 14201 50036 1779991 1476651 X 6687484 7893422 6687484 7893422 8467475 9370073 X 0 1 1 X 0 232960 232960 2207596 697745 1509851 135053 39285 95768 2075412 1613374 462038 2308185 1424469 883716 3184333 Goodwill 1393082 1393082 Related party payable 50036 50036 Part X: Description of Uncertain Tax Positions Under FIN 48: Certain controlled organizations are subject to income taxes. Deferred income tax assets and liabilities are recognized for the differences between the financial and income tax reporting basis of assets and liabilities based on enacted tax rates and laws. A tax benefit from an uncertain tax position may be recognized when it is more likely than not that the position will be sustained upon examination. The deferred income tax provision or benefit generally reflects the net change in deferred income tax assets and liabilities during the year. The current income tax provision reflects the tax consequences of revenues and expenses currently taxable or deductible on various income tax returns for the year reported. F-M Ambulance Service, Inc. did not have an income tax liability at June 30, 2010; however, some related organizations have established reserves. 1 1 1 0 0 0 1 0 0 Kelby Krabbenhoft 0 746924 0 0 0 376922 0 730587 0 18132 0 1872565 0 79234 Roger Gilbertson MD 0 567216 0 0 0 437527 0 973515 0 15645 0 1993903 0 48624 Terrence Grimm MD 0 497424 0 108201 0 1584 0 32720 0 8369 0 648298 0 0 Mark Paulson MD 0 180376 0 45053 0 552 0 28836 0 14996 0 269813 0 0 Michael Olson MD 0 535584 0 1456 0 24710 0 39748 0 14032 0 615530 0 15838 John Vander Woude Jr MD 0 1038461 0 0 0 1096095 0 7350 0 22054 0 2163960 0 920379 Kushal Handa MD 0 527834 0 33583 0 360 0 32720 0 13937 0 608434 0 0 Roxanne Newman MD 0 1128886 0 47873 0 360 0 32720 0 6401 0 1216240 0 0 David Wilcox MD 0 194330 0 31592 0 552 0 29078 0 17883 0 273435 0 0 Lisa Carlson 0 292197 0 0 0 1857 0 32720 0 16883 0 343657 0 0 Michael Gibbs 0 256916 0 0 0 2428 0 0 0 13836 0 273180 0 0 Linda O'Halloran 0 257798 0 0 0 1032 0 0 0 5116 0 263946 0 0 Roger Lee 0 134513 0 0 0 6868 0 18469 0 6417 0 166267 0 0 Bruce Pitts MD 0 434319 0 0 0 5570 0 32720 0 16537 0 489146 0 0 Paul Richard 0 285250 0 0 0 1032 0 32720 0 16883 0 335885 0 0 Gregory Post MD 0 556692 0 0 0 3884 0 32720 0 10853 0 604149 0 0 Rhonda Ketterling MD 0 304532 0 0 0 0 0 32720 0 12778 0 350030 0 0 Jeffrey Hoss 0 253328 0 0 0 2221 0 32720 0 17525 0 305794 0 0 Evelyn Quigley 0 170489 0 0 0 6149 0 25112 0 15745 0 217495 0 0 Douglas Vang 0 281769 0 0 0 3233 0 32720 0 15937 0 333659 0 0 Part I, Line 1a On Part I, Questions Regarding Compensation, Sanford checked several of the items as provided to listed persons: First Class or Charter Travel - Charter travel for business purposes is provided for individuals as needed and as cost appropriate. These costs are not included in the W-2's of the individuals as they meet the business purpose of Sanford Health. Travel for Companions - Limited travel for companions is required for an annual meeting. These costs are not included in the W-2's of the individuals as they meet the business purpose of Sanford Health. Tax Indemnification and gross-up payments - Compensation may be grossed up to include appropriate tax amounts in certain circumstances. Health or social club dues or initiation fees - All Sanford employees are eligible for discounted wellness memberships, a portion of these discounts and other club dues are taxed as fringe benefits. Personal services - Individuals may have benefits which include tax preparation or planning, this benefit is included in income and taxed. Part I, Line 3: The Sanford Board of Trustees directly engages a nationally recognized independent compensation consulting firm to annually review the total compensation of arrangements of the officers of the organization, and to report findings and recommendations to the Sanford Board of Trustees for deliberation and action. The most recent study was completed in 2010. Part I, Line 4a Part I, Line 4a: To be in compliance with the IRS regulatory environment, listed individuals compensation includes a one-time payment of deferred compensation; this compensation was earned over multiple periods, and should be treated as earned over that length of time in exchange for services provided. These amounts were already reported in previous years as compensation. Distributions were paid to the following individuals: Kelby Krabbenhoft $79,234 Michael Olson, MD $15,838 Dr. Roger Gilbertson was President and CEO of MeritCare Health System. MeritCare and Sanford Health merged on November 2, 2009 at which time Dr. Gilbertson retired. Upon retirement Dr. Gilbertson received a separation payment of $1,000,920 of which $48,624 was paid during the calendar year and $952,295 was accrued to be paid monthly through November 1, 2011. The payment was consistent with the President's Employment Agreement effective January 1, 2007. Part I, Line 4b/Schedule J, Part II, Column C: In addition to employer contributions to pension plans, amounts representing increases and decreases in actuarial value (actuarial value factors include age, tenure and salary) of defined contribution and defined benefit SERP Plans are included in Column C. Participants and changes in values include: Kelby Krabbenhoft $706,194 Roger Gilbertson, MD $ 94,324 Part I, Line 4c: Several listed individuals received payment distributions from a benefit plan that falls within the definition of an "equity based" compensation plan. These amounts were deferred over multiple year periods, and were included in compensation in those periods. Distributions were paid to: John Vander Woude, MD $920,379 Part I, Line 6 Sanford physicians are compensated based on the professional services they perform within the clinic in which they provide care. Generally, the model is revenues less expenses. Physicians listed that were paid on this model include: Michael Olson, MD Supplemental Information Part III Compensation reported on Schedule J, Part II includes: (B)(i) Base compensation - salaries are based on the experience and performance of each executive and bench-marked using independent compensation survey information. (B)(ii) - Bonus & incentive compensation - as part of executive compensation, individuals may be eligible for incentive performance compensation, however if the organization does not make its financial budget, the Executive does not receive an incentive payment regardless of performance. (B)(iii) Other Reportable Compensation - generally includes taxable executive benefits. It also includes the one-time payout of previously deferred compensation (which was also reported as compensation in the earned period). To be in compliance with the IRS regulatory environment, listed individuals compensation includes a one-time payment of deferred compensation; this compensation was earned over multiple periods, and should be treated as earned over that length of time in exchange for services provided. (C) Deferred Compensation includes employer contributions to pension plans and the increase (or decrease) in the actuarial value (actuarial value factors include age, tenure and salary) of the benefit plans. (D) Nontaxable Benefits generally includes health insurance premiums. Supplemental Information Part III A memo regarding executive compensation, written by the Chairman of the Sanford Board of Trustees, is on file and available upon request. Supplemental Information Part III The total compensation paid to Kelby Krabbenhoft of $1,123,846 is comprised of Base salary of $746,924, the one-time payment of previously deferred compensation of $79,234 (see also explanation above) and Other Taxable Earning of $297,688. Supplemental Information Part III Schedule J, Part 1, Line 3 The Sanford Board of Trustees directly engages a nationally recognized independent compensation consulting firm to annually review the total compensation of arrangements of the officers of the organization, and to report findings and recommendations to the Sanford Board of Trustees for deliberation and action. The most recent study was completed in 2010. Form 990, Part VI, Section A, line 2 Pamela Anderson, Trustee, and Lisa Carlson, CFO, have a business relationship. Board members also serve on the boards of Sanford and/or related entities. Form 990, Part VI, Section A, line 4 The composition for the Board of F-M Ambulance has changed in the past fiscal year. F-M Ambulance stock is owned by Sanford North. The Board of Directors shall consist of no more than 18 employees of Sanford North or its controlled entities. The officers of F-M Ambulance shall include a President, Vice President, Secretary and Treasurer. All directors and officers are appointed by the President and CEO of Sanford North. All expenditures, guaranteeing debts, and incurring of loans, regardless of dollar amount, require approval by the Directors. Form 990, Part VI, Section A, line 6 Sanford North is the sole stockholder of F-M Ambulance. Form 990, Part VI, Section A, line 7a Board members are appointed by the President and CEO of Sanford North. Form 990, Part VI, Section A, line 7b Sanford North must approve the following actions: * Modifying the purpose of the Corporation * Unbudgeted capital expenses in excess of 1/2 of 1% of approved operating budgets *Adoption of capital and operating budgets *Acquisition, sale, lease, disposition, or mortgaging of real property *Guarantee of debts or obligations of any other person, firm, corporation, partnership, association, or other entity which if held in deafult would obligate the corporation to an aggregate amount in excess of $100,000 *Merger or consolidation of the Corporation *Incurring a loan or other obligation in an agreement in excess of $500,000 for more than 60 days *Making of a gift, grant or other donation in an amount in excess of $5,000 to an organization not related to the Corporation or Member *Member has the authority to direct the Corporation regardless of the vote by the Corporation's Board of Directors to transger assets and/or funds to the health system to satisfy obligations of the health system. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by the finance department and reviewed by executive management, including both the System CEO and CFO. An external accounting firm reviews the return prior to filing and presents return highlights and key disclosures to the Board of Trustees at the meeting immediately following the return filing date. After the return is filed, a complete copy is made available to the current trustees. Form 990, Part VI, Section B, line 12c The annual Conflict of Interest disclosure process is managed by the Chief Compliance Officer (CCO). The CCO is responsible for assuring that all completed forms are returned in a timely and complete manner. Conflict of Interest questionnaires are sent to Sanford Trustees, members of the governing boards for subsidiary entities, officers, and key employees. The disclosures are summarized for review by the executive committee of the Board of Trustees, pursuant to policy. This review allows: 1) The Board to acquire an awareness of financial relationships of board members and key management employees and can invoke the recusal process on a case-by-case basis when potential conflicts are implicated in Board decisions and deliberations, and, 2) Gives the Board the opportunity to seek additional information and clarification about disclosures to determine potential conflicts of interest and how to manage such. Form 990, Part VI, Section B, line 15 The Sanford Board of Trustees directly engages a nationally recognized independent compensation consulting firm to annually review the total compensation arrangements of the officers and operating unit executives of the organization, including the CEO, and to report the findings and recommendations to them for deliberation and action. The deliberations and actions are recorded in the minutes of the Sanford Board of Trustees. The most recent study was completed in 2010. Form 990, Part VI, Section C, line 19 Although the organization does not maintain a website where the public can access these documents, it would respond individually to any requests or inquiries from the public for these documents. Form 990, Part VII Board members of Sanford provide services to Sanford subsidiaries. Hours reported for each individual reflect the time spent on work related to either the filing organization or related organization. Sanford Board of Trustees has ultimate governance responsibilities for each entity within the Sanford system. In addition, a Board of Directors is established for each entity, which has specific delegated responsibilities from the Board of Trustees related to the oversight of day to day operations of that entity. Sanford North PO Box 2010 Fargo ND 58122 450385890 Supporting Organization ND 501(c)(3) 11-II Sanford Sanford Clinic North PO Box 2010 Fargo ND 58122 911770748 Clinical Services ND 501(c)(3) 9 Sanford North MeritCare Minnesota 1720 South Highway 59 Thief River Falls MN 56701 261530302 Promotion of health MN 501(c)(3) 3 Sanford North Sanford Medical Center Fargo PO Box 2010 Fargo ND 58122 450226909 Hospital ND 501(c)(3) 3 Sanford North Sanford Health Foundation North PO Box 2010 Fargo ND 58122 450398104 Supporting Organization ND 501(c)(3) 7 Sanford North Sanford Health Network North PO Box 2010 Fargo ND 58122 450409348 Hospitals / Clinics ND 501(c)(3) 11-II Sanford North MeritCare Health Enterprises Inc PO Box 2010 Fargo ND 58122 450359785 Sales of prescription drugs ND 501(c)(4) Sanford North Sanford Medical Center Thief River Falls 120 Labree Ave S Thief River Falls MN 56701 410709579 Hospital MN 501(c)(3) 3 Sanford North Sanford Medical Center Mayville 42 6th Ave SE Mayville ND 58257 450228899 Hospital ND 501(c)(3) 3 Sanford North Sanford Medical Center Wheaton 401 12th St N Wheaton MN 56296 272042143 Hospitals / Clinics MN 501(c)(3) 3 Sanford North Agassiz Assurance Company 100 Bank Street No 610 Burlington VT 05401 743121855 Malpractice Insurance VT 501(c)(3) 11-II Sanford North Sanford Health 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 311527032 Supporting Organization SD 501(c)(3) 11-III Sanford Sanford USD Medical Center 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 460227855 Hospital SD 501(c)(3) 3 Sanford Health Sanford Clinic 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 460447693 Clinical Services SD 501(c)(3) 3 Sanford Health Sanford Health Network 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 460388596 Hospitals / Clinics SD 501(c)(3) 11-1 Sanford Health Sanford Home Health 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 460282134 Home Health Services SD 501(c)(3) 9 Sanford Health Sanford Health Foundation 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 363297853 Supporting Organization SD 501(c)(3) 11-1 Sanford Health Sanford Research USD 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 460450378 Medical Research SD 501(c)(3) 3 Sanford Health Sanford 801 N Broadway Drive Fargo ND 58122 271218956 Supporting Organization ND 501(c)(3) 11-II SHM-MeritCare 801 N Broadway Drive Fargo ND 58122 271213717 Supporting Organization ND 501(c)(3) 11-II SHM-Sanford 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 271213769 Supporting Organization SD 501(c)(3) 11-II Sanford World Clinics 1305 W 18th St PO Box 5039 Sioux Falls SD 571175039 262707628 Healthcare SD 501(c)(3) 3 Sanford Health National Student Housing - South Dakota LLC 100 S Phillips Ave Sioux Falls SD 57104 202129839 Investment SD Sanford Health Related 0 0 RAC Rentals LLC 100 S Phillips Ave Sioux Falls SD 57104 261961077 Investment SD Sanford Health Related 0 0 Healthcare Environmental Services Inc 1420 40th St NW Fargo ND 58102 450336598 Laundry & Incineration Services ND Sanford North C Heart Partners at Sanford 1305 West 18th St Sioux Falls SD 57117 460449572 Healthcare SD Sanford Health C Sanford Home Medical Equipment Inc 2710 West 12th ST Sioux Falls SD 571043701 460388597 Healthcare Equipment SD Sanford Health C Sanford Health Plan 300 Cherapa Place 201 Sioux Falls SD 57103 911842494 Insurance SD Sanford Health C Sanford Health Plan of Minnesota 301 Cherapa Place 201 Sioux Falls SD 57103 460445852 Insurance MN Sanford Health C 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0