2024-04-19T15:20:43-05:00 2023-06-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2022-07-01 421520494 HANSEN FAMILY HOSPITAL FOUNDATION HANS 6416487188 920 SOUTH OAK STREET IOWA FALLS IA 50126 SHANE R COUGHENOUR CFO 6416487188 2024-03-26 1 SHANE COUGHENOUR 999009999 0 RYAN ENGEBRETSON P01585625 6123764500 2024-03-26 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z SHANE R COUGHENOUR 920 SOUTH OAK STREET IOWA FALLS IA 50126 112207 0 X N/A X 2001 IA FOSTER CHARITABLE PARTNERSHIPS THAT ENHANCE HEALTH CARE FOR THOSE WE HAVE THE PRIVILEGE TO SERVE. 6 5 0 6 0 0 85034 81974 0 0 466 2898 19070 27335 104570 112207 42419 113482 0 0 0 0 0 0 0 270 20 42689 113502 61881 -1295 711472 717920 0 0 711472 717920 X THE MISSION OF THE HANSEN FAMILY HOSPITAL FOUNDATION IS TO FOSTER CHARITABLE PARTNERSHIPS THAT ENHANCE HEALTHCARE FOR THOSE WE HAVE THE PRIVILEGE TO SERVE. 0 0 113482 113482 0 TO RECEIVE CONTRIBUTIONS, GIFTS, AND GRANTS AND DISBURSE FUNDS FOR THE WELFARE AND IMPROVEMENT OF ELLSWORTH MUNICIPAL HOSPITAL DBA: HANSEN FAMILY HOSPITAL. HANSEN FAMILY HOSPITAL FOUNDATION ASSISTS AND PROMOTES WELLNESS, CARE, TREATMENT, AND REHABILITATION OF SICK, AFFLICTED AND INJURED, IN HARDIN COUNTY AND THE AREA SERVED BY HANSEN FAMILY HOSPITAL. DURING THE YEAR, THE FOUNDATION'S FOCUS WAS SUPPORTING THE OPERATIONS OF THE HANSEN FAMILY HOSPITAL. PURCHASES MADE DURING THE YEAR, WITH DONOR-RESTRICTED GIFTS, WERE TO SUPPORT THE COMMUNITY CONCUSSION SCREENING PROGRAM, THE PATIENT ADVOCATE PROGRAM AND MAMMOGRAM SUPPORT FOR PATIENTS OF THE HOSPITAL.THE FOUNDATION IS GOVERNED BY A BOARD OF DIRECTORS MADE UP OF MEMBERS OF THE COMMUNITY, LOCAL BUSINESS, AND REPRESENTATIVES FROM THE MEDICAL STAFF, ADMINISTRATION, BOARD OF DIRECTORS AND EMPLOYEES OF HANSEN FAMILY HOSPITAL. 113482 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 X RUTH STEIG 6416417047 920 SOUTH OAK STREET IOWA FALLS IA 50126 X DR QUINN HOVERSTEN BOARD CHAIR 2.00 0.00 X X 0 0 0 MOLLY ACKERSON VICE CHAIR 2.00 0.00 X X 0 0 0 SARA KELSEY SECRETARY 2.00 0.00 X X 0 0 0 JANELLE CHAPLIN TREASURER 2.00 0.00 X X 0 0 0 GEORGE VON MOCK HFH CEO/BOARD DIRECTOR 2.00 40.00 X 0 0 0 DAN QUINLIN DIRECTOR 2.00 0.00 X 0 0 0 0 0 0 0 0 0 0 0 81974 81974 2898 2898 27335 0 27335 27335 112207 0 0 30233 112682 112682 800 800 OTHER EXPENSES 20 20 113502 113482 20 0 464312 454517 8500 128338 134013 118822 120890 711472 717920 0 0 X 546029 537900 165443 180020 711472 717920 711472 717920 X -1295 5674 2069 X 0 1 X 1 0 X 85609 161730 102829 85034 81974 517176 85609 161730 102829 85034 81974 517176 90000 427176 3985 2686 879 466 2898 10914 19070 27335 46405 574495 12276 0.74360 0.82490 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 118822 50 9107 5900 1189 120890 146353 1000 -19640 7488 1403 118822 117981 1000 35808 7070 1366 146353 126889 1100 -2039 6720 1249 117981 127450 1000 5674 5974 1261 126889 0.00000 1.00000 0.00000 0 0 0 BENEFICIAL INTEREST IN NET ASSETS OF COMMUNITY FOUNDATION 120890 F 120890 X 117881 5674 5674 112207 0 112207 113502 0 113502 0 113502 PART V, LINE 4: INTEREST FROM THE ENDOWMENT FUNDS IS USED AS NEEDED FOR HOSPITAL OPERATIONS REQUESTED OF THE FOUNDATION. PART X, LINE 2: THE FOUNDATION IS AN IOWA NON-PROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE FOUNDATION IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE, AS APPLICABLE. THE FOUNDATION FOLLOWS THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. AS A RESULT OF THE APPLICATION OF THE STANDARD, THE FOUNDATION HAS RECOGNIZED NO LIABILITY FOR UNRECOGNIZED TAX BENEFITS. THE FOUNDATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE FOUNDATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. NO SHOW LEGACY BALL 27335 27335 27335 27335 27335 1 ELLSWORTH MUNICIPAL HOSPITAL DBA HANSEN FAMILY HOSPITAL 920 SOUTH OAK STREET IOWAS FALLS IA 50126 426005855 501(C)(3) 112682 0 AVERA E-PHARMACY 1 0 PART I, LINE 2: HANSEN FAMILY HOSPITAL IS THE PRIMARY BENEFICIARY OF THE FOUNDATION'S DONATIONS. THE FOUNDATION PROVIDES GRANTS TO THE HOSPITAL TO ADVANCE AND IMPROVE HEALTH CARE TO THOSE SERVED BY THE HOSPITAL. BILLS AND RECEIPTS FOR THE ITEMS PURCHASED ARE PROVIDED FOR PROOF THE FUNDS WERE USED APPROPRIATELY. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE CONSISTS OF TWO OR MORE DIRECTORS ELECTED BY THE BOARD OF DIRECTORS. THE COMMITTEE HAS THE POWERS AND DUTIES DELEGATED TO IT BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS ELLSWORTH MUNICIPAL HOSPITAL DBA: HANSEN FAMILY HOSPITAL. FORM 990, PART VI, SECTION A, LINE 7A THE FOLLOWING OFFICERS OF ELLSWORTH MUNICIPAL HOSPITAL APPOINTED AS EX-OFFICIO, VOTING MEMBERS OF THE FOUNDATION ARE CHIEF EXECUTIVE OFFICER (ADMINISTRATOR), ONE MEMBER OF THE HOSPITAL STAFF, ONE MEMBER OF THE HOSPITAL MEDICAL STAFF AND ONE MEMBER OF THE HOSPITAL BOARD OF TRUSTEES. THE REMAINING FOUNDATION DIRECTORS ARE APPOINTED FROM A LIST OF PERSONS NOMINATED BY THE HOSPITAL'S NOMINATING COMMITTEE, AND HOLD OFFICE FOR ONE YEAR OR UNTIL THEIR SUCCESSOR IS APPOINTED AND QUALIFIED, OR UNTIL THEIR DEATH OR UNTIL THEY RESIGN. ALL FOUNDATION DIRECTORS APPOINTED BY THE HOSPITAL MAY BE REMOVED WITH OR WITHOUT CAUSE WHEN THE HOSPITAL DEEMS THEIR REMOVAL TO BE IN THE BEST INTERESTS OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL BY THE SOLE MEMBER, ELLSWORTH MUNICIPAL HOSPITAL, IS REQUIRED TO APPROVE ANY AMENDMENT OF THE ARTICLES OF INCORPORATION OR THE BY-LAWS, TO APPROVE ANY DISSOLUTION, CONSOLIDATION, MERGER, ACQUISITION OR CREATION OF ANY WHOLLY-OWNED OR CONTROLLED CORPORATIONS, APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGETS AND ALL MATERIAL VARIATIONS FROM THESE BUDGETS, APPROVE ALL NON-BUDGETED CAPITAL EXPENDITURES, AND APPROVE ALL LOANS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PRESENTED TO THE FULL BOARD BEFORE IT IS FILED. THE CFO OF ELLSWORTH MUNICIPAL HOSPITAL DBA: HANSEN FAMILY HOSPITAL, A RELATED ORGANIZATION, AND THE FOUNDATION DIRECTOR ALSO REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS AND OFFICERS ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ANNUALLY. ANY DIRECTOR OR OFFICER HAVING AN EXISTING OR POTENTIAL INTEREST IN A CONTRACT OR OTHER TRANSACTION PRESENTED TO THE FOUNDATION'S BOARD OF DIRECTORS OR A COMMITTEE THEREOF FOR DELIBERATION, AUTHORIZATION, APPROVAL, OR RATIFICATION, OR ANY SUCH PERSON WHO REASONABLY BELIEVES SUCH AN INTEREST EXISTS IN ANOTHER PERSON, SHOULD MAKE A PROMPT, FULL, AND FRANK DISCLOSURE OF THE INTEREST TO THE FOUNDATION BOARD OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. THE INTERESTED PARTY IS REQUIRED TO DISCLOSE THE NATURE AND EXTENT OF HIS/HER INTEREST ABOUT THE CONTRACT OR TRANSACTION WHICH MIGHT REASONABLY BE CONSTRUED TO BE ADVERSE TO THE FOUNDATION'S INTEREST. THE BODY TO WHICH SUCH DISCLOSURE IS MADE SHOULD DETERMINE, BY MAJORITY VOTE, WHETHER THE DISCLOSURE SHOWS THAT THE NON-VOTING AND NON-PARTICIPATION PROVISIONS BELOW MUST BE OBSERVED. IF SO, SUCH PERSON SHOULD NOT VOTE ON, OR USE HIS/HER PERSONAL INFLUENCE ON, NOR PARTICIPATE (OTHER THAN TO PRESENT FACTUAL INFORMATION OR TO RESPOND TO QUESTIONS) IN THE DISCUSSIONS OR DELIBERATIONS WITH RESPECT TO, SUCH CONTRACT OR TRANSACTION. SUCH PERSON MAY BE COUNTED IN DETERMINING THE EXISTENCE OF A QUORUM AT ANY MEETING WHERE THE CONTRACT OR TRANSACTION UNDER DISCUSSION ARE TO BE VOTED UPON. THE MINUTES OF THE MEETING SHOULD REFLECT THE DISCLOSURE MADE, THE VOTE, AND WHERE APPLICABLE, THE ABSTENTION FROM VOTING AND PARTICIPANTION, AND WHETHER A QUORUM WAS PRESENT. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION AND BENEFITS FOR THE FOUNDATION DIRECTOR ARE DETERMINED BY ELLSWORTH MUNICIPAL HOSPITAL DBA: HANSEN FAMILY HOSPITAL, A RELATED ORGANIZATION. ELLSWORTH MUNICIPAL HOSPITAL DBA: HANSEN FAMILY HOSPITAL USES THESE METHODS TO DETERMINE COMPENSATION AND BENEFITS FOR THE FOUNDATION DIRECTOR. THE ADMINISTRATOR IS COMPENSATED THROUGH AN UNRELATED MANAGEMENT COMPANY FOR SERVICES TO THE HOSPITAL. THE TIME SPENT ON THE FOUNDATION IS VOLUNTEER. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN ASSETS OF COMMUNITY FOUNDATION 2,069. ELLSWORTH MUNICIPAL HOSPITAL DBA HANSEN FAMILY HOSPITAL 920 SOUTH OAK STREET IOWA FALLS IA 50126 426005855 PROVISION FOR HEALTH CARE SERVICES IA 501(C)(3) LINE 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0