2024-09-27T10:22:47-05:00 2024-03-31 450250958 Eide Bailly LLP 4585 Coleman St Ste 200 Bismarck ND 58503 990 2023-04-01 363513553 Good Samaritan Health Services Foundation GOOD 7017765455 800 S Main Avenue Rugby ND 58368 Melissa Shepard CFO 7017765455 2024-09-20 1 1 Lisa Chaffee CPA P00193453 7012551091 2024-09-20 2023 2024-10-15 13:58:12Z Erik Christenson 800 S Main Avenue Rugby ND 58368 407228 0 X www.hamc.com/foundation/ X 1987 ND To provide equipment and financial support for the advancement of medical, scientific, nursing, and health care delivery for Good Samaritan Hospital Association Rugby, ND. 7 6 0 20 0 0 3742483 314077 0 0 64890 50933 9950 13174 3817323 378184 1453251 923173 0 0 0 0 0 0 0 74743 56080 1527994 979253 2289329 -601069 4339404 3850274 653691 688477 3685713 3161797 X Our mission is to provide financial resources and act in the best interests of the Good Samaritan Hospital Association with regard to both short-term and long-range needs, including but not limited to the purchase of new equipment and services and plant replacement. These resources shall be obtained by our active role in meeting and building relationships with potential donors, managing relationships with exisiting donors, and introducing new ways of fundraising as well as improving upon current methods. We will, furthermore, participate in the prudent management of all investments of the Foundation for the benefit of the Good Samaritan Hospital Association. 0 0 923173 923173 The Good Samaritan Health Services Foundation's stated mission is to support the mission of the Good Samaritan Hospital Association, to "Advance the physical and spiritual wellbeing of the communities we serve." GSHS Foundation board members and staff support this mission primarily through fundraising and by acting as goodwill ambassadors for GSHA. The Foundation solicits, documents, and manages donations from individuals, businesses, nonprofit organizations, and other foundations, ensuring that donor-designated contributions are invested as directed. The GSHS Foundation director seeks grants in support of GSHA's strategic plan and helps to manage the grants once they are received. Additionally, the Foundation hosts two fundraisers each year, a social event and a golf tournament. In fiscal year 24, the Greatest Needs Gala was held in April and the Charity Golf Classic was held in July. The proceeds from both events were used to support the remodel of the Haaland Estates Kitchen. The GSHS Foundation also awards the $500 Carol Shively Memorial Scholarship each year to show its support for local individuals pursuing degrees in nursing. 923173 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 7 6 1 0 0 0 0 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 MN X Melissa Shepard 7017765455 800 S Main Avenue Rugby ND 58368 Joshua Mattson President 2.00 0.00 X X 0 0 0 Lynda Childress Vice President 1.00 0.00 X X 0 0 0 Patricia Paul Secretary / Treasurer 1.00 0.00 X X 0 0 0 Julie Baustad HAMC Employee Rep 1.00 4.00 X 0 16195 0 Dr Kathy Santjer Medical Staff Rep 1.00 0.00 X 0 0 0 Kevin Leier Director 1.00 0.00 X 0 0 0 Michael Hurly Director 1.00 0.00 X 0 0 0 Tanner Johnson - GSHA Board Rep (nonvoting) (As of Apr 23) 1.00 1.00 X 0 0 0 Tony Coffman - Foundation and Marketing Director (Until July) 20.00 20.00 X 0 33417 703 Erik Christenson GSHA CEO 2.00 58.00 X 0 153379 44032 Melissa Shepard GHSA CFO 2.00 58.00 X 0 137138 15966 0 340129 60701 0 0 1 0 0 49979 264098 16126 314077 32479 32479 18454 0 18454 18454 18454 42218 49979 29044 13174 13174 378184 0 0 64107 923173 923173 1235 1235 21695 21695 7072 7072 89 89 25989 25989 979253 923173 56080 0 172078 175174 2276359 1582447 1807902 1938677 83065 153976 4339404 3850274 298 955 653393 687522 653691 688477 X -682500 -1071370 4368213 4233167 3685713 3161797 4339404 3850274 -601069 77153 0 X 0 1 X 1 0 X 206228 348143 204027 3742483 314077 4814958 206228 348143 204027 3742483 314077 4814958 2055313 2759645 24143 12011 31188 41820 32479 141641 4956599 98870 0.55680 0.53510 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 279449 50000 78189 70387 337251 197638 45878 56177 20244 279449 197638 18445 18445 197638 197638 19666 19666 197638 197638 18395 -18395 197638 0.00000 0.40700 0.59300 1 0 0 Related Party Trust Obligations 687522 687522 X 446560 77153 77153 369407 21695 -12918 8777 378184 970476 12918 12918 957558 21695 21695 979253 Part V, Line 4: Endowment funds are used to support the operations of Good Samaritan Hospital Association. The Organization has part of the reported endowment assets ($153,976) held by the North Dakota Community Foundation and the St. Joseph's Community Health Foundation. The remaining are held by the Organization. Part X, Line 2: 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. Part XI, Line 4b - Other Adjustments: Fundraising Expenses Reported in Expense in Audited Financial Statement -12,918. Part XII, Line 2d - Other Adjustments: Fundraising Expenses Reported in Expense in Audited Financial Statement 12,918. Greatest Needs Gala 66967 35839 31128 16126 250 5498 305 1325 Charity Golf Classic 25230 14140 11090 920 2920 443 1257 92197 49979 42218 920 16126 3170 5941 305 2582 29044 13174 1 Good Samaritan Hospital Association 800 South Main Avenue Rugby ND 58368 450226419 501(c)(3) 923173 0 To support operations and projects for Good Samaritan Hospital Association 1 0 Part I, Line 2: The Foundation board is answerable in all matters to the Association board of trustees. A member of the Good Samaritan Hospital Association board of trustees and the Association CEO serve on the Good Samaritan Health Services Foundation board of directors. As a representative of the Association board of trustees, the CEO advises the Foundation board on fundraising priorities and goals. Fundraising activities conducted by the Foundation on behalf of the Association include, but are not limited to: grant writing, presenting fundraising events, conducting fundraising campaigns, and soliciting individual gifts and memorials. Funds generated and managed by the Foundation are distributed to Good Samaritan Association in the following ways: 1. The Foundation director is authorized by the Foundation board to distribute up to $1,000 in donor-designated funds for specific Good Samaritan Hospital Association departments or projects. 2. The Foundation director is authorized by the Foundation board to manage and release grant funds designated by granting agencies for specific Good Samaritan Hospital Association departments or projects. 3. Distributions of more than $1,000, or distribution of undesignated Foundation funds, must be approved by a majority vote of the Foundation Board of Directors. 0 0 0 0 0 0 0 0 0 Erik Christenson GSHA CEO 0 153379 0 0 0 0 0 3726 0 41815 0 198920 0 0 Melissa Shepard GHSA CFO 0 134584 0 2554 0 0 0 3444 0 13000 0 153582 0 0 Part I, Line 3 Compensation for the CEO is determined by the related organization using one or more of the methods listed in question 3. Form 990, Part VI, Section A, line 1a The Executive Committee may act on behalf of the full board between regular meetings, but their decisions must be ratified by the full board. Form 990, Part VI, Section A, line 2 Erik Christenson and Melissa Shepard have a business relationship. Erik Christenson and Melissa Shepard also have a business relationship with Julie Baustad, Tanner Johnson, and Tony Coffman. Form 990, Part VI, Section A, line 7a Directors must be approved by the Good Samaritan Hospital Association Board. Form 990, Part VI, Section A, line 7b The Foundation Board shall be answerable in all Foundation matters to the board of trustees of the Good Samaritan Hospital Association. Form 990, Part VI, Section A, line 8b No committees met separately from the board. Form 990, Part VI, Section B, line 11b The Board receives an electronic copy of the draft Form 990 prior to a board meeting to review. An overview of the 990 is provided as part of the financial summary for the Board during the actual board meeting to answer any questions they may have as well. A motion is made to approve the draft. Form 990, Part VI, Section B, line 12c Covered Persons: All employees, managers, medical staff, executive leadership, board members, volunteers, contractors, and others engaged in the work place. A conflict of Interest Statement must be signed by each board member and shall be dated no later than December 31st of each year. Determination of conflict: All employees and board members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Conflict review: Actual or potential board member conflicts of interest must be disclosed to the Corporate Compliance Committee (CCC). The CCC will handle reports or concerns of situations that may give rise to a conflict of interest with the assistance of legal counsel. The CCC will issue its decision to the Covered Persons in writing and will document and file its decision. Restrictions on those with a conflict: In self-dealing transactions the board member shall not participate in the board decision-making and shall make full disclosure of their interests. If the fairness of the transaction is questioned, the burden of establishing fairness falls upon the trustee involved and the board member must seek guidance and approval from the CCC prior to pursuing any business or personal activity that may constitute a conflict of interest. Form 990, Part VI, Section B, line 15 Good Samaritan Hospital Association, a related organization, has a process in place and determines compensation for the CEO and CFO. The Foundation coordinator/director is paid by the Good Samaritan Hospital Association. Wages are determined in the same manner as other Association employees based on wage bands, years of experience and merit increases. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy, and financial statements are open for review by the general public upon request. Good Samaritan Hospital Association 800 S Main Ave Rugby ND 58368 450226419 Healthcare ND 501(c)(3) Line 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1 1