TY 2013 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) PAUL BAHE........................................................................ BOARD MEMBER - CHAIR	1.30 ........................80	X	X		0	0
(2) MIKE MEYER........................................................................ BOARD MEMBER - VICE CHAIR	1.30 .......................0.00	X	X		0	0
(3) DEB TOENGES........................................................................ BOARD MEMBER - SEC/TREAS	1.30 .......................0.00	X	X		0	0
(4) DEB BECKNER........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(5) CONNIE LEICHER........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(6) RANDIE MUELLER........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(7) LUARA NECKER........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(8) DIANE PAGEL........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(9) RICK PEDERSON........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(10) BILL SCHWAKE........................................................................ BOARD MEMBER	.80 ........................80	X			0	0
(11) DAVE VOSS........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(12) BRENDA WINZENBURG........................................................................ BOARD MEMBER	.80 .......................0.00	X			0	0
(13) MARY WELLS........................................................................ CEO	38.00 .......................2.00		X		141,950	22,432
(14) SARA TRAINOR........................................................................ CFO (1/1/13 - 8/9/13)	39.50 ........................50		X		97,654	24,488
(15) DAWN EVERDING........................................................................ CFO (8/9/13 - 12/31/13)	39.50 ........................50		X		34,720	4,769
(16) LYNNE NIEMANN........................................................................ DIRECTOR OF NURSING & PATI	39.70 ........................30		X		88,413	18,606
(17) TROY BUCHHOLZ........................................................................ PHYSICIAN	40.00 .......................0.00			X	328,636	39,724

(A) Name and business address	(B) Description of services	(C) Compensation
GRAHAM CONSTRUCTION421 GRAND AVENUEDES MOINESIA50309	CONSTRUCTION SERVICES	2,789,942
IOWA HEALTH SYSTEMUNITYPOINT HEALTH1776 W LAKES PARKWAY SUITE 400WEST DES MOINESIA50266	IT (EPIC) SUPPORT	666,966
PERFORMANCE REHAB LLC909 W 1ST STSUMNERIA50674	REHAB SERVICES	417,776
DR JAYASWAL, 8315 W 119TH TERRACEOVERLANDKS66213	ED COVERAGE	278,035
HEALTH ENTERPRISES OF IOWA5825 DRY CREEK LANE NECEDAR RAPIDSIA52402	XRAY/CRNA SERVICES	233,606
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 9

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21
2	Grants and other assistance to individuals in the United States. See Part IV, line 22
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	433,032		433,032
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	23,206	23,206
7	Other salaries and wages	3,938,487	3,479,615	458,872
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....
9	Other employee benefits .......	736,551	653,546	83,005
10	Payroll taxes ...........	308,546	246,528	62,018
11	Fees for services (non-employees):
a	Management ......	60,000		60,000
b	Legal .........	22,337		22,337
c	Accounting ...........	66,776		66,776
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	2,167,871	1,878,832	289,039
12	Advertising and promotion ....	48,821	48,821
13	Office expenses .......	405,629	330,742	74,887
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	203,643	203,643
17	Travel ............	44,943	40,855	4,088
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......
19	Conferences, conventions, and meetings ....
20	Interest ...........	275,032	275,032
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization .....	1,670,792	1,670,792
23	Insurance ..............	56,672	56,672
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	MEDICAL SUPPLIES	866,186	866,186
b	PROVISION FOR BAD DEBT	419,024	419,024
c	DUES AND SUBSCRIPTIONS	117,675	117,675
d
e	All other expenses	15,452	15,452
25	Total functional expenses. Add lines 1 through 24e	11,880,675	10,326,621	1,554,054	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............	100	1	100
2	Savings and temporary cash investments .........	3,435,704	2	7,434,635
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	1,301,417	4	2,134,687
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
			5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
			6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	108,269	8	118,771
9	Prepaid expenses and deferred charges ..........	302,422	9	99,318
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,109,566
b	Less: accumulated depreciation .....	10b	3,094,841	16,049,786	10c	18,014,725
11	Investments—publicly traded securities ..........	5,204,499	11	0
12	Investments—other securities. See Part IV, line 11 .....	4,171,601	12	4,483,296
13	Investments—program-related. See Part IV, line 11 .....		13
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	355,204	15	150,037
16	Total assets. Add lines 1 through 15 (must equal line 34)......	30,929,002	16	32,435,569
	17	Accounts payable and accrued expenses .........	2,885,944	17	1,156,384
18	Grants payable .................		18
19	Deferred revenue ................		19
20	Tax-exempt bond liabilities .............	18,000,000	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..	62,978	23	18,000,000
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	21,752	25	2,445,925
26	Total liabilities. Add lines 17 through 25.........	20,970,674	26	21,602,309
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	5,786,727	27	6,349,964
28	Temporarily restricted net assets ...........		28	0
29	Permanently restricted net assets ...........	4,171,601	29	4,483,296
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	9,958,328	33	10,833,260
34	Total liabilities and net assets/fund balances ........	30,929,002	34	32,435,569

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.
right arrow

Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the supported organization? ................

11g(i)

(ii) A family member of a person described in (i) above? ......................

11g(ii)

(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2013

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here................................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2012 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2013. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2012. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2013. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2013

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2012 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2012 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2013. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2012. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2013

Page 4

Part IV

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2013

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 2

Name of organization SUMNER COMMUNITY CLUB

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTEDRESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 3

Name of organization SUMNER COMMUNITY CLUB

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 4

Name of organization
SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions. SchDMd Bullet

Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2013

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....	4,171,601	3,544,459	2,684,825	2,638,298	2,634,633
b	Contributions ........
c	Net investment earnings, gains, and losses	563,439	858,953	1,033,086	110,582	58,750
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........	251,744	231,811	173,452	64,055	55,085
f	Administrative expenses ....
g	End of year balance ......	4,483,296	4,171,601	3,544,459	2,684,825	2,638,298

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

100.000 %

Temporarily restricted endowment SchDMd Bullet

0 %

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

Yes

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	100,421		100,421
b	Buildings ................	13,358,930	810,266	12,548,664
c	Leasehold improvements ............
d	Equipment ................	5,553,078	2,156,417	3,396,661
e	Other .................	2,097,137	128,158	1,968,979
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				18,014,725

Schedule D (Form 990) 2013

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
(3)Other (A) PERPETUAL TRUST	4,483,296	F








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	4,483,296

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes
CAPITAL LEASE OBLIGATIONS		846,758
ESTIMATED THIRD-PARTY PAYOR SETTLEMENT		1,599,167







Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		2,445,925
2. Liability for uncertain tax positions In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII ..................................................

Schedule D (Form 990) 2013

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
PART V, LINE 4:	THE HOSPITAL IS BENEFICIARY OF A DONOR CREATED PERPETUAL TRUST. ASSETS HELD BY THE TRUST INCLUDE CASH AND CASH EQUIVALENTS, CDS, EQUITITIES, FARMLAND, LIVESTOCK, EQUIPMENT, GRAINS, ETC. A PROVISION OF THE TRUST REQUIRES THAT INCOME EARNED BE DISTRIBUTED AT LEAST ANNUALLY TO THE HOSPITAL. INCOME DISTRIBUTIONS FROM THE TRUST ARE UNRESTRICTED AND CAN BE USED FOR ANY PURPOSE DEEMED BENEFICIAL.
PART X, LINE 2:	THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND ARE EXEMPT FROM FEDERAL INCOME TAXES IN RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. 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 DECEMBER 31, 2013 AND 2012, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2010.

Return Reference

Explanation

PART V, LINE 4:

THE HOSPITAL IS BENEFICIARY OF A DONOR CREATED PERPETUAL TRUST. ASSETS HELD BY THE TRUST INCLUDE CASH AND CASH EQUIVALENTS, CDS, EQUITITIES, FARMLAND, LIVESTOCK, EQUIPMENT, GRAINS, ETC. A PROVISION OF THE TRUST REQUIRES THAT INCOME EARNED BE DISTRIBUTED AT LEAST ANNUALLY TO THE HOSPITAL. INCOME DISTRIBUTIONS FROM THE TRUST ARE UNRESTRICTED AND CAN BE USED FOR ANY PURPOSE DEEMED BENEFICIAL.

PART X, LINE 2:

THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND ARE EXEMPT FROM FEDERAL INCOME TAXES IN RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. 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 DECEMBER 31, 2013 AND 2012, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. WITH FEW EXCEPTIONS, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS ENDED PRIOR TO DECEMBER 31, 2010.

Schedule D (Form 990) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a ...

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: .........

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? ......

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? ..............

Did the organization prepare a community benefit report during the tax year? ..........

Yes

If "Yes," did the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) ..	36,859	0	36,859	0.320 %
b	Medicaid (from Worksheet 3, column a) ....	640,398	648,006	-7,608	0 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) .
d	Total Financial Assistance and Means-Tested Government Programs .	677,257	648,006	29,251	0.320 %
Other Benefits		23,486	2,948	20,538	0.180 %
e	Community health improvement services and community benefit operations (from Worksheet 4) ..	23,486	2,948	20,538	0.180 %
f	Health professions education (from Worksheet 5) ..	46,388	0	46,388	0.400 %
g	Subsidized health services (from Worksheet 6) ..	267,724	30,455	237,269	2.070 %
h	Research (from Worksheet 7)
i	Cash and in-kind contributions for community benefit (from Worksheet 8)	15,390	0	15,390	0.130 %
j	Total. Other Benefits ..	352,988	33,403	319,585	2.780 %
k	Total. Add lines 7d and 7j .	1,030,245	681,409	348,836	3.100 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2013

Schedule H (Form 990) 2013

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

419,024

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

37,000

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

5,851,635

Enter Medicare allowable costs of care relating to payments on line 5.....

5,868,903

Subtract line 6 from line 5. This is the surplus (or shortfall)........

-17,268

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2013

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions) How many hospital facilities did the organization operate during the tax year?1 Name, address, primary website address, and state license number					Other (Describe)
1	SUMNER COMMUNITY CLUB DBA COMMUNITY MEMORIAL HOSP 909 W 1ST ST PO BOX 148 SUMNER,IA50674	X	X	X	PROVIDER-BASED MEDICAL CLINIC

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	COMMUNITY MEMORIAL HOSPITAL
Name of hospital facility or facility reporting group

If reporting on Part V, Section B for a single hospital facility only: line number of
hospital facility (from Schedule H, Part V, Section A)

Yes

Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 9....................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

Information gaps that limit the hospital facility’s ability to assess the community’s health needs

Other (describe in Part VI)

Indicate the tax year the hospital facility last conducted a CHNA: 20 13

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ....................

Yes

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Part VI................................

Yes

Did the hospital facility make its CHNA report widely available to the public? .............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): WWW.CMHSUMNER.ORG

Other website (list url):

Available upon request from the hospital facility

Other (describe in Part VI)

If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply as of the end of the tax year):

Adoption of an implementation strategy that addresses each of the community health needs identified through the CHNA

Execution of the implementation strategy

Participation in the development of a community-wide plan

Participation in the execution of a community-wide plan

Inclusion of a community benefit section in operational plans

Adoption of a budget for provision of services that address the needs identified in the CHNA

Prioritization of health needs in its community

Prioritization of services that the hospital facility will undertake to meet health needs in its community

Other (describe in Part VI)

Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs ........

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? ...........................

If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax? ......

If "Yes" to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

Financial Assistance Policy			Yes	No
9	Did the hospital facility have in place during the tax year a written financial assistance policy that:
	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?	9	Yes
10	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........	10	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 200.000000000000% If "No," explain in Part VI the criteria the hospital facility used.
11	Used FPG to determine eligibility for providing discounted care?.................	11	Yes
	If "Yes," indicate the FPG family income limit for eligibility for discounted care: 400.000000000000% If "No," explain in Part VI the criteria the hospital facility used.
12	Explained the basis for calculating amounts charged to patients?.................	12		No
	If "Yes," indicate the factors used in determining such amounts (check all that apply):
a	Income level
b	Asset level
c	Medical indigency
d	Insurance status
e	Uninsured discount
f	Medicaid/Medicare
g	State regulation
h	Residency
i	Other (describe in Part VI)
13	Explained the method for applying for financial assistance?...................	13	Yes
14	Included measures to publicize the policy within the community served by the hospital facility?.......	14	Yes
	If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a	The policy was posted on the hospital facility’s website
b	The policy was attached to billing invoices
c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
d	The policy was posted in the hospital facility’s admissions offices
e	The policy was provided, in writing, to patients on admission to the hospital facility
f	The policy was available upon request
g	Other (describe in Part VI)
Billing and Collections
15	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......	15	Yes
16	Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Section C)
17	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?..........	17		No
	If "Yes," check all actions in which the hospital facility or a third party engaged:
a	Reporting to credit agency
b	Lawsuits
c	Liens on residences
d	Body attachments
e	Other similar actions (describe in Section C)

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

Indicate which efforts the hospital facility made before initiating any of the actions listed in line 17 (check all that apply):

Notified individuals of the financial assistance policy on admission

Notified individuals of the financial assistance policy prior to discharge

Notified individuals of the financial assistance policy in communications with the individuals regarding the individuals’ bills

Documented its determination of whether individuals were eligible for financial assistance under the hospital facility’s financial assistance policy

Other (describe in Section C)

Policy Relating to Emergency Medical Care

Yes

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)

Other (describe in Part VI)

Charges to Individuals Eligible for Assistance under the FAP (FAP-Eligible Individuals)

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged

The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged

The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged

Other (describe in Part VI)

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................

If "Yes," explain in Part VI.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? .........................

If "Yes," explain in Part VI.

Schedule H (Form 990) 2013

Page

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B.Provide descriptions required for Part V, Section B, lines 1j, 3, 4, 5d, 6i, 7, 10, 11, 12i, 14g, 16e, 17e, 18e, 19c, 19d, 20d, 21, and 22. If applicable, provide separate descriptions for each facility in a facility reporting group, designated by "Facility A," "Facility B," etc.
Form and Line Reference	Explanation
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 1J: THE STEERING COMMITTEE FROM THE NEEDS ASSESSMENT UTILITZED THE INFORMATION GATHERED TO IDENTIFY A LIST OF 15 NEED CATEGORIES. THESE CATEGORIES INCLUDED: 1) ACCESS, 2) CHRONIC DISEASE MANAGEMENT, 3) DENTAL HEALTH, 4) ELDERLY POPULATION, 5) ETHNICITIES/MINORITIES, 6) HEALTH LITERACY, 7) MENTAL HEALTH, 8) NUTRITION, 9) PHYSICAL ACTIVITY, 10) SEXUAL HEALTH, 11) SUBSTANCE ABUSE, 12) VETERANS, 13) VISION HEALTH, 14) WOMEN'S HEALTH AND 15) YOUTH. COMMUNITY MEMORIAL HOSPITAL USED THE INFORMATION PRESENTED IN THIS PROCESS TO FOCUS IN ON RESULTS RECEIVED FROM THOSE WE SERVE AND DEVELOP STRATEGIES TO BENEFIT OUR LOCAL AREA AND RESIDENTS. THE BOARD OF DIRECTORS OF COMMUNITY MEMORIAL HOSPITAL HAVE CHOSEN TO ADDRESS MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT AS THE PRIMARY NEEDS FROM THE ASSESSMENT. ALTHOUGH THE REMAINING IDENTIFIED NEEDS ARE NOT BEING ADDRESSED AT THE CURRENT TIME, THEY CONTINUE TO HAVE IMPORTANCE AND WILL BE MONITORED AS WELL.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 3: THERE WERE 51 AGENCIES THAT RESPONDED TO THE NEEDS ASSESSMENT SURVEY THAT WAS CONDUCTED. THE AGENCIES CONSISTED OF SCHOOLS, BUSINESSES, CHURCHES, COMMUNITY ORGANIZATIONS, PUBLIC HEALTH AGENCIES, HEALTHCARE PROVIDERS, WELLNESS PROVIDERS, INSTITUTIONS OF HIGHER LEARNING AND OTHERS. THIS SURVEY SAMPLE REPRESENTED A LARGE CROSS-SECTION OF THE POPULATION AREAS IN ALL OF THE COMMUNITIES INCLUDED IN THE ASSESSMENT. THE SERVICE AREA THAT WAS SURVEYED INCLUDED 10 COUNTIES THAT ARE ALL SERVED BY THE HOSPITALS THAT COLLABORATED IN THE NEEDS ASSESSMENT PROCESS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 4: GRUNDY COUNTY MEMORIAL HOSPITAL, GRUNDY CENTER, IAUNITYPOINT - ALLEN HOSPITAL, WATERLOO, IAWAVERLY HEALTH CENTER, WAVERLY, IAWHEATON FRANSISCAN HEALTHCARE - COVENANT MEDICAL CENTER, WATERLOO, IAWHEATON FRANSISCAN HEALTHCARE - SARTORI MEMORIAL HOSPITAL, CEDAR FALLS, IAWHEATON FRANSISCAN HEALTHCARE - MERCY HOSPITAL, OELWEIN, IA
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 6I: THE BOARD OF DIRECTORS REVIEWED THE LIST OF NEEDS IDENTIFIED USING 2 DIFFERENT METHODS. THE FIRST METHOD WAS BY SIMPLY LOOKING AT THE NUMBER OF RESPONSES RECEIVED FOR EACH INDIVIDUAL NEED. THE SECOND METHOD WAS TO LOOK AT WEIGHTED RESULTS FROM THE SURVEY. THE WEIGHTED RESULTS ARE DONE BY ASSIGNING A POINT VALUE FOR LEVEL OF PRIORITY ASSIGNED, WHICH THEN TAKES INTO ACCOUNT THE LEVEL OF IMPORTANCE FOR THE RESPONDENT. THESE SEPARATE MECHANISMS RESULTED IN THE SAME TOP 3 NEEDS BEING RECOGNIZED BY COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS TO DEVELOP A PLAN AND CREATE AN IMPLEMENTATION PLAN. THE NEEDS THAT HAVE BEEN CHOSEN TO ADDRESS INCLUDE MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT. THE BOARD OF DIRECTORS SAW THAT THESE NEEDS FALL WITHIN THE SCOPE OF THE MISSION AND EACH COVERS A BROAD SPECTRUM AND OFFER ONGOING OPPORTUNITIES FOR IMPROVEMENT. THE BOARD OF DIRECTORS IS COMMITTED TO THE SUCCESS AND SUSTAINABILITY OF QUALITY LOCAL HEALTHCARE AND PLACING A FOCUS ON THESE THREE NEEDS HELPS ACHIEVE THIS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 7: THE REMAINING NEEDS ON THE NEEDS ASSESSMENT INCLUDE ELDERLY, YOUTH, NUTRITION, WOMEN'S HEALTH, DENTAL HEALTH, PHYSICAL ACTIVITY, SUBSTANCE ABUSE, SEXUAL HEALTH, ETHNIC/MINORITY GROUPS, VISION/EYE HEALTH, HEALTH LITERACY AND VETERANS. IT IS NOT TO SAY THAT THESE NEEDS WILL NOT BE ADDRESSED OR FOLLOWED BY THE HOSPITAL, BUT INSTEAD ARE NOT INCLUDED IN THE CHNA IMPLEMENTATION STRATEGY. THE HOSPITAL WILL MONITOR THE OVERALL NEEDS OF THE COMMUNITY SERVED AND RE-ASSESS AS WE MOVE FORWARD. IN ADDITION, THERE ARE SERVICES, ORGANIZATIONS AND BUSINESSES WITHIN THE SERVICE AREA THAT WERE IDENTIFIED THAT FOCUS ON THESE NEEDS CURRENTLY.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 18E: THE HOSPITAL MADE NO SUCH EFFORTS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 20D: CMH CHARGES ALL PATIENTS THE SAME AMOUNT WHEN THE SAME CARE IS GIVEN REGARDLESS OF IF THEY HAVE INSURANCE COVERAGE OR WHAT CARRIER THEY HAVE FOR INSURANCE. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, AN ADJUSTMENT IS MADE TO THEIR ACCOUNT BASED ON THEIR QUALIFYING RATES.

Schedule H (Form 990) 2013

Page

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2013

Page

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 1J: THE STEERING COMMITTEE FROM THE NEEDS ASSESSMENT UTILITZED THE INFORMATION GATHERED TO IDENTIFY A LIST OF 15 NEED CATEGORIES. THESE CATEGORIES INCLUDED: 1) ACCESS, 2) CHRONIC DISEASE MANAGEMENT, 3) DENTAL HEALTH, 4) ELDERLY POPULATION, 5) ETHNICITIES/MINORITIES, 6) HEALTH LITERACY, 7) MENTAL HEALTH, 8) NUTRITION, 9) PHYSICAL ACTIVITY, 10) SEXUAL HEALTH, 11) SUBSTANCE ABUSE, 12) VETERANS, 13) VISION HEALTH, 14) WOMEN'S HEALTH AND 15) YOUTH. COMMUNITY MEMORIAL HOSPITAL USED THE INFORMATION PRESENTED IN THIS PROCESS TO FOCUS IN ON RESULTS RECEIVED FROM THOSE WE SERVE AND DEVELOP STRATEGIES TO BENEFIT OUR LOCAL AREA AND RESIDENTS. THE BOARD OF DIRECTORS OF COMMUNITY MEMORIAL HOSPITAL HAVE CHOSEN TO ADDRESS MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT AS THE PRIMARY NEEDS FROM THE ASSESSMENT. ALTHOUGH THE REMAINING IDENTIFIED NEEDS ARE NOT BEING ADDRESSED AT THE CURRENT TIME, THEY CONTINUE TO HAVE IMPORTANCE AND WILL BE MONITORED AS WELL.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 3: THERE WERE 51 AGENCIES THAT RESPONDED TO THE NEEDS ASSESSMENT SURVEY THAT WAS CONDUCTED. THE AGENCIES CONSISTED OF SCHOOLS, BUSINESSES, CHURCHES, COMMUNITY ORGANIZATIONS, PUBLIC HEALTH AGENCIES, HEALTHCARE PROVIDERS, WELLNESS PROVIDERS, INSTITUTIONS OF HIGHER LEARNING AND OTHERS. THIS SURVEY SAMPLE REPRESENTED A LARGE CROSS-SECTION OF THE POPULATION AREAS IN ALL OF THE COMMUNITIES INCLUDED IN THE ASSESSMENT. THE SERVICE AREA THAT WAS SURVEYED INCLUDED 10 COUNTIES THAT ARE ALL SERVED BY THE HOSPITALS THAT COLLABORATED IN THE NEEDS ASSESSMENT PROCESS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 4: GRUNDY COUNTY MEMORIAL HOSPITAL, GRUNDY CENTER, IAUNITYPOINT - ALLEN HOSPITAL, WATERLOO, IAWAVERLY HEALTH CENTER, WAVERLY, IAWHEATON FRANSISCAN HEALTHCARE - COVENANT MEDICAL CENTER, WATERLOO, IAWHEATON FRANSISCAN HEALTHCARE - SARTORI MEMORIAL HOSPITAL, CEDAR FALLS, IAWHEATON FRANSISCAN HEALTHCARE - MERCY HOSPITAL, OELWEIN, IA
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 6I: THE BOARD OF DIRECTORS REVIEWED THE LIST OF NEEDS IDENTIFIED USING 2 DIFFERENT METHODS. THE FIRST METHOD WAS BY SIMPLY LOOKING AT THE NUMBER OF RESPONSES RECEIVED FOR EACH INDIVIDUAL NEED. THE SECOND METHOD WAS TO LOOK AT WEIGHTED RESULTS FROM THE SURVEY. THE WEIGHTED RESULTS ARE DONE BY ASSIGNING A POINT VALUE FOR LEVEL OF PRIORITY ASSIGNED, WHICH THEN TAKES INTO ACCOUNT THE LEVEL OF IMPORTANCE FOR THE RESPONDENT. THESE SEPARATE MECHANISMS RESULTED IN THE SAME TOP 3 NEEDS BEING RECOGNIZED BY COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS TO DEVELOP A PLAN AND CREATE AN IMPLEMENTATION PLAN. THE NEEDS THAT HAVE BEEN CHOSEN TO ADDRESS INCLUDE MENTAL HEALTH, ACCESS AND CHRONIC DISEASE MANAGEMENT. THE BOARD OF DIRECTORS SAW THAT THESE NEEDS FALL WITHIN THE SCOPE OF THE MISSION AND EACH COVERS A BROAD SPECTRUM AND OFFER ONGOING OPPORTUNITIES FOR IMPROVEMENT. THE BOARD OF DIRECTORS IS COMMITTED TO THE SUCCESS AND SUSTAINABILITY OF QUALITY LOCAL HEALTHCARE AND PLACING A FOCUS ON THESE THREE NEEDS HELPS ACHIEVE THIS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 7: THE REMAINING NEEDS ON THE NEEDS ASSESSMENT INCLUDE ELDERLY, YOUTH, NUTRITION, WOMEN'S HEALTH, DENTAL HEALTH, PHYSICAL ACTIVITY, SUBSTANCE ABUSE, SEXUAL HEALTH, ETHNIC/MINORITY GROUPS, VISION/EYE HEALTH, HEALTH LITERACY AND VETERANS. IT IS NOT TO SAY THAT THESE NEEDS WILL NOT BE ADDRESSED OR FOLLOWED BY THE HOSPITAL, BUT INSTEAD ARE NOT INCLUDED IN THE CHNA IMPLEMENTATION STRATEGY. THE HOSPITAL WILL MONITOR THE OVERALL NEEDS OF THE COMMUNITY SERVED AND RE-ASSESS AS WE MOVE FORWARD. IN ADDITION, THERE ARE SERVICES, ORGANIZATIONS AND BUSINESSES WITHIN THE SERVICE AREA THAT WERE IDENTIFIED THAT FOCUS ON THESE NEEDS CURRENTLY.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 18E: THE HOSPITAL MADE NO SUCH EFFORTS.
COMMUNITY MEMORIAL HOSPITAL	PART V, SECTION B, LINE 20D: CMH CHARGES ALL PATIENTS THE SAME AMOUNT WHEN THE SAME CARE IS GIVEN REGARDLESS OF IF THEY HAVE INSURANCE COVERAGE OR WHAT CARRIER THEY HAVE FOR INSURANCE. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, AN ADJUSTMENT IS MADE TO THEIR ACCOUNT BASED ON THEIR QUALIFYING RATES.

Schedule H (Form 990) 2013

Additional Data

Software ID:
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Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2013

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)MARY WELLSCEO	(i) (ii)	139,184 0	2,766 0	0 0	7,255 0	15,177 0	164,382 0	0 0
(2)TROY BUCHHOLZPHYSICIAN	(i) (ii)	278,241 0	50,125 0	270 0	12,750 0	26,974 0	368,360 0	0 0
(3)JEFFREY ROSKEPHYSICIAN	(i) (ii)	121,658 0	25,000 0	33,506 0	2,850 0	7,135 0	190,149 0	0 0

Schedule J (Form 990) 2013

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Return Reference	Explanation
PART I, LINE 3	THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH. A CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION.

Schedule J (Form 990) 2013

Additional Data

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Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(c) Description of transaction	(d) Corrected?
1(a) Name of disqualified person	(c) Description of transaction	Yes	No

Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22

(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	(d) Loan to or from the organization?		(e)Original principal amount	(f)Balance due	(g) In default?		(h) Approved by board or committee?		(i)Written agreement?
(a) Name of interested person	(b) Relationship with organization	(c) Purpose of loan	To	From	(e)Original principal amount	(f)Balance due	Yes	No	Yes	No	Yes	No






Total ...... $

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of assistance	(d) Type of assistance	(e) Purpose of assistance

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2013

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) JUSTIN TRAINOR	SPOUSE OF INDIVIDUAL WHO WAS CFO THRU 8/31/13	417,776	PERFORMANCE REHAB IS 40% OWNED BY JUSTIN TRAINOR, THE SPOUSE OF SARA TRAINOR, CFO THRU 8/31/13. THIS ENTITY PROVIDES PHYSICAL AND OCCUPATIONAL THERAPIES AT CMH. PERFORMANCE REHAB'S COMPENSATION FROM CMH IS CALCULATED AS A PERCENTAGE OF CMH'S NET REIMBURSEMENT FOR THERAPY SERVICES.	Yes
(2) ROBERT L RAWLINS	SON-IN-LAW OF BOARD MEMBER	23,206	ROBERT L. RAWLINS IS A COMPENSATED EMPLOYEE OF CMH AND ALSO THE SON-IN-LAW OF BOARD MEMBER, DIANE PAGEL.		No

Part V

Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).

Return Reference	Explanation

Schedule L (Form 990 or 990-EZ) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 3	THE ORGANIZATION HAS AN EXTENDED MANAGEMENT CONTRACT WITH UNITYPOINT HEALTH - WATERLOO, FORMALLY KNOWN AS ALLEN HEALTH SYSTEMS.
FORM 990, PART VI, SECTION A, LINE 6	THE ORGANIZATION'S ARTICLES OF INCORPORATION PROVIDE THAT THE CORPORATION "HAS NO CAPITAL STOCK AND THE CAPITAL OF THIS ASSOCIATION SHALL BE THE MEMBERSHIP FEES . . . FIXED BY THE BOARD OF DIRECTORS". ANYONE IN THE COMMUNITY MAY BE A MEMBER OF THE CORPORATION UPON PAYMENT OF THE $1 MEMBERSHIP FEE, AS FIXED BY THE BOARD OF DIRECTORS ACCORDING TO THE BYLAWS. THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7A	EACH BOARD OF DIRECTOR SHALL BE ELECTED BY THE LARGEST VOTE CAST BY THE MEMBERS PRESENT AT THE ANNUAL MEETING. ABSENTEE BALLOTS WILL BE ALLOWED FOR EMPLOYEES WORKING AT COMMUNITY MEMORIAL HOSPITAL DURING THE ACTUAL HOURS OF THE ANNUAL MEETING.
FORM 990, PART VI, SECTION A, LINE 7B	IN 2003, COMMUNITY MEMORIAL HOSPITAL (CMH) ENTERED INTO AN OPERATING AGREEMENT WITH UNITYPOINT HEALTH. UNDER THE TERMS OF THAT AGREEMENT, A JOINT GOVERNANCE STRUCTURE WAS ESTABLISHED, WHEREBY UNITYPOINT HEALTH AND THE BOARD OF DIRECTORS OF CMH EXERCISE JOINT AUTHORITY FOR THE OPERATION OF THE HOSPITAL. WHILE UNITYPOINT HEALTH HAS DAY-TO-DAY OPERATIONAL CONTROL, CERTAIN GOVERNANCE AUTHORITY ACTIONS REQUIRE THE PARTICIPATION OF BOTH UNITYPOINT'S AND CMH'S BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11	THE IRS FORM 990 IS PRESENTED TO THE CMH BOARD OF DIRECTORS AT A REGULARLY SCHEDULED MONTHLY MEETING FOR REVIEW. IT WILL BE NOTED AS AN AGENDA ITEM UNDER "NEW BUSINESS" AND REQUIRES THE PROPER APPROVAL FROM THE BOARD PRIOR TO BEING SUBMITTED TO IRS.
FORM 990, PART VI, SECTION B, LINE 12C	THE BOARD OF DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE/QUESTIONNAIRE. THESE ARE REVIEWED BY THE CEO AND BOARD CHAIR. EACH MONTH THERE IS AN AGENDA ITEM AT THE BOARD MEETING FOR ANY CONFLICTS RELATED TO THE REST OF THE AGENDA TO BE DISCLOSED. IF NONE ARE NOTED, BUT THE BOARD CHAIR FEELS ONE EXISTS, IT IS THE CHAIR'S RESPONSIBILITY TO INQUIRE ABOUT IT BEFORE PROCEEDING. WHEN THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT ABSTAINS FROM VOTING.
FORM 990, PART VI, SECTION C, LINE 19	THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, FINANCIAL STATEMENTS ARE MADE AVAILABLE AT THE SUMNER COMMUNITY CLUB MEETING AND A PERSON MAY BECOME A MEMBER OF THE SUMNER COMMUNITY CLUB BY PAYING THE $1.00 ANNUAL MEMBERSHIP FEE.
FORM 990, PART IX, LINE 11G	OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 656,790. MANAGEMENT AND GENERAL EXPENSES 289,039. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 945,829. EMERGENCY ROOM SPECIALIST FEES: PROGRAM SERVICE EXPENSES 660,028. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 660,028. PHYSICAL THERAPY FEES: PROGRAM SERVICE EXPENSES 405,600. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 405,600. ANESTHESIOLOGIST FEES: PROGRAM SERVICE EXPENSES 156,414. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 156,414.
FORM 990, PAGE 12, PART XII, LINE 2C:	THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS.
FORM 990, PAGE 6, PART VI, SECTION B, LINE 15	THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH. THE CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR MARY WELLS, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. THE CMH CEO IS RESPONSIBLE FOR SETTING THE SALARIES OF DAWN EVERDING, CFO AND LYNNE NIEMANN, DIRECTOR OF NURSING (BOTH ARE OFFICERS). COMPARABILITY DATA IS ALSO USED IN SETTING THE OFFICERS' COMPENSATION.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2013

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

SUMNER COMMUNITY CLUB

Employer identification number

42-0670596

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION 909 W 1ST STREET SUMNER,IA50674 42-1408693	HOSPITAL FOUNDATION	IA	501(C)(3)	LINE 7	SUMNER COMMUNITY CLUB	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2013

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2013

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION	C	499,642	CASH GIFT

Schedule R (Form 990) 2013

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V?UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V?UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2013

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2013

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: COMMUNITY MEMORIAL HOSPITAL SERVES THE AREA THROUGH ITS HEALTHCARE AND EDUCATIONAL SERVICES. WE EMPHASIZE CONCERN FOR THE QUALITY OF A PERSON'S LIFE, THROUGH EVERY MEASURE INTENDED TO PRESERVE LIFE WITH DIGNITY AND RESPECT. WE ARE DEDICATED TO CREATING AND MAINTAINING AN ENVIRONMENT SUPPORTING EXCELLENCE IN HEALTHCARE. WE PROVIDE QUALIFIED AND PROPERLY TRAINED PERSONNEL AND MEDICAL STAFF IN AN ATMOSPHERE WHICH INSPIRES A CREATIVE APPROACH TO THE COMPLEX HEALTHCARE CHALLENGES OF TODAY AND TOMORROW.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	12
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	11
5	Total number of individuals employed in calendar year 2013 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	26
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	1,318
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	-87

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,694,875	685,564
9	Program service revenue (Part VIII, line 2g) .........	9,527,751	11,404,134
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	-6,172	138,114
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	149,207	216,100
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	11,365,661	12,443,912
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	5,088,957	5,439,822
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	4,766,967	6,440,853
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	9,855,924	11,880,675
19	Revenue less expenses. Subtract line 18 from line 12.......	1,509,737	563,237
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	30,929,002	32,435,569
21	Total liabilities (Part X, line 26).............	20,970,674	21,602,309
22	Net assets or fund balances. Subtract line 21 from line 20.....	9,958,328	10,833,260

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 1,144,721 including grants of $ ) (Revenue $ 1,987,902 )
	COMMUNITY MEMORIAL HOSPITAL (CMH) MEDICAL CLINIC CONTINUED TO SERVE SUMNER, IA AND THE SURROUNDING AREA IN THE YEAR 2013. CMH CLINIC WAS STAFFED WITH 3 PROVIDERS UNTIL JULY, WHEN A FOURTH PROVIDER WAS ADDED. THE CMH CLINIC NOW HAS TWO NURSE PRACTITIONERS AND TWO PHYSICIANS. PATIENTS WERE SERVED IN MANY CAPACITIES INCLUDING, BUT NOT LIMITED TO, WELL CHILD VISITS, IMMUNIZATIONS, ROUTINE PEDIATRIC CARE, SHARED MATERNITY CARE, WOUND CARE, THERAPEUTIC INJECTIONS AND MANIPULATION TREATMENTS. PATIENTS RANGED FROM NEWBORN TO GERIATRIC. A 50-MILE RADIUS OF SUMNER WAS SERVED WITH A TOTAL PATIENT VOLUME OF 7,712 FOR 2013. IN ADDITION TO CLINIC VISITS, OUR PROVIDERS CONTINUE THEIR SERVICE TO SURROUNDING NURSING HOMES WITH PATIENTS SEEN MONTHLY AT HILLCREST HOME IN SUMNER AND TRIPOLI NURSING & REHAB IN TRIPOLI. OTHER SERVICES TO THE COMMUNITY WERE PHYSICALS FOR AREA FIREFIGHTERS AND EMS AGENCIES AND POST-JOB OFFER PHYSICALS FOR TWO LOCAL BUSINESSES. PROVIDERS CONTINUE TO TAKE CALL FOR THE EMERGENCY DEPARTMENT ON A REGULAR SCHEDULED BASIS THROUGHOUT EACH MONTH. CLINIC STAFF CONTINUED TO GO TO AN AREA BANK THE FIRST TUESDAY OF EACH MONTH TO OFFER FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. PROVIDERS AVIDLY PRECEPT FOR STUDENTS VARIOUS PROGRAMS WITH ALLEN COLLEGE IN WATERLOO, IA TAKING ADVANTAGE OF THIS IN 2013. THE CLINIC HOURS ARE MONDAY THROUGH FRIDAY STARTING AT 7 AM AND ENDING AT 5 PM.

4b	(Code: ) (Expenses $ 1,119,521 including grants of $ ) (Revenue $ 1,345,942 )
	ACUTE NURSING HAD 335 ADMISSIONS IN 2013. CMH UTILIZES A COMPANY CALLED MCKESSON'S INTERQUAL FOR QUALIFYING PATIENTS TO DETERMINE IF THEY MEET INPATIENT ADMISSION CRITERIA. THE AVERAGE LENGTH OF STAY FOR ACUTE WAS 60.16 HOURS. THIS IS WELL BELOW THE 96 HOURS THRESHOLD FOR CRITICAL ACCESS.

4c	(Code: ) (Expenses $ 888,611 including grants of $ ) (Revenue $ 1,192,351 )
	THE CMH EMERGENCY DEPARTMENT SERVED 1,238 PATIENTS IN 2013. THIS IS AN INCREASE OF 120 PATIENT VISITS FROM 1,118 VISITS IN 2012. THE NUMBER OF PHYSICIAN HOURS SPENT IN THE EMERGENCY DEPARTMENT INCREASED FROM 2,062 IN 2012 TO 2,655 IN 2013. IN 2013, THE EMERGENCY DEPARTMENT IMPLEMENTED CQI PROJECTS DOCUMENTATION OF MECHANISM OF INJURY, CHIEF COMPLAINT, TIME ASPIRIN TAKEN PRIOR TO ARRIVAL FOR CHEST PAIN PATIENTS, ACUITY LEVELS, AND RETURN VISITS FOR PATIENTS WITH THE SAME COMPLAINT.THE EDUCATIONAL FOCUS FOR 2013 CENTERED ON MONTHLY TRAUMA TRAINING TRACC'S PROVIDED BY HENNEPIN COUNTY HOSPITAL. OTHER AREAS OF EDUCATION WERE THE CONTINUATION OF MONTHLY MOCK CODES, HAZMAT TRAINING, ALICE TRAINING, AND ACUTE STROKE MANAGEMENT.

	(Code: ) (Expenses $ 7,173,768 including grants of $ ) (Revenue $ 7,031,279 )
	VARIOUS INPATIENT AND OTHER HEALTH CARE SERVICES.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 7,173,768 including grants of $ ) (Revenue $ 7,031,279 )
4e	Total program service expenses10,326,621

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,099,202	0	153,321

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) JEFFREY ROSKE........................................................................ PHYSICIAN	40.00 .......................0.00	X	180,164	0	9,985
(19) CAMILLE ELLIOT........................................................................ ARNP	40.00 .......................0.00	X	114,366	0	11,900
(20) ROBERTA MITTELSTED........................................................................ ARNP	40.00 .......................0.00	X	113,299	0	21,417

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512-514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		499,642
e	Government grants (contributions)1e		24,510

f	All other contributions, gifts, grants, and similar amounts not included above1f		161,412

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			685,564
			Business Code
2a	MEDICARE/MEDICAID PAYMENTS		621400	6,667,295	6,667,295
b	PATIENT REVENUE - PRIVATE PAY		621400	4,193,646	4,193,646
c	MEANINGFUL USE INCENTIVE PAYMENT		621400	488,073	488,073
d	COMMUNITY WELLNESS		621990	20,800	20,800
e
f	All other program service revenue .			34,320	34,320
g	Total. Add lines 2a–2f........			11,404,134
3	Investment income (including dividends, interest, and other similar amounts).......			16,409			16,409
4	Income from investment of tax-exempt bond proceeds..
5	Royalties...........
		(i) Real	(ii) Personal
6a	Gross rents	33,512
b	Less: rental expenses	0
c	Rental income or (loss)	33,512
d	Net rental income or (loss).......			33,512			33,512
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory		167,530
b	Less: cost or other basis and sales expenses		45,825
c	Gain or (loss)		121,705
d	Net gain or (loss)..........			121,705			121,705
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..
Miscellaneous Revenue			Business Code
11a	AMH OPERATING AGREEMENT INCOME		561000	153,340	153,340
b	CAFETERIA EMPLOYEES		900099	27,930			27,930
c	CATERING		722320	1,318		1,318
d	All other revenue ....
e	Total. Add lines 11a–11d ......			182,588
12	Total revenue. See Instructions......			12,443,912	11,557,474	1,318	199,556


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............			100	1	100
2	Savings and temporary cash investments .........			3,435,704	2	7,434,635
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			1,301,417	4	2,134,687
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
					6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			108,269	8	118,771
9	Prepaid expenses and deferred charges ..........			302,422	9	99,318
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	21,109,566
b	Less: accumulated depreciation .....	10b	3,094,841	16,049,786	10c	18,014,725
11	Investments—publicly traded securities ..........			5,204,499	11	0
12	Investments—other securities. See Part IV, line 11 .....			4,171,601	12	4,483,296
13	Investments—program-related. See Part IV, line 11 .....				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			355,204	15	150,037
16	Total assets. Add lines 1 through 15 (must equal line 34)......			30,929,002	16	32,435,569
17	Accounts payable and accrued expenses .........			2,885,944	17	1,156,384
18	Grants payable .................				18
19	Deferred revenue ................				19
20	Tax-exempt bond liabilities .............			18,000,000	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..			62,978	23	18,000,000
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			21,752	25	2,445,925
26	Total liabilities. Add lines 17 through 25.........			20,970,674	26	21,602,309
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			5,786,727	27	6,349,964
28	Temporarily restricted net assets ...........				28	0
29	Permanently restricted net assets ...........			4,171,601	29	4,483,296
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			9,958,328	33	10,833,260
34	Total liabilities and net assets/fund balances ........			30,929,002	34	32,435,569