• Bridges Healthcare, Inc.

    Bridges Healthcare, Inc.

    ANNUAL DISCLOSURE STATEMENT PERSONAL AND CONFIDENTIAL

  • Instructions: In connection with completing this disclosure statement, please review the Conflicts of Interest and Documentation Policy ("Policy") of Bridges Healthcare, Inc. ("Corporation" Terms used in this form with initial letters capitalized and not otherwise defined will have the meaning given to them in the Policy. When providing answers, if there is insufficient space, please complete your answer on a separate sheet of paper and attach to this form. Please submit the completed form to the Executive Office Manager.

  • Position with the Corporation (Check all that apply)*

  • Section I: POSITIONS AND FINANCIAL INTERESTS:

  • Note: For purposes of this disclosure statement, the family of an individual includes his or her spouse, ancestors, brother and sisters (whether whole or half-blood), children grandchildren, and (whether natural or adopted), spouses of brothers, sisters, children, and grandchildren.

  • Did you or any member of your family during the past year engage in, or do you anticipate that you or any member of your family will engage in, a transaction or arrangement with the Corporation?*
  • Do you or any member of your family hold, or anticipate holding, a Position (e.g., director, trustee, officer, employee, agent, consultant, advisor, etc.) with any entity that to the best of your knowledge and belief provides goods or services to, or has any other transaction or arrangement with, the Corporation or is negotiating such a transaction or arrangement? If yes, please answer Section VIII.*
  • Do you or any member of your family, directly or indirectly, have, or anticipate receiving or acquiring, a Financial Interest or receive any compensation (wages, commissions, fringe benefits, royalties, honoraria, fees, gifts, etc.) with respect to any entity that provides goods or services to, or during the past year or current year has had any other transaction or arrangement with, the Corporation or is negotiating such a transaction or arrangement?*

  • IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS IN SECTION I, PLEASE COMPLETE SECTION VIII OF THIS FORM. PLEASE FILL OUT A SEPARATE SECTION VIII FOR EACH FAMILY MEMBER FOR WHICH YOU ARE REPORTING.

  • Section II: EMPLOYER INFORMATION (FAMILY MEMBERS):

  • Does any member of your family hold a Position (e.g., director, officer, employee, agent, consultant, advisor, etc.) with the Corporation? If yes, please state his or her name, Position and relationship to you:*

  • Section III: OTHER INTERESTS:

  • Section IV: INDEPENDENCE OF BOARD MEMBER TO BE ANSWERED BY

  • Are you an independent board member? A member of the board is considered independent only if all three of these circumstances applied at all times during the Corporation's tax year.*
    1. The member was not compensated as an officer or other employee of Corporation or of a related organization, except for the religious the exception discussed below.
    2. The member did not receive total compensation or other payments exceeding $10,000 for the year from the Corporation or from related organizations as an independent contractor, other than reimbursement of expenses or reasonable compensation for services provided in the capacity as a member of the governing body. For example, a person who receives reasonable expense reimbursements and reasonable compensation as a director of the organization does not cease to be independent merely because he or she also receives payments of $7,500 from the Corporation for other arrangements.
    3. Neither the director, nor any family member of the director, was involved in a transaction with the Corporation, directly or indirectly through affiliation with another organization, that is required to be reported on Form 990, Schedule L (Transactions with Interested Persons) for the Corporation's tax year or in a transaction with a related organization of a type and amount that would be reportable on Form 990, Schedule L if required to be filed by the related organization. Generally, Schedule L transactions are transactions between the Corporation and one or more of its directors, officers, or key employees that are (Grants) and VII described in Sections VI (Business Transactions) of this disclosure statement.

    A member of the governing body is not considered to lack independence merely because of any of the following circumstances:

    1.  The member is a major donor to the Corporation, regardless of the amount of the contribution.
    2.  The member has taken a bona fide vow of poverty and either (a) receives compensation as an agent of a religious order or of a religious and apostolic organization, but only under circumstances in which the individual does not receive taxable income or (b) belongs to a religious order that receives sponsorship or payments from the organization that do not constitute taxable income to the member.
    3. The member receives financial benefits from the Corporation solely in the capacity of being a consumer of the charitable or other class served by the Corporation in the exercise of its function.

  • Section V: RELATIONSHIPS WITH OTHER OFFICERS, DIRECTORS, OR KEY EMPLOYEES

  • Do you have a family relationship with any other director, officer or key employee?*
  • Do you have a business relationship with any other director, officer or key employee?*

  •  Business relationships between two persons include the following:

    1.  One person is employed by the other in a sole proprietorship or by an organization with which the other is associated as a trustee, director, officer, key employee, or greater-than-35 percent owner.
    2. One person is transacting business with the other (other than in the ordinary course of either party's business on the same terms as are generally offered to the public), directly or indirectly, in one or more contracts of sale, lease, license, loan, performance of services, or other transaction involving transfers of cash or property valued in excess of $10,000 in the aggregate during the tax year. Indirect transactions are transactions with an organization with which the one person is associated as a trustee, director, officer, key employee, or greaterthan-35 percent owner.
    3. The two persons are each a director, trustee, officer, or greater than 10 percent owner in the same business or investment entity.

    Ownership is measured by stock ownership (either voting power or value) of a corporation, profits or capital interest in a partnership or limited liability company, membership interest in a nonprofit organization, or beneficial interest in a trust. Ownership includes indirect ownership (e.g., ownership in an entity that has ownership in the entity in question); there may be ownership through multiple tiers of entities. A business relationship does not include, for these purposes, the following privileged relationships: (1) attorney-client; (2) medical professional (including psychologist) and patient; and (3) priest/clergy and penitent/communicant.

  • Section VI: GRANTS FROM CORPORATION:

  • Did you or a related person receive a grant or assistance from the Corporation in the past year?*

  • A related person is a family member or an entity that is 35% controlled by you and your family. A related person also includes an entity (other than a tax-exempt entity under Section 501(c of which you were serving, at the time of the transaction, as an officer, director, trustee, key employee, partner/member with an ownership interest of more than 5% if the entity is taxable as an partnership, or a shareholder with an ownership interest of more than 5% if the entity is a professional corporation.

    Examples of grants are scholarships, fellowships, internships, prizes and awards.

  • Section VII: BUSINESS TRANSACTION WITH CORPORATION

  • Did you or a related person engage in a business transaction with the corporation?*

  • Business transactions include, but are not limited to, contracts of sale, lease, license, and performance of services whether initiated during the year or ongoing from a prior year. Business transactions also include joint ventures (new or ongoing) in which either the profits or capital interest of the Corporation and you (and/or a related person) each exceed 10%. Business transactions also include a transaction between the corporation and a management company if you are a direct or indirect 35% owner, or an officer, director, trustee, or key employee.

  • Section VIII: DISCLOSURE OF POSITIONS AND FINANCIAL INTERESTS

  • This section should be completed ONLY IF YOU ANSWERED "YES" to one or both of the questions in “Section I: POSITIONS AND FINANCIAL INTERESTS.” If you are disclosing multiple interests, please make the appropriate number of copies of this and the next page before completing.

  • PERSON HOLDING POSITION OR FINANCIAL INTEREST:

  • The disclosures made in this Section relate to a Position or Financial Interest held by:*

  • If a family member, indicate his or her name and relationship to you:

  • ENTITY OR INDIVIDUAL WITH RESPECT TO WHICH POSITION OR FINANCIAL INTEREST HELD:

  • Information regarding the entity with respect to which the Position or Financial Interest is held:

  • Type of Entity in which Interest is held

  • POSITION OR FINANCIAL INTEREST HELD:

  • Is a position held with the entity or individual? If Yes, please check all that apply:*
  • Please check all that apply:*
  • Is a Financial Interest held with respect to the entity or individual?*
  • If Yes, please check all that apply:*
  • Has the Position and/or the Financial Interest been affected by the provision of goods or services to, or other transaction or arrangement with, the Corporation or, to the best of your knowledge and belief, will such Position and/or Financial Interest be affected by such provision or other transaction or arrangement in the future?*

  • Section IX: SIGNATURE AND AFFIRMATION STATEMENT

  • By signing below, I am affirming that the foregoing answers on this disclosure statement are, to the best of my knowledge, true, accurate and correct, and that I have received a copy of the Corporation's Conflicts of Interest and Documentation Policy (the "Policy"), that I have read and understand the Policy, that I agree to comply with the Policy, and that I understand the Corporation is an entity that is exempt from federal income tax and must engage primarily in activities that accomplish one or more of its exempt purposes to maintain its tax exemption.

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