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      <ContributorInformationGrp>
        <ContributorNum>RESTRICTED</ContributorNum>
        <ContributorBusinessName>
          <BusinessNameLine1>RESTRICTED</BusinessNameLine1>
        </ContributorBusinessName>
        <ContributorUSAddress>
          <AddressLine1>RESTRICTED</AddressLine1>
          <AddressLine2>RESTRICTED</AddressLine2>
          <City>RESTRICTED</City>
          <State>RESTRICTED</State>
          <ZIPCode>RESTRICTED</ZIPCode>
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      <DisclosedForCharitablePrpsInd>false</DisclosedForCharitablePrpsInd>
      <WrittenPolicyMonitoringInd>false</WrittenPolicyMonitoringInd>
      <Section170hRqrStsfdInd>false</Section170hRqrStsfdInd>
      <SolicitedAssetsSaleInd>false</SolicitedAssetsSaleInd>
      <AgentTrusteeEtcInd>true</AgentTrusteeEtcInd>
      <BeginningBalanceAmt>730602</BeginningBalanceAmt>
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      <EndingBalanceAmt>735556</EndingBalanceAmt>
      <InclEscrowCustodialAcctLiabInd>true</InclEscrowCustodialAcctLiabInd>
      <EndowmentsHeldUnrelatedOrgInd>false</EndowmentsHeldUnrelatedOrgInd>
      <EndowmentsHeldRelatedOrgInd>false</EndowmentsHeldRelatedOrgInd>
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        <FormAndLineReferenceDesc>P4, Ln 1b</FormAndLineReferenceDesc>
        <ExplanationTxt>FOUNDATION MAINTAINS A DONOR RESTRICTED ENDOWMENT FUND</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>P4, Ln 1b</FormAndLineReferenceDesc>
        <ExplanationTxt>AS WELL AS BANK ACCOUNTS THAT ARE RESTRICTED FOR EMS</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>P4, Ln 1b</FormAndLineReferenceDesc>
        <ExplanationTxt>AS WELL AS HOSPITAL RESTRICTED FUNDS FROM SALE</ExplanationTxt>
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        <Event2Nm>GOLF TOURNAMENT</Event2Nm>
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        <GrossRevenueEvent2Amt>8448</GrossRevenueEvent2Amt>
        <OtherDirectExpensesEvent2Amt>1538</OtherDirectExpensesEvent2Amt>
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        <DirectExpenseSummaryEventsAmt>5522</DirectExpenseSummaryEventsAmt>
        <NetIncomeSummaryAmt>15741</NetIncomeSummaryAmt>
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        <PurposeOfGrantTxt>CARM PAIN MANAGEMENT UNIT</PurposeOfGrantTxt>
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          <BusinessNameLine1Txt>MERCYONE HOSPITAL ELKADER</BusinessNameLine1Txt>
        </RecipientBusinessName>
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          <AddressLine1Txt>901 DAVIDSON ST NW</AddressLine1Txt>
          <CityNm>ELKADER</CityNm>
          <StateAbbreviationCd>IA</StateAbbreviationCd>
          <ZIPCd>52043</ZIPCd>
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        <RecipientEIN>420818642</RecipientEIN>
        <CashGrantAmt>10000</CashGrantAmt>
        <NonCashAssistanceAmt>0</NonCashAssistanceAmt>
        <PurposeOfGrantTxt>EMS COT</PurposeOfGrantTxt>
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        <FormAndLineReferenceDesc>Part VI Line 2</FormAndLineReferenceDesc>
        <ExplanationTxt>MICHAEL BECK PROVIDES INSURANCE TO THE ORGANIZATION</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part VI Line 8a</FormAndLineReferenceDesc>
        <ExplanationTxt>ORGANIZATION DID CONTEMPORANEOUSLY DOCUMENT MEETINGS</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part VI Line 11b</FormAndLineReferenceDesc>
        <ExplanationTxt>COMPLETED 990 IS PRESENTED AND REVIEW BY BOARD PRIOR TO</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part VI Line 11b</FormAndLineReferenceDesc>
        <ExplanationTxt>FILING DEADLINE</ExplanationTxt>
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      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part VI Line 18</FormAndLineReferenceDesc>
        <ExplanationTxt>AVAILABLE UPON REQUEST</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part VI Line 19</FormAndLineReferenceDesc>
        <ExplanationTxt>AVAILABLE UPON REQUEST</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>Part XI Line 9</FormAndLineReferenceDesc>
        <ExplanationTxt>ROUNDING</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>PART VI LINE 8a</FormAndLineReferenceDesc>
        <ExplanationTxt>ORGANIZATION DID CONTEMPORANEOUSLY DOCUMENT MEETINGS</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>PART VI LINE 11b</FormAndLineReferenceDesc>
        <ExplanationTxt>COMPLETED 990 IS PRESENTED TO BOARD MEMBERS AT MEETING</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>PART VI LINE 11b</FormAndLineReferenceDesc>
        <ExplanationTxt>PRIOR TO FILING DEADLINE</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>PART VI LINE 18</FormAndLineReferenceDesc>
        <ExplanationTxt>AVAILABLE UPON REQUEST</ExplanationTxt>
      </SupplementalInformationDetail>
      <SupplementalInformationDetail>
        <FormAndLineReferenceDesc>PART VI LINE 19</FormAndLineReferenceDesc>
        <ExplanationTxt>AVAILABLE UPON REQUEST</ExplanationTxt>
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