Schedule L
(Form 990 or 990-EZ)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet 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.
MediumBulletInformation 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
Arkansas Valley Regional Medical Center
 
Employer identification number

84-1465990
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 (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No





2
Enter the amount of tax incurred by organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
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?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
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
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Schedule L (Form 990 or 990-EZ) 2013
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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?
Yes No
(1) DALE LEIGHTY BOARD MEMBER 250,000 CD'S HELD AT BANK   No
(2) BOB BLAIR BOARD MEMBER 183,743 CD'S HELD AT BANK   No
(3) Roy Trivett Brother-in-law of CFO 19,783 Contractor Services   No
Part V
Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).
Return Reference Explanation
PART IV, LINE 1 DALE LEIGHTY IS A MEMBER ON THE BOARD OF DIRECTORS AND ALSO THE PRESIDENT OF FIRST NATIONAL BANK OF LAS ANIMAS WHERE THE MEDICAL CENTER Holds a certificate of Deposit.
PART IV, LINE 2 BOB BLAIR IS A MEMBER ON THE BOARD OF DIRECTORS AND ALSO THE PRESIDENT OF COLORADO EAST BANK WHERE THE MEDICAL CENTER holds a certificate of deposit.
PART IV, LINE 3 CFO Janette Benders brother-in-law, Roy Trivett, owns Royal Electrical Services. The hospital uses them for various services. The hospital paid them $19,783 during the fiscal year ended 03/31/2014.
Schedule L (Form 990 or 990-EZ) 2013


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