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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2017
Open to Public
Inspection
Name of the organization
HARBOR HOUSE
 
Employer identification number

36-4003095
Return Reference Explanation
FORM 990 PART V, LINE 1A AS PART OF THE COORDINATION OF SERVICES AGREEMENT WITH CHI HEALTH, CHI HEALTH PERFORMS THE ACCOUNTS PAYABLE FUNCTION FOR HARBOR HOUSE. HARBOR HOUSE REIMBURSES CHI HEALTH FOR VENDOR PAYMENTS, THEREFORE, NO FORMS 1099 ARE ISSUED BY HARBOR HOUSE. CHI HEALTH ISSUES THE FORMS 1099 AND COMPLIES WITH BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS.
FORM 990, PART VI, SECTION A, LINE 2 STEVE GOESER AND JACKIE THIELEN - BUSINESS RELATIONSHIP. JOANIE KUSH AND JAMES SUMMERFELT - BUSINESS RELATIONSHIP. NEIL FORTKAMP, THERESA FRANCO AND JAMES SUMMERFELT - BUSINESS RELATIONSHIP.
FORM 990, PART VI, SECTION A, LINE 3 HARBOR HOUSE ENTERED INTO A COORDINATION OF SERVICES AGREEMENT WITH CHI HEALTH TO PERFORM AND MANAGE FINANCIAL SERVICES FOR A MONTHLY FEE. SERVICES INCLUDE BUT ARE NOT LIMITED TO FINANCIAL REPORTING, BUDGETING, BILLING AND COLLECTIONS AND FIXED ASSET MANAGEMENT. IN ADDITION TO FINANCIAL SERVICES, CHI HEALTH PROVIDES INFORMATION SYSTEMS SUPPORT, SECURITY, RISK MANAGEMENT AND CORPORATE COMPLIANCE, PURCHASING, MAINTENANCE AND VARIOUS OTHER SUPPORT SERVICES.
FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATE MEMBERS OF HARBOR HOUSE ARE CHI HEALTH, THE VISITING NURSE ASSOCIATION OF THE MIDLANDS, NEBRASKA METHODIST HOSPITAL AND THE NEBRASKA MEDICAL CENTER.
FORM 990, PART VI, SECTION A, LINE 7A EACH CORPORATE MEMBER WILL BE EQUALLY REPRESENTED ON THE BOARD OF DIRECTORS. THE NUMBER OF VOTING DIRECTORS SHALL BE NO LESS THAN FOUR (4), THE EXACT NUMBER TO BE DETERMINED FROM TIME TO TIME BY DECISION OF THE CORPORATE MEMBERS. CURRENTLY, EACH MEMBER APPOINTS SIX (6) DIRECTORS, FOR A TOTAL OF TWENTY-FOUR (24) DIRECTORS.
FORM 990, PART VI, SECTION A, LINE 7B SUBJECT TO THE NEBRASKA NONPROFIT CORPORATION ACT AND OTHER APPLICABLE LAW, THE CORPORATE MEMBERS, BY UNANIMOUS AGREEMENT, SHALL HAVE THE POWER TO A) FIX THE NUMBER OF DIRECTORS OF THE CORPORATION B) APPROVE, AMEND, OR REPEAL THE BYLAWS OR ARTICLES OF INCORPORATION OF THE CORPORATION C) APPROVE THE MERGER, DISSOLUTION OR CONSOLIDATION OR REORGANIZATION OF THE CORPORATION D) APPROVE THE FORMATION OF OTHER ENTITIES BY THE CORPORATION E) APPROVE THE ACQUISITION, SALE, LEASE, TRANSFER OR OTHER ALIENATION OF SUBSTANTIALLY ALL OF THE PROPERTY OF THE CORPORATION, OTHER THAN IN THE USUAL AND REGULAR COURSE OF THE CORPORATIONS BUSINESS F) APPROVE DEBT INCURRED BY THE CORPORATION IN EXCESS OF $25,000 G) APPROVE THE LONG-RANGE FINANCIAL AND STRATEGIC PLAN FOR THE CORPORATION H) APPROVE ASSESSMENT UPON, OR REQUIRE CAPITAL CONTRIBUTIONS BY, THE CORPORATE MEMBERS I) APPROVE ANY DISTRIBUTIONS OF CAPITAL OR NET EARNINGS OF THE CORPORATION UPON EXERCISE OF ANY POWER DESCRIBED ABOVE, EACH CORPORATE MEMBER SHALL PROMPTLY DELIVER TO THE CORPORATION A DULY EXECUTED CERTIFICATE OR OTHER DOCUMENT EVIDENCING THE APPROVAL OF THAT EXERCISE OF POWER BY SUCH CORPORATE MEMBER.
FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY HARBOR HOUSES'S FINANCE COMMITTEE. THE BOARD OF DIRECTORS ARE PROVIDED THE FORM 990 ELECTRONICALLY TO REVIEW AND ASK QUESTIONS PRIOR TO THE FILING.
FORM 990, PART VI, SECTION B, LINE 12C HARBOR HOUSE HAS ADOPTED THE CONFLICT INVESTIGATION PROCESS OF CHI HEALTH. ANNUAL COMPLETION OF THE DISCLOSURE STATEMENT IS REQUIRED BY THE BOARD OF DIRECTORS. STATED DISCLOSURES ARE INVESTIGATED BY AN APPOINTED DISINTERESTED PERSON OR COMMITTEE THAT IS SELECTED BY THE CHAIRMAN OF THE BOARD. AFTER EXCERCISING DUE DILIGENCE, THE BOARD SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANAGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION. FINALLY, THE BOARD MAKES ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT. IN CONFORMITY WITH SUCH DETERMINATION, AT ANY TIME A BOARD MEMBER MAY DECLARE A CONFLICT OF INTEREST AND RECUSE HIM/HERSELF FROM THE DISCUSSION. THE INDIVIDUAL IS ALSO REQUIRED TO DISCLOSE ANY KNOWN OR POSSIBLE CONFLICTS OF INTEREST THAT ARISE DURING THE CALENDAR YEAR.
FORM 990, PART VI, SECTION C, LINE 19 HARBOR HOUSE HAS ADOPTED THE CONFLICT OF INTEREST POLICY OF CHI HEALTH, WHICH IS AVAILABLE TO THE PUBLIC AT WWW.CHIHEALTH.COM. HARBOR HOUSE DOES NOT MAKE THE GOVERNING DOCUMENTS OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, THE ARTICLES OF INCORPORATION ARE AVAILABLE ONLINE THROUGH THE NEBRASKA SECRETARY OF STATE WEBSITE.
FORM 990, PART IX, LINES 5-10 EMPLOYEES OF THE ORGANIZATION ARE PAID BY CHI HEALTH, AN UNRELATED ORGANIZATION. ACCORDINGLY, ALL PAYROLL AND RELATED EXPENSES, INCLUDING EMPLOYEE BENEFITS, ARE PAID BY CHI HEALTH. THE ORGANIZATION REIMBURSES CHI HEALTH ON A MONTHLY BASIS.
FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 221,877. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 221,877. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 193,768. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 193,768. CONSULTING: PROGRAM SERVICE EXPENSES 39,203. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 39,203.
FORM 990 PART XII, LINE 2C THE FINANCE COMMITTEE ASSUMES RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2017


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