2017-11-13T11:12:55-06:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-01-01 412012560 EBENEZER LAKES ASSISTED LIVING EBEN 6128743460 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 TODD WILLETT CHIEF FINANCIAL OFFICER 6128743460 2017-11-13 1 KURT BENNION P01469618 6123764500 67.137.57.251 2017-11-13 08:22:51 PS P EB5B0B88F5DF23A80CA306F7B03D11E28B72914C 9C59EE6D3CCD21689CFBADFF7A4DB800BA897A92 2016 2017-02-10 21:41:12Z MEADOWS ON FAIRVIEW MARK THOMAS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 4251264 0 X WWW.FAIRVIEWEBENEZER.ORG X 1906 MN PROVIDE ASSISTED LIVING SERVICES TO IMPROVE THE QUALITY OF LIFE FOR THE ELDERLY AND DISABLED. 8 7 87 10 0 0 11434 34956 3649006 4195925 209 355 9091 20028 3669740 4251264 0 0 0 0 2203780 2429362 0 0 0 2224568 2415122 4428348 4844484 -758608 -593220 7718252 7810019 9208772 9893759 -1490520 -2083740 X EBENEZER HELPS OLDER ADULTS AND OTHERS MAKE THEIR LIVES MORE INDEPENDENT, HEALTHFUL, MEANINGFUL AND SECURE. BUILDING ON OUR LUTHERAN HERITAGE, WE RESPOND TO PHYSICAL, PSYCHOLOGICAL, SOCIAL AND SPIRITUAL DIMENSIONS OF THE WHOLE PERSON. WE WELCOME PERSONS OF DIVERSE CULTURES AND FAITH TRADITIONS. WE PRACTICE RESPONSIBLE STEWARDSHIP OF HUMANS, PROPERTY, AND FINANCIAL RESOURCES AND ENCOURAGE CONTINUAL LEARNING AND INNOVATION TO STRIVE FOR EXCELLENCE. 0 0 2333172 0 2183690 TO PROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 61 UNITS AND WELCOMES PERSONS OF DIVERSE VULTURES AND FAITH TRADITIONS. WE PRACTICE RESPONSIBLE STEWARDSHIP OF HUMANS, PROPERTY, AND FINANCIAL RESOURCES AND ENCOURAGE CONTINUAL LEARNING AND INNOVATION TO STRIVE FOR EXCELLENCE. 2149981 0 2012235 TO PROVIDE TRANSITIONAL CARE FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE TCU HAS 14 UNITS FOR THE BENEFIT OF INDIVIDUALS LEAVING THE HOSPITAL UNTIL THEY ARE STRONG ENOUGH TO GO HOME. 4483153 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 60 0 87 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CONNIE BEDNAREK 6128743460 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 RICHARD HOWARD CHAIR 0.25 2.00 X X 0 0 0 JOHN SELSTAD 1ST VICE CHAIR 0.25 2.00 X X 0 0 0 KENT EKLUND 2ND VICE CHAIR 0.25 2.00 X X 0 0 0 SHARY MULHERE SECRETARY 0.25 2.00 X X 0 0 0 MAGGIE COLLINS DIRECTOR THROUGH MAY 2016 0.25 2.00 X 0 0 0 TERRY HAKES DIRECTOR THROUGH DECEMBER 2016 & STAFF 0.25 40.00 X 0 193184 18484 THOMAS HOKR DIRECTOR 0.25 2.00 X 0 0 0 DEB PAONE DIRECTOR THROUGH SEPTEMBER 2016 0.25 2.00 X 0 0 0 JEANNE RIPLEY DIRECTOR 0.25 2.00 X 0 0 0 CARL RUNCK DIRECTOR 0.25 2.00 X 0 0 0 MARK THOMAS PRESIDENT & CEO 2.00 40.00 X X 0 482641 77779 JONATHAN LUNDBERG COO & ASSISTANT SECRETARY 2.00 40.00 X 0 280819 16630 TODD WILLETT TREASURER 2.00 40.00 X 0 36060 0 0 992704 112893 0 0 1 0 CENTREX 8120 PENN AVENUE S SUITE 227 BLOOMINGTON MN 55431 THERAPY SERVICES 434059 1 19956 15000 34956 NURSING REVENUE 623000 2667353 2667353 RENT REVENUE 532000 1528572 1528572 4195925 355 355 MISCELLANEOUS 900099 14667 14667 MEAL INCOME 900099 5361 5361 20028 4251264 4195925 0 20383 2027440 1875200 152240 14094 14094 232298 232298 155530 155530 41266 41266 17912 17912 477897 476206 1691 10170 525 9645 56860 45 56815 858 858 339583 339583 5277 4824 453 26697 20467 6230 312017 312017 297532 297532 51869 51869 MEDICAL SUPPLIES 258376 258376 FOOD 257683 256476 1207 BAD DEBT 72597 72597 OVERHEAD 57592 57592 130936 129661 1275 4844484 4483153 361331 0 257709 450339 760862 807047 314518 331401 81565 174539 8510025 2520943 6246145 5989082 57453 57611 7718252 7810019 350225 313897 3783 590 49729 50674 6031483 5925997 2773552 3602601 9208772 9893759 X -1490520 -2083740 -1490520 -2083740 7718252 7810019 -593220 0 X 0 1 X 1 1 1 X 21663 15749 22419 11434 34956 106221 2276737 2368895 2169836 3649006 4195925 14660399 2298400 2384644 2192255 3660440 4230881 14766620 0 0 0 14766620 261 379 346 209 355 1550 261 379 346 209 355 1550 94757 79906 8940 9091 20028 212722 2393418 2464929 2201541 3669740 4251264 14980892 0.98570 0.98400 0.00010 0.00010 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS NONPATIENT MEALS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 29265 29265 8018683 2285967 5732716 172516 55645 116871 289561 179331 110230 5989082 RELATED PARTY PAYABLE 3602601 3602601 X 4251264 0 4251264 0 4251264 4844484 0 4844484 0 4844484 PART IV, LINE 2B: EBENEZER LAKES ASSISTED LIVING HOLDS IN TRUST DEPOSIT AMOUNTS RECEIVED BY TENANTS UPON MOVE-IN. THE TENANT DEPOSITS ARE MAINTAINED IN AN INTEREST-BEARING ACCOUNT SEPARATE FROM EBENEZER LAKES ASSISTED LIVING'S ACCOUNTS. DEPOSITS ARE REFUNDED, MINUS ANY AMOUNTS FOR REPAIRS, WHEN THE TENANT LEAVES THE FACILITY. PART X, LINE 2: THE PROJECT IS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND APPLICABLE MINNESOTA STATUTES. CONSEQUENTLY, NO PROVISION HAS BEEN MADE FOR INCOME TAXES. THE PROJECT'S ANNUAL TAX FILINGS ARE SUBJECT TO REVIEW BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE PROJECT IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE PROJECT IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OTHER TAXES. 0 1 0 0 0 0 0 0 0 TERRY HAKES DIRECTOR THROUGH DECEMBER 2016 & STA 0 193184 0 0 0 0 0 0 0 18484 0 211668 0 0 MARK THOMAS PRESIDENT & CEO 0 307721 0 174920 0 0 0 59397 0 18382 0 560420 0 0 JONATHAN LUNDBERG COO & ASSISTANT SECRETARY 0 243739 0 37080 0 0 0 0 0 16630 0 297449 0 0 PART I, LINE 4B MARK THOMAS PARTICIPATES IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN ADMINISTERED BY FAIRVIEW. THE CONTRIBUTION TO THIS PLAN DURING 2016 WAS $40,847. FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT OF EBENEZER LAKES ASSISTED LIVING IS PROVIDED THROUGH AN AGREEMENT WITH EBENEZER MANAGEMENT SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 6 EBENEZER SOCIETY, A MINNESOTA NONPROFIT ORGANIZATION, IS THE SOLE MEMBER OF EBENEZER LAKES ASSISTED LIVING. FORM 990, PART VI, SECTION A, LINE 7A THE PRESIDENT OF EBENEZER LAKES ASSISTED LIVING IS A VOTING MEMBER OF THE BOARD OF DIRECTORS. EBENEZER SOCIETY, THE SOLE MEMBER, APPOINTS ALL OTHER DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS MUST BE APPROVED BY EBENEZER SOCIETY, THE SOLE MEMBER: (A) ALL AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS; (B) ALL CAPITAL BUDGETS OF THIS ORGANIZATION AND ALL OTHER ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS ORGANIZATION, AND ALL MAJOR CAPITAL EXPENDITURES BEFORE FUNDS ARE EXPENDED THEREFOR; (C) ALL OPERATING BUDGETS OF THIS ORGANIZATION AND ALL OTHER ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS ORGANIZATION, BEFORE AUTHORIZED EXPENDITURES MAY BE MADE THEREFROM; (D) STRATEGIC PLANS OF THIS ORGANIZATIONAND ALL OTHER ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS ORGANIZATION; (E) THE INCURRING OF ANY LONG TERM DEBT OF THIS ORGANIZATION AND ALL OTHER ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS ORGANIZATION, OTHER THAN INTRA-SYSTEM OF REFINANCING DEBT; (F) ALL HUMAN RESOURCES AND BENEFITS POLICIES; (G) ANY MAJOR RISK CONTRACTING AGREEMENTS, WHICH FOR THESE PURPOSES MEANS ANY CONTRACT THAT DEALS WITH CAPITATION OR A SIMILAR RISK BEARING CONCEPT; (H) ANY MERGER, CONSOLIDATION, OR TOTAL OR PARTIAL DISSOLUTION; (I) THE NUMBER OF DIRECTORS; AND (J) ANY GOVERNANCE AND ACTION OF THE TYPE SET FORTH IN SUBPARAGRAPHS (A) AND (F) THROUGH (I) ABOVE AS PROPOSED BY THE BOARD OF DIRECTORS OF ANY ENTITY DIRECTLY CONTROLLED BY THIS ORGANIZATION TO THE EXTENT THAT THE GOVERNING DOCUMENTS OF SUCH ENTITY GIVE THIS ORGANIZATION OR THE BOARD A RIGHT OF APPROVAL OVER SUCH GOVERNANCE ACTION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS REVIEWED BY THE CFO AND PRESIDENT, THEN IT WAS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C MANAGERS, DIRECTORS AND SENIOR MANAGEMENT ARE REQUIRED TO ANNUALLY COMPLETE EBENEZER'S DUTY OF LOYALTY AND CONFLICT OF INTEREST STATEMENT IN COMPLIANCE WITH EBENEZER'S CONFLICT OF INTEREST POLICY. DISCLOSURES ARE REVIEWED BY THE COMPLIANCE DEPARTMENT. ANY CONFLICTS OF INTEREST BY BOARD MEMBERS ARE BROUGHT TO THE BOARD FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 15 FAIRVIEW DETERMINES THE COMPENSATION FOR THE PRESIDENT/CEO AND COO. THE SOCIETY DETERMINES THE COMPENSATION FOR THE TREASURER. FORM 990, PART VI, SECTION C, LINE 19 EBENEZER LAKES ASSISTED LIVING'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY CAN BE OBTAINED UPON REQUEST. FAIRVIEW HEALTH SERVICES 2450 RIVERSIDE AVENUE MINNEAPOLIS MN 55454 410991680 HOSPITAL/HEALTHCARE PROVIDER MN 501(C)(3) LINE 3 N/A 0 EBENEZER SOCIETY 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 410706141 NURSING HOME CARE/ADMIN SUPPORT MN 501(C)(3) LINE 10 N/A 0 EBENEZER RIDGES ASSISTED LIVING 13810 COMMUNITY DRIVE BURNSVILLE MN 55337 411964691 ASSISTED LIVING MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 EBENEZER RIDGES 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411287792 NURING HOME CARE MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 EBENEZER SOCIETY FOUNDATION 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411356565 MANAGEMENT SUPPORT - EBENEZER MN 501(C)(3) LINE 12A, I EBENEZER SOCIETY 0 EBENEZER RIDGE POINT APARTMENTS INC 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411769727 AFFORDABLE HOUSING MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 EBENEZER TOWERS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 237005359 AFFORDABLE HOUSING MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 EBENEZER PARK APARTMENTS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411378656 AFFORDABLE HOUSING MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 FAIRVIEW FOUNDATION 2450 RIVERSIDE AVENUE MINNEAPOLIS MN 55454 411573810 MANAGEMENT SUPPORT - FAIRVIEW HEALTH SERVICES MN 501(C)(3) LINE 7 FAIRVIEW HEALTH SERVICES 0 EBENEZER LAKES SENIOR HOUSING 5430 MEADOW LANE WYOMING MN 55092 320190409 AFFORDABLE HOUSING MN 501(C)(3) LINE 10 EBENEZER SOCIETY 0 FAIRVIEW WOODS ASSISTED LIVING LLC 470 FAIRVIEW BOULEVARD RED WING MN 55066 204381407 ASSISTED LIVING MN N/A YORK GARDENS LLC 3451 PARKLAWN AVENUE EDINA MN 55435 262912486 ASSISTED LIVING MN N/A EBENEZER MANAGEMENT SERVICES INC 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411567046 MANAGEMENT SERVICES MN N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0