2017-05-15T12:23:39-05:00 2016-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2015-07-01 411936717 Living Services Foundation LIVI 7632310410 700 North Monroe Street Minneota MN 56264 Jennifer Gleason Chief Operating Officer 7632310410 2017-05-15 1 Deb Nelson CPA P01264758 6122536500 2017-05-15 2015 2021-01-29 14:40:06Z X Dennis Kamstra 700 North Monroe Street Minneota MN 56264 7925186 0 X www.lsfdn.org X 1999 MN To support subsidiaries of Benedictine Health System. X 5 4 143 0 0 0 0 0 7390511 7349513 22091 575673 0 0 7412602 7925186 1067 3478 0 0 3089168 2967296 0 0 0 5926629 7103234 9016864 10074008 -1604262 -2148822 39235798 30939425 45186678 37924240 -5950880 -6984815 X The Foundation is organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of the subsidiaries of Benedictine Living Community of Winsted, Benedictine Living Community of New London, Benedictine Living Community of Mora, Benedictine Living Community of Wahpeton, and Benedictine Living Community of Byron. 0 1 9207026 3478 7349513 The organization owns and provides management oversight to the following wholly owned subsidiaries:Living Services Foundation/Minneota, LLC consists of a 67-bed skilled nursing facility and 33-unit assisted living facility located in Minneota, Minnesota. Living Services Foundation/New London, LLC consists of a 62-bed licensed nursing facility, 36-unit attached apartment center and a 12-unit attached assisted living building located in New London, Minnesota. Living Services Foundation/Winsted, LLC consists of a 70-bed licensed nursing facility and a 16-unit attached memory care assisted living building located in Winsted, Minnesota. Living Services Foundation/Mora, LLC consists of a 80-bed skilled nursing facility, a 35-unit assisted living facility and clinic space located in Mora, Minnesota. Living Services Foundation/Wahpeton, LLC consists of a 32-unit assisted living facility located in Wahpeton, North Dakota. This organization was sold during the fiscal year.Living Services Foundation/Byron, LLC will consist of 20 units of independent living, 16 units of assisted living, and 14 units of memory care assisted living when construction is complete in the spring of 2016. The project is located in Byron, Minnesota. This organization was sold during the fiscal year. The organization operates Living Services Foundation - Minneota, but leases the other facilities through the wholly owned subsidiaries to Benedictine Living Community of New London, Benedictine Living Community of Winsted, Benedictine Living Community of Mora, and Benedictine Living Community of Wahpeton and Benedictine Living Community of Byron, which are subsidiaries of Benedictine Health System (BHS), who operates those facilities. 9207026 1 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 0 1 21 0 1 143 1 0 0 0 0 0 0 0 0 0 0 X 5 4 1 0 0 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 MN X Jennifer Gleason 7632310410 700 North Monroe Street Minneota MN 56264 Robert Sundberg Chair 5.00 0.00 X X 0 0 0 Rod Pakonen Board Member 5.00 0.00 X 0 0 0 Kevin Rymanowski Board Member 3.00 2.00 X 0 0 0 Paul Sanders Board Member 5.00 0.00 X 0 0 0 Dennis Kamstra CEO 40.00 0.00 X X 240000 0 21800 Jennifer Gleason COO/Secretary/Treasurer 40.00 0.00 X 130000 0 8447 370000 0 30247 2 0 1 0 Big Stone 450 Eastvold Ave Ortonville MN 56278 Therapy 482875 A 'Viands 1751 County B Rd W 300 St Paul MN 55113 Food Services 224965 Prime Health PO Box 3544 Omaha NE 681030544 Pool Nursing 143239 3 Resident Service Reven 623000 4421307 4421307 Lease Revenue 532000 2868736 2868736 59470 59470 7349513 38425 38425 537248 0 537248 537248 537248 7925186 7349513 0 575673 3478 3478 399299 35321 363978 2209650 2101406 108244 14274 11808 2466 163239 156448 6791 180834 149587 31247 237262 237262 72305 72305 44689 44689 184060 184060 23262 23262 180328 180328 529 529 179612 179612 25944 25944 40900 40900 2391312 2391312 1562229 1562229 68947 68947 License 670590 670590 Financing Costs 546386 546386 Food 207115 207115 DHS Surcharge 188605 188605 479159 479159 10074008 9207026 866982 0 55928 128931 447906 1719932 2841895 86306 58346 35375075 10641639 32377762 24733436 3593301 2674595 1456885 39235798 30939425 1570568 1494926 42964479 35117078 17101 16358 245000 245000 282500 325000 243105 64530 525273 45186678 37924240 X -5950880 -6984815 -5950880 -6984815 39235798 30939425 -2148822 22169 1092718 0 X 0 0 0 X X 6 Bendictine Living Community of Winsted 274219293 9 1 1713766 0 Bendictine Living Community of New London 274218436 9 1 884645 0 Bendictine Living Community of Mora 274219119 9 1 586004 0 Bendictine Living Community of Wahpeton 454274091 9 1 351814 0 Benedictine Living Community of Byron 471538777 9 1 0 0 Benedictine Health System 411531892 1 1 0 0 6 3536229 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 Part IV, Section D, Line 3: Benedictine Health System's CEO appointed one of the Foundation's five Directors, Kevin Rymanowski. In addition to his service on the Foundation's Board, Mr. Rymanowski serves as the Chief Financial Officer of BHS and each of the Supported Organizations. He is actively engaged as a Board member in the Foundation's governance and participates in decisions and discussions at the Board level and with the Foundation's leadership in all aspects of the Foundation's management and use of its income and assets for the benefit of BHS and the Supported Organizations. In this manner, the Supported organizations have a significant voice in the Foundation's management and use of its income and assets. Part IV, Section E, Line 2a: The Foundation holds title to and manages properties used by the Supported Organizations in furtherance of their exempt purposes of providing senior housing and long-term care services with special concern for the underserved and those in need of such services. The Supported Organizations each use the respective properties to provide housing to seniors and offer supportive long-term care services. Part IV, Section E, Line 2b: If these facilities were not owned and managed by the Foundation, the Supported Organizations would own and manage such facilities itself because these activities are critical to the Supported Organizations' ability to carry out their own activities in furtherance of their mission and purposes. Because the Supported Organizations would otherwise conduct these same activities if they were not performed by the Foundation, the Foundation's activities represent an integral part of the activities of the Supported Organizations. Part IV, Section A, Line 11: Benedictine Health System is a Type III Functionally Integrated Supporting Organization and is also recognized within the IRS Group Ruling for Catholic organizations under IRC Section 170(b)(1)(A)(i). 0 1 X 1194322 1194322 30042643 7820325 22222318 2861802 2354775 507027 1276308 466539 809769 24733436 Asset retirement obligation 67756 Due To/From Parent Company 457517 525273 Part IV, Line 2b: The Organization acts as custodian for the funds of the residents and holds tenant security deposits. These funds are included in cash and cash equivalents and current liabilities. X X X X X 0 0 0 0 0 0 0 0 0 Dennis Kamstra CEO 240000 0 0 0 0 0 0 0 21800 0 261800 0 0 0 A City of Spicer 416005550 84844VAJ4 2006-12-28 9600000 To purchase a nursing & assisted living facility & clinic in Spicer, MN. 0 0 0 B City of Winsted 416005652 975574AQ7 2010-09-16 16505000 Refinance Series 2008 notes issued in 8/29/2008 & fund new construction. 0 0 0 C City of Mora 416005389 2009-04-30 6258382 To purchase a nursing & assisted living facility in Mora, MN. 0 0 0 D City of Mora 416005389 2013-09-06 4851795 Refinance a portion of Series 2009 notes issues in 4/30/2009. 0 0 0 A 970519 9460519 695298 189210 8558787 2007 0 0 1 1 B 588895 16112135 1321256 322243 6170490 8308071 2011 1 0 1 1 C 1707377 6258382 6258382 2009 0 0 1 1 D 300790 4851795 97035 5059 4749701 2013 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 0 1 0 0 0 0 0 1 D 0 0 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 Schedule K, Part I, Line A, Column (e): The issue price for Bond A, Part I, Line A, Column (e) is different than the Part II, Line 3 due to the bonds being issued at a discount of $139,481. Schedule K, Part I, Line B, Column (e): The issue price for Bond B, Part I, Line B, Column (e) is different than the Part II, Line 3 due to the bonds being issued at a discount of $392,865. A City of Minneota 416005373 2013-12-31 4397409 To purchase a nursing & assisted living facility in Minneota, MN. 0 0 0 A 302175 4397409 150000 34437 4212972 2013 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 1 0 0 0 1 A 1 Robert Sundberg Board Member Capital improvements to skilled nursing facility. X 120000 120000 0 1 1 Paul S and Gretchen M Sanders Revocable Trust Entity owned by Board Member Capital improvements to skilled nursing facility. X 125000 125000 0 1 1 245000 50 unit senior housing facility in Byron, MN 2016-03-09 1 See statement 411531892 Benedictine Health System 1995 East Rum River Drive Sout Cambridge MN 55008 501(c)(3) 32 unit assisted living facility in Wahpeton, ND 2016-03-09 463937 See statement 454274091 Benedictine Living Community of Wahpeton 1995 East Rum River Drive Sout Cambridge MN 55008 501(c)(3) 0 0 0 0 Schedule N, Part II, Line 1 - Byron Sale: Living Services Foundation entered into a purchase agreement with Benedictine Health System to sell the Membership Interest in Living Services Foundation Byron, LLC. The purchase price for the Membership Interest was $1.00. In addition, Benedictine Health System assumed Living Services Foundation's obligations as guarantor, which included the following: *City of Byron, Minnesota, $8,015,000 Senior Housing Facility Revenue Note (Living Services Foundation Byron Project) Series 2014A; *City of Byron, Minnesota, $305,000 Senior Housing Facility Revenue Note (Living Services Foundation Byron Project) Series 2014A-T; and *City of Byron, Minnesota, $1,985,000 Subordinate Senior Housing Facility Revenue Bonds (Living Services Foundation Byron Project) Series 2014B Schedule N, Part II, Line 1 - Wahpeton Sale: Living Services Foundation entered into a purchase agreement with Benedictine Living Community of Wahpeton to sell the Membership Interest in Living Services Foundation Wahpeton, LLC. The purchase price for the Membership Interest was $463,937. In addition, Benedictine Living Community of Wahpeton assumed Living Services Foundation's obligations as guarantor, which included the following: *City of Wahpeton, North Dakota, Senior Loan Participation Revenue Notes (St. Catherine's Assisted Living Community Project) Series 2011A in the original principal amount of $4,285,000; and *City of Wahpeton, North Dakota, Subordinate Loan Participation Revenue Notes (St. Catherine's Assisted Living Community Project) Series 2011B in the original principal amount of $1,320,000. Form 990, Part III, line 3 Operations in Wahpeton and Byron were sold in March 2016 to Benedictine Health System, a related organization. Form 990, Part VI, Section A, line 2 Dennis Kamstra and Jennifer Gleason have a family relationship. Form 990, Part VI, Section A, line 7a Benedictine Health Systems may appoint one board member with voting rights. Form 990, Part VI, Section A, line 8b No committees are able to act on behalf of the board. Form 990, Part VI, Section B, line 11 An electronic draft of the Form 990 is distributed to the full board of directors for review and approval prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The Conflict of Interest policy is enforced and consistently monitored. An interested person must disclose the existence of their financial interest to the board considering the proposed transaction or arrangement. The remaining board members then determine if a conflict of interest exists. Corrective action is taken by the board of directors as deemed necessary when a conflict of interest is determined to have occurred. Disclosure of a conflict of interest would prevent that person from taking part in discussions or voting on related issues. Form 990, Part VI, Section B, line 15 The process for determining compensation for the CEO and COO is determined by a compensation survey and study. The compensation is then approved by the independent members of the Board of Directors. The last review took place during the summer of 2014. Form 990, Part VI, Section C, line 19 The Organization makes the governing documents and conflict of interest policy available upon request. Living Services Foundation Mora LLC 110 North 7th Street Mora MN 55051 263614974 Leasing of skilled nursing and assisted living facility. DE 544103 5200943 Living Services Foundation Living Services Foundation New London LLC 100 Glen Oaks Drive New London MN 56273 204504668 Leasing of skilled nursing, assisted and independent living facility. DE 765299 7310533 Living Services Foundation Living Services Foundation Winsted LLC 551 4th Street North Winsted MN 55395 208684862 Leasing of skilled nursing and assisted living facility. DE 1309396 12985374 Living Services Foundation Living Services Foundation Minneota LLC 700 North Monroe Street Minneota MN 56264 263614760 Operation of skilled nursing, assisted lving, and home health agency. DE 4373759 3711529 Living Services Foundation Living Services Foundation Wahpeton LLC 711 14th Avenue North Wahpeton ND 58075 453638196 Leasing of assisted living facility DE 0 0 Benedictine Health Systems (from March 2016) Living Services Foundation Byron LLC 4000 Lexington Avenue Ste 201 Shoreview MN 55126 472337717 Operation of assisted living facility DE 0 0 Benedictine Health Systems (from March 2016) Benedictine Living Community of Winsted 1995 East Rum River Drive South Cambridge MN 55008 274219293 Skilled nursing care center and memory care assisted living MN 501(c)(3) Line 9 Benedictine Health Systems 0 Benedictine Living Community of New London 1995 East Rum River Drive South Cambridge MN 55008 274218436 Skilled nursing care center, assisted living, and senior apartments. MN 501(c)(3) Line 9 Benedictine Health Systems 0 Benedictine Living Community of Mora 1995 East Rum River Drive South Cambridge MN 55008 274219119 Skilled nursing care center and assisted living facility. MN 501(c)(3) Line 9 Benedictine Health Systems 0 Benedictine Health System 1995 East Rum River Drive South Cambridge MN 55008 411531892 Health Care System MN 501(c)(3) Line 11c, III-FI 0 Benedictine Living Community of Wahpeton 1995 East Rum River Drive South Cambridge MN 55008 454274091 Assisted living and basic care facility MN 501(c)(3) Line 9 Benedictine Health Systems 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 Schedule R, Part I - Disregarded Entities: The Wahpeton and Byron facilities were sold to Benedictine Health System in March 2016.