2016-10-14T12:15:22-05:00 2015-12-31 390859910 Baker Tilly Virchow Krause LLP 225 S 6th St 2300 Minneapolis MN 55402 990 2015-01-01 412012560 Ebenezer Lakes Assisted Living EBEN 6128743460 2722 Park Avenue South Minneapolis MN 55407 Terry Hakes CFO 6128743460 2016-09-23 1 Dianne Hickok CPA P00043906 6128764500 2015 2017-02-10 21:41:12Z MARK THOMAS 2722 Park Avenue South Minneapolis MN 55407 3669740 0 X www.fairviewebenezer.org X 1906 MN TO PROVIDE ASSISTED LIVING SERVICES TO IMPROVE THE QUALITY OF LIFE FOR THE ELDERLY AND DISABLED. 10 8 49 9 0 0 22419 11434 2169836 3649006 346 209 8940 9091 2201541 3669740 0 0 0 0 1471195 2203780 0 0 0 1544974 2224568 3016169 4428348 -814628 -758608 7895812 7964420 8627724 9454940 -731912 -1490520 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.WELCOME PERSONS OF DIVERSE CULTURES AND FAITH TRADITIONS.PRACTICE RESPONSIBLE STEWARDSHIP OF HUMAN, PROPERTY AND FINANCIAL RESOURCES.ENCOURAGE CONTINUING LEARNING AND INNOVATION.STRIVE FOR EXCELLENCE. 1 0 1608358 1865944 PROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 61 UNITS. WELCOME PERSONS OF DIVERSE CULTURES AND FAITH TRADITIONS. PRACTICE RESPONSIBLE STEWARDSHIP OF HUMAN, PROPERTY AND FINANCIAL RESOURCES. ENCOURAGE CONTINUING LEARNING AND INNOVATION. STRIVE FOR EXCELLENCE. 1132404 1792153 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 HOPSITAL UNTIL THEY ARE STRONGE ENOUGH TO GO HOME. 2740762 1 1 0 0 0 0 0 0 0 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 23 0 49 1 0 0 0 0 0 0 0 0 0 0 X 10 8 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 MN X Connie Bednarak 6128743460 2722 Park Avenue Minneapolis MN 55407 Kent Eklund Director 1.00 10.00 X 0 0 0 RICHARD HOWARD Director 1.00 10.00 X 0 0 0 Shary Mulhere board Secretary 1.00 10.00 X X 0 0 0 Deborah Paone Director 1.00 10.00 X 0 0 0 JEANNE RIPLEY Director 1.00 10.00 X 0 0 0 Carl Runck Director (Part year) 1.00 10.00 X 0 0 0 Thomas Hokr Director (Part year) 1.00 10.00 X 0 0 0 John Selstad Vice Chair 1.00 10.00 X X 0 0 0 Mark Thomas President & CEO 1.00 40.00 X X 0 564065 42021 Maggie Collins Chair 1.00 10.00 X X 0 0 0 stephan grygar CFO (Part Year) 1.00 40.00 X 0 322578 19970 Terry Hakes CFO (Part Year) 1.00 40.00 X 0 152035 17821 0 1038678 79812 0 0 1 0 0 11434 11434 Housing Service Revenu 623000 1548344 1548344 RENT REVENUE 532000 1466431 1466431 Other Patient Revenue 623000 634231 634231 3649006 209 209 MISCELLANEOUS 900099 9091 9091 9091 3669740 3658097 0 209 1848604 1003483 845121 8177 8177 210106 581 209525 136893 136893 39323 39323 11621 11621 316364 316364 1049 1049 399738 19406 380332 291578 291578 4911 4911 317475 317475 289259 289259 39049 39049 ELDERLY CARE EXPENSE 457607 457607 Overhead Allocations 56594 56594 4428348 2740762 1687586 0 304527 257709 722721 760862 108776 314518 23306 81565 8471946 2225801 6434612 6246145 301870 303621 7895812 7964420 277905 350225 1418 3783 6206647 6104218 2141754 2996714 8627724 9454940 X -731912 -1490520 -731912 -1490520 7895812 7964420 -758608 0 X X 0 1 X 1 1 1 X 8010 21663 15749 22419 11434 79275 2148019 2276737 2368895 2169836 3649006 12612493 2156029 2298400 2384644 2192255 3660440 12691768 0 0 0 12691768 69 261 379 346 209 1264 69 261 379 346 209 1264 12190 94757 79906 8940 9091 204884 2168288 2393418 2464929 2201541 3669740 12897916 0.98400 0.98210 0.00010 0.00010 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 29265 29265 7993032 2044329 5948703 168379 49460 118919 268733 132012 136721 12537 12537 6246145 Tenant Security Deposits 49729 Premium on Bonds 173434 Amount Due to Ebenezer Society, A Related Party 2769974 Management fee payable to Ebenezer management Service, A Related Party 3577 2996714 X 3669740 0 3669740 0 3669740 4428348 0 4428348 0 4428348 Part X, Line 2: In accordance with the standard related to the accounting for uncertainty in income taxes, the Company addresses the determination of whether tax benefits claimed should be recorded in the financial statements. Under this guidance, the Company may recognize the tax benefit from an uncertain tax position only if is more likely than not that the tax position will be sustained on examination by taxing authorities, based on the technical merit of the position. Examples of tax positions include the tax-exempt status of the Company and various positions related to the potential sources of unrelated business taxable income. There are no unrecognized tax benefits identified or recorded as a liability during 2015. Open tax years subject to examination by the U.S. and state taxing authorities are for the years 2012 to 2014, which statues expires 2016 to 2018, respectively. The measurement and disclosure principles of the standard normally do not affect the financial statements of an entity that is not subject to income tax. However, there are certain exceptions where the Company would bear the burden of an uncertain tax position. 0 1 0 0 0 0 0 0 0 Mark Thomas President & CEO 0 555052 0 0 0 9013 0 18550 0 23471 0 606086 0 0 stephan grygar CFO (Part Year) 0 318548 0 0 0 4030 0 8449 0 11521 0 342548 0 0 Terry Hakes CFO (Part Year) 0 152035 0 0 0 0 0 0 0 17821 0 169856 0 0 Part I, Line 4b Mark Thomas participated in a supplemental non-qualified retirement plan from a related organization. Part ii: MARK THOMAS AND STEPHAN GRYGAR ARE EMPLOYEES OF FAIRVIEW HEALTH SERVICES. THEIR SALARY IS PASSED TO EBENEZER SOCIETY AND IS AN EXPENSE OF EBENEZER SOCIETY. Form 990, Part III, line 2 LAKES ASSISTED LIVING STARTED A NEW TRANSITIONAL CARE UNIT PROGRAM IN 2015 Form 990, Part VI, Section A, line 2 MARK THOMAS, STEPHAN GRYGAR AND RICHARD HOWARD: BUSINESS RELATIONSHIP Form 990, Part VI, Section A, line 8b No committees have authority to act on the behalf of the organization. Form 990, Part VI, Section B, line 11 The 990 is reviewed by the President and vice president before filing. Any comments or concerns will be discussed with the complete governing body. The complete governing body receives a copy of the 990 after the return has been filed. Form 990, Part VI, Section B, line 12c ALL POTENTIAL CONFLICTS OF INTEREST OR OTHER MATTERS RELATING TO THE DUTY OF LOYALTY RESPECTING ALL DIRECTORS OR OFFICERS OF FAIRVIEW (OF THE RANK OF SENIOR VICE PRESIDENT OR ABOVE), SHALL BE REPORTED TO THE FAIRVIEW SYSTEM BOARD VIA THE AUDIT AND COMPLIANCE COMMITTEE. ALL ISSUES RELATING TO THE DUTY OF LOYALTY RESPECTING ALL DIRECTORS, TRUSTEES, OR OFFICERS OF A FAIRVIEW DIVISION WITH AN OPERATING BOARD OR A FAIRVIEW SUBSIDIARY SHALL BE REPORTED TO THE BOARD OF TRUSTEES OR DIRECTORS OF THE APPROPRIATE DIVISION OR SUBSIDIARY. THE CHIEF COMPLIANCE OFFICE SHALL MONITOR CONFLICT ISSUES REPORTED AT THE DIVISION AND SUBSIDIARY LEVEL AND PERIODICALLY REPORT TO THE AUDIT AND COMPLIANCE COMMITTEE WITH RESPECT TO SUCH CONFLICTS. ALL POTENTIAL CONFLICTS OR OTHER ISSUES RELATING TO THE DUTY OF LOYALTY RESPECTING ALL OTHER INTERESTED PERSONS SHALL BE REPORTED TO FAIRVIEW'S CHIEF COMPLIANCE OFFICER, (OR IN THE CASES OF DIVISIONS AND SUBSIDIARIES TO THE CEO OF SUCH DIVISION OR SUBSIDIARY), AND IN HIS OR HER DISCRETION TO THE AUDIT AND COMPLIANCE COMMITTEE OF THE FAIRVIEW SYSTEM BOARD. THE CHIEF COMPLIANCE OFFICER, IN CONJUNCTION WITH FAIRVIEW SENIOR MANAGEMENT, SHALL MAKE THE DECISION AS TO WHETHER A POTENTIAL CONFLICT OF INTEREST IS AN ACTUAL CONFLICT OF INTEREST WITH RESPECT TO SUCH OTHER PERSONS. IN THE CASE OF A CONFLICT OF INTEREST RELATING TO A DIRECTOR OR TRUSTEE OF A FAIRVIEW DIVISION WITH AN OPERATING BOARD OR A DIRECTOR, OFFICER OR EMPLOYEE OF A FAIRVIEW SUBSIDIARY, DECISIONS RELATING TO THE CONFLICT SHALL BE MADE BY THE DIVISION OR SUBSIDIARY USING GUIDELINES DEVELOPED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE FAIRVIEW SYSTEM BOARD. ALL SUCH MATTERS SHALL BE SUBJECT TO REVIEW BY THE AUDIT AND COMPLIANCE COMMITTEE. Form 990, Part VI, Section B, line 15 Raises are based on increase given for reimbursement by the state. Any increases above 1% are given based on market rates for the position. They are reviewed and approved by upper management. Form 990, Part VI, Section C, line 19 Ebenezer Lakes Assisted Living financial statements and conflict of interest policy can be obtained upon request. FORM 990, PART XII, LINE 2C: THE ORGANIZATION DID NOT CHANGE EITHER THE OVERSIGHT PROCESS OF THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT DURING THE TAX YEAR. 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 9 N/A 0 Ebenezer Ridges Assisted Living 13810 Community Drive Burnsville MN 55337 411964691 assisted living facility MN 501(c)(3) Line 9 Ebenezer Society 0 Ebenezer Ridges 2722 Park Avenue South Minneapolis MN 55407 411287792 Nursing home care MN 501(c)(3) Line 9 Ebenezer Society 0 Ebenezer Society Foundation 2722 Park Avenue South Minneapolis MN 55407 411356565 Support Ebenezer Society MN 501(c)(3) Line 11c, III-FI Ebenezer Society 0 Ebenezer Ridge Point Apartments Inc 2722 Park Avenue South Minneapolis MN 55407 411769727 affordable housing MN 501(c)(3) Line 9 Ebenezer Society 0 Ebenezer Towers 2722 Park Avenue South Minneapolis MN 55407 237005359 affordable housing MN 501(c)(3) Line 9 Ebenezer Society 0 Ebenezer Park Apartments 2722 Park Avenue South Minneapolis MN 55407 411378656 affordable housing MN 501(c)(3) Line 9 Ebenezer Society 0 Fairview Foundation 2450 Riverside Avenue minneapolis MN 55454 411573810 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 9 ebenezer Society 0 Fairview Woods Assisted Living LLC 470 Fairview Boulevard Red Wing MN 55066 204381407 assisted living facility MN N/A York Gardens LLC 3451 Parklawn Ave Edina MN 55435 262912486 assisted living facility 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 Ebenezer Management Services Inc M 39323 AGREED UPON RATE Ebenezer Society P 4107578 Cost