2015-01-23T14:09:48-06:00 2014-09-30 208896204 Dennis G Koch CPA PO Box 1007 Quincy IL 623061007 990 2013-10-01 370724112 Good Samaritan Home of Quincy GOOD 2172238717 2130 Harrison Street Quincy IL 62301 William Winn President 2172228471 2015-01-23 1 Dennis G Koch P01210686 2172248484 2015-01-22 X 2013 2016-02-25 16:41:14Z Michael Duffy 3831 Newcastle Dr Quincy IL 62301 17822819 0 X www.gshq.org X 1953 IL To maintain a home for the care of the aged, without regard to poverty or riches of residents. 21 21 440 180 0 0 478865 490692 14435240 15226048 2967420 1991363 144229 114716 18025754 17822819 0 0 0 0 9841505 10115789 0 0 80999 6587632 6958004 16429137 17073793 1596617 749026 57865161 58335801 12755695 12477309 45109466 45858492 To establish, support and maintain a home and related facilities for the care of the aged, without regard to poverty or riches of residents. 0 0 15922599 17332127 Nursing, therapy, home care and apartments for the elderly. 15922599 1 1 0 0 0 0 0 0 0 1 1 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 5 0 1 440 1 0 0 0 0 0 0 0 0 X 21 21 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X X The Good Samaritan Home of Quincy 2172238717 2130 Harrison Street Quincy IL 62301 William Winn President 10.00 X X 0 0 0 Laura Ehrhart 1st Vice President 5.00 X X 0 0 0 Larry Shepherd 2nd Vice President 5.00 X X 0 0 0 Steve Wavering 3rd Vice President 5.00 X X 0 0 0 Carla Derrick Secretary/Treasurer 5.00 X X 0 0 0 Bob Johnson Im Past President 5.00 X X 0 0 0 Mike Bickhaus Director 5.00 X 0 0 0 John Letts Director 5.00 X 0 0 0 Gena Awerkamp Director 5.00 X 0 0 0 Billie Menke Director 5.00 X 0 0 0 Ray Scheiter Director 5.00 X 0 0 0 Janet Schneeberger Director 5.00 X 0 0 0 Paul Kemner Director 5.00 X 0 0 0 Jerry Jackson Director 5.00 X 0 0 0 Daron Duke Director 5.00 X 0 0 0 Richard Walz Director 5.00 X 0 0 0 Michael Oberdahlhoff Director 5.00 X 0 0 0 Jeff Spear Director 5.00 X 0 0 0 John Heidbreder Director 5.00 X 0 0 0 Robert Young Director 5.00 X 0 0 0 Michael Duffy Adminstrator 45.00 X 136748 0 14109 136748 0 14109 3 0 1 0 Kohl Wholesale 130 Jersey St Quincy IL 62301 Quincy IL 62301 Cafeteria Food 933146 First Choice Physical Therapy 5 W State 8th Plaza Quincy IL 62305 Physical Therapy 534599 Maas Construction 3615 At Anthony Rd Quincy IL 62305 Construction Services 373669 CPI Qualified Plan Consultants PO Box 167 Great Bend KS 67530 Quincy IL 62305 Thrid Party Administration 370211 Medline Industries Dept CH 14400 Palatine IL 60055 Nursing Supplies 230751 13 490692 490692 Room Care 623000 7805055 7805055 Medicaid 623000 3329424 3329424 Cottage Rentals 623000 2349750 2349750 Medicare 623000 1741819 1741819 15226048 1991363 1991363 Barber/Beauty/Gift Shop 623000 99526 99526 Miscellaneous 623000 15190 15190 114716 17822819 17332127 0 0 136748 136748 8324668 7642198 618438 64032 257451 232493 22413 2545 798902 721459 67919 9524 598020 542178 50944 4898 55712 55712 228771 228771 53546 53546 643032 643032 79791 79791 246957 246957 1507664 1507664 511593 511593 Food 915416 915416 Supplies 743520 660448 83072 Therapy 547550 547550 Maintenance & Repairs 536363 536363 888089 797428 90661 17073793 15922599 1070195 80999 917403 853398 1279024 2225994 123881 16455 2101815 2444478 313911 321805 46835138 17622061 29904841 29213077 23224286 23260594 57865161 58335801 1641959 1311084 7915374 7618741 3198362 3547484 12755695 12477309 X 36776495 37820547 8232971 7937945 100000 100000 45109466 45858492 57865161 58335801 749026 0 X X 0 1 X 1 0 X 1119527 434410 985260 478865 490692 3508754 13164178 14334868 14689534 14435240 15226048 71849868 14283705 14769278 15674794 14914105 15716740 75358622 0 0 0 75358622 2615852 23383 3519080 2967420 1991363 11117098 2615852 23383 3519080 2967420 1991363 11117098 206184 205025 248228 144229 114716 918382 17105741 14997686 19442102 18025754 17822819 87394102 0.86230 0.86450 0.12720 0.12380 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 24380738 333701 1995544 1550884 199739 24959360 28596406 369637 2931120 7287019 229406 24380738 27990135 892976 3507128 3566544 227289 28596406 32285791 352352 7208 4397420 257796 27990135 26692748 3286598 2535488 229043 32285791 1.00000 0 0 1135037 1135037 35456525 11971135 23485390 10243576 5650926 4592650 29213077 US Government Bonds 1309867 F US Governmant Agencies 1993665 F Corporate Bonds 609526 F Mutual Funds & Equities 19347536 F 23260594 Refundable Deposits 3547484 3547484 X 17822819 0 17822819 0 17822819 17073793 0 17073793 0 17073793 Part V, Line 4: The Home's endowment fund is used to 1) provide income to offset operating costs in order to provide affordable skilled nursing care to residents and 2) provide a source of income to pay for capital improvements to the Home's physical plant. Part X, Line 2: The evaluation of a tax position in accordance with this Interpretation 48 is a two-step process. The first step is recognition: The organization determines whether it is more likely than not that a tax position will be sustained upon examination, including resolution of any related appeals or litigation processes, based on the technical merits of the position. In evaluating whether a tax position has met the more-likely-than-not recognition threshold, the enterprise should presume that the position will be examined by the appropriate taxing authority that has full knowledge of all relevant information. The second step is measurement: A tax position that meets the more-likely-than-not recognition threshold is measured to determine the amount of benefit to recognize in the financial statements. The tax position is measured at the largest amount of benefit that is greater than 50 percent likely of being realized upon ultimate settlement. Implementation of ASC Section 740 began with Good Samaritan's year ended September 30, 2009. The implementation of ASC Section 740 has not had any material effect on the financial statements of the Good Samaritan Home of Quincy. X X X 0 0 0 0 0 0 0 0 0 Michael Duffy Adminstrator 136748 0 0 0 0 0 5435 0 8674 0 150857 0 0 0 Part I, Line 3 The Board's Executive Committee serves as the compensation committee and reviews the compensation of the Administrator annually. Salary comparisons are made to other comparable nursing homes in the area when determining the salary. A City of Quincy Adams County Illinois 376000378 2009-12-01 100 To finance a portion of the Home's construction project 0 0 0 A 293936 2011 0 0 1 1 A 0 0 0 0 0 0 0 A 1 0 0 0 0 0 A 0 Form 990, Part VI, Section A, line 2 One board member is a partner in the law firm that represents the Organization, a second board member is a principal in a painting firm that was hired by the general contractor overseeing the construction and renovation project undertaken by the Organization. Form 990, Part VI, Section B, line 11 Federal Form 990 and the audited financial statements are presented to the Board of Directors for their review. The auditor is available to members of the finance committee for questions before the 990 is filed. Form 990, Part VI, Section B, line 12c Officers and directors are required to disclose any potential conflicts of interest to the CEO and to abstain from voting on any such item. Form 990, Part VI, Section B, line 15 The Executive Committee of the Organization annually reviews the performance of the Administrator and Assistant Administrator. Compensation is determined by reviewing the performance assessment and comparable salaries of like individuals in area and regional nursing homes of similar size. The salary package is approved by the Executive Committee and documented in the records of the Organization. Form 990, Part VI, Section C, line 18 Federal Form 990 is available online at www.guidestar.org Form 990, Part VI, Section C, line 19 Information regarding the tax-exempt status of the Organization is available upon request. Federal Form 990 is available upon request or online at www.guidestar.org Form 990, Part XI, Line 2C The Finance Commitee of the Board of Directors is responsible for oversight of the audit