2013-11-13T11:59:53-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-01-01 870694180 ANNE CARLSEN CENTER ANNE 8005685175 701 3RD STREET NE BOX 8000 JAMESTOWN ND 58402 ERIC MONSON 8005685175 2013-11-07 1 XIAOYAN LUO P01305207 6123764500 2012 2016-02-24 21:20:13Z ERIC MONSON 701 3RD STREET NE BOX 8000 JAMESTOWN ND 58402 23157296 0 X WWW.ANNECENTER.ORG X 1941 ND TO PROVIDE SERVICES TO DEVELOPMENTALLY DISABLED INDIVIDUALS AND OTHER CHILDREN AND ADULTS WITH SPECIALIZED HEALTH CARE AND EDUCATION NEEDS. 11 11 655 125 0 0 568679 8578 21803802 23125190 -385 5301 103929 18227 22476025 23157296 15000 15000 0 0 17555376 21674420 0 0 0 4786304 5627564 22356680 27316984 119345 -4159688 9245993 4215340 5810157 4939192 3435836 -723852 X TO PROVIDE SERVICES TO DEVELOPMENTALLY DISABLED INDIVIDUALS AND OTHER CHILDREN AND ADULTS WITH SPECIALIZED HEALTH CARE AND EDUCATION NEEDS. OPERATING LOSSES GENERATED IN FULFILLMENT OF THE CENTER'S MISSION ARE COMPENSATED FOR BY THE ACTIVE FOUNDATION FUND RAISING EFFORTS. 0 0 11451449 15000 11488007 RESIDENT/MEDICAL:COMPLEX MEDICAL CARE, PSYCHOLOGICAL, HOME LIFE ENVIRONMENT, DIETARY, PHYSICIAN. REVENUE IS REFLECTED AT GROSS, CONTRACTUAL DISCOUNTS TOTAL $465,236. 6604118 0 6123376 COMMUNITY SERVICES:CATEGORY INCLUDES IN HOME AND DAY SUPPORTS, OTHER OUTREACH SERVICES, EARLY INTERVENTION PROGRAM GROSS REVENUES ARE REFLECT IN COMMUNITY SERVICES OR $3,391,135. DAY SUPPORTS DEDUCTIONS ARE $642,434; IN-HOME SUPPORT DEDUCTIONS ARE $310,188. OUTREACH SERVICES (THERAPY, WORKSHOPS, EVALUATIONS, CONSULTATIONS AND MISC OTHER REVENUE TOTAL $170,793). CONTRACTUAL PAYMENTS FOR OUTREACH THERAPY SERVICES TOTALED $64,783. TOTAL EARLY INTERVENTION REVENUES WERE $3,563,174 AND EXPENSES WERE $3,713,061. 4005721 0 3881673 EDUCATION:NINE MONTH SCHOOL, TEN WEEK EXTENDED SUMMER PROGRAM. SERVED 61 STUDENTS OR 10,631 CENSUS DAYS. 1819299 0 1632134 THERAPEUTIC SUPPORT:PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY, RECREATIONAL. PROVIDED TO BOTH CENTER STUDENTS AND OUTPATIENT IN JAMESTOWN, CARRINGTON AND VALLEY CITY. SENSORY MOTOR, INTEGRATION, AQUATIC THERAPY, DYSPHASIA TREATMENT, AND ADAPTIVE EQUIPMENT. TOTAL UNITS OF SERVICES 37,222. REVENUE IS REFLECTED AS GROSS. DEDUCTIONS FROM REVENUE INCLUDE OP MEDICAID $90,740; OP COMMERCIAL INSURANCE $86,458. 1819299 1632134 23880587 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 81 0 655 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 MN ND WA WI X ALLAN HARTMANN 7012523850 701 3RD STREET NE BOX 8000 JAMESTOWN ND 58402 PAT TRAYNOR 2.00 2.00 X X 0 0 0 BRUCE ISERMAN 1.00 1.00 X X 0 0 0 PAT MCCULLOUGH 1.50 1.50 X X 0 0 0 HARVEY HUBER 1.50 1.50 X X 0 0 0 TIM FLAKOLL 1.00 1.00 X 0 0 0 JOEL FREMSTAD 1.00 1.00 X 0 0 0 ROBERT MONTGOMERY 1.00 1.00 X 0 0 0 SUE OFFUTT 1.00 1.00 X 0 0 0 THOMAS ROHLEDER 1.00 1.00 X 0 0 0 JANET SEAWORTH 1.00 1.00 X 0 0 0 REESA WEBB 1.00 1.00 X 0 0 0 ERIC MONSON 40.00 10.00 X 187973 0 24207 JUDY KULLA 40.00 10.00 X 103474 0 12400 MARCIA GUMS 50.00 0.00 X 133955 0 24560 MARGIE JOHNSON 50.00 0.00 X 100410 0 26644 525812 0 87811 4 0 1 0 CLIFTONLARSONALLEN LLP 220 S SIXTH ST 300 MINNEAPOLIS MN 554021436 ACCOUNTING SERVICES 194332 INNOVIS HEALTH LLC 3000 - 32ND AVE S FARGO ND 58103 HEALTH CARE SERVICES 130528 2 8578 8578 STUDENT SERVICE REV 623990 13386430 13386430 COMMUNITY SUPPORT REV 623990 5978197 5978197 EARLY INTERVENTION 623990 3563752 3563752 RESOURCE CENTER REV 623990 85629 85629 SCHOOL LUNCH PROGRAM 611710 78950 78950 32232 32232 23125190 1161 1161 4140 0 4140 4140 4140 MISCELLANEOUS REVENUE 900099 18227 18227 18227 23157296 23125190 0 23528 15000 15000 486569 486569 16964478 15189137 1775341 397382 349226 48156 2450388 2229217 221171 1375603 1265880 109723 13065 13065 106720 106720 855232 583975 271257 298779 203849 94930 919656 842413 77243 663991 591439 72552 974363 974363 178461 178461 PROGRAM SUPPLIES 563904 563706 198 STAFF DEVELOPMENT 284070 130132 153938 EQUIPMENT AND REPAIRS 267928 238125 29803 DUES AND SUBSCRIPTIONS 47495 28888 18607 453900 10207 443693 27316984 23880587 3436397 0 -3491978 -8872323 4490453 4589422 17555 16836 112752 120453 20310920 12354811 8038535 7956109 78676 404843 9245993 4215340 2333939 2313116 3476218 2626076 5810157 4939192 X 3435836 -723852 3435836 -723852 9245993 4215340 -4159688 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 0 1 0 0 1 13989 0 0 13989 0 PART IV, SUPPLEMENTAL INFORMATION: COSTS INCURRED FOR EDUCATION AND ADVOCACY IN ORDER TO ADVOCATE ADDITIONAL FUNDING FOR REIMBURSEMENT TO MEET COMPLEX NEEDS FOR CHILDREN WITH MEDICAL FRAGILITY AND BEHAVIOR CHALLENGES. EDUCATION OF LEGISLATORS AND STATE DEPARTMENT OF HUMAN SERVICES ON SPECIAL NEEDS OF CHILDREN WHO ARE MEDICALLY FRAGILE WITH FRAGILITY AND BEHAVIOR CHALLENGES AND COSTS THAT WERE BEING INCURRED AND NOT FUNDED. PRESENTATIONS REGARDING CHILDHOOD AUTISM WERE MADE AT THE REQUEST OF LEGISLATIVE COMITTEES. 1173971 15000 90948 1279919 1206731 5000 -37660 100 1173971 959049 10000 239682 1206731 0.00000 0.75150 0.24860 0 1 1 132290 132290 10328035 6132134 4195901 9013063 5718667 3294396 837532 504010 333522 7956109 DUE FROM ANNE CARLSEN CENTER FOUNDATION 404843 404843 THIRD PARTY PAYOR SETTLEMENTS 2626076 2626076 X DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE ANNE CARLSEN CENTER FOUNDATION FOR THE SUPPORT OF THE MISSION OF THE ANNE CARLSEN CENTER PROGRAMS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE CENTER IS ORGANIZED AS A NORTH DAKOTA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE CENTER UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THOSE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES, AS DEFINED BY ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA. THE CENTER BELIEVES THE ORGANIZATION IS COMPLIANT WITH ALL IRS REGULATIONS AND AS OF DECEMBER 31, 2012, HAS NOT RECORDED A TAX LIABILITY FOR A TAX UNCERTAINTY. THE CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. ANNE CARLSEN IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE TAX RETURNS FOR THE FISCAL YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 1 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 EXPLANATION OF NONDISCRIMINATORY POLICY PUBLICATION SCHEDULE E, PART I, LINE 3 THE CENTER'S NONDISCRIMINATORY POLICY IS PUBLICIZED IN THE STUDENT HANDBOOKS, EMPLOYEE HANDBOOKS AND THE "AMBASSADOR" NEWSLETTER PUBLICATION. EXPLANATION OF DOCUMENT RETENTION SCHEDULE E, PART I, LINE 4 STUDENT TUITION COSTS FOR BASIC CURRICULUM ARE PAID BY LOCAL SCHOOL DISTRICTS THROUGH CONTRACTS WITH THE CENTER WHILE NOT OFFERING SCHOLARSHIPS. THE CENTER SEEKS AND SECURES DONATIONS FOR ADVANCED CURRICULUM AND STATE OF THE ART TECHNOLOGY APPLICATION IN THE CLASSROOM AND COMMUNITY SETTINGS. NAMED AN APPLE DISTINGUISHED SCHOOL, THE CENTERS SCHOOL PROVIDES SIGNIFICANT RESOURCES TO ENHANCE THE EDUCATION EXPERIENCE FOR THE STUDENTS AT THE CENTER. EXPLANATION OF GOVERNMENT FINANCIAL ASSISTANCE SCHEDULE E, PART I, LINE 6 THE CENTER RECEIVED ASSISTANCE UNDER THE SCHOOL LUNCH PROGRAM - $78,950; TUITION REIMBURSEMENTS FROM LOCAL SCHOOL DISTRICTS, SPECIAL EDUCATION UNITS, BUREAU OF INDIAN EDUCATION AND THE STATE DEPARTMENT OF PUBLIC INSTRUCTIONS. THE CENTER RECEIVED MEDICAID FUNDING FROM NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES FOR RESIDENTIAL/MEDICAL AND KIDS PROGRAM ON STATE MEDICAID PROGRAM. 1 CAMP GRASSICK PO BOX F DAWSON ND 584580005 456012705 501(C)(3) 15000 N/A N/A SUPPPORT DISABLED CHILDREN; IN ADDITION, ACC HOLDS A ONE WEEK TECHNO CAMP 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE CENTER RECEIVES AN ANNUAL UPDATE REPORT AS TO THE USE OF THE DOLLARS THAT THEY GRANT TO ELKS CAMP GRASSICK. X X X X 0 0 0 0 0 0 0 0 0 ERIC MONSON 164273 0 23700 0 0 0 6809 0 17398 0 212180 0 0 0 MARCIA GUMS 115371 0 11924 0 6660 0 4423 0 20137 0 158515 0 0 0 ADDITIONAL ORGANIZATION MISSION INFORMATION FORM 990, PART III, LINE 1 ADDITIONALLY, THE PURPOSES FOR WHICH THE CORPORATION IS ORGANIZED ARE: A) TO PROVIDE EXCELLENCE IN SERVICES TO DEVELOPMENTALLY DISABLED INDIVIDUALS AND OTHER CHILDREN AND ADULTS WITH SPECIALIZED HEALTH CARE AND EDUCATIONAL NEEDS; B) TO SUPPORT INDIVIDUALS, ALONG WITH THEIR FAMILIES, AS THEY PURSUE GROWTH AND FULFILLMENT IN THEIR LIVES THROUGH LEADERSHIP IN EDUCATION, LIFE SKILLS TRAINING AND TECHNOLOGY; C) TO SEEK, OBTAIN AND MAINTAIN ONGOING COMMUNITY PARTNERSHIPS AND PHILANTHROPIC SUPPORT TO ACCOMPLISH SUCH PURPOSES; D) TO ENGAGE IN ANY LAWFUL NONPROFIT ACTIVITY NOT INCONSISTENT WITH THE CORPORATION'S STATUS AS A CHARITABLE TAX-EXEMPT CORPORATION. FORM 990, PART VI, SECTION A, LINE 1 THE GOVERNANCE COMMITTEE CONSISTS OF THE CHAIR, VICE CHAIR, PAST CHAIR, CORPORATE TREASURER AND CORPORATE SECRETARY. THE GOVERNANCE COMMITTEE HAS THE POWER TO TRANSACT ALL BUSINESS OF THE CENTER DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION SO TAKEN DOES NOT CONFLICT WITH THE POLICIES AND EXPRESS WISHES OF THE BOARD OF TRUSTEES, AND THE COMMITTEE REFERS ALL MATTERS OF MAJOR IMPORTANCE TO THE FULL BOARD. THE COMMITTEE IS RESPONSIBLE FOR BOARD DEVELOPMENT, NOMINATING BOARD MEMBERS, GOVERNANCE POLICIES, AS WELL AS EMPLOYMENT REVIEW AND COMPENSATION OF THE PRESIDENT/CEO. FORM 990, PART VI, SECTION B, LINE 11 THE CFO PROVIDES THE FORM 990 ELECTRONICALLY TO ALL BOARD MEMBERS FOR THEIR REVIEW. THE FINANCE COMMITTEE, CFO AND CEO WILL CONDUCT A FINAL REVIEW AND APPROVAL OF THE FORM 990 BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED ANNUALLY BY THE BOARD. THE PURPOSE OF THIS POLICY IS TO ENSURE IDENTIFICATION AND RESOLUTION OF THOSE INSTANCES IN WHICH GOVERNING BOARD MEMBERS, OFFICERS, EMPLOYEES AND OTHER AGENTS OR REPRESENTATIVES OF THE CENTER (AND ITS AFFILIATES AND SUBSIDIARIES) MAY FIND THEMSELVES IN CIRCUMSTANCES GIVING RISE TO A POTENTIAL OR ACTUAL CONFLICT OF INTEREST. TO PROTECT THE CENTER'S INTEREST IN SUCH SITUATIONS, AND TO PROVIDE FOR ADEQUATE REPORTING MECHANISMS, ANNE CARLSEN CENTER WILL NOT ENTER INTO ANY TRANSACTION OR ARRANGEMENT WITH ANY ENTITY IN WHICH ANY BOARD MEMBER, OFFICER, EMPLOYEE OR AGENT THAT HAS A FINANCIAL INTEREST UNLESS SUCH TRANSACTION OR ARRANGEMENT IS FULLY DISCLOSED TO, AND APPROVED BY THE PRESIDENT/CEO (OR THE BOARD, IF THE PRESIDENT/CEO OR A BOARD MEMBER HAS THE FINANCIAL INTEREST). AFTER DISCLOSURE OF THE FINANCIAL INTEREST OR FIDUCIARY RESPONSIBILITY AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE OR SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINAL DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS.ALL PROCEEDINGS RELATED TO CONFLICTS OF INTEREST ARE DOCUMENTED IN THE MEETING MINUTES. FORM 990, PART VI, SECTION B, LINE 15A CEO COMPENSATION AND BENEFITS ARE REVIEWED, SET AND APPROVED INITIALLY BY THE GOVERNANCE COMMITTEE AND APPROVED BY THE FULL BOARD OF DIRECTORS. AN INDEPENDENT CONSULTANT IS USED TO DEVELOP AND CONDUCT A MARKET SURVEY FOR CASH COMPENSATION AND BENEFITS. THE SURVEY IS SENT TO STATE AND REGIONAL HEALTH AND HUMAN SERVICE PROVIDERS OF LIKE SIZED ORGANIZATIONS. PUBLISHED SURVEYS ARE ALSO USED BY THE CONSULTANT. A REPORT IS FILED WITH THE GOVERNANCE COMMITTEE AND BOARD AS WELL AS REVIEWED WITH THE INDEPENDENT CONSULTANT. DOCUMENTATION WOULD INCLUDE THE COMPENSATION REPORT AND MINUTES OF GOVERNANCE COMMITTEE AND BOARD DELIBERATIONS. ACC FOLLOWS THIS PROCESS EACH YEAR AND WAS MOST RECENTLY UNDERTAKEN IN MAY, 2013 FOR THE CEO, E. MONSON. THE CEO DETERMINES MANAGEMENT COMPENSATION PACKAGES FOR OTHER OFFICERS IN CONSULTATION AND RECOMMENDATION FROM AN EXTERNAL COMPENSATION CONSULTANT. AN INDEPENDENT CONSULTANT IS USED TO DEVELOP AND CONDUCT A MARKET SURVEY FOR CASH COMPENSATION AND BENEFITS. THE SURVEY IS SENT TO STATE AND REGIONAL HEALTH AND HUMAN SERVICE PROVIDERS OF LIKE SIZED ORGANIZATIONS. PUBLISHED SURVEYS ARE ALSO USED BY THE CONSULTANT. THIS PROCESS WAS MOST RECENTLY UNDERTAKEN IN MAY, 2013 FOR THE CFO, J. KULLA, THE COO, M. GUMS AND ALL OTHER EXECUTIVE POSITIONS. FORM 990, PART VI, SECTION C, LINE 19 THE CENTER'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO PUBLIC UPON REQUEST. ANNE CARLSEN CENTER FOUNDATION 701 3RD STREET NE BOX 8000 JAMESTOWN ND 58402 721524988 TO SUPPORT THE MISSION OF ANNE CARLSEN CENTER THROUGH FUNDRAISING ND 501(C)(3) LINE 7 ANNE CARLSEN CENTER 1 NIERLING ANNE CARLSEN CENTER TRUST 701 3RD STREET NE BOX 8000 JAMESTOWN ND 58402 912004887 PRIVATE FOUNDATION ND 501(C)(3) PF ANNE CARLSEN CENTER 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 ANNE CARLSEN CENTER FOUNDATION P 327063 FMV