2013-05-29T16:49:15-05:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 370 INTERLOCKEN BLVD SUITE 500 BROOMFIELD CO 80021 990 2012-01-01 840194430 EBEN EZER LUTHERAN CARE CENTER EBEN 9708422861 122 HOSPITAL ROAD BRUSH CO 80723 SHELLY GRIFFITH 9708422861 2013-05-28 1 JEFF PARKER P00970069 3034668822 2012 2016-03-07 17:11:31Z SHELLY GRIFFITH 122 HOSPITAL ROAD BRUSH CO 80723 12073964 0 X WW.EBENEZER-CARES.ORG X 1903 CO THE EBEN EZER LUTHERAN CARE CENTER (THE CARE CENTER) WAS ESTABLISHED TO PROVIDE SKILLED NURSING CARE, RESPITE CARE, ASSISTED LIVING, INDEPENDENT LIVING, PERSONAL CARE AND HOMEMAKING AND LIFELINE EMERGENCY RESPONSE SERVICES TO THE ELDERLY AND PERSONS WITH SPECIAL NEEDS. THE CARE CENTER IS CERTIFIED FOR MEDICARE AND MEDICAID AND IS AFFILIATED WITH THE EVANGELICAL LUTHERAN CHURCH OF AMERICA. 9 9 329 250 10011 6223 372771 188198 11626051 11598079 161576 175399 53925 109827 12214323 12071503 3999 3691 0 0 7529952 7779918 0 0 54331 3658847 3649552 11192798 11433161 1021525 638342 13862838 14448920 5020132 4863698 8842706 9585222 X THE EBEN EZER LUTHERAN CARE CENTER (THE CARE CENTER) WAS ESTABLISHED TO PROVIDE SKILLED NURSING CARE, RESPITE CARE, ASSISTED LIVING, INDEPENDENT LIVING, PERSONAL CARE AND HOMEMAKING AND LIFELINE EMERGENCY RESPONSE SERVICES TO THE ELDERLY AND PERSONS WITH SPECIAL NEEDS. THE CARE CENTER IS CERTIFIED FOR MEDICARE AND MEDICAID AND IS AFFILIATED WITH THE EVANGELICAL LUTHERAN CHURCH OF AMERICA. 0 0 10412271 3691 11615255 PROVIDING SKILLED NURSING CARE, RESPITE CARE, ASSISTED LIVING, INDEPENDENT LIVING, PERSONAL CARE, HOMEMAKING AND LIFELINE EMERGENCY RESPONSE SERVICES TO THE ELDERLY AND PERSONS WITH SPECIAL NEEDS. THE CARE CENTER PROVIDED SERVICE TO MORE THAN 400 PERSONS FOR PERSONAL AND HOMEMAKING CARE, AND RESIDENTIAL SERVICES TO OVER 300 PERSONS. 10412271 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 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 0 0 1 1 1 0 0 1 17 0 329 1 1 1 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X LESLIE MASON 9708422861 122 HOSPITAL ROAD BRUSH CO 80723 ANDREW LARRICK 1.00 1.00 X X 0 0 0 GEORGE DIKEOU 1.00 1.00 X 0 0 0 DR ALAN DAHMS 1.00 1.00 X 0 0 0 MIKE BERRYHILL 1.00 1.00 X X 0 0 0 ROGER SCHAEFER 1.00 1.00 X 0 0 0 DR KERRY HART 1.00 X 0 0 0 ROBERT CHAPIN 1.00 X X 0 0 0 NORMAN AARESTAD 1.00 X 0 0 0 PAUL OLSEN 1.00 X 0 0 0 DR WENDY KALAN 1.00 X 0 0 0 BARBARA BRADSHAW 40.00 1.00 X 33192 0 2131 SHELLY GRIFFITH 40.00 1.00 X 88633 0 8358 LESLIE MASON 40.00 1.00 X 49702 0 6955 171527 0 17444 0 0 0 0 0 186902 1296 188198 PATIENT SERVICE 623000 11409045 11409045 AUXILIARY 623000 189034 189034 11598079 85578 196 85382 12276 2461 9815 9815 9815 89821 0 89821 89821 89821 EARNINGS OF EQUITY INV 524298 82836 82836 INSURANCE PROCEEDS 624200 17176 17176 100012 12071503 11615255 10011 258039 3691 3691 6190151 5738937 410381 40833 59558 53271 5646 641 1066281 1001802 61845 2634 463928 411042 49278 3608 4380 4380 51594 51594 24103 24103 197433 191946 5487 28952 28952 73161 67894 5111 156 261186 121871 139315 483998 477411 6587 220053 127327 92726 ANCILLARY 757904 757904 FOOD 498176 498176 SUPPLIES 416678 389788 26621 269 UTILITIES 247344 247344 384590 294915 83485 6190 11433161 10412271 966559 54331 700 596 3414669 3842745 1111390 960317 64904 57320 38957 151576 15663124 9508432 6361911 6154692 1371031 1817363 1499276 1464311 13862838 14448920 789754 818445 1685 1677 4097705 3899062 130988 144514 5020132 4863698 X 8842706 9585222 8842706 9585222 13862838 14448920 638342 104174 0 X X 0 1 X 1 0 X 691233 151590 543964 372771 188198 1947756 10332705 11800024 11187753 11590548 11598079 56509109 11023938 11951614 11731717 11963319 11786277 58456865 0 0 0 58456865 80041 45535 52021 66188 85382 329167 7925 1048 7393 10011 26377 87966 46583 59414 66188 95393 355544 57716 412425 125880 91561 100012 787594 11169620 12410622 11917011 12121068 11981682 59600003 0.98080 0.97940 0.00600 0.00600 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS - 2008 AMOUNT: $ 57,716. 2009 AMOUNT: $ 412,425. 2010 AMOUNT: $ 125,880. 2011 AMOUNT: $ 91,561. 2012 AMOUNT: $ 100,012. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 288250 10000 298250 231847 56403 288250 231847 231847 224347 7500 231847 224347 224347 1.00000 0 1 1 66372 66372 10518007 5492086 5025921 5048209 4016346 1031863 30536 30536 6154692 DUE FROM FOUNDATION 321295 BOND ISSUANCE COSTS-NET 145245 BOND PROCEEDS HELD IN TRUST 479434 BOND INTEREST FUND 34678 BOND PRINCIPAL FUND 35834 INV IN CAPTIVE INSURANCE 417695 OTHER RECEIVABLE 19028 INTEREST RECEIVABLE 11102 1464311 DEPOSITS OF RESIDENTS 38876 ASSET RETIREMENT OBLIGATION 66862 DEFERRED COMPENSATION 38776 144514 X 12178138 104174 2461 106635 12071503 0 12071503 11435622 2461 2461 11433161 0 11433161 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENTS ARE HELD BY EBEN EZER LUTHERAN CARE CENTER FOUNDATION, A RELATED ORGANIZATION. THE ENDOWMENT CONSISTS OF TWO INDIVIDUAL FUNDS ESTABLISHED TO SUPPORT THE OPERATIONS OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION FOLLOWS A MORE-THAN-LIKELY-THAN-NOT MEASUREMENT METHODOLOGY TO REFLECT THE FINANCIAL STATEMENT IMPACT OF UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN AFTER EVALUATION THE TAX POSITIONS TAKEN, NONE ARE CONSIDRED TO BE UNCERTAIN, THEREFORE, NO AMOUNTS HAVE BEEN RECOGNIZED AS OF DECEMBER 31, 2011 OR 2010 IF INCURRED, INTEREST AND PENALTIES ASSOCIATED WITH TAX POSITIONS ARE RECORDED IN THE PERIOD ASSESSED AS OTHER EXPENSES. NO INTEREST OR PENALTIES HAVE BEEN ASSESSED AS OF DECEMBER 31, 2011 AND 2012 TAX YEARS THAT REMAIN SUBJECT TO EXAMINATIONN INCLUDE 2008 THROUGH CURRENT FOR THE FEDERAL RETURN AND 2007 THROUGH CURRENT FOR THE COLORADO RETURN. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,461. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 2,461. A CITY OF BRUSH COLORADO 846000638 117416BV8 2004-09-01 640000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 B CITY OF BRUSH COLORADO 846000638 117416BW6 2004-09-01 1350000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 C CITY OF BRUSH COLORADO 846000638 117416BX4 2004-09-01 2125000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 A 200000 640000 34522 605478 1 0 1 1 B 1350000 69045 1280955 1 0 1 1 C 2125000 110472 2014528 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 1 0 1 0 0 0 1 B 0 0 1 0 1 0 0 0 1 C 0 0 1 0 1 0 0 0 1 A 1 B 1 C 1 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE OFFICERS OF THE BOARD AND SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION TAKEN SHALL NOT BE IN CONFLICT WITH THE POLICIES, OR ANY PRIOR ACTION OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD. IT SHALL CONSIDER ALL MATTERS REFERRED TO IT BY THE BOARD AND SHALL ACT FOR THE BOARD IN EMERGENCIES. THE EXECUTIVE COMMITTEE SHALL NOT ACT WITHOUT BOARD APPROVAL IN THE FOLLOWING MATTERS: (I) ANY SALE OR PURCHASE OF LAND OR BUILDINGS, (II) ANY FUNDING FOR CAPITAL IMPROVEMENTS THROUGH EITHER MORTGAGE FUNDING OR A FUND CAMPAIGN, (III) ANY ESTABLISHMENT OF ADMINISTRATIVE POSITIONS, INCLUDING POSITION DESCRIPTIONS AND FILLING OF SAID POSITIONS. FORM 990, PART VI, SECTION B, LINE 11 THE AUDIT COMMITTEE REVIEWS THE FORM 990 IN DETAIL BEFORE IT IS FILED AND APPROVES THE FILING OF THE RETURN. THE BOARD OF DIRECTORS THEN IS PROVIDED WITH A COPY OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY. AT EVERY BOARD MEETING, THE MEMBERS ARE ASKED IF THERE HAS BEEN A CHANGE IN THEIR INDEPENDENCE WITH THE ORGANIZATION. THIS INFORMATION IS DOCUMENTED WITHIN THE MINUTES. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD REVIEWS SURVEYS FROM OTHER SIMILAR ORGANIZATIONS ON COMPENSATION LEVELS. THE BOARD REVIEWS AND APPROVES THE COMPENSATION FOR THE CEO BASED ON COMPARABLE COMPENSATION. THE ORGANIZATION MAINTAINS THE APPROPRIATE DOCUMENTATION OF HOW THE COMPENSATION IS SET. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES IT GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 12, PART XII, LINE 2C THESE POLICIES / PROCEDURES DID NOT CHANGE IN THE CURRENT YEAR. EBEN EZER LUTHERAN CARE CENTER FOUNDATION 122 HOSPITAL ROAD BRUSH CO 80723 742480396 SUPPORT CO 501(C)(3) LINE 11A, I EBEN EZER LUTHERAN CARE CENTER 1 EBEN EZER LUTHERAN HOUSING CENTER 1900 EDISON STREET BRUSH CO 80723 840884015 HOUSING CO 501(C)(3) LINE 7 EBEN EZER LUTHERAN CARE CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 EBEN EZER LUTHERAN CARE CENTER FOUNDATION C 186902 FMV