2013-11-12T11:42:23-06:00 2012-12-31 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST STE 2300 MINNEAPOLIS MN 55402 990 2012-01-01 412012560 EBENEZER LAKES ASSISTED LIVING EBEN 6128743460 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 STEPHAN GRYGAR 6128743460 2013-11-08 1 LAWRENCE H MOHR CPA P00447603 6128764500 2012 2016-02-24 21:20:13Z MARK THOMAS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 2393418 0 X WWW.FAIRVIEWEBENEZER.ORG X 1906 MN PROVIDE ASSISTED LIVING FOR THE ELDERLY 11 8 64 9 0 0 8010 21662 2148019 2276737 69 261 12190 94758 2168288 2393418 0 0 0 0 372889 1050112 0 0 0 1787729 1305571 2160618 2355683 7670 37735 6958505 7114603 6965830 7084193 -7325 30410 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, PYSCHOLOGICAL, 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. 0 0 1722563 2371495 PROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 59 UNITS. 1722563 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 82 0 64 1 0 0 0 0 0 0 0 0 0 0 X 11 8 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 MN X TERRY HAKES 6128743479 2722 PARK AVENUE MINNEAPOLIS MN 55407 MAGGIE COLLINS 1.00 10.00 X X 0 0 0 KENT EKLUND 1.00 10.00 X 0 0 0 STEPHAN GRYGAR 1.00 40.00 X X 0 208146 23467 REVEREND RUSSELL HELGESEN 1.00 10.00 X 0 0 0 SHARY MULHERE 1.00 10.00 X X 0 0 0 PASTOR CHRISTOPHER NELSON 1.00 10.00 X 0 0 0 JEANNE RIPLEY 1.00 10.00 X 0 0 0 JOHN SELSTAD 1.00 10.00 X X 0 0 0 MARK THOMAS 1.00 40.00 X X 0 403511 49547 DEBORAH PAONE 1.00 10.00 X 0 0 0 RICHARD HOWARD 1.00 40.00 X 0 251894 34887 0 863551 107901 0 0 1 0 0 21662 21662 RENT REVENUE 532000 1718098 1718098 ELDERLY CARE SERVICES 623000 558639 558639 2276737 261 261 FORGIVENESS OF DEBT BY 900099 88097 88097 MISCELLANEOUS 900099 6661 6661 94758 2393418 2371495 0 261 X 849679 690706 158973 1772 1772 133875 4758 129117 64786 64786 40502 40502 8743 8743 262815 262815 464 464 80071 1529 78542 186394 186394 2914 2914 328183 328183 192230 192230 46271 46271 OVERHEAD ALLOCATIONS 150685 150685 ELDERLY CARE EXPENSE 6299 6299 2355683 1722563 633120 0 233132 436766 546152 625256 64183 93087 30179 28291 7116017 1519226 5748525 5596791 336334 334412 6958505 7114603 140603 165927 19953 7479 6403984 6326506 401290 584281 6965830 7084193 X -7325 30410 -7325 30410 6958505 7114603 37735 0 X X 0 1 X 1 0 X 792 5388 8010 21663 35853 1873745 2089781 2510477 2148019 2276737 10898759 1873745 2090573 2515865 2156029 2298400 10934612 0 0 0 10934612 33499 727 333 69 261 34889 33499 727 333 69 261 34889 5610 13395 12190 94757 125952 1907244 2096910 2529593 2168288 2393418 11095453 0.98550 0.98990 0.00310 0.00680 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 29265 29265 6843129 1435646 5407483 150230 35010 115220 93393 48570 44823 5596791 TENANT SECURITY DEPOSITS 53928 PREMIUM ON BONDS 191584 AMOUNT DUE TO EBENEZER SOCIETY, A RELATED PARTY 335433 MANAGEMENT FEE PAYABLE TO EBENEZER MANAGEMENT SERVICE, A RELATED PARTY 3336 584281 X 2393418 0 2393418 0 2393418 2355683 0 2355683 0 2355683 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 IT 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 2012. OPEN TAX YEARS SUBJECT TO EXAMINATION BY THE U.S. AND STATE TAXING AUTHORITIES ARE FOR THE YEARS 2009 TO 2011, WHICH STATUES EXPIRES 2013 TO 2015, 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. X X X X X 0 1 0 0 0 0 0 0 0 STEPHAN GRYGAR 0 204557 0 0 0 3589 0 8350 0 15117 0 231613 0 0 MARK THOMAS 0 396728 0 0 0 6783 0 17500 0 32047 0 453058 0 0 RICHARD HOWARD 0 248363 0 0 0 3531 0 17500 0 17387 0 286781 0 0 PART I, LINE 4B MARK THOMAS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN FROM A RELATED ORGANIZATION. SUPPLEMENTAL INFORMATION PART III MARK THOMAS AND STEPHAN GRYGAR ARE EMPLOYEES OF FAIRVIEW HEALTH SERVICES. THEIR SALARY IS PASSED TO EBENEZER AND IS AN EXPENSE OF CORPORATE EBENEZER. THE PROFIT/(LOSS) ON CORPORATE EBENEZER IS ALLOCATED OUT AS A CORPORATE ALLOCATION ON EACH OWNED SITE. FORM 990, PART VI, SECTION A, LINE 2 MARK THOMAS, STEPHAN GRYGAR: 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 TREASURER 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, (ON 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. OTHER FEES FORM 990, PART IX, LINE 11G FOOD SERVICE: PROGRAM SERVICE EXPENSES 234,650. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 234,650. EXTERNAL VENDORS: PROGRAM SERVICE EXPENSES 28,165. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 28,165. 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 MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER RIDGES ASSISTED LIVING 13810 COMMUNITY DRIVE BURNSVILLE MN 55337 411964691 NURSING HOME CARE 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 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER TOWERS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 237005359 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER PARK APARTMENTS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411378656 NURSING HOME CARE 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 N/A 0 FAIRVIEW WOODS ASSISTED LIVING LLC 470 FAIRVIEW BOULEVARD RED WING MN 55066 204381407 NURSING HOME CARE MN N/A YORK GARDENS LLC 3451 PARKLAWN AVE EDINA MN 55435 262912486 NURSING HOME CARE MN N/A EBENEZER MANAGEMENT SERVICES INC 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411567046 MANAGEMENT SERVICES MN N/A C 0 EBENEZER LAKES SENIOR HOUSING 5430 MEADOW LANE WYOMING MN 55092 320190409 NURSING HOME CARE 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 40502 AGREED UPON RATE EBENEZER SOCIETY P 2194244 COST