2013-08-14T12:58:37-05:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-10-01 311608691 APPLE VALLEY VILLA APARTMENTS APPL 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385205 2013-08-13 1 JEFF VRIEZE P01273590 6123764500 2011 2016-02-25 16:41:14Z TIM TUCKER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 4720742 0 X WWW.AUGUSTANACARE.ORG X 1997 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 7 7 85 45 0 0 16461 12583 4155469 4265578 449 463 21357 442118 4193736 4720742 650000 802282 0 0 1506083 1738185 0 0 0 2293702 2385331 4449785 4925798 -256049 -205056 13340592 13007811 10890167 10762441 2450425 2245370 TO SERVE GOD BY FOSTERING FULLNESS OF LIFE FOR OLDER ADULTS AND OTHER PEOPLE IN NEED THROUGH THE PROVISION OF HEALTH CARE, HOUSING AND OTHER SERVICES IN A CHRISTIAN TRADITION. 0 0 4105059 802282 4265578 APPLE VALLEY VILLA APARTMENTS IS A 207-UNIT SENIOR SERVICE AND CONGREGATE HOUSING COMPLEX IN APPLE VALLEY, MINNESOTA. APPLE VALLEY VILLA APARTMENTS SERVED 256 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2012. 4105059 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 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 0 0 0 0 1 0 0 85 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CRAIG KITTELSON - AUGUSTANA CARE SE 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X REV DR GARY WILKERSON 1.00 X X 0 0 0 MARSHALL MACKAY 1.00 X X 0 0 0 CHARLES PARKS JR 1.00 X X 0 0 0 ERIC RICK ELLINGSON 1.00 X X 0 0 0 JIM EHLEN 1.00 X 0 0 0 SCOTT RAMSDALE 1.00 X 0 0 0 PR ELIZABETH BEISSEL 1.00 X 0 0 0 TIM TUCKER 4.50 X 0 319547 54491 CRAIG KITTELSON 4.50 X 0 253836 50711 TIM MIDDENDORF 4.50 X 0 205906 38163 KATHERINE KOPP 4.50 X 0 221780 40457 0 1001069 183822 0 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 235732 1 12583 12583 SENIOR APARTMENTS 623000 3003546 3003546 CATERED LIVING 623000 1262032 1262032 4265578 463 463 DIETARY REVENUE 722210 289008 289008 TELEPHONE REVENUE 623990 65433 65433 HOUSEKEEPING REVENUE 623990 60225 60225 27452 27452 442118 4720742 4265578 0 442581 800000 800000 2282 2282 1462018 1128098 333920 20991 14580 6411 148921 110950 37971 106255 81721 24534 235732 235732 2022 2022 17873 17873 162419 141268 21151 32166 32166 95737 68340 27397 501316 501316 3956 3956 8909 8909 449382 449382 454122 454122 41507 41507 DIETARY EXPENSES 318174 318174 NURSING SUPPLIES 29384 29384 BAD DEBT EXPENSE 14466 14466 MISCELLANEOUS 5379 5379 12787 5442 7345 4925798 4105059 820739 0 848891 928593 164958 239648 37627 40427 13015637 2181931 11000832 10833706 167934 170478 1120350 794959 13340592 13007811 395957 424733 106135 114793 10312107 10155105 75968 67810 10890167 10762441 X 1522667 1337238 927233 907607 525 525 2450425 2245370 13340592 13007811 -205056 0 X 0 1 1 X 1 1 X 6696 183075 2792 16461 12583 221607 2562923 2937739 3407014 3735670 4265578 16908924 2569619 3120814 3409806 3752131 4278161 17130531 500 220 720 0 500 220 720 17129811 6455 3843 244 449 463 11454 6455 3843 244 449 463 11454 502553 547426 530765 441156 442118 2464018 3078627 3672083 3940815 4193736 4720742 19606003 0.87370 0.86270 0.00060 0.00130 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: DIETARY INCOME FROM TENANTS MISCELLANEOUS INCOME FROM TENANTS HOUSEKEEPING INCOME FROM TENANTS TELEPHONE INCOME FROM TENANTS LAUNDRY INCOME FROM TENANTS MAINTENANCE INCOME FROM TENANTS CABLE TV INCOME FROM TENANTS 0 1 525 525 275 250 525 275 16 16 275 275 275 0.00000 1.00000 0.00000 0 1 1 1332579 1332579 11009496 1821700 9187796 652810 360231 292579 20752 20752 10833706 TENANT SECURITY DEPOSITS 118190 ASSETS UNDER BOND INDENTURE AGREEMENTS 676244 BENEFICIAL INTEREST IN NET ASSETS OF THE FOUNDATION 525 794959 DUE TO AFFILIATES 67810 67810 4720742 4925798 -205056 -205056 4747940 30476 30476 4717464 3278 3278 4720742 4125798 0 4125798 800000 800000 4925798 PART IV, LINE 2B: SECURITY DEPOSITS ARE REQUIRED FOR THE ORGANIZATION'S TENANTS AND INCLUDE RESERVED APARTMENTS IF AMOUNTS ARE PAID BEFORE THE TENANT ACTUALLY MOVES IN. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE PRINCIPAL WILL BE INVESTED AND KEPT INTACT FOR PERPETUITY TO PROVIDE AN ADDITIONAL SOURCE OF INCOME. THE INCOME GENERATED WILL BE USED TO SUPPORT THE FUND DESIGNATED PROGRAM. THE ORGANIZATION'S ENDOWMENT IS HELD AND ADMINISTERED BY AUGUSTANA CARE FOUNDATION. SEE SCHEDULE R FOR ADDITIONAL DETAILS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: APPLE VALLEY VILLA APARTMENTS HAVE BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND MINNESOTA CORPORATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND APPLICABLE STATE CODES. THE PROJECT HAS BEEN CLASSIFIED AS AN ORGANIZATION THAT IS NOT A PRIVATE FOUNDATION UNDER SECTION 509(A). THE PROJECT'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. THE PROJECT IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAXEXEMPT STATUS. THE PROJECT IS ALSO NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. THE INFORMATION TAX RETURNS FOR THE FISCAL YEARS ENDED 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 30,476. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EQUITY TRANSFER TO RELATED ORGANIZATION 800,000. 1 AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 501(C)(3) 800000 TRANSFER OF EXCESS CASH 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: APPLE VALLEY VILLA APARTMENTS MAKES INTERCOMPANY TRANSFERS TO RELATED ORGANIZATIONS. APPLE VALLEY VILLA APARTMENTS AND THE RELATED ORGANIZATIONS ARE UNDER COMMON MANAGEMENT WHO REGULARLY MONITOR THE USE OF FUNDS. 0 1 0 0 0 0 0 0 0 TIM TUCKER 0 247516 0 44415 0 27616 0 31283 0 23208 0 374038 0 0 CRAIG KITTELSON 0 187311 0 33897 0 32628 0 23724 0 26987 0 304547 0 0 TIM MIDDENDORF 0 165401 0 30123 0 10382 0 16202 0 21961 0 244069 0 0 KATHERINE KOPP 0 170993 0 35721 0 15066 0 15305 0 25152 0 262237 0 0 PART I, LINE 1A PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN PROVIDED BY AUGUSTANA CARE SERVICES, A RELATED ORGANIZATION: TIM TUCKER, PRESIDENT AND CEO - $22,708 CRAIG KITTELSON, VICE PRESIDENT OF FINANCE AND CFO - $15,958 TIM MIDDENDORF, VICE PRESIDENT OF OPERATIONS AND COO - $11,000 KATHERINE KOPP, VICE PRESIDENT OF NEW BUSINESS DEVELOPMENT - $8,000 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: FOR THE PURPOSE OF DETERMINING COMPENSATION, APPLE VALLEY VILLA APARTMENTS RELIED ON A RELATED ORGANIZATION, AUGUSTANA CARE SERVICES, TO ESTABLISH THE COMPENSATION OF THE PRESIDENT/CEO. AUGUSTANA CARE SERVICES USED THE FOLLOWING PRACTICES TO ESTABLISH COMPENSATION FOR THE PRESIDENT/CEO: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ORGANIZATION MISSION STATEMENT OVERALL MISSION OF AUGUSTANA ENTITIES AUGUSTANA CARE, AND ITS SUBSIDIARIES', MISSION IS TO FOSTER FULLNESS OF LIFE FOR OLDER ADULTS AND OTHERS IN NEED THROUGH THE PROVISION OF HEALTHCARE, HOUSING AND OTHER SERVICES. BECAUSE ELDERS ARE VITAL TO OUR COMMUNITIES, WE PROVIDE SERVICES TO HELP THEM CONTINUE LIVING LIFE TO THE FULLEST, GIVING US ALL THE BENEFIT OF THEIR WISDOM AND EXPERIENCE. WE OFFER A FULL SPECTRUM OF SERVICES FOR OLDER ADULTS AND SERVE MORE THAN 6,000 PEOPLE EACH YEAR IN COMMUNITIES IN MINNESOTA AND COLORADO. OUR HEALTH CARE FACILITIES PROVIDE TRANSITIONAL CARE, LONG-TERM CARE, DEMENTIA CARE, AND REHABILITATION SERVICES TO MORE THAN 3,500 PEOPLE EACH YEAR. AUGUSTANA CARE ALSO OWNS AND MANAGES A VARIETY OF LIVING COMMUNITIES SERVING OLDER ADULTS WITH COMFORTABLE LIVING AND CARE OPTIONS, INCLUDING APARTMENTS FOR INDEPENDENT LIVING, HOUSING WITH SERVICES, AND ASSISTED LIVING AND MEMORY CARE. ADDITIONALLY, WE OFFER A RANGE OF COMMUNITY-BASED SUPPORT SERVICES SUCH AS ADULT DAY PROGRAMS TO ENHANCE THE QUALITY OF LIFE FOR OLDER ADULTS WHO CONTINUE TO LIVE IN THEIR OWN HOMES, AS WELL AS MANAGEMENT CONSULTING SERVICES TO OTHER ORGANIZATIONS THAT SERVE OLDER ADULTS. FORM 990, PART VI, SECTION A, LINE 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR APPLE VALLEY VILLA APARTMENTS. AUGUSTANA CARE SERVICES PROVIDES FINANCIAL ACCOUNTING, OPERATIONAL OVERSIGHT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, CLINICAL NURSING CONSULTATION, CORPORATE COMPLIANCE, COORDINATED ADVERTISING AND MARKETING, STAFFING FOR FUND DEVELOPMENT, AND NEW BUSINESS DEVELOPMENT. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS AUGUSTANA CARE. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION'S BOARD OF DIRECTORS ARE APPOINTED BY A MAJORITY VOTE FROM THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS REQUIRE AFFIRMATIVE APPROVAL FROM THE SOLE MEMBER OF THE ORGANIZATION, AUGUSTANA CARE: (A) AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS OF THIS CORPORATION; (B) CAPITAL BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, AND ALL MAJOR EXPENDITURES BEFORE FUNDS ARE EXPENDED THEREFORE; (C) OPERATING BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, BEFORE AUTHORIZED EXPENDITURES MAY BE MADE THEREFROM; (D) STRATEGIC PLANS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSIHPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION; (E) THE INCURRING OF ANY LONG TERM DEBT OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, OTHER THAN INTRA-SYSTEM OR REFINANCING DEBT; (F) HUMAN RESOURCES AND BENEFITS POLICIES OF THIS CORPORATION; (G) MAJOR RISK CONTRACTING AGREEMENTS, WHICH FOR THESE PURPOSES MEANS ANY CONTRACT WHICH DEALS WITH CAPITATION OR SIMILAR RISK BEARING CONCEPT; (H) MERGER, CONSOLIDATION, OR TOTAL OR PARTIAL DISSOLUTION INVOLVING THIS CORPORATION; (I) GOVERNANCE AND ACTION OF THE TYPE SET FORTH IN SUBPARAGRAPH (A) AND SUBPARAGRAPHS (F) THROUGH (H) ABOVE AS PROPOSED BY THE BOARD OF DIRECTORS OF ANY CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITES DIRECTLY CONTROLLED BY THIS CORPORATION AS A MEMBER, SHAREHOLDER OR OTHERWISE, TO THE EXTENT THAT THE GOVERNING DOCUMENTS OF SUCH CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITIES GIVE THIS CORPORATION OR THE BOARD A RIGHT OF APPROVAL OVER SUCH GOVERNANCE ACTION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED IN DETAIL BY THE ORGANIZATION'S VP - FINANCE/CFO. THE FORM 990 WAS THEN PRESENTED TO THE FULL BOARD BY THE VP - FINANCE/CFO PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS AND KEY EMPLOYEES. ALL COVERED INDIVIDUALS ARE REQUIRED TO COMPLETE AN ANNUAL CONFLICT OF INTEREST STATEMENT. ALL COVERED INDIVIDUALS ARE REQUIRED TO DISCLOSE ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST TO THE APPROPRIATE LEVEL OF MANAGEMENT OR TO THE BOARD OF DIRECTORS AS OUTLINED IN THE POLICY BASED ON THE INDIVIDUAL'S POSITION WITHIN THE ORGANIZATION. CONFLICTS ARE DETERMINED AT THE APPROPRIATE LEVEL OF MANAGEMENT OR BY THE BOARD OF DIRECTORS. INDIVIDUALS WITH ACTUAL OR POTENTIAL CONFLICTS WILL ABSTAIN FROM DISCUSSING OR VOTING ON ANY MATTERS RELATING TO THE CONFLICT. ALL PROCEEDINGS RELATING TO ACTUAL OR POTENTIAL CONFLICTS WILL BE NOTED IN THE MEETING MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. EXPLANATION FOR HOURS WORKED FORM 990, PART VII, LINE 1A TIM TUCKER, CRAIG KITTELSON, TIM MIDDENDORF, AND KATHERINE KOPP EACH SERVE APPLE VALLEY VILLA APARTMENTS AND ITS RELATED ORGANIZATIONS. EACH INDIVIDUAL SPENDS APPROXIMATELY 4.5 HOURS PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL HOURS OF 45 PER WEEK. REV. DR. GARY WILKERSON, CHARLES PARKS, JR., MARSHALL MACKAY, ERIC (RICK) ELLINGSON, JIM EHLEN, SCOTT RAMSDALE, AND PR. ELIZABETH BEISSEL EACH SERVE ON THE BOARD OF APPLE VALLEY VILLA APARTMENTS AND ITS RELATED ORGANIZATIONS, WITH THE EXCEPTION OF AUGUSTANA CARE FOUNDATION. EACH INDIVIDUAL SPENDS APPROXIMATELY 1 HOUR PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL OF 8 HOURS. AUGUSTANA APARTMENTS OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608701 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA CARE 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411728753 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 7 N/A 0 AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 CHARITABLE FOUNDATION MN 501(C)(3) 11 - TYPE 1 AUGUSTANA CARE 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411806946 MANAGEMENT SERVICES MN 501(C)(3) 11 - TYPE 1 AUGUSTANA CARE 0 AUGUSTANA CHAPEL VIEW HOMES INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 410693953 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA COMMUNITY PARTNERS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411783680 HOME HEALTH CARE SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608696 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA HOME OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311572624 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 OPEN CIRCLE ADULT DAY CENTER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411424801 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA SENIOR DEVELOPMENT INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 481293891 CONSULTING MN N/A C 0 1 0 0 0 0 0 0 1 1 0 1 1 1 1 1 0 0