2013-02-14T19:06:31-06:00 2012-09-30 941239084 ATHERTON & ASSOCIATES LLP PO BOX 4339 MODESTO CA 953524339 990 2011-10-01 770562224 COMMUNITY HOSPICE FOUNDATION OF STANISLAUS COUNTY COMM 2095786300 4368 SPYRES WAY MODESTO CA 95356 RICK DAHLSEID CPA 2095786300 2013-02-14 1 RONALD EHRKE P00141781 2095774800 X 2011 2016-03-07 17:11:31Z HAROLD A PETERSON III 4368 SPYRES WAY MODESTO CA 95356 1372521 0 X WWW.HOSPICEHEART.ORG X 2002 CA SUPPORT OF COMMUNITY HOSPICE, INC. 21 21 6 86 0 0 780785 875868 0 0 53593 57862 245222 262255 1079600 1195985 371635 622902 0 0 203885 255075 0 0 136909 233244 226375 808764 1104352 270836 91633 5229864 5623091 273454 392177 4956410 5230914 X THE FOUNDATION EXISTS TO RAISE FUNDS AND AWARENESS OF THE COMMUNITY HOSPICE MISSION. COMMUNITY HOSPICE PROVIDES COMPASSIONATE END-OF-LIFE CARE AND BEREAVEMENT SUPPORT TO PATIENTS AND THEIR FAMILIES REGARDLESS OF ABILITY TO PAY. THE FOUNDATION RAISES FUNDS UTILIZING A NUMBER OF FUNDRAISING AVENUES. 0 0 904608 TO RAISE FUNDS TO SUPPORT THE OPERATIONS OF COMMUNITY HOSPICE, INC., A RELATED NOT-FOR-PROFIT CORPORATION. COMMUNITY HOSPICE, INC., USES THESE FUNDS TO PROVIDE SERVICES AND SUPPORT TO THE TERMINALLY ILL AND THEIR FAMILIES. 904608 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 1 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 11 0 1 6 1 0 0 0 0 0 1 1 0 0 0 0 0 X 21 21 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X RICK DAHLSEID CPA 2095786300 4368 SPYRES WAY MODESTO CA 95356 CATHY TUXSON 1.00 X 0 0 0 JANICE LUCERO 1.00 X 0 0 0 LESLIE KALIM MCHUGH 1.00 X 0 0 0 GARY ERVIN 1.00 X 0 0 0 JAMES COGDILL 1.00 X 0 0 0 DR ASHLEY BARBOZA 1.00 X 0 0 0 SALLY COFER-LINDBERG 1.00 X 0 0 0 PATTY DUVAL 1.00 X 0 0 0 RONI EDGMON 1.00 X 0 0 0 SUZANNE CANDINI 1.00 X 0 0 0 DON GAEKLE 1.00 X 0 0 0 MICHAEL C HERRERO 1.00 X 0 0 0 JYOTHI PRABHU SEETHARAM 1.00 X 0 0 0 KIM JOHNSON 1.00 X 0 0 0 GARRAD MARSH 1.00 X 0 0 0 GINA MACHADO 1.00 X 0 0 0 PETER RODRIGUEZ 1.00 X 0 0 0 MERYL SNIDER 1.00 X 0 0 0 JON TREMAYNE 1.00 X 0 0 0 TICIA SODHI 1.00 X 0 0 0 EMILY WIROWEK 1.00 X 0 0 0 HAROLD A PETERSON III 5.00 X 0 212762 10220 RICK DAHLSEID CPA 5.00 X 0 119084 6208 0 331846 16428 0 0 1 0 0 45418 830450 45418 875868 57862 57862 370670 45418 176536 194134 194134 16409 0 16409 16409 GAIN FROM LIMITED PART 900099 50393 50393 MISCELLANEOUS INCOME 900099 1319 1319 51712 1195985 51712 0 268405 622902 622902 75726 37863 37863 156627 78314 78313 7093 3547 3546 15629 7815 7814 20109 20109 120 120 27399 27399 18000 18000 1823 1823 5995 5995 5578 5578 MANAGEMENT SERVICE FEES 62835 62835 BANK, CREDIT CARD & PAY 22908 22908 POSTAGE 19034 19034 COMPUTER MAINTENANCE 14909 14909 27665 18292 9373 1104352 904608 62835 136909 735104 391046 7227 10351 7116 3636 0 7500 3552 3373 9202 4136 44265 27035 11207 17230 4085584 4756237 370872 429582 5229864 5623091 53698 55089 219756 337088 273454 392177 X 4536664 4781602 0 37910 419746 411402 4956410 5230914 5229864 5623091 X 91633 182871 X X 0 1 1 X 0 X X X 0 0 0 COMMUNITY HOSPICE INC 942638213 9 1 1 1 622902 1 622902 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 422502 3426 44392 470320 440781 -11770 -6509 422502 417600 1253 21928 440781 189918 216266 11416 417600 0 0 19074 8085 10989 25191 18950 6241 17230 LIMITED PARTNERSHIP 2720000 F PUBLICLY TRADED SECURITIES 2036237 F 4756237 INVESTMENT PROPERTY 7800 ENDOWMENT INVESTMENTS 393782 PLEDGES RECEIVABLE RESTRICTED FOR ENDOWMENT 28000 429582 RELATED PARTY PAYABLE 337088 337088 1195985 1104352 91633 182871 182871 274504 1548992 182156 176536 358692 1190300 5685 5685 1195985 651586 176536 176536 475050 629302 629302 1104352 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS ARE TO FUND FUTURE OPERATING EXPENSES. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: MANAGEMENT EVALUATED THE FOUNDATIONS TAX POSITIONS AND CONCLUDED THAT THE FOUNDATION HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS. THEREFORE, NO PROVISION OR LIABILITY FOR INCOME TAXES HAS BEEN INCLUDED IN THE FINANCIAL STATEMENTS. LINE 2D - OTHER REVENUE - COST OF GOOD SOLD FOR FUNDRAISING EVENTS LINE 4B - OTHER REVENUE - MISCELLANEOUS REVENUE LINE 2D OTHER EXPENSES - COST OF GOODS SOLD FOR FUNDRAISING EVENTS LINE 4B OTHER EXPENSES - TRANSFERS MADE TO RELATED PARTIES GALA 210384 34314 176070 25800 36990 43919 GOLF FORE HOSPICE 61892 4887 57005 18125 1768 12802 5 143812 6217 137595 2179 11902 23051 416088 45418 370670 46104 50660 79772 176536 194134 16409 1 0.95000 16409 16409 CA 1 0 0 0 1.00000 RICK DAHLSEID CPA 4368 SPYRES WAY MODESTO CA 95356 0 LYNIS CHAFFEY 75726 REGISTRATION AND OPERATION OF RAFFLES. X 0 1 COMMUNITY HOSPICE INC 4368 SPYRES WAY MODESTO CA 95356 942638213 501(C)(3) 622902 FUNDS RAISED AND REIMBURSED EXPENSES FOR COMMUNITY HOSPICE INC PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL FUNDS ARE DISTRIBUTED TO COMMUNITY HOSPICE, INC. WHICH IS A RELATED ENTITY. X X X X X 0 0 0 0 0 0 0 0 0 HAROLD A PETERSON III 0 212762 0 0 0 0 0 10220 0 0 0 222982 0 223232 X MISCELLANEOUS 400 BASED ON DONORS REPRESENTATION X PRIZES 42085 BASED ON DONORS REPRESENTATION X FOOD 618 BASED ON DONORS REPRESENTATION X NON-EE GIFT AWARDS 200 BASED ON DONORS REPRESENTATION X ADVERTISING 3012 BASED ON DONORS REPRESENTATION 0 1 0 FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT DUTIES ARE PERFORMED BY CHI MANAGEMENT, INC. WHICH IS A RELATED PARTY EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER (CFO) OBTAINS THE COMPLETED FORM 990 FROM THE PREPARER AND REVIEWS IT FOR ACCURACY AND COMPLETENESS. IF CONSIDERED ACCURATE AND COMPLETE, THE COMPLETE 990 IS CONVERTED TO A PDF FILE FOR ELECTRONIC STORAGE AND VIEWING AND A PDF COPY OF THE 990 IS FORWARDED TO EACH MEMBER OF THE CHI FOUNDATION AUDIT COMMITTEE FOR THEIR REVIEW. AFTER THE CHI FOUNDATION AUDIT COMMITTEE REVIEWS THE 990, THE CFO WILL GO OVER THE 990 WITH THEM FOR A FINAL REVIEW AND THEIR APPROVAL FOR FILING. AT THE CONCLUSION OF THE REVIEW, ANY UNANSWERED QUESTIONS WILL BE FORWARDED TO THE PREPARER FOR REPLY. THOSE REPLIES WILL BE ELECTRONICALLY FORWARDED TO THE MEMBERS OF THE CHI FOUNDATION AUDIT COMMITTEE FOR COMMENT. ABSENT ANY ADDITIONAL QUESTIONS OF THE PREPARER, THE FORM 990 WILL BE CONSIDERED TO BE COMPLETE AND READY TO FILE WITH THE INTERNAL REVENUE SERVICE. THE CHI FOUNDATION AUDIT COMMITTEE WILL MOVE TO APPROVE THE FORM 990. THE FORM 990 WILL BE SIGNED BY THE CFO AND FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C ALL EMPLOYEES, VOLUNTEERS, AND MEMBERS OF THE BOARD OF DIRECTORS AND ADVISORY COMMITTEES WILL SIGN A CONFLICT OF INTEREST DOCUMENT UPON EMPLOYMENT, APPOINTMENT, OR REAPPOINTMENT, INDICATING THAT THEY HAVE READ AND UNDERSTOOD THE RELEVANT POLICIES AND THAT THEY WILL OBSERVE THEM. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS APPROVED BY THE INDEPENDENT BOARD OF DIRECTORS WHERE THE VOTE OF EACH MEMBER IS COUNTED. COMPENSATION ANALYSIS OF SIMILARLY SITUATED ORGANIZATIONS (TAXABLE AND TAX-EXEMPT) WITH RESPECT TO SIZE AND RESPONSIBILITIES OF EACH POSITION ARE COMPARED. THIS ANALYSIS IS PREPARED ANNUALLY. THE PROCESS OF ARRIVING AT EACH INDIVIDUAL'S COMPENSATION ARRANGEMENT IS DOCUMENTED IN BOARD MINUTES, PERSONAL ACTION FORMS, AND THE EMPLOYEE'S PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES AVAILABLE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND ANNUAL REPORT TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 182,871. MEMBERS OF THE BOARD OF DIRECTORS FROM COMMUNITY HOSPICE, INC., CHI MANAGEMENT, INC. AND COMMUNITY HOSPICE FOUNDATION OF STANISLAUS COUNTY MAKE UP THE AUDIT COMMITTEE CHARGED WITH RESPONSIBILITY OF OVERSIGHT IN CONNECTION TO THE AUDITED FINANCIAL STATEMENTS AND SELECTION OF INDEPENDENT AUDITORS. COMMUNITY HOSPICE INC 4368 SPYRES WAY MODESTO CA 95356 942638213 HOSPICE CARE FOR THE TERMINALLY ILL CA 501(C)(3) 509(A)(2) N/A 0 CHI MANAGEMENT INC 4368 SPYRES WAY MODESTO CA 95356 200178425 PROVIDE PROFESSIONAL SERVICES FOR CHI INC., CHI FOUNDATION AND HOPE CHEST CA 501(C)(3) 509(A)(2) N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 COMMUNITY HOSPICE INC Q 372902 FAIR MARKET VALUE COMMUNITY HOSPICE INC O 250000 FAIR MARKET VALUE COMMUNITY HOSPICE MANAGEMENT INC N 62835 FAIR MARKET VALUE