2013-05-15T18:10:13-05:00 2012-06-30 910605875 PETERSON SULLIVAN LLP CPA'S 601 UNION ST STE 2300 SEATTLE WA 981012345 990 2011-07-01 910593488 PROVAIL PROV 2063637303 12550 AURORA AVE N SEATTLE WA 98133 MICHAEL J HATZENBELER 2063637303 2013-05-15 1 MATTHEW R MATSON P00775671 2063827777 2013-05-15 2011 2016-02-24 21:20:13Z MICHAEL J HATZENBELER 12550 AURORA AVE N SEATTLE WA 98133 11697477 0 X WWW.PROVAIL.ORG X 1942 WA PROVAIL'S MISSION IS TO SUPPORT PEOPLE WITH DISABILITIES TO FULFILL THEIR LIFE CHOICES. 15 15 384 360 0 0 7865773 7834091 892810 477894 8480 2421 574176 602440 9341239 8916846 0 0 0 0 7605822 7701291 0 0 204456 1764199 1340738 9370021 9042029 -28782 -125183 3416379 3154085 2319849 2222017 1096530 932068 PROVAIL'S MISSION IS TO SUPPORT PEOPLE WITH DISABILITIES TO FULFILL THEIR LIFE CHOICES. 0 0 5543820 COMMUNITY LIVING SERVICES - PROVIDES SUPPORTED LIVING SERVICES TO ADULTS WITH SEVERE DEVELOPMENT DISABILITIES. WE PROVIDE 24-HOUR SUPPORT, INSTRUCTION, PERSONAL CARE, AND NURSING SERVICES IN ACCESSIBLE, COMMUNITY-BASED HOMES THROUGHOUT THE GREATER SEATTLE AREA. APPROXIMATELY 64 CLIENTS ARE SERVED. 1128453 560997 SUPPORTED EMPLOYMENT AND VOCATIONAL SERVICES - WE WORK WITH INDIVIDUALS WITH DISABILITIES TO SECURE AND RETAIN COMPETITIVE EMPLOYMENT BY HELPING WITH THE PROCESS OF IDENTIFYING CAREER GOALS, MATCHING CANDIDATES TO POSITIONS, TRAINING AND ORIENTATION AND ONGOING SUPPORT WHERE NEEDED. APPROXIMATE CASELOAD IS 225 CLIENTS. WE OPERATE A LIGHT MANUFACTURING FACILITY THAT PROVIDES EMPLOYMENT AND VOCATIONAL SERVICES FOR APPROXIMATELY 24 PERSONS WITH DISABILITIES IN AN INTEGRATED, COMPETITIVE WORKPLACE. 1150246 477894 THERAPEUTIC AND ASSISTIVE TECHNOLOGY SERVICES - OUR SERVICES INCLUDE SPEECH THERAPY, OCCUPATIONAL THERAPY AND ASSISTIVE TECHNOLOGY. THESE SERVICES ENABLE CHILDREN AND ADULTS WITH DISABILITIES OR INJURIES TO MAXIMIZE THEIR PERFORMANCE AND PRODUCTIVITY AT HOME, WORK, SCHOOL, AND IN LEISURE ACTIVITIES. APPROXIMATELY 380 CLIENTS ARE SERVED EACH YEAR. IN ADDITION, THE DENTAL CLINIC PROVIDES PROFESSIONAL DENTAL SERVICES TO PEOPLE WITH DISABILITIES, SERVING APPROXIMATELY 225 CLIENTS EACH YEAR. 7822519 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 8 0 1 384 1 0 0 0 0 0 1 1 0 0 0 0 X 15 15 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 0 0 WA X KELLY RONDOU 2063637303 12550 AURORA AVE N SEATTLE WA 98133 KEN TOOLE 1.00 X X 0 0 0 KATIE CISSELL 1.00 X X 0 0 0 CARLY LIST 1.00 X X 0 0 0 DEREK CRUMP 1.00 X X 0 0 0 DOUG MCFARLAND 1.00 X X 0 0 0 JIM CHESEMORE 1.00 X 0 0 0 JENNY COCHRANE 1.00 X 0 0 0 DOUG DURBIN 1.00 X 0 0 0 JARED HAGER 1.00 X 0 0 0 JEANA JORGENSEN 1.00 X 0 0 0 CHRIS KING 1.00 X 0 0 0 KEVIN KOPPES 1.00 X 0 0 0 SKYLAR SHERWOOD 1.00 X 0 0 0 ZOE VINSON 1.00 X 0 0 0 BART WILSON 1.00 X 0 0 0 MICHAEL HATZENBELER 40.00 X 137815 0 11019 JAMES MACKELLAR-HERTAN 40.00 X 99636 0 7137 237451 0 18156 1 0 0 0 0 112674 150996 7462115 108306 7834091 REHABILITATION & DENTA 900099 402894 402894 TRAUMATIC BRAIN INJURY 900099 75000 75000 477894 2421 2421 50261 150996 86307 -36046 -36046 3255321 2694324 560997 560997 L&I REBATES 900099 48544 48544 COBRA PAYMENTS 900099 21957 21957 MISCELLANEOUS 900099 5993 5993 995 995 77489 8916846 1038891 0 43864 257234 227913 24188 5133 6259362 5547153 589392 122817 453852 401045 41987 10820 730843 675772 44647 10424 5450 5450 54275 47425 6850 98016 68565 25041 4410 17200 3543 2072 11585 176295 147573 23295 5427 449491 339993 92850 16648 115778 113554 1408 816 35574 17558 14576 3440 50305 47614 2053 638 61873 38040 23415 418 68026 51697 15430 899 GENERAL AND ADMINISTRAT 148045 61824 80393 5828 DUES & SUBSCRIPTIONS 24151 9724 13973 454 TAXES, LICENSES AND FEE 23151 19524 3354 273 MISCELLANEOUS 8682 4002 4680 4426 4426 9042029 7822519 1015054 204456 184657 102881 732182 371101 1641197 1776876 41877 111481 63243 101026 2164741 1604732 613937 560009 87663 87663 51623 43048 3416379 3154085 979269 947796 1147786 1081955 192794 192266 2319849 2222017 X 1096530 932068 1096530 932068 3416379 3154085 X -125183 -39279 X X 0 1 1 X 0 X 8104453 8005524 7862553 7865773 7834091 39672394 8104453 8005524 7862553 7865773 7834091 39672394 39672394 19730 6919 6925 7343 2421 43338 12751 5515 3970 14215 77489 113940 39829672 7819267 0.99610 0.99750 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MISCELLANEOUS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 70500 70500 614556 420589 193967 612559 408631 203928 867126 775512 91614 560009 DEFERRED RENT 192266 192266 8916846 9042029 -125183 -39279 -39279 -164462 11740461 6984 2816631 2823615 8916846 0 8916846 11936307 6984 2887294 2894278 9042029 0 9042029 PART XI, LINE 8 - OTHER ADJUSTMENTS: LOSS ON INVENTORY OBSOLESCENCE -39,279. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE INCLUDED ON PAGE 9 LINE 8B 86,307. REVENUE REPORTED BY PROVAIL AFFILIATES EIN 91-2146011 75,279. COGS EXPENSE REPORTED ON PAGE 9 LINE 10B 2,694,324. LOSS ON INVENTORY OBSOLESCENCE -39,279. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT EXPENSE INCLUDED ON PAGE 9 LINE 8B 86,307. EXPENSES REPORTED BY PROVAIL AFFILIATES EIN 91-2146011 106,663. COGS EXPENSE REPORTED ON PAGE 9 LINE 10B 2,694,324. LUNCHEON 40154 35354 4800 3000 11310 3071 GOLF TOURNAMENT 143163 101302 41861 1000 35806 17405 10372 2 17940 14340 3600 559 3784 201257 150996 50261 1000 38806 29274 17227 86307 -36046 PATRICIA TOOLE SPOUSE OF A BOARD MEMBER 25622 TRISH IS EMPLOYED BY PROVAIL AS AN OCCUPATIONAL THERAPIST. 0 FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION WILL PROVIDE A DRAFT COPY OF THE FORM 990 TO THE GOVERNING BOARD PRIOR TO IT BEING FILED AND REQUEST ANY QUESTIONS OR COMMENTS BE DIRECTED TO THE CFO. THE ORGANIZATION WILL PROVIDE A DRAFT COPY OF THE FORM 990 TO THE MANAGEMENT OF THE ORGANIZATION PRIOR TO IT BEING FILED AND REQUEST ANY QUESTIONS OR COMMENTS BE DIRECTED TO THE CFO. FORM 990, PART VI, SECTION B, LINE 12C EACH BOARD MEMBER IS ASKED TO REVIEW AND SIGN THE CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS AND ALSO FILL OUT A QUESTIONNAIRE AS PART OF THE PREPARATION FOR THE 990 DEALING WITH INDEPENDENCE. WE HAVE HAD NO CONFLICTS TO DEAL WITH. FORM 990, PART VI, SECTION B, LINE 15A THE EXECUTIVE COMMITTEE OF THE BOARD UNDERTOOK THE EVALUATION AND COMPENSATION SETTING FOR THE CEO. THEY COMPLETED THE EVALUATION PORTION GETTING INPUT FROM THE BOARD OF DIRECTORS AND EMPLOYEES SUPERVISED BY THE CEO. THEY ALSO REVIEWED SALARIES AT COMPARABLE AGENCIES BY PULLING 990'S FROM THEM. MINUTES OF THESE MEETINGS WERE KEPT. USING BOTH THE EVALUATION AND THE COMPARABLE SALARY INFORMATION THEY SET THE SALARY FOR THE CEO. WE HAVE NO OTHER EMPLOYEES WHO MEET THE DEFINITION OF KEY EMPLOYEE. FORM 990, PART VI, SECTION C, LINE 19 THESE ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: LOSS ON INVENTORY OBSOLESCENCE -39,279. TOTAL TO FORM 990, PART XI, LINE 5: -39,279. FORM 990, PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. AFFILIATED GROUP MEMBERS LIST OF ALL MEMBERS OF THE GROUP THIS RETURN WILL COVER: PROVAIL 12550 AURORA AVE. N SEATTLE, WA 98133 EIN 91-0593488 LIST OF ALL MEMBER OF THE GROUP THIS RETURN WILL NOT COVER: AUBURN COMMUNITY LIVING 12550 AURORA AVE. N SEATTLE, WA 98133 EIN 91-1814582 EASTSIDE COMMUNITY LIVING 12550 AURORA AVE. N SEATTLE, WA 98133 EIN 94-3206977 PROVAIL - AFFILIATES 12550 AURORA AVE N SEATTLE WA 98133 912146011 COMMUNITY HOUSING WA 501(C)(3) 7 N/A 0 AUBURN COMMUNITY LIVING 12550 AURORA AVE N SEATTLE WA 98133 911814582 COMMUNITY HOUSING WA 501(C)(3) 7 N/A 0 EASTSIDE COMMUNITY LIVING 12550 AURORA AVE N SEATTLE WA 98133 943206977 COMMUNITY HOUSING WA 501(C)(3) 7 N/A 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0