2013-08-13T09:09:16-05:00 2012-09-30 560747981 DIXON HUGHES PLLC 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-10-01 561089384 CAROLINA ADVENTIST RETIREMENT SYSTEMS INC CARO 7046679851 95 HOLCOMBE COVE RD CANDLER NC 287159450 DEBORAH HAWKINS 7046679851 2013-08-13 1 AMY BIBBY P00445891 8282542254 2011 2016-02-24 21:20:13Z DAVID KIDDER 95 HOLCOMBE COVE RD CANDLER NC 287159450 22664373 0 X WWW.PISGAHVALLEY.ORG X 1975 NC SERVING HEALTHCARE AND RESIDENTIAL NEEDS WHILE UPHOLDING CHRISTIAN PRINCIPLES. 25 13 642 13 82882 -39543 136638 1221934 22585889 21085506 39881 27838 392247 324440 23154655 22659718 90467 429735 0 0 12274838 11873674 0 0 0 9053558 9077441 21418863 21380850 1735792 1278868 25165506 36800001 10721808 22511675 14443698 14288326 AS A FAITH-BASED SEVENTH-DAY ADVENTIST ORGANIZATION, WE ARE DEDICATED TO SERVING THE HEALTHCARE AND RESIDENTIAL NEEDS OF OUR COMMUNITY WHILE UPHOLDING CHRISTIAN PRINCIPLES. 0 0 8971058 200090 10550571 PISGAH VALLEY RETIREMENT COMMUNITY OWNS AND OPERATES A LICENSED CONTINUING CARE RETIREMENT COMMUNITY WITH 21 INDEPENDENT LIVING DUPLEX CONDOMINIUM UNITS, A 24-UNIT MULTI-UNIT ASSISTED HOUSING WITH SERVICES FACILITY, AND A 118-BED SKILLED NURSING FACILITY IN CANDLER, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, WELLNESS CENTER/ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). 9200967 229645 10624093 WINSLOW OPERATES A RETIREMENT COMMUNITY WITH 24 INDEPENDENT LIVING STUDIO APARTMENT UNITS AND A 146-BED SKILLED NURSING FACILITY IN ELIZABETH CITY, NORTH CAROLINA. PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE THE PROVIDING OF ROOM AND BOARD (SHELTER, UTILITIES, MEALS, HOUSEKEEPING, LAUNDRY, AND MAINTENANCE), TRANSPORTATION, ACTIVITIES, ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, AND MEDICAL SERVICES TO OUR COMMUNITY (PRIMARILY AGE 55 AND OLDER). 18172025 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 1 0 0 1 40 0 1 642 1 1 1 0 0 0 0 0 0 0 0 0 X 25 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DEBORAH HAWKINS 8284182334 95 HOLCOMBE COVE ROAD CANDLER NC 28715 RICHARD ANDERSON 1.00 X 0 50460 9954 SAMUEL BONHAM 1.00 X 0 75 0 ERNEST BOUGHMAN JR 1.00 X 0 300 0 JIMM BUNCH 1.00 X 0 0 0 DEWAYNE BUTCHER MD 1.00 X 0 0 0 BRENNA BOULANGER 1.00 X 0 0 0 JOHN COELHO 1.00 X 0 62655 30014 NOEMI CRUZ 1.00 X 0 0 0 JIM DAVIDSON 1.00 X 0 64810 41113 LESLIE LOUIS 1.00 X 0 0 0 DONOVAN DAVIS 1.00 X 0 65347 40461 JOHN EARNHARDT 1.00 X 0 65179 49512 CHARLES FERGUSON 1.00 X 0 67114 31477 SAMUEL GARCIA 1.00 X 0 0 0 MAURY GILMORE 1.00 X 0 150 0 CHAD GRUNDY 1.00 X 0 65002 14690 ROBERT CUNDIFF 1.00 X 0 71518 46022 LARRY KROLL MD 1.00 X 0 0 0 MINERVINO LABRADOR JR 1.00 X 0 81268 49773 JEFFREY DONALDSON 1.00 X 0 58879 31537 GARY MOYER 1.00 X X 0 77452 31958 RICHARD RUSSELL 1.00 X 0 71193 14774 WON LEE 1.00 X 0 75 0 ARLEEN STUBBS 1.00 X 0 0 0 ANDREW WILLIAMS 1.00 X 0 0 0 KEVIN WORTH 1.00 X 0 49975 9954 DEBORAH HAWKINS 40.00 X 129792 0 22898 DAVID KIDDER 40.00 X 142121 0 28684 271913 851452 452821 2 0 1 0 SYNERTX 7540 NORTH 19TH AVENUE PHOENIX AZ 85021 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 1030548 KINDRED REHAB SERVICES INC (DBA PEOPLEF PO BOX 277365 ALTANTA GA 30384 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 854209 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 AUDIT, TAX, DATA PROCESSING, CONSULTING 217431 5 1093000 128934 1075000 1221934 MEDICARE/MEDICAID PAYM 623000 15939790 15939790 SKILLED NURSING, ASSIS 623000 5095611 5095611 AMORTIZATION OF ENTRAN 623000 50105 50105 21085506 32493 32493 5400 0 5400 5400 5400 4655 -4655 -4655 -4655 MANAGEMENT FEES FROM H 531390 147000 147000 WELLNESS CENTER REVENU 713940 125664 42782 82882 MISCELLANEOUS INCOME 623000 46376 46376 319040 22659718 21174664 82882 180238 429735 429735 368080 368080 62266 62266 9302880 8451772 851108 53364 45800 7564 1381211 1260019 121192 705873 614230 91643 23509 23509 96574 96574 3018300 3003697 14603 59246 59246 1031160 743677 287483 148232 148232 1094587 889714 204873 107894 74845 33049 29571 15270 14301 5086 5086 1046168 1031344 14824 109676 8371 101305 MED. RELATED SUPPLIES 1598465 1598465 BAD DEBT 398604 398604 PROVIDER TAX 265040 265040 WRITE OFF OF FINANCING 39517 39517 5812 5812 21380850 18172025 3208825 0 900 900 7277195 13584622 73668 75753 1722580 2198198 98300 101300 200252 442980 30157545 9953741 15631927 20203804 160684 192444 25165506 36800001 1938060 2445966 2847997 349169 13045000 5734528 1702483 201223 4969057 10721808 22511675 X 14443698 14288326 14443698 14288326 25165506 36800001 X 1278868 -1434240 X 0 1 1 X 0 X 1638448 275538 619724 24378 146934 2705022 18804594 21068695 21709744 22585889 21085506 105254428 270525 253795 236752 288899 220605 1270576 20713567 21598028 22566220 22899166 21453045 109230026 0 0 0 109230026 80286 59082 74806 63194 33238 310606 80286 59082 74806 63194 33238 310606 20793853 21657110 22641026 22962360 21486283 109540632 0.99720 0.99670 0.00280 0.00330 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2616 2616 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF THE HEALTHCARE FACILITIES ASSOCIATION (HFA) AND THE LEADING AGE ASSOCIATION (LAA). EACH YEAR, A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS ALLOCATED TOWARDS LOBBYING EFFORTS ON BEHALF OF THEIR MEMBERSHIP BODIES. FOR FY 2012, AMOUNTS OF MEMBERSHIP DUES ALLOCATED TO THESE EXPENDITURES WERE $1,765 FOR HFA AND $ 851 FOR LAA. 1720000 1720000 19429377 7019241 12410136 197580 77542 120038 4004927 2367776 1637151 4805661 489182 4316479 20203804 DUE TO RELATED PARTIES 147000 INTEREST RATE SWAP LIABILITY 923595 PATIENT TRUST FUND LIABILITY 40789 RESIDENT REFUNDS PAYABLE 3857673 4969057 22659718 21380850 1278868 -730119 -704121 -1434240 -155372 22659718 0 22659718 0 22659718 22535311 1154461 1154461 21380850 0 21380850 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME TAXES - CARS IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC), AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE IRC. THE ORGANIZATION ACCOUNTS FOR UNCERTAIN TAX POSITIONS BY RECORDING A LIABILITY FOR ANY TAX POSITION TAKEN THAT IS BENEFICIAL TO THE ORGANIZATION, INCLUDING ANY RELATED INTEREST AND PENALTIES, WHEN IT IS MORE LIKELY THAN NOT THE POSITION TAKEN BY MANAGEMENT WITH RESPECT TO A TRANSACTION OR CLASS OF TRANSACTIONS WILL BE OVERTURNED BY A TAXING AUTHORITY UPON EXAMINATION. MANAGEMENT BELIEVES THERE WERE NO SUCH POSITIONS AS OF SEPTEMBER 30, 2011 AND 2012 AND, ACCORDINGLY, NO LIABILITY WAS ACCRUED. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2009 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: LOSS ON ABANDON PROJECT -424,342. RESTATEMENT DUE TO CHANGE IN ACCOUNTING METHOD OF ENTRANCE FEES -279,779. TOTAL TO SCHEDULE D, PART XI, LINE 8: -704,121. PART XIII, LINE 2D - OTHER ADJUSTMENTS: LOSS ON ABANDONED PROJECT 424,342. UNREALIZED LOSS ON SWAPS 730,119. 1 CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS 2701 WT HARRIS BLVD CHARLOTTE NC 28256 454284485 501(C)(3) 35611 FMV TO ASSIST WITH LOCAL PASTOR SALARY MOUNT PISGAH ACADEMY 75 ACADEMY DRIVE CANDLER NC 28715 560713794 501(C)(3) 390150 FMV STUDENT SCHOLARSHIPS AND GENERAL OPERATIONS 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES ASSISTANCE TO OTHER SEVENTH-DAY ADVENTIST NOT-FOR-PROFIT ORGANIZATIONS FOR SPECIFIC PURPOSES RELATED TO ONE-TIME TRANSACTIONS (STUDENT SCHOLARSHIPS AND PASTOR SALARIES); THEREFORE, MONITORING OF THE EXPENDITURES IS ACCOMPLISHED THROUGH OBSERVATIONS. X 1 0 X X X 0 0 0 0 0 0 0 0 0 DEBORAH HAWKINS 127034 0 1918 0 840 0 3207 0 19691 0 152690 0 0 0 DAVID KIDDER 123241 0 2074 0 16806 0 3996 0 24688 0 170805 0 0 0 PART I, LINE 1A CARS WAIVES 100% AND 50% OF THE STANDARD MEMBERSHIP FEE FOR THE CEO AND CFO, RESPECTIVELY, FOR MEMBERSHIP AT CARS' PISGAH VALLEY WELLNESS CENTER. ANY REMAINING PORTION OF THE MEMBERSHIP FEE DUE IS PAID BY THE EMPLOYEE THROUGH PAYROLL DEDUCTIONS. ALL EMPLOYEES AT CARS' PISGAH VALLEY RETIREMENT COMMUNITY CAMPUS ARE ELIGIBLE FOR WAIVER OF SOME PORTION OF PISGAH VALLEY WELLNESS CENTER MEMBERSHIP FEES. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2012-03-27 13045000 REFUNDING, NEW CONSTRUCTION 0 0 0 13051939 145816 225591 3109235 3611204 5960092 2013 1 0 0 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 1 BB&T 10.000000000000 0 0 0 0 0 X SCHEDULE K, PART I, DESCRIPTION OF PURPOSE: THE PURPOSE OF THE ISSUE IS TO PROVIDE FUNDS TO (1) REFUND A PORTION OF THE 2008 BANK LOAN ALLOCABLE TO THE PRIOR PROJECT, (2) PAY OR REIMBURSE THE ORGANIZATION FOR PAYING A PORTION OF THE COST OF ACQUIRING, CONSTRUCTING AND EQUIPPING A NEW APPROXIMATELY 66,000 SQUARE-FOOT, 118-BED SKILLED NURSING FACILITY TO REPLACE THE PISGAH VALLEY RETIREMENT MANOR, (3) PAY INTEREST ON THE NEW MONEY PORTION OF THE BONDS FOR APPROXIMATELY 13 MONTHS, AND (4) PAY CERTAIN COSTS INCURRED IN CONNECTION WITH THE ISSUANCE OF THE BONDS. SCHEDULE K, PART II, LINE 3, TOTAL PROCEEDS: TOTAL PROCEEDS PRESENTED ON LINE 3 INCLUDE INVESTMENT EARNINGS TO DATE, CALCULATED AS SHOWN: BOND (A) - SALE PROCEEDS: $ 13,045,000 INVESTMENT EARNINGS: 6,939 TOTAL TO LINE 3: 13,051,939 SCHEDULE K, PART II, LINE 11, OTHER SPENT PROCEEDS: THE AMOUNT PRESENTED ON LINE 11 REPRESENTS AMOUNTS USED TO CURRENTLY REFUND A PORTION OF A PRIOR BANK LOAN ISSUED IN 2008. ELLA KIDDER FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 62266 ELLA KIDDER IS AN EMPLOYEE OF THE ORGANIZATION 0 X 23 ACRES OF LAND 1 1075000 FMV 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 AS STATED IN CARS' BYLAWS SECTION 3.1 "THE MEMBERS OF THE CORPORATION SHALL BE THE MEMBERS OF THE EXECUTIVE COMMITTEE OF THE CAROLINA CONFERENCE." FORM 990, PART VI, SECTION A, LINE 7A AS STATED IN CARS' BYLAWS SECTION 4.3 "EACH VOTING MEMBER OF THE EXECUTIVE COMMITTEE OF THE CAROLINA CONFERENCE SHALL SERVE EX OFFICIO AS A VOTING MEMBER OF THE CARS BOARD OF DIRECTORS (I.E., CONSTITUENT BOARD)." FORM 990, PART VI, SECTION A, LINE 7B AS STATED IN CARS' BYLAWS SECTION 4.1 "THE BUSINESS AND AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY A BOARD OF DIRECTORS, REFERRED TO HEREIN AS THE "CONSTITUENT BOARD" AND SECTION 4.13 "EXCEPT AS OTHERWISE PROVIDED IN THESE BYLAWS, THE ACT OF THE MAJORITY OF THE DIRECTORS PRESENT AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE THE ACT OF THE CONSTITUENT BOARD." FORM 990, PART VI, SECTION B, LINE 11 THE RETURN WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM WITH ASSISTANCE AND OVERSIGHT BY MANAGEMENT. A COPY OF THE RETURN WAS PROVIDED TO EACH BOARD OF DIRECTORS MEMBER PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C AT THE BOARD OF DIRECTORS ANNUAL MEETING, THE PRESIDENT AND CEO OF CAROLINA ADVENTIST RETIREMENT SYSTEMS, INC. PRESENTS A "STATEMENT OF ACCEPTANCE" OF THE POLICY ON CONFLICT OF INTEREST TO EACH OFFICER, DIRECTOR (I.E., BOARD MEMBER), AND KEY EMPLOYEE (I.E., ADMINISTRATORS). EACH OF THESE INDIVIDUALS ARE ASKED TO REVIEW AND SIGN THE STATEMENT WHICH INCLUDES A REPRESENTATION THAT THEY DO NOT HAVE A CONFLICT OF INTEREST. ADDITIONALLY, EACH OFFICER, DIRECTOR, AND KEY EMPLOYEE RECEIVE AN ORIENTATION AND ANNUAL TRAINING RELATED TO THE ORGANIZATION'S CORPORATE COMPLIANCE POLICY, INCLUDING ITS CORE VALUE OF CARING, DEDICATION, INTEGRITY, PROFESSIONALISM, QUALITY, RESPECT, AND SAFETY. FORM 990, PART VI, SECTION B, LINE 15 ANNUALLY MANAGEMENT PREPARES A SCHEDULE SHOWING THE PRIOR YEAR SALARIES PAID AND THE CURRENT YEAR BUDGETED SALARIES FOR THE CEO AND CFO. THE SCHEDULE COMPARES THE BUDGETED SALARY TO THE MOST CURRENT NORTH CAROLINA ASSOCIATION OF NOT-FOR-PROFIT HOMES FOR THE AGED WAGE & BENEFIT SURVEY AND SALARIES OF FOUR NORTH CAROLINA NOT-FOR-PROFIT CCRC'S AS OBTAINED FROM THEIR ORGANIZATION'S FORM 990 AS AVAILABLE ON GUIDESTAR. THIS SCHEDULE IS REVIEWED AND APPROVED BY THE EXECUTIVE BOARD OF THE BOARD OF DIRECTORS. THE EXECUTIVE BOARD THEN PRESENTS THIS INFORMATION AS PART OF THE BUDGET TO THE FULL BOARD OF DIRECTORS AT THEIR ANNUAL MEETING. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION MAKES ITS FORM 990 AVAILABLE UPON REQUEST AND ON WWW.GUIDESTAR.ORG CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -730,119. LOSS ON ABANDON PROJECT -424,342. RESTATEMENT DUE TO CHANGE IN ACCOUNTING METHOD OF ENTRANCE FEES -279,779. TOTAL TO FORM 990, PART XI, LINE 5: -1,434,240. CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS INC PO BOX 44270 CHARLOTTE NC 28215 454284485 SPIRITUAL DEVELOPMENT NC 501(C)(3) 1 N/A 0 PISGAH ESTATES UNIT OWNERS ASSOCIATION 95 HOLCOMBE COVE ROAD CANDLER NC 28715 561769989 HOME OWNERS ASSOCIATION NC N/A C 0 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 PISGAH ESTATES UNIT OWNERS ASSOCIATION K 147000 CASH PISGAH ESTATES UNIT OWNERS ASSOCIATION L 63527 CASH