2013-05-10T13:23:10-07:00 2012-12-31 990 2012-01-01 381366927 HOLLAND HOME HOLL 6162355034 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 H David Claus 6162355000 2013-05-10 2012 2016-02-24 21:20:13Z H David Claus 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 67463048 0 X www.hollandhome.org X 1892 MI Provide nursing therapy and benevolent services for aged residents in skilled nursing, dementia nursing, assisted living and independent living centers. 13 12 1257 675 17644 16644 857441 2391717 55046905 55784173 496265 495718 132761 175497 56533372 58847105 0 0 0 0 29092866 30404460 44368 50792 520611 28383794 29410773 57521028 59866025 -987656 -1018920 220943764 231861600 244547593 249654758 -23603829 -17793158 In fulfilling God's calling to serve others, the organization will serve aged persons (1) with love and compassion, (2) with a commitment to excellence and (3) follow Christ's teachings and example in all that the organization does. 0 0 53126994 55770213 Provide nursing and residential care at three facilities located in Grand Rapids, Michigan to an average of 1,534 residents each day in skilled nursing (225), assisted living (378) and independent living (931). Of the 378 residents in assisted living, the organization provides financial assistance to 15% or 58 residents on average which amounts to $2.1 million in benevolence. In skilled nursing, the organization serves an average of 119 residents (53%) on Medicaid and 37 residents (16%) on Medicare. These contractural allowances cost the organization $6.0 million in 2012. The organization provides uncompensated costs of private rooms to most of the 119 residents on Medicaid. 0 0 0 53126994 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 56 0 1 1257 1 1 1 0 0 0 0 1 1 0 0 0 0 X 13 12 0 0 0 0 1 0 1 1 1 0 0 0 1 1 1 1 1 1 1 0 MI X David Tiesenga 6162355035 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 Robert Smedes 2 0 X X 0 0 0 H David Claus 50 0 X X 391870 0 17000 Carl VerBeek 2 0 X X 0 0 0 Lynwood VandenBosch 2 0 X 0 0 0 Karen Helder 2 0 X 0 0 0 Bruce Neckers 2 0 X X 0 0 0 John Steigenga 2 0 X 0 0 0 Paul Farr 2 0 X 0 0 0 Max Smith 2 0 X 0 0 0 Susan Vogel-Vanderson 2 0 X X 0 0 0 Jerry Kooiman 2 0 X 0 0 0 Gary Malburg 2 0 X 0 0 0 Mary Ursul 2 0 X 0 0 0 David Tiesenga 50 0 X 226081 0 17000 Hermina Breuker 50 0 X 198921 0 13895 Chris Nicely 50 0 X 106989 0 2922 Scott Hull 50 0 X 105450 0 3496 Carolyn Flietstra 50 0 X 132696 0 3455 Bruce Quist 50 0 X 103509 0 5472 1265516 0 63240 7 0 1 0 Morrison Services 39395 W 12 Mile Rd Farmington Hills MI 48331 Dietary Services 3618012 Plante & Moran 27400 Northwestern Highway Southfield MI 48037 Accountants 242785 Rehab Care Group Inc PO Box 503534 St Louis MO 63150 Therapy Services 1239609 3 0 0 30725 0 0 2360992 0 2391717 HFA and Independent Living 623000 18603478 18603478 0 0 Medicare/Medicaid 623000 12630781 12630781 0 0 Skilled Nursing 623000 7247466 7247466 0 0 Amortization of Endowments 623000 6935063 6935063 0 0 Ancillary Revenue 623000 682427 682427 0 0 9684958 9670998 13960 0 55784173 378583 0 3684 374899 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8018934 640011 7796005 745805 222929 -105794 117135 0 0 117135 249630 30725 74133 175497 0 175497 0 0 0 0 0 0 0 0 0 0 0 0 0 58847105 55770213 17644 667531 0 0 0 0 0 0 0 0 560084 0 560084 0 0 0 0 0 23587658 20986021 2271739 329898 1675700 1364383 289870 21447 2669349 2319845 313036 36468 1911669 1661369 224183 26117 354617 270648 83304 665 122516 0 122516 0 81195 0 81195 0 0 0 0 0 50792 50792 59125 0 59125 0 0 0 0 0 642317 0 642317 0 2614572 2400758 182041 31773 291426 0 291426 0 0 0 0 0 4532236 3826914 705322 0 308155 273618 25672 8865 0 0 0 0 53329 36496 14785 2048 6497375 6497375 0 0 0 0 0 0 6714701 6481684 233017 0 0 0 0 0 Purchased Services 4557546 4557546 0 0 Medicaid Quality Assurance Fees 1694525 1694525 0 0 Bad Debt 120663 120663 0 0 Miscellaneous 156647 52364 99329 4954 609828 582785 19459 7584 59866025 53126994 6218420 520611 2127639 918093 2429360 5442688 0 7000000 3969840 3159660 0 0 0 0 6820350 6737407 417253 491937 359028 558934 238455979 66227674 176700508 172228305 16611301 22133872 0 0 8389406 9530777 0 0 3119079 3659927 220943764 231861600 30289261 33103618 0 0 37231085 36641283 101855000 109345000 0 0 0 0 0 0 3440000 3430000 71732247 67134857 244547593 249654758 X -23603829 -24793158 0 7000000 0 0 -23603829 -17793158 220943764 231861600 X -1018920 218862 0 0 0 6610729 X 0 1 X 1 0 X 2252316 2188947 1272682 990202 2567214 9271361 44406576 49211439 52814769 55046905 55784173 257263862 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 46658892 51400386 54087451 56037107 58351387 266535223 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 266535223 871768 602482 644588 496265 495718 3110821 0 0 0 0 0 0 871768 602482 644588 496265 495718 3110821 0 0 0 0 0 0 0 0 0 0 0 0 47530660 52002868 54732039 56533372 58847105 269646044 0.98846 0.98380 0.01154 0.01620 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 13730873 13730873 0 201419576 58238741 143180835 0 484281 212918 271363 0 12180953 6062202 6118751 0 10640296 1713813 8926483 172228305 0 Mortgage Notes Payable 856349 Refundable Amounts Payable 54609065 Fair Value Interest Rate Swap 11669443 67134857 X X X X 1 The Breton Group 2504 Ardmore St SE Grand Rapids MI 49546 Consults with the development department on fund raising procedures. 0 0 45500 -45500 0 45500 -45500 MI Christmas Dinner 280355 30725 249630 0 4150 7417 38199 5712 18655 0 0 280355 30725 249630 0 4150 7417 38199 5712 18655 74133 175497 X 0 1 X X X 0 0 0 0 0 0 0 0 0 H David Claus 334003 0 0 0 57864 0 17000 0 5586 0 414453 0 335759 0 David Tiesenga 226081 0 0 0 0 0 17000 0 7547 0 250628 0 223279 0 Hermina Breuker 198921 0 0 0 0 0 13895 0 0 0 212816 0 174667 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a The CFO is reimbursed on a monthly basis for health club dues he pays for personally. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b The CFO is reimbursed on a monthly basis for health club dues he pays for personally. A Michigan Strategic Fund 521417332 59469C6U2 2004-01-30 9940000 Construction and equipping of facility 0 0 0 B Michigan Strategic Fund 521417332 59470FAC7 2005-12-01 10795000 Refund prior issue from 07/15/1998 0 0 0 C Economic Development Corporation of the City of Kentwood 381844797 491740DW3 2006-08-31 50590705 See Part VI 1 0 0 D Michigan Strategic Fund 521417332 59470FAD5 2009-01-08 7320000 See Part VI 0 0 0 A 0 0 10013092 0 297723 0 198800 34901 254986 9226692 0 0 2005 0 0 1 1 B 2105000 0 12052094 0 0 0 215900 6601 0 0 11829593 0 1999 0 1 1 1 C 16130000 0 52214001 3171582 0 0 1002277 68371 113697 33164506 14693567 0 2005 0 1 1 1 D 1005000 0 7320000 0 0 0 0 0 0 0 7320000 0 1999 1 0 1 1 A 0 0 0 0 0 0 0 1 0 0 B 0 0 0 0 0 0 0 1 0 0 C 0 0 0 0 0 0 0 1 0 0 D 0 0 0 0 0 0 0 1 0 0 A 0 0 1 1 1 0 0 0 0 B 0 0 0 1 1 1 See Part VI 22.9 0 0 0 0 0 C 0 0 0 1 1 1 See Part VI 26.2 0 1 1 Lehman Brothers 30.2 1 0 0 D 0 1 1 0 1 1 See Part VI 19.8 0 0 0 0 0 A 0 B 0 C 0 D 0 SchK_P01_S00_L00f Schedule K, Part I, Column f Entity 1 - Part I, Line C - Construction of facility, land purchases, refund prior issue (10/03/2002) Entity 1 - Part I, Line D - Conversion of Taxable Bonds (issued 12/01/2005) to Tax Exempt Bonds Entity 2 - Part I, Line A - Refund prior Bonds (08/02/2000, 08/31/2006, 10/02/2002) SchK_P02_S00_L03 Schedule K, Part II, Line 3 Entity 1 & 2 - the total proceeds do not agree to the issue price in Part I, Column (e) due to investment earnings. Entity 2 - The total proceeds do not equal the summation of lines 4 - 12 due to transferred or replacement proceeds in line 4. SchK_P04_S00_L02c Schedule K, Part IV, Line 2c (a) Issuer Name: Michigan Strategic Fund Date the Rebate Computation was Performed: 01/30/2006 (a) Issuer Name: Michigan Strategic fund Date the Rebate Computation was Performed: 11/15/2008 (a) Issuer Name: Economic Development Corporation of the City of Kentwood Date the Rebate Computation was Performed: 11/15/2012 Note regarding rebate computation on 01/30/2006: Since the bond proceeds have been spent, a spending exception was met, and the debt service fund was operated on a bona fide basis no further rebate calculations were necessary. Note regarding rebate computation on 11/15/2008: Since the bond proceeds have been spent and the debt service fund was operated on a bona fide basis no futher calculations were necessary. SchK_P04_S00_L04b Schedule K, Part IV, Line 4b Entity 1 - Column B - The Swap entered into with Lehman Brothers Special Financing, Inc. on 12/01/2005 was assigned to the 1271 Counterparty Company LLC on 11/29/2011 on terms essentially similar to the Leham Swap. Entity 1 - Column C - Morgan Stanley Capital Services, Inc. Entity 1 - Column D - The Swap entered into with Lehman Brothers Special Financing, Inc. on 12/01/2005 was assigned to the 1271 Counterparty Company LLC on 11/29/2011 on terms essentially similar to the Lehman Swap. SchK_P04_S00_L04e Schedule K, Part IV, Line 4e Entity 1 - Column C - GIC terminated in November, 2011 A Economic Development Corporation of the City of Kentwood 381844797 491740DF0 2012-06-29 50090801 See Part VI 0 0 0 A 0 0 50622288 5097223 0 0 1001816 0 0 0 43435529 0 2005 1 0 1 1 A 0 0 0 0 0 0 0 0 0 0 A 0 1 1 0 0 0 1 Wachovia 27.8 1 0 0 A 0 Robert Israels Director 88946 Purchase of Assets 0 Carl VerBeek Chair/Director 101450 Legal Services 0 Lynwood VandenBosch Director 257983 Legal Services 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 Pursuant to its Articles of Incorporation as amended, the corporation is organized on a "nonstock membership basis." F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Pursuant to its Bylaws as amended, the corporation is a subsidiary of Christian Living Services and not withstanding any other provision in their Bylaws to the contrary, the approval of Christian Living Services as the member of this corporation is required to: (1) change the purpose, philosophy, core values, or mission of the corporation, (2) amend the Articles of Incorporation or Bylaws of the corporation, (3) make any change to the structure of operation of the corporation which would affect its status as a nonprofit entity, exempt from taxation under Section 501(c)(3) of the Internal Revenue Code, (4) dissolve or liquidate the corporation, (5) merge or consolidate with another entity, (6) remove a Director of the corporation, (7) create or acquire a new subsidiary entity or enter into a joint venture or partnership, (8) purchase, acquire or lease any real property or sell, lease, exchange, give as security, mortgage, or dispose of any personal property owned, held or leased by the corporation, (9) purchase, lease (as lessor or lessee), sell or otherwise dispose of any personal property that would be a capital asset of the corporation under generally accepted accounting purposes, (10) borrow or enter into a guaranty, (11) adopt a budget, schedule of fees, marketing plan or long-range plan for the corporation, (12) enter into a material contract such as an employee lease arrangement or a contract to subcontract the provision of food service, facilities maintenance or janitorial service, or (13) change accountants or attorneys. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Form 990 and appropriate Schedules are prepared by the organization. The completion of the Form is reported to the organization's Audit Committee. The Form 990 and appropriate Schedules are then submitted to the Internal Revenue Service. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c On an annual basis each director, principal officer and member of a committee with board delegated powers must complete a statement that (1) they have received a copy of the Conflict of Interest Policy, (2) they have read and understand the policy, (3) they have agreed to comply with the policy, and (4) understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The organization purchases compensation surveys and bases the executive compensation on the fiftieth percentile of prevailing market rates for similar positions, market trends and the financial capabilities of the organization. The organization continuously strives to balance financial realities with the diesire to pay people fairly. Then the executive pay is reviewed with a subgroup of the Board of Directors. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The organization does not make its governing documents or Conflict of Interest Policy available to the public. Howerver, a summary of the annual financial statement is printed once each year in the New Horizons, a publication of the organization which is sent to residents, residents' family members and donors on a quarterly basis. A copy of the audited financial statement is available upon request and this is also communicated in the New Horizons. F990_P11_S00_L09 Form 990, Part XI, Line 9 Other Changes in Net Assets of Fund Balances: Change in Fair Market Value of Interest Rate Swap: $4,050,313 Change in Interest in New Asset of Foundation: $1,141,371 Pension Related Changes in Other Than Net Periodic Benefit Cost: $(1,888,956) Loss on Termination of Swap: $(3,692,000) Pledges Receivable: $7,000,000 Total: $6,610,728 Holland Home Foundation 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 382663466 Receive and manage funds MI 501(c)(3) 7 N/A 0 Home Health Care Agency of Holland Home 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 382660300 Home care MI 501(c)(3) 9 N/A 0 Rehab Dimensions 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 383337881 Rehabilitation services MI 501(c)(3) 9 N/A 0 Christian Living Services 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 261126816 Administrative services MI 501(c)(3) 11b N/A 0 HHS Health Options 2100 Raybrook St SE Suite 203 Grand Rapids MI 495465783 382295909 Care management MI 501(c)(3) 9 N/A 0 Faith Hospice 2100 Raybrook St SE Suite 300 Grand Rapids MI 495465783 383062893 Hospice care MI 501(c)(3) 9 N/A 0 Helpers of Holland Home 2100 Raybrook St SE Grand Rapids MI 49546 271062997 Private Duty Assistance MI 501(c)(3) 11b N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 Holland Home Foundation c 250000 Cash Receipts Helpers of Holland Home q 605614 Accounts Payable Home Health Care Agency of Holland Home p 523494 Accounts Payable Home Health Care Agency of Holland Home q 982005 Accounts Payable Faith Hospice q 2806317 Accounts Payable HHS Health Options q 817917 Accounts Payable