2013-05-13T11:58:00-05:00 2012-12-31 560571159 BERNARD ROBINSON & COMPANY LLP PO BOX 19608 GREENSBORO NC 274199608 990 2012-01-01 560529956 MASONIC AND EASTERN STAR HOME OF NORTH CAROLINA INC MASO 3362990031 700 S HOLDEN ROAD GREENSBORO NC 27407 MARK KOLADA 3362990031 2013-05-13 1 LORY H KELLEY P00431638 3362944494 2013-05-08 2012 2016-02-24 21:20:13Z WHITESTONE MARK KOLADA 700 S HOLDEN ROAD GREENSBORO NC 27407 32318228 0 X WWW.MESHHOME.ORG X 1912 NC AS A RETIREMENT COMMUNITY LEADER SINCE 1912, MASONIC AND EASTERN STAR HOME OF NC IS DEVOTED TO EXCELLENCE IN HOSPITALITY WITH TRADITIONAL VALUES PROMOTING FRATERNAL SERVICE, DIGNITY, DEPENDABILITY, AND CHOICE. 20 20 298 100 0 0 1697836 966338 12012809 12820044 -196722 722079 2176 35814 13516099 14544275 1314415 1348412 0 0 5898486 6422606 0 0 0 4880782 6135121 12093683 13906139 1422416 638136 54497984 59313156 37095401 41170734 17402583 18142422 AS A RETIREMENT COMMUNITY LEADER SINCE 1912, MASONIC AND EASTERN STAR HOME OF NC IS DEVOTED TO EXCELLENCE IN HOSPITALITY WITH TRADITIONAL VALUES PROMOTING FRATERNAL SERVICE, DIGNITY, DEPENDABILITY, AND CHOICE. 0 0 12345485 1348412 12855858 MASONIC AND EASTERN STAR HOME OF NC PROVIDES RESIDENTIAL, HEALTH CARE, AND OTHER RELATED SERVICES TO ELDERLY RESIDENTS. THE HOME OFFERS INDEPENDENT LIVNG, ASSISTED LIVING, AND SKILLED NURSING SERVICES. 12345485 1 1 0 0 0 0 0 0 0 1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 51 0 1 298 1 0 0 0 0 0 0 0 0 0 0 X 20 20 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X PHIL HUGHES 3362990031 700 S HOLDEN ROAD GREENSBORO NC 27407 GENE JERNIGAN 1.00 X X 0 0 0 DONNA YATES 1.00 X X 0 0 0 BRUCE AYRES III 1.00 X 0 0 0 LINDA BONNER 1.00 X 0 0 0 DONNA CHESSER 1.00 X 0 0 0 DAVID CRISP 1.00 X 0 0 0 KENNETH EZZELL 1.00 X 0 0 0 ROBERT E GRESHAM JR 1.00 X 0 0 0 BETTY HARRIS 1.00 X 0 0 0 MELISSA HOGAN 1.00 X 0 0 0 SUSAN JACKSON 1.00 X 0 0 0 THOMAS JACKSON 1.00 X 0 0 0 ARCHIBALD JARRELL 1.00 X 0 0 0 CHARLES A LEWIS 1.00 X 0 0 0 DALTON MAYO 1.00 X 0 0 0 DEWEY PRESLAR JR 1.00 X 0 0 0 DICK SLOOP 1.00 X 0 0 0 JACK WALTERS 1.00 X 0 0 0 FREDERICK HINES WHITTY 1.00 X 0 0 0 DAVID WICKER JR 1.00 X 0 0 0 FRAN SOUTHERN 1.00 X 0 0 0 MARK KOLADA 40.00 X 0 0 0 LORRI YASKIEWICZ 40.00 X 102396 0 4744 102396 0 4744 1 0 0 1 LIFE CARE SERVICES LLC 400 LOCUST STREET STE 820 DES MOINES IA 503092334 MGMT SERVICES 610575 HERITAGE HEALTHCARE INC 536 OLD HOWELL RD GREENVILLE SC 29615 THERAPY SERVICES 461654 ZILLNER MARKETING COMMUNICATIONS INC 8725 ROSEHILL RD LENEXA KS 66215 MARKETING 402597 AJ GALLAGHER RISK MGMT SVCS RM 5229 PAYSPHERE CIRCLE CHICAGO IL 60674 INSURANCE BROKER 266495 RODGERS BUILDERS INC POST OFFICE BOX 18446 CHARLOTTE NC 28218 CONSTRUCTION/REPAIRS 231093 6 570666 395672 966338 RESIDENT SERVICES 623000 12820044 12820044 12820044 299778 299778 18196254 17773953 422301 422301 422301 OTHER INCOME 623000 35814 35814 35814 14544275 12855858 0 722079 1348412 1348412 5317910 4816504 501406 36061 34314 1747 509880 471066 38814 558755 525720 33035 504864 116732 388132 38098 11465 26633 51437 51437 47766 24700 23066 1221791 1221791 22691 7417 15274 528624 528624 1414437 1414437 169439 112 169327 MEDICAL SERVICES 974344 974344 REPAIRS AND MAINTENANCE 373057 304299 68758 VARIOUS SUPPLIES 345190 322136 23054 MISCELLANEOUS 217448 107030 110418 225935 116382 109553 13906139 12345485 1560654 0 905439 2594657 3665274 51287 933405 1844384 34801 41369 326758 276911 48917070 12833684 26641400 36083386 1762108 5325256 5067554 5376304 15161245 7719602 54497984 59313156 1233651 2002868 7063839 10451086 28797911 28716780 37095401 41170734 X 9936678 10231797 1118273 1285930 6347632 6624695 17402583 18142422 54497984 59313156 X 638136 -207047 308750 X 0 1 X 1 0 X 1475256 1177302 1930137 1697836 966338 7246869 1475256 1177302 1930137 1697836 966338 7246869 2296639 4950230 825510 616467 191422 321294 299778 2254471 57208 36569 21091 2176 35814 152858 9654198 56026830 0.51280 0.50370 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6347632 277063 6624695 6556430 -208798 6347632 6213730 342700 6556430 5538689 675041 6213730 7277779 -1739090 5538689 1.00000 0 0 55677 55677 46221263 11215351 35005912 2487053 1508276 978777 153077 110057 43020 36083386 ASSETS IN SPLIT INTEREST AGREEMENTS 5376304 F 5376304 BOND INVESTMENTS 7719602 F 7719602 REFUNDABLE ADVANCE FEES 1410520 DEPOSITS ON UNOCCUPIED UNITS 527310 RESIDENT TRUST FUNDS 85943 BONDS PAYABLE 26693007 28716780 X 13297566 -207047 308750 101703 13195863 1348412 1348412 14544275 12557727 0 12557727 1348412 1348412 13906139 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IT IS THE HOME'S POLICY TO EVALUATE ALL TAX POSITIONS TO IDENTIFY ANY THAT MAY BE CONSIDERED UNCERTAIN. ALL IDENTIFIED MATERIAL TAX POSITIONS ARE ASSESSED AND MEASURED BY A "MORE-LIKELY-THAN-NOT" THRESHOLD TO DETERMINE IF THE TAX POSITION IS UNCERTAIN AND WHAT, IF ANY, THE EFFECT OF THE UNCERTAIN TAX POSITION MAY HAVE ON THE FINANCIAL STATEMENTS. NO MATERIAL UNCERTAIN TAX POSITIONS WERE IDENTIFIED DURING 2012. CURRENTLY, THE STATUTE OF LIMITATIONS REMAINS OPEN SUBSEQUENT TO AND INCLUDING 2009; HOWEVER, NO EXAMINATIONS ARE IN PROGRESS OR ANTICIPATED. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SPLIT INTEREST AGREEMENTS 308,750. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANTS MADE TO RESIDENTS 1,348,412. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANTS MADE TO RESIDENTS 1,348,412. 1 WAIVER OF FEES FOR INDIVIDUALS DUE TO HARDSHIPS. 57 1348412 FMV RESIDENTIAL AND HEALTH SERVICES. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES GRANTS FOR RESIDENTS UNABLE TO AFFORD TO PAY FOR THEIR CARE. THE MAJORITY OF THE GRANT RECIPIENTS ALSO RECEIVE MEDICAID BENEFITS. EACH RESIDENT IS REQUIRED TO CONTRIBUTE AS MUCH AS THEY CAN AFFORD TOWARDS THE COST OF THEIR CARE. THE GRANTS ARE PAID DIRECTLY TO THE VENDORS PROVIDING THE CARE, TO ENSURE THE FUNDS ARE USED APPROPRIATELY. X 0 0 0 0 0 0 0 0 0 SUPPLEMENTAL INFORMATION PART III MARK KOLADA IS THE EXECUTIVE DIRECTOR OF MASONIC AND EASTERN STAR HOME OF NORTH CAROLINA. HOWEVER, MARK KOLADA IS EMPLOYED BY LIFE CARE SERVICES, LLC. (AN UNRELATED ORGANIZATION). MASONIC AND EASTERN STAR HOME OF NC PAYS LIFE CARE SERVICES, LLC. TO MANAGE OPERATIONS OF THE HOME. MARK KOLADA'S SALARY AND BENEFITS ARE PAID BY LIFE CARE SERVICES, LLC. FOR THE 2012 TAX YEAR, LIFE CARE SERVICES, LLC PAID MARK KOLADA MEDICARE WAGES IN THE AMOUNT OF $119,521. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820YJN7 2011-04-28 26642514 SEE PART VI 0 0 0 A 26642514 1971475 2234840 3874001 532850 12196700 5832648 2012 1 0 0 1 A 0 0 0 0 0 0 0 A 0 0 0 0 1 0 0 0 0 THE BONDS WERE ISSUED TO PAY FOR CONSTRUCTION OF AN EXPANSION TO THE HOMES' EXISTING FACILITY, REFUNDING CERTAIN INDEBTEDNESS INCURRED TO FINANCE A PORTION OF THE EXPANSION, FUNDING A DEBT SERVICE RESERVE FUND AND PAYING CERTAIN EXPENSES INCURRED IN CONNECTION WITH THE ISSUANCE OF THE BONDS. FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF DIRECTORS HAS CONTRACTED WITH LIFE CARE SERVICES, LLC. TO MANAGE, OPERATE AND MAINTAIN THE RETIREMENT COMMUNITY. THE EXECUTIVE DIRECTOR, MARK KOLADA, IS AN EMPLOYEE OF LIFE CARE SERVICES, LLC. FORM 990, PART VI, SECTION A, LINE 7A THE GRAND MASTER APPOINTS THREE BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS WILL REVIEW THE FORM 990 AS IT IS PRESENTED BY LIFE CARE SERVICES, LLC. THE BOARD OF DIRECTORS WILL ASK ANY PERTINENT QUESTIONS AT THAT TIME. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL MONITORING OF CONFLICT OF INTEREST IS PART OF THE DUTIES OF THE CORPORATE COMPLIANCE COMMITTEE, CHAIRED BY TRACY ARMWOOD. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR CEO, CURRENT OFFICERS, ETC ARE REVIEWED AS A PART OF ANNUAL BUDGET BY THE BOARD OF DIRECTORS, FINANCE COMMITTEE AND PERSONNEL COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST. THE AUDITED FINANCIALS ARE INCLUDED IN ANNUAL DISCLOSURE AS REQUIRED BY DEPARTMENT OF INSURANCE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: CHANGE IN VALUE OF SPLIT INTEREST AGREEMENTS 308,750. GRAND LODGE OF THE AF AND AM OF NC PO BOX 6506 RALEIGH NC 27628 560228750 PROVIDE SUPPORT FOR NC MASONS NC 501(C)(10) 0 GRAND CHAPTER OF THE ORDER OF THE EASTERN STAR OF NC PO BOX 5516 KINSTON NC 28503 560239941 CHARITABLE, EDUCATIONAL AND FRATERNAL NC 501(C)(8) 0 NC MASONIC FOUNDATION INC PO BOX 6506 RALEIGH NC 27628 566049500 RECEIVE DONATIONS AND DISTRIBUTE ALL INCOME TO CHARITABLE ORGANIZATIONS NC 501(C)(3) LINE 11B, II 0 NC EASTERN STAR FOUNDATION INC PO BOX 5516 KINSTON NC 28503 561974972 INVEST FUNDS RAISED TO PROVIDE PERPETUAL FUND TO EASTERN STAR HOME NC 501(C)(3) PF 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NORTH CAROLINA MASONIC FOUNDATION INC C 34155 NORTH CAROLINA EASTERN STAR FOUNDATION INC C 145398 GRAND CHAPTER OF OES C 177470