2012-09-26T15:45:26-05:00 2011-12-31 840869721 EHRHARDT KEEFE STEINER & HOTTMAN PC 7979 E TUFTS AVENUE SUITE 400 DENVER CO 802372843 990 2011-01-01 840194430 EBEN EZER LUTHERAN CARE CENTER EBEN 9708422861 122 HOSPITAL ROAD BRUSH CO 80723 SHELLY GRIFFITH 9708422861 2012-09-25 1 RYAN C HARRIS P00614618 3037409400 2011 2016-02-24 21:20:13Z SHELLY GRIFFITH 122 HOSPITAL ROAD BRUSH CO 80723 16239034 0 X WWW.EBENEZER-CARES.ORG X 1903 CO OUR MISSION IS TO PROVIDE HOUSING, HEALTH CARE, AND SPIRITUAL SERVICES FOR THOSE IN NEED. 11 11 329 250 -2133 -2475 543964 372771 11187753 11626051 140251 161576 133273 53925 12005241 12214323 0 3999 0 0 7092215 7529952 0 0 74272 3905670 3658847 10997885 11192798 1007356 1021525 13278330 13862838 5197757 5020132 8080573 8842706 X SEE SCHEDULE O 0 0 10130988 3999 11626051 PROVIDING SKILLED NURSING CARE, RESPITE CARE, ASSISTED LIVING,INDEPENDENT LIVING, PERSONAL CARE, HOMEMAKING AND LIFELINEEMERGENCY RESPONSE SERVICES TO THE ELDERLY AND PERSONS WITHSPECIAL NEEDS. THE CARE CENTER PROVIDED SERVICE TO MORE THAN 400PERSONS FOR PERSONAL AND HOMEMAKING CARE AND RESIDENTIAL SERVICESTO OVER 300 PERSONS. 10130988 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 17 0 1 329 1 1 1 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X LESLIE MASON 9708422861 122 HOSPITAL ROAD BRUSH CO 80723 ANDREW LARRICK 1.00 X X 0 0 0 GEORGE DIKEOU 1.00 X 0 0 0 DR ALAN DAHMS 1.00 X 0 0 0 MIKE BERRYHILL 1.00 X X 0 0 0 ROGER SCHAEFER 1.00 X 0 0 0 DR KERRY HART 1.00 X 0 0 0 JO ANN KRUGLET 1.00 X X 0 0 0 ROBERT CHAPIN 1.00 X X 0 0 0 NORMAN AARESTAD 1.00 X 0 0 0 PAUL OLSEN 1.00 X 0 0 0 JEFF HANSON 1.00 X 0 0 0 BARBARA BRADSHAW 40.00 X 102933 0 8489 SHELLY GRIFFITH 40.00 X 61047 0 7592 LESLIE MASON 40.00 X 28395 0 3563 192375 0 19644 1 0 0 0 0 372771 372771 PATIENT SERVICE 623000 11445074 11445074 AUXILIARY 623000 180977 180977 11626051 66188 66188 2671 4841 -2170 -2170 -2170 4115258 4019870 95388 95388 95388 EARNINGS OF EQUITY INV 524298 53858 53858 INSURANCE PROCEEDS 624200 2200 2200 INCOME FROM K-1 900003 37 37 56095 12214323 11628251 -2133 215434 3999 3999 212018 169198 42820 5848341 5551395 278202 18744 58749 52429 5534 786 968941 928288 39769 884 441903 405305 29247 7351 54449 54449 21887 21887 179121 168638 10483 25664 25664 67799 25109 42690 36295 36295 284757 284757 73433 67176 6199 58 26352 16437 9915 282078 130314 151764 474263 467762 6501 246936 139387 107549 ANCILLARY 716930 716930 FOOD 518455 518455 SUPPLIES 387686 360416 24997 2273 MAINTENANCE AND REPAIR 130996 121607 9389 131746 110625 19765 1356 11192798 10130988 987538 74272 500 700 2444856 3414669 1084794 1111390 53648 64904 76539 38957 15400265 9038354 6303760 6361911 1586831 1371031 1727402 1499276 13278330 13862838 774232 789754 1968 1685 4291349 4097705 130208 130988 5197757 5020132 X 8080573 8842706 8080573 8842706 13278330 13862838 X 1021525 -259392 X 0 1 1 X 0 X 237613 691233 151590 543964 372771 1997171 9492751 10332705 11800024 11187753 11590548 54403781 9730364 11023938 11951614 11731717 11963319 56400952 0 0 0 56400952 77555 80041 45535 52021 66188 321340 10393 7925 1048 7393 26759 87948 87966 46583 59414 66188 348099 151635 57716 412425 125880 91561 839217 9969947 11169620 12410622 11917011 12121068 57588268 0.97940 0.97980 0.00600 0.00650 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 231847 56403 288250 231847 231847 224347 7500 231847 224347 224347 1.00000 0 1 1 66372 66372 10196242 5230303 4965939 4978889 3808051 1170838 158762 158762 6361911 DUE FROM FOUNDATION 386318 BOND ISSUANCE COSTS-NET 153925 BOND PROCEEDS HELD IN TRUST 479374 BOND INTEREST FUND 44924 BOND PRINCIPAL FUND 33333 INV. IN CAPTIVE INSURANCE 374817 OTHER RECEIVABLE 18813 INTEREST RECEIVABLE 7772 1499276 DEPOSITS OF RESIDENTS 36675 ASSET RETIREMENT OBLIGATION 63536 DEFERRED COMPENSATION 30777 130988 12214323 11192798 1021525 -259355 -37 -259392 762133 11959772 -259355 -259355 12219127 -4804 -4804 12214323 11197639 4841 4841 11192798 0 11192798 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENTS ARE HELD BY EBEN EZER LUTHERAN CARE CENTER FOUNDATION, A RELATED ORGANIZATION. THE ENDOWMENT CONSISTS OF TWO INDIVIDUAL FUNDS ESTABLISHED TO SUPPORT THE OPERATIONS OF THE ORGANIZATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION FOLLOWS A MORE-LIKELY-THAN-NOT MEASUREMENT METHODOLOGY TO REFLECT THE FINANCIAL STATEMENT IMPACT OF UNCERTAIN TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. AFTER EVALUATION THE TAX POSITIONS TAKEN, NONE ARE CONSIDERED TO BE UNCERTAIN; THEREFORE, NO AMOUNTS HAVE BEEN RECOGNIZED AS OF DECEMBER 31, 2011 OR 2010. IF INCURRED, INTEREST AND PENALTIES ASSOCIATED WITH TAX POSITIONS ARE RECORDED IN THE PERIOD ASSESSED AS OTHER EXPENSES. NO INTEREST OR PENALTIES HAVE BEEN ASSESSED AS OF DECEMBER 31, 2011 AND 2010. TAX YEARS THAT REMAIN SUBJECT TO EXAMINATION INCLUDE 2008 THROUGH CURRENT FOR THE FEDERAL RETURN AND 2007 THROUGH CURRENT FOR THE COLORADO RETURN. PART XI, LINE 8 - OTHER ADJUSTMENTS: INCOME FROM K-1 -37. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -4,841. INCOME FROM K-1 37. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 4,841. CITY OF BRUSH COLORADO 846000638 117416BV8 2004-09-01 640000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 CITY OF BRUSH COLORADO 846000638 117416BW6 2004-09-01 1350000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 CITY OF BRUSH COLORADO 846000638 117416BX4 2004-09-01 2125000 INDUSTRIAL DEVELOPMENT REVENUE 0 0 0 640000 34522 605478 2004 1 0 1 1 1350000 69045 1280955 2004 1 0 1 1 2125000 110472 2014528 2004 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 ORGANIZATION MISSION STATEMENT FORM 990, PART III, LINE 1 THE EBEN EZER LUTHERAN CARE CENTER (THE CARE CENTER) WAS ESTABLISHED TO PROVIDE SKILLED NURSING CARE, RESPITE CARE, ASSISTED LIVING, INDEPENDENT LIVING, PERSONAL CARE AND HOMEMAKING AND LIFELINE EMERGENCY RESPONSE SERVICES TO THE ELDERLY AND PERSONS WITH SPECIAL NEEDS. THE CARE CENTER IS CERTIFIED FOR MEDICARE AND MEDICAID AND IS AFFILIATED WITH THE EVANGELICAL LUTHERAN CHURCH OF AMERICA. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE OFFICERS OF THE BOARD AND SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION TAKEN SHALL NOT BE IN CONFLICT WITH THE POLICIES, OR ANY PRIOR ACTION, OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL REFER ALL MATTERS OF MAJOR IMPORTANCE TO THE BOARD. IT SHALL CONSIDER ALL MATTERS REFERRED TO IT BY THE BOARD AND SHALL ACT FOR THE BOARD IN EMERGENCIES. THE EXECUTIVE COMMITTEE SHALL NOT ACT WITHOUT BOARD APPROVAL IN THE FOLLOWING MATTERS: (I)ANY SALE OR PURCHASE OF LAND OR BUILDINGS. (II)ANY FUNDING FOR CAPITAL IMPROVEMENTS THROUGH EITHER MORTGAGE FUNDING OR A FUND CAMPAIGN. (III)ANY ESTABLISHMENT OF ADMINISTRATIVE POSITIONS, INCLUDING POSITION DESCRIPTIONS AND FILING OF SAID POSITIONS. FORM 990, PART VI, SECTION B, LINE 11 THE AUDIT COMMITTEE REVIEWS THE FORM 990 IN DETAIL BEFORE IT IS FILED AND APPROVES THE FILING OF THE RETURN. THE BOARD OF DIRECTORS THEN IS PROVIDED WITH A COPY OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY. AT EVERY BOARD MEETING, THE MEMBERS ARE ASKED IF THERE HAS BEEN A CHANGE IN THEIR INDEPENDENCE WITH THE ORGANIZATION. THIS INFORMATION IS DOCUMENTED WITHIN THE MINUTES. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD REVIEWS SURVEYS FROM OTHER SIMILAR ORGANIZATIONS ON COMPENSATION LEVELS. THE BOARD REVIEWS AND APPROVES THE COMPENSATION FOR THE CEO BASED ON COMPARABLE COMPENSATION. THE ORGANIZATION MAINTAINS THE APPROPRIATE DOCUMENTATION OF HOW THE COMPENSATION IS SET. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -259,355. INCOME FROM K-1 -37. TOTAL TO FORM 990, PART XI, LINE 5: -259,392. EBEN EZER LUTHERAN CARE CTR FOUNDATION 122 HOSPITAL ROAD BRUSH CO 80723 742480396 SUPPORT CO 501(C)(3) LINE 11A, I N/A 1 EBEN EZER LUTHERAN HOUSING CENTER 1900 EDISON STREET BRUSH CO 80723 840884015 HOUSING CO 501(C)(3) LINE 7 N/A 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 EBEN EZER LUTHERN CARE CENTER FOUNDATION C 372771 FMV