2012-03-01T15:30:22-06:00 2011-09-30 DIXON HUGHES PLLC 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-10-01 561089384 CAROLINA ADVENTIST RETIREMENT SYSTEMS INC CARO 7046679851 95 HOLCOMBE COVE RD CANDLER NC 287159450 DEBORAH HAWKINS 7046679851 2012-03-01 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z DAVID KIDDER 95 HOLCOMBE COVE RD CANDLER NC 287159450 23154655 0 X WWW.PISGAHVALLEY.ORG X 1975 NC SERVING HEALTHCARE AND RESIDENTIAL NEEDS WHILE UPHOLDING CHRISTIAN PRINCIPLES. 24 12 609 12 80035 -6540 619724 136638 21709744 22585889 46968 39881 355860 392247 22732296 23154655 76635 90467 0 0 12061953 12274838 0 0 0 8827971 9053558 20966559 21418863 1765737 1735792 23101642 25165506 10200260 10721808 12901382 14443698 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 8504701 6940 10899272 PISGAH VALLEY RETIREMENT COMMUNITY OWNS AND OPERATES A LICENSED CONTINUING CARE RETIREMENT COMMUNITY WITH 18 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). 9808097 83527 11686617 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). 18312798 1 1 0 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 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 33 0 1 609 1 1 1 0 0 0 0 0 0 0 0 0 X 24 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X DEBORAH HAWKINS 8284182334 95 HOLCOMBE COVE ROAD CANDLER NC 28715 RICHARD ANDERSON 1.00 X 0 50329 12845 SAMUEL BONHAM 1.00 X 0 450 0 ERNEST BOUGHMAN JR 1.00 X 0 150 0 JIMM BUNCH 1.00 X 0 0 0 DEWAYNE BUTCHER MD 1.00 X 0 300 0 BRENNA BOULANGER 1.00 X 0 0 0 JOHN COELHO 1.00 X 0 59092 14101 NOEMI CRUZ 1.00 X 0 0 0 JIM DAVIDSON 1.00 X 0 68316 14549 DONOVAN DAVIS 1.00 X 0 51843 13962 FAITH DURKIN 1.00 X 0 225 0 JOHN EARNHARDT 1.00 X 0 64551 14140 CHARLES FERGUSON 1.00 X 0 61234 14125 J KENNETH FORD 1.00 X 0 70932 14176 SAMUEL GARCIA 1.00 X 0 150 0 MAURY GILMORE 1.00 X 0 75 0 CHAD GRUNDY 1.00 X 0 60824 14256 CRYSTAL HALL 1.00 X 0 0 0 ROBERT CUNDIFF 1.00 X 0 63335 14057 WANDA HINDMAN 1.00 X 0 450 0 RALPH HOLLENBECK 1.00 X 0 64803 14523 LARRY KROLL MD 1.00 X 0 0 0 MINERVINO LABRADOR JR 1.00 X 0 74644 14256 JEFFREY DONALDSON 1.00 X 0 55637 15385 GARY MOYER 1.00 X X 0 60402 14335 MARK RUMSEY 1.00 X 0 75 0 RICHARD RUSSELL 1.00 X 0 70710 14335 ANDRES SEQUERA 1.00 X 0 22062 1395 JENNIFER HOWLAND 1.00 X 0 0 0 WON LEE 1.00 X 0 0 0 GARY TOLBERT 1.00 X 0 61655 14296 ANDREW WILLIAMS 1.00 X 0 0 0 KEVIN WORTH 1.00 X 0 49690 12845 DEBORAH HAWKINS 40.00 X 116787 0 18661 DAVID KIDDER 40.00 X 139497 375 22889 256284 1012309 269131 2 0 1 0 KINDRED REHAB SERVICES INC (DBA PEOPLEF 705 JUNIPER STREET NE ALTANTA GA 30308 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 990172 SYNERTX 7540 NORTH 19TH AVENUE PHOENIX AZ 85021 PHYSICAL, SPEECH AND OCCUPATIONAL THERAP 958965 DIXON HUGHES PLLC 500 RIDGEFIELD COURT ASHEVILLE NC 28806 AUDIT, TAX, DATA PROCESSING, CONSULTING 197114 3 24000 112638 136638 MEDICARE/MEDICAID PAYM 623000 17281975 17281975 SKILLED NURSING, ASSIS 623000 5150300 5150300 AMORTIZATION OF ENTRAN 623000 153614 153614 22585889 39881 39881 23313 23313 23313 23313 MANAGEMENT FEES FROM H 531390 154500 154500 MISCELLANEOUS INCOME 623000 109883 109883 WELLNESS CENTER REVENU 713940 104551 24516 80035 368934 23154655 22610405 80035 327577 90467 90467 314972 314972 58157 58157 9832195 9036023 796172 1284451 1193370 91081 785063 695363 89700 7401 7401 91864 91864 2188631 2175231 13400 32551 32551 2766978 2521780 245198 168788 168788 1509146 1278153 230993 91927 71456 20471 76724 30036 46688 7163 7163 1102567 1092315 10252 116493 9181 107312 BAD DEBT 525165 525165 PROVIDER TAX 250682 250682 UNCOLLECTIBLE PLEDGES 112260 112260 MISCELLANEOUS 5218 5218 21418863 18312798 3106065 0 900 900 5439870 7277195 235000 73668 2065225 1722580 91400 98300 207094 200252 21655996 6024069 14898761 15631927 163392 160684 23101642 25165506 1477089 1938060 2573241 2847997 6146115 5734528 3815 201223 10200260 10721808 X 12901382 14443698 12901382 14443698 23101642 25165506 X 1735792 -193476 X 0 1 1 X 0 X 2170584 1638448 275538 619724 24378 4728672 16463098 18804594 21068695 21709744 22585889 100632020 208296 270525 253795 236752 288899 1258267 18841978 20713567 21598028 22566220 22899166 106618959 0 0 0 106618959 70683 80286 59082 74806 63194 348051 70683 80286 59082 74806 63194 348051 18912661 20793853 21657110 22641026 22962360 106967010 0.99670 0.99670 0.00330 0.00330 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 640000 640000 7083132 1336730 5746402 8451770 1649574 6802196 4308185 2595994 1712191 1172909 441771 731138 15631927 ESTIMATED 3RD PARTY SETTLEMENTS 7003 DUE TO RELATED PARTIES 744 INTEREST RATE SWAP LIABILITY 193476 201223 23154655 21418863 1735792 -193476 -193476 1542316 23018695 0 23018695 135960 135960 23154655 21476379 193476 193476 21282903 135960 135960 21418863 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, 2010 AND 2011 AND, ACCORDINGLY, NO LIABILITY WAS ACCRUED. FISCAL YEARS ENDING ON OR AFTER SEPTEMBER 30, 2008 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: UNREALIZED LOSS FROM INTEREST RATE SWAP -193,476. PART XII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES INCLUDED IN EXPENSES 23,700. CONTRIBUTION REVENUE 112,260. PART XIII, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED LOSS FROM INTEREST RATE SWAP 193,476. PART XIII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES INCLUDED IN EXPENSES 23,700. UNCOLLECTABLE CONTRIBUTIONS 112,260. 1 MOUNT PISGAH ACADEMY 75 ACADEMY DRIVE CANDLER NC 28715 560713794 501(C)(3) 5750 FMV TO ASSIST WITH STUDENT SCHOLARSHIPS CAROLINA CONFERENCE OF SEVENTH-DAY ADVENTISTS 2701 WT HARRIS BLVD CHARLOTTE NC 28256 454284485 501(C)(3) 35212 FMV TO ASSIST WITH LOCAL PASTOR SALARY 2 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 DAVID KIDDER 122609 0 2672 0 14216 375 0 0 22889 0 162386 375 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. ELLA KIDDER FAMILY RELATIONSHIP WITH DAVID KIDDER, CEO 58157 ELLA KIDDER IS AN EMPLOYEE OF THE ORGANIZATION 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 A DRAFT OF THE FORM 990 WAS REVIEWED BY THE CFO WITH THE EXECUTIVE BOARD OF THE BOARD DIRECTORS AND CEO PRIOR TO ITS FILING DATE. IT WAS THEN FINALIZED BY THE PREPARER AND 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 AND ON WWW.GUIDESTAR.ORG. 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: UNREALIZED LOSS FROM INTEREST RATE SWAP -193,476. TOTAL TO FORM 990, PART XI, LINE 5: -193,476. 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 154500 PISGAH ESTATES UNIT OWNERS ASSOCIATION L 49718