2012-05-15T09:27:25-05:00 2011-06-30 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-07-01 411936717 LIVING SERVICES FOUNDATION LIVI 7632100410 900 LONG LAKE ROAD NO 130 NEW BRIGHTON MN 55112 JENNIFER KAMSTRA 7632310410 2012-05-14 1 JOHN RACEK 6123764500 2010 2016-02-24 21:20:13Z DENNIS KAMSTRA 900 LONG LAKE ROAD NO 130 NEW BRIGHTON MN 55112 12085987 0 X WWW.LSFDN.ORG X 1999 MN TO PROVIDE HEALTHCARE SERVICES AND HOUSING TO THE ELDERLY. 5 1 651 1 0 0 19615 238620 18536285 10517064 19626 4879 720063 1325424 19295589 12085987 0 321945 0 0 11537717 6362454 0 0 0 8808519 6342748 20346236 13027147 -1050647 -941160 28324855 34180217 27918241 34723033 406614 -542816 X THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED EXCLUSIVELY FOR CHARITABLE PURPOSES WITHIN THE MEANING OF SECTIONS 170(C)(2), 501(C)(3), AND 2055(A) OF THE INTERNAL REVENUE CODE OF 1986 AS AMENDED ("THE CODE"). WITHIN THE LIMITATIONS ESTABLISHED BY THE PRECEDING SENTENCE, THE FOUNDATION IS ORGANIZED AND SHALL BE OPERATED TO OWN, MAINTAIN, OPERATE AND CONDUCT DIRECTLY OR INDIRECTLY, HOUSING AND LONG TERM CARE FACILITIES FOR THE ELDERLY AND TO ASSIST AND COORDINATE ACTIVITIES OF FACILITIES FOR HEALTH CARE, SOCIAL SERVICES, EDUCATION AND RESEARCH, AND TO DO ANY AND ALL OTHER ACTS AND THINGS AND EXERCISE ANY AND ALL OTHER RIGHTS AND POWERS WHICH MAY BE REASONABLY NECESSARY, INCIDENTAL, DESIRABLE, OR EXPEDIENT IN THE ACCOMPLISHMENT OF SUCH PURPOSES. 0 1 11443370 321945 10517064 HEALTHCARE SERVICES AND HOUSING TO ELDERLY IN APARTMENT, ASSISTED LIVING, AND HEALTHCARE CENTER UNITS FOR OVER 100 RESIDENTS AND OVER 2OO SENIORS. SERVICES ARE LICENSED BY VARIOUS GOVERNMENTAL AGENCIES. 11443370 1 1 0 0 0 0 0 1 0 1 0 0 1 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 0 0 1 0 0 1 1 0 0 0 0 0 1 62 0 1 651 1 0 0 0 0 0 0 0 0 0 0 X 5 1 1 1 1 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X JENNIFER KAMSTRA 7632310410 900 LONG LAKE ROAD SUITE 130 NEW BRIGHTON MN 55112 DENNIS KAMSTRA 40.00 X X 216000 0 12851 ROD PAKONEN 5.00 X X 14000 0 0 PAUL SAUNDERS 5.00 X X 14000 0 0 ROBERT SUNDBERG 5.00 X 14000 0 0 KEVIN RYMANOWSKI 5.00 X 0 0 0 JENNIFER KAMSTRA 40.00 X 90000 0 6044 348000 0 18895 1 0 1 0 BENEDICTINE HEALTH SYSTEMS 1995 EAST RUM RIVER DRIVE SOUTH CAMBRIDGE MN 55008 MANAGEMENT SERVICES 1393729 A'VIANDS FOOD AND SERVICES MANAGEMENT 1751 COUNTY ROAD B WEST ROSEVILLE MN 55113 FOOD SERVICES 380512 2 238620 235000 238620 RESIDENT REVENUE 623000 10517064 10517064 10517064 4879 4879 904899 904899 904899 904899 MANAGEMENT FEES 623990 291462 291462 DEVELOPMENT REVENUE 623990 199980 199980 LOSS ON REFINANCING 900099 -296577 -296577 225660 225660 420525 12085987 10517064 0 1330303 321945 321945 412747 210731 202016 4879620 4752267 127353 622734 593898 28836 447353 426638 20715 389940 389940 60801 60801 8282 8282 219869 219869 30286 30286 1205977 1112757 93220 125836 125836 394783 266948 127835 10730 10730 1651294 1574830 76464 1114943 1063315 51628 144331 137648 6683 LICENSE SURCHAGE 348713 348713 FOOD 293595 293595 UNCOLLECTIBLE ACCOUNTS 128776 128776 REPAIRS & MAINTENANCE 124681 120216 4465 MISCELLANEOUS 89911 89911 13027147 11443370 1583777 0 1001335 61991 37018 13568 2570172 478988 111938 117661 31042071 3672092 22262298 27369979 2342094 6138030 28324855 34180217 2377817 1915504 9575000 25501855 18290 15896572 7252584 50562 53090 27918241 34723033 X 386949 -542816 19665 0 406614 -542816 28324855 34180217 X -941160 -8270 X 0 1 1 X 0 X 19615 238620 258235 9309365 10977151 12761445 18536285 10517064 62101310 9309365 10977151 12761445 18555900 10755684 62359545 0 0 0 62359545 40113 2796245 39491 19626 909778 3805253 40113 2796245 39491 19626 909778 3805253 80173 384079 666210 720063 420525 2271050 9429651 14157475 13467146 19295589 12085987 68435848 0.91120 0.91770 0.05560 0.05020 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 919599 919599 25531729 2983544 22548185 1431675 645129 786546 3159068 43419 3115649 27369979 DEFERRED FINANCING COSTS 1198681 BOND FUNDS 4392369 PROJECT FUND 354933 OTHER 192047 6138030 ASSET RETIREMENT OBLIGATION 53090 53090 PART IV, LINE 2B: THE ORGANIZATION HOLDS IN TRUST RESIDENT FUNDS. RESIDENTS WITHDRAW FUNDS AS NEEDED FROM THEIR RESIDENT TRUST ACCOUNT. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3); CONSEQUENTLY, NO PROVISION HAS BEEN MADE FOR INCOME TAXES. THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING UNCERTAIN TAX POSITIONS. THE ORGANIZATION FILES INFORMATION RETURNS AS A TAX-EXEMPT ORGANIZATION. SHOULD THAT STATUS BE CHALLENGED IN THE FUTURE, ALL YEARS SINCE INCEPTION COULD BE SUBJECT TO REVIEW BY THE INTERNAL REVENUE SERVICE (IRS). THE ORGANIZATION'S 2008, 2009 AND 2010 TAX YEARS ARE OPEN TO EXAMINATION BY THE IRS. 0 BENEDICTINE LIVING COMMUNITY OF MORA 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 274219119 501(C)(3) 119738 BOOK VALUE EQUITY TRANSFER TRANSFER OF OPERATIONS BENEDICTINE LIVING COMMUNITY OF NEW LONDON 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 274218436 501(C)(3) 70699 BOOK VALUE EQUITY TRANSFER TRANSFER OF OPERATIONS BENEDICTINE LIVING COMMUNITY OF WINSTED 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 274219293 501(C)(3) 131508 BOOK VALUE EQUITY TRANSFER TRANSFER OF OPERATIONS 3 0 OTHER INFORMATION: PART IV: EQUITY TRANSFERS WERE RECORDED AS PART OF TRANSFER OF ASSETS IN 2011. X X X X 0 0 0 0 0 0 0 0 0 DENNIS KAMSTRA 216000 0 0 0 0 0 0 0 12851 0 228851 0 0 0 CITY OF SPICER 204504668 84844VAJ4 2006-12-28 9850000 FINANCE ACQUISITION 0 0 0 CITY OF WINSTED 416005652 975574AQ7 2010-09-16 16505000 REFINANCE SERIES 2008 NOTES AND FUND CONSTRUCTION OF MEMORY CARE FACILITY 0 0 0 80519 9460519 712522 294354 8453643 2007 0 1 1 1 16112135 1311331 8308071 322243 6170490 1 0 0 1 1 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 CITY OF SPICER SERIES 2006 BONDS INCLUDE A DISCOUNT OF 139,481 WHICH IS THE DIFFERENCE BETWEEN THE ISSUE PRICE INCLUDED IN PART I, LINE A, COLUMN E AND PART II, LINE 3, COLUMN A. CITY OF WINSTED SERIES 2010 BONDS INCLUDE A DISCOUNT OF 392,865 WHICH IS THE DIFFERENCE BETWEEN THE ISSUE PRICE INCLUDED IN PART I, LINE B, COLUMN E AND PART II, LINE 3, COLUMN B. CITY OF WINSTED SERIES 2010 BONDS INCLUDE A DISCOUNT OF 392,865. X 1 235000 FAIR VALUE 0 0 0 0 CASH, ACCOUNTS RECEIVABLE, AND OTHER CURRENT ASSETS 2011-02-01 1008898 BOOK VALUE 274219119 BENEDICTINE LIVING COMMUNITY OF MORA 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 501(C)(3) CASH, ACCOUNTS RECEIVABLE, AND OTHER CURRENT ASSETS 2011-02-01 638207 BOOK VALUE 274218436 BENEDICTINE LIVING COMMUNITY OF NEW LONDON 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 501(C)(3) CASH, ACCOUNTS RECEIVABLE, AND OTHER CURRENT ASSETS 2011-02-01 1063162 BOOK VALUE 274219293 BENEDICTINE LIVING COMMUNITY OF WINSTED 1995 EAST RUM RIVER ROAD CAMBRIDGE MN 55008 501(C)(3) 0 0 0 0 CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 THE ORGANIZATION BECAME A SUPPORTING ORGANIZATION OF BENEDICTINE HEALTH SYSTEMS IN FEBRUARY OF 2011. ALL PROPERTIES ARE LEASED TO BENEDICTINE HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 2 DENNIS KAMSTRA - JENNIFER KAMSTRA - FAMILY RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 3 LIVING SERVICES FOUNDATION HAS ALL THEIR PROPERTIES MANAGED BY BENEDICTINE HEALTH SYSTEMS. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED TO REFLECT THE ACTIVITIES OF THE ORGANIZATION TO CONSIST OF HOLDING TITLE AND MANAGING PROPERTIES OPERATED BY BENEFICIARY ORGANIZATIONS. FORM 990, PART VI, SECTION A, LINE 7A BENEDICTINE HEALTH SYSTEMS MAY APPOINT ONE BOARD MEMBER. FORM 990, PART VI, SECTION B, LINE 11 ALL MEMBERS OF THE BOARD RECEIVE AN ELECTRONIC DRAFT AND ARE GIVEN THE OPPORTUNITY TO REVIEW THE 990 AND GIVE APPROVAL PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS ENFORCED AND CONSISTENTLY MONITORED. AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THEIR FINANCIAL INTEREST TO THE BOARD CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING BOARD MEMBERS THEN DETERMINE IF A CONFLICT OF INTEREST EXISTS. CORRECTIVE ACTION IS TAKEN BY THE BOARD OF DIRECTORS AS DEEMED NECESSARY WHEN A CONFLICT OF INTEREST IS DETERMINED TO HAVE OCCURRED. THE PROCESS FOR DETERMINING COMPENSATION FOR OFFICERS IS DETERMINED BY A COMPENSATION SURVEY AND STUDY THAT IS DONE ANNUALLY WITH THE LAST REVIEW TAKING PLACE IN 2008. THE COMPENSATION MUST THEN BE APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES AVAILABLE TO THE PUBLIC THEIR GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET ASSETS RELEASED FROM RESTRICTION -8,270. TOTAL TO FORM 990, PART XI, LINE 5: -8,270. LIVING SERVICES FOUNDATIONMORA LLC 110 NORTH 7TH STREET MORA MN 55051 263614974 SKILLED NURSING FACILITY, ASSISTED LIVING FACILITY DE 4053724 6472819 LIVING SERVICES FOUNDATION LIVING SERVICES FOUNDATIONNEW LONDON LLC 100 GLEN OAKS DRIVE NEW LONDON MN 56273 204504668 SKILLED NURSING FACILITY, ASSISTED LIVING, INDEPENDENT LIVING DE 3428512 9334330 LIVING SERVICES FOUNDATION LIVING SERVICES FOUNDATIONWINSTED LLC 551 4TH STREET NORTH WINSTED MN 55395 208684862 SKILLED NURSING FACILITY, ASSISTED LIVING FACILITY DE 4327769 17897437 LIVING SERVICES FOUNDATION