2012-06-20T15:59:02-05:00 2011-09-30 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-10-01 311608691 APPLE VALLEY VILLA APARTMENTS APPL 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385205 2012-05-30 1 6123764500 2010 2016-02-24 21:20:13Z TIM TUCKER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 4193736 0 X WWW.AUGUSTANACARE.ORG X 1997 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 7 7 63 39 0 0 2792 16461 3834364 4155469 243 449 103416 21357 3940815 4193736 0 650000 0 0 1385761 1506083 0 0 0 2129921 2293702 3515682 4449785 425133 -256049 12203450 13340592 9496975 10890167 2706475 2450425 TO PROVIDE HEALTH CARE FACILITIES, HOUSING ALTERNATIVES AND COMMUNITY SERVICES FOR THE PHYSICAL, CULTURAL, SOCIAL AND RECREATIONAL NEEDS OF THE ELDERLY AND THE DISABLED IN A CHRISTIAN ENVIRONMENT. 0 0 3555327 650000 4155469 APPLE VALLEY VILLA APARTMENTS IS A 208-UNIT SENIOR SERVICE AND CONGREGATE HOUSING COMPLEX IN APPLE VALLEY, MINNESOTA. APPLE VALLEY VILLA APARTMENTS SERVED 246 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2011, WITH AN ADDITIONAL 129 PEOPLE BEING SERVED BY CATERED LIVING. 3555327 1 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 63 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CRAIG KITTELSON 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X REV DR GARY WILKERSON 1.00 X X 0 0 0 MARSHALL MACKAY 1.00 X X 0 0 0 CHARLES PARKS JR 1.00 X X 0 0 0 ERIC RICK ELLINGSON 1.00 X X 0 0 0 JIM EHLEN 1.00 X 0 0 0 SCOTT RAMSDALE 1.00 X 0 0 0 PR ELIZABETH BEISSEL 1.00 X 0 0 0 TIM TUCKER 4.50 X 0 313025 52237 CRAIG KITTELSON 4.50 X 0 249454 48561 TIM MIDDENDORF 4.50 X 0 198120 36133 KATHERINE KOPP 4.50 X 0 217223 28266 0 977822 165197 0 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 209687 1 16461 16461 SENIOR APARTMENTS 623000 3282856 3282856 CATERED LIVING 623000 872613 872613 4155469 449 449 MISCELLANEOUS REVENUE 900099 21357 21357 21357 4193736 4155469 0 21806 650000 650000 1247092 925281 321811 21295 13966 7329 148414 106347 42067 89282 65700 23582 209687 209687 118 118 17227 17227 109748 95312 14436 33529 33529 106976 76355 30621 456050 456050 3738 3738 3458 3458 472627 472627 379582 379582 41785 41785 DIETARY EXPENSES 287625 287625 LOSS ON EXTINGUISHMENT 99490 99490 BAD DEBT EXPENSE 27315 27315 NURSING SUPPLIES 21547 21547 MISCELLANEOUS 11523 11523 11677 4935 6742 4449785 3555327 894458 0 911127 848891 172589 164958 59683 37627 12734497 1733665 10150167 11000832 104241 167934 805643 1120350 12203450 13340592 442740 395957 7820000 9939338 102947 106135 1065443 372769 65845 75968 9496975 10890167 X 1760375 1522667 945825 927233 275 525 2706475 2450425 12203450 13340592 -256049 0 X 0 1 1 X 0 X 800 6696 183075 2792 16461 209824 2540308 2562923 2937739 3407014 3735670 15183654 2541108 2569619 3120814 3409806 3752131 15393478 500 220 720 0 500 220 720 15392758 11677 6455 3843 244 449 22668 11677 6455 3843 244 449 22668 404224 502553 547426 530765 441156 2426124 2957009 3078627 3672083 3940815 4193736 17842270 0.86270 0.86340 0.00130 0.00180 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: DIETARY INCOME FROM TENANTS MISCELLANEOUS INCOME FROM TENANTS HOUSEKEEPING INCOME FROM TENANTS TELEPHONE INCOME FROM TENANTS LAUNDRY INCOME FROM TENANTS MAINTENANCE INCOME FROM TENANTS CABLE TV INCOME FROM TENANTS 0 1 275 250 525 275 16 16 275 275 275 0.00000 1.00000 0.00000 0 1 1 1332579 1332579 10623487 1403575 9219912 553013 266808 286205 225418 63282 162136 11000832 TENANT SECURITY DEPOSITS 106431 ASSETS UNDER BOND INDENTURE AGREEMENTS 1013394 BENEFICIAL INTEREST IN NET ASSETS OF THE FOUNDATION 525 1120350 DUE TO(FROM) AFFILIATES 75968 75968 4193736 4449785 -256049 0 -256049 4212080 18594 18594 4193486 250 250 4193736 3799786 0 3799786 650000 650000 4449786 PART IV, LINE 2B: SECURITY DEPOSITS ARE REQUIRED FOR THE ORGANIZATION'S TENANTS AND INCLUDE RESERVED APARTMENTS IF AMOUNTS ARE PAID BEFORE THE TENANT ACTUALLY MOVES IN. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE PRINCIPAL WILL BE INVESTED AND KEPT INTACT FOR PERPETUITY TO PROVIDE AN ADDITIONAL SOURCE OF INCOME. THE INCOME GENERATED WILL BE USED TO SUPPORT THE FUND DESIGNATED PROGRAM. THE ORGANIZATION'S ENDOWMENT IS HELD AND ADMINISTERED BY AUGUSTANA CARE FOUNDATION. SEE SCHEDULE R FOR ADDITIONAL DETAILS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITYS FINANCIAL STATEMENTS. THE STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. AUGUSTANA CARE AND ITS AFFILIATES' INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE ORGANIZATION REPORTS ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES AND FILES ALL PROPER RETURNS RELATED TO THESE ACTIVITIES. THE TAX RETURNS FOR THE FISCAL YEARS 2008 TO 2010 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION 18,594. PART XII, LINE 4B - OTHER ADJUSTMENTS: RESTRICTED CONTRIBUTIONS 250. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EQUITY TRANSFER TO RELATED ORGANIZATION 650,000. 1 AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 501(C)(3) 650000 TRANSFER OF EXCESSIVE CASH 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: APPLE VALLEY VILLA APARTMENTS MAKES INTERCOMPANY TRANSFERS TO RELATED ORGANIZATIONS. APPLE VALLEY VILLA APARTMENTS AND THE RELATED ORGANIZATIONS ARE UNDER COMMON MANAGEMENT WHO REGULARLY MONITOR THE USE OF FUNDS. 0 1 0 0 0 0 0 0 0 TIM TUCKER 0 247016 0 41438 0 24571 0 31459 0 20778 0 365262 0 0 CRAIG KITTELSON 0 186511 0 33323 0 29620 0 23704 0 24857 0 298015 0 0 TIM MIDDENDORF 0 165502 0 24654 0 7964 0 16702 0 19431 0 234253 0 0 KATHERINE KOPP 0 171494 0 32005 0 13724 0 15008 0 13258 0 245489 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN PROVIDED BY AUGUSTANA CARE SERVICES, A RELATED ORGANIZATION: TIM TUCKER, PRESIDENT AND CEO - $22,708 CRAIG KITTELSON, VICE PRESIDENT OF FINANCE AND CFO - $15,958 TIM MIDDENDORF, VICE PRESIDENT OF OPERATIONS AND COO - $11,500 KATHERINE KOPP, VICE PRESIDENT OF SENIOR DEVELOPMENT - $8,500 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: FOR THE PURPOSE OF DETERMINING COMPENSATION, APPLE VALLEY VILLA APARTMENTS RELIED ON A RELATED ORGANIZATION, AUGUSTANA CARE SERVICES, TO ESTABLISH THE COMPENSATION OF THE PRESIDENT/CEO. AUGUSTANA CARE SERVICES USED THE FOLLOWING PRACTICES TO ESTABLISH COMPENSATION FOR THE PRESIDENT/CEO: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. ORGANIZATION MISSION STATEMENT OVERALL MISSION OF AUGUSTANA ENTITIES AUGUSTANA CARE, AND ITS SUBSIDIARIES, MISSION IS TO FOSTER FULLNESS OF LIFE FOR OLDER ADULTS AND OTHERS IN NEED THROUGH THE PROVISION OF HEALTHCARE, HOUSING AND OTHER SERVICES. BECAUSE ELDERS ARE VITAL TO OUR COMMUNITIES, WE PROVIDE SERVICES TO HELP THEM CONTINUE LIVING LIFE TO THE FULLEST, GIVING US ALL THE BENEFIT OF THEIR WISDOM AND EXPERIENCE. WE OFFER A FULL SPECTRUM OF SERVICES FOR OLDER ADULTS AND SERVE MORE THAN 6,000 PEOPLE EACH YEAR IN COMMUNITIES IN MINNESOTA AND COLORADO. OUR HEALTH CARE FACILITIES PROVIDE TRANSITIONAL CARE, LONG-TERM CARE, DEMENTIA CARE, AND REHABILITATION SERVICES TO MORE THAN 3,500 PEOPLE EACH YEAR. AUGUSTANA CARE ALSO OWNS AND MANAGES A VARIETY OF OLDER ADULT LIVING COMMUNITIES WITH COMFORTABLE LIVING AND CARE OPTIONS, INCLUDING APARTMENTS FOR INDEPENDENT LIVING, HOUSING WITH SERVICES, AND ASSISTED LIVING AND MEMORY CARE. ADDITIONALLY, WE OFFER A RANGE OF COMMUNITY-BASED SUPPORT SERVICES SUCH AS ADULT DAY PROGRAMS TO ENHANCE THE QUALITY OF LIFE FOR OLDER ADULTS WHO CONTINUE TO LIVE IN THEIR OWN HOMES, AS WELL AS MANAGEMENT CONSULTING SERVICES TO OTHER ORGANIZATIONS THAT SERVE OLDER ADULTS. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL INCLUDE THE CHAIR, THE VICE-CHAIR, THE TREASURER, AND THE SECRETARY, AND SUCH OTHER DIRECTORS AS THE BOARD MAY DESIGNATE FROM TIME TO TIME. THE PRESIDENT SHALL BE A NON-VOTING MEMBER OF THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL HAVE THE AUTHORITY OF THE BOARD IN THE MANAGEMENT OF THE BUSINESS OF THE CORPORATION IN THE INTERVAL BETWEEN BOARD MEETINGS, AND THE EXECUTIVE COMMITTEE SHALL AT ALL TIMES BE SUBJECT TO THE CONTROL AND DIRECTION OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL HAVE SUCH OTHER DUTIES AS MAY BE PRESCRIBED BY THE BOARD FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR APPLE VALLEY VILLA APARTMENTS. AUGUSTANA CARE SERVICES PROVIDES FINANCIAL ACCOUNTING, OPERATIONAL OVERSIGHT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, CLINICAL NURSING CONSULTATION, CORPORATE COMPLIANCE, COORDINATED ADVERTISING AND MARKETING, STAFFING FOR FUND DEVELOPMENT, AND NEW BUSINESS DEVELOPMENT. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS AUGUSTANA CARE. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION'S BOARD OF DIRECTORS ARE APPOINTED BY A MAJORITY VOTE FROM THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE, AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS REQUIRE AFFIRMATIVE APPROVAL FROM THE SOLE MEMBER OF THE ORGANIZATION, AUGUSTANA CARE: (A) AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS OF THIS CORPORATION; (B) CAPITAL BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, AND ALL MAJOR EXPENDITURES BEFORE FUNDS ARE EXPENDED THEREFORE; (C) OPERATING BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, BEFORE AUTHORIZED EXPENDITURES MAY BE MADE THEREFROM; (D) STRATEGIC PLANS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSIHPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION; (E) THE INCURRING OF ANY LONG TERM DEBT OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, OTHER THAN INTRA-SYSTEM OR REFINANCING DEBT; (F) HUMAN RESOURCES AND BENEFITS POLICIES OF THIS CORPORATION; (G) MAJOR RISK CONTRACTING AGREEMENTS, WHICH FOR THESE PURPOSES MEANS ANY CONTRACT WHICH DEALS WITH CAPITATION OR SIMILAR RISK BEARING CONCEPT; (H) MERGER, CONSOLIDATION, OR TOTAL OR PARTIAL DISSOLUTION INVOLVING THIS CORPORATION; (I) GOVERNANCE AND ACTION OF THE TYPE SET FORTH IN SUBPARAGRAPH (A) AND SUBPARAGRAPHS (F) THROUGH (H) ABOVE AS PROPOSED BY THE BOARD OF DIRECTORS OF ANY CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITES DIRECTLY CONTROLLED BY THIS CORPORATION AS A MEMBER, SHAREHOLDER OR OTHERWISE, TO THE EXTENT THAT THE GOVERNING DOCUMENTS OF SUCH CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITIES GIVE THIS CORPORATION OR THE BOARD A RIGHT OF APPROVAL OVER SUCH GOVERNANCE ACTION. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS MUST BE APPROVED, BY A 2/3-MAJORITY VOTE, BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS THAT RELATE TO THE REQUIREMENTS FOR AFFILIATION WITH THE EVANGELICAL LUTHERAN CHURCH IN AMERICA MUST BE APPROVED BY THE DIVISION FOR SOCIAL MINISTRY ORGANIZATIONS OF THE EVANGELICAL LUTHERAN CHURCH IN AMERICA. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED IN DETAIL BY THE ORGANIZATION'S VP - FINANCE/CFO. THE FORM 990 WAS THEN PRESENTED TO THE FULL BOARD BY THE VP - FINANCE/CFO PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS AND EMPLOYEES. ALL COVERED INDIVIDUALS ARE REQUIRED TO COMPLETE AN ANNUAL CONFLICT OF INTEREST STATEMENT. ALL COVERED INDIVIDUALS ARE REQUIRED TO DISCLOSE ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST TO THE APPROPRIATE LEVEL OF MANAGEMENT OR TO THE BOARD OF DIRECTORS AS OUTLINED IN THE POLICY BASED ON THE INDIVIDUAL'S POSITION WITHIN THE ORGANIZATION. CONFLICTS ARE DETERMINED AT THE APPROPRIATE LEVEL OF MANAGEMENT OR BY THE BOARD OF DIRECTORS. INDIVIDUALS WITH ACTUAL OR POTENTIAL CONFLICTS WILL ABSTAIN FROM DISCUSSING OR VOTING ON ANY MATTERS RELATING TO THE CONFLICT. ALL PROCEEDINGS RELATING TO ACTUAL OR POTENTIAL CONFLICTS WILL BE NOTED IN THE MEETING MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. EXPLANATION FOR HOURS WORKED FORM 990, PART VII, LINE 1A TIM TUCKER, CRAIG KITTELSON, TIM MIDDENDORF, AND KATHERINE KOPP EACH SERVE APPLE VALLEY VILLA APARTMENTS AND ITS RELATED ORGANIZATIONS. EACH INDIVIDUAL SPENDS APPROXIMATELY 4.5 HOURS PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL HOURS OF 45 PER WEEK. REV. DR. GARY WILKERSON, CHARLES PARKS, JR., MARSHALL MACKAY, ERIC (RICK) ELLINGSON, JIM EHLEN, SCOTT RAMSDALE, AND PR. ELIZABETH BEISSEL EACH SERVE ON THE BOARD OF APPLE VALLEY VILLA APARTMENTS AND ITS RELATED ORGANIZATIONS, WITH THE EXCEPTION OF AUGUSTANA CARE FOUNDATION. EACH INDIVIDUAL SPENDS APPROXIMATELY 1 HOUR PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL OF 8 HOURS. AUGUSTANA APARTMENTS OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608701 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA CARE 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411728753 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 7 N/A 0 AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 CHARITABLE FOUNDATION MN 501(C)(3) 11 - TYPE 1 AUGUSTANA CARE 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411806946 MANAGEMENT SERVICES MN 501(C)(3) 11 - TYPE 1 AUGUSTANA CARE 0 AUGUSTANA CHAPEL VIEW HOMES INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 410693953 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA COMMUNITY PARTNERS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411783680 HOME HEALTH CARE SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608696 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA HOME OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311572624 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 OPEN CIRCLE ADULT DAY CENTER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411424801 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 AUGUSTANA CARE 0 AUGUSTANA SENIOR DEVELOPMENT INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 481293891 CONSULTING MN N/A C 0 1 0 0 0 0 0 0 1 1 0 1 1 1 1 0 0 0