EBENEZER LAKES ASSISTED LIVING: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
EBENEZER LAKES ASSISTED LIVING (EIN 41-2012560)
Tax period
2011-01-01 to 2011-12-31
Filed
2012-11-13
IRS object ID
201223189349304317
Schema version
2011v1.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2012-11-13T16:10:49-06:00Timestamp
Tax Period End Date2011-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN390859910EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1BAKER TILLY VIRCHOW KRAUSE LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1225 S 6TH ST STE 2300AddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55402ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN412012560EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1EBENEZER LAKES ASSISTED LIVINGBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlEBENNameControl
Phone6128743460Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line12722 PARK AVENUE SOUTHAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55407ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameSTEPHAN GRYGARName
TitleCFOTitle
Phone6128743460Phone
Date Signed2012-10-26DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameLAWRENCE H MOHR CPAName
PTINP00447603PTIN
Phone6128764500Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-24 21:20:13ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonMARK THOMASNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line12722 PARK AVENUE SOUTHAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55407ZIPCode
FieldValueIRS element (for citing)
Gross Receipts2168288GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.FAIRVIEWEBENEZER.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1906YearFormation
State Legal DomicileMNStateLegalDomicile
Activity Or Mission DescriptionPROVIDE ASSISTED LIVING FOR THE ELDERLYActivityOrMissionDescription
Nbr Voting Members Governing Body10NbrVotingMembersGoverningBody
Nbr Independent Voting Members8NbrIndependentVotingMembers
Total Nbr Employees74TotalNbrEmployees
Total Nbr Volunteers19TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year5388ContributionsGrantsPriorYear
Contributions Grants Current Year8010ContributionsGrantsCurrentYear
Program Service Revenue Prior Year2510477ProgramServiceRevenuePriorYear
Program Service Revenue CY2148019ProgramServiceRevenueCY
Investment Income Prior Year333InvestmentIncomePriorYear
Investment Income Current Year69InvestmentIncomeCurrentYear
Other Revenue Prior Year13395OtherRevenuePriorYear
Other Revenue Current Year12190OtherRevenueCurrentYear
Total Revenue Prior Year2529593TotalRevenuePriorYear
Total Revenue Current Year2168288TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year321829SalariesEtcPriorYear
Salaries Etc Current Year372889SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year1834718OtherExpensePriorYear
Other Expenses Current Year1787729OtherExpensesCurrentYear
Total Expenses Prior Year2156547TotalExpensesPriorYear
Total Expenses Current Year2160618TotalExpensesCurrentYear
Revenues Less Expenses Prior Year373046RevenuesLessExpensesPriorYear
Revenues Less Expenses CY7670RevenuesLessExpensesCY
Total Assets BOY7041579TotalAssetsBOY
Total Assets EOY6958505TotalAssetsEOY
Total Liabilities BOY7127738TotalLiabilitiesBOY
Total Liabilities EOY6965830TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY-86159NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY-7325NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionEBENEZER HELPS OLDER ADULTS AND OTHERS MAKE THEIR LIVES MORE INDEPENDENT, HEALTHFUL, MEANINGFUL AND SECURE. BUILDING ON OUR LUTHERAN HERITAGE, WE RESPOND TO PHYSICAL, PYSCHOLOGICAL, SOCIAL AND SPIRITUAL DIMENSIONS OF THE WHOLE PERSON.WELCOME PERSONS OF DIVERSE CULTURES AND FAITH TRADITIONS.PRACTICE RESPONSIBLE STEWARDSHIP OF HUMAN, PROPERTY AND FINANCIAL RESOURCES.ENCOURAGE CONTINUING LEARNING AND INNOVATION.STRIVE FOR EXCELLENCE.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense1549776Expense
Revenue2160209Revenue
DescriptionPROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 59 UNITS.Description
Total Program Service Expense1549776TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With109612NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees74NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members10NbrVotingGoverningBodyMembers
Number Independent Voting Members8NumberIndependentVotingMembers
Family Or Business Relationship1FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees0MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body0Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledMNStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1TERRY HAKESBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number6128743479TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line12722 PARK AVENUEAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55407ZIPCode
FieldValueIRS element (for citing)
Info In Schedule O Part VIIXInfoInScheduleOPartVII

Form990 Part VII Section A Form990PartVIISectionA (10 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensation
MAGGIE COLLINS
CHAIR1.00XX000
KENT EKLUND
DIRECTOR1.00X000
STEPHAN GRYGAR
TREASURER1.00XX021588222642
REVEREND RUSSELL HELGESEN
DIRECTOR1.00X000
SHARY MULHERE
SECRETARY1.00XX000
PASTOR CHRISTOPHER NELSON
DIRECTOR1.00X000
JEANNE RIPLEY
DIRECTOR1.00X000
JOHN SELSTAD
DIRECTOR1.00X000
MARK THOMAS
PRESIDENT1.00XX040517231002
DEBORAH PAONE
DIRECTOR1.00X000
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs621054TotalReportableCompFrmRltdOrgs
Total Other Compensation53644TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources
Number Of Contractors GT100 K0NumberOfContractorsGT100K
All Other Contributions8010AllOtherContributions
Total Contributions8010TotalContributions

Program Service Revenue ProgramServiceRevenue (2 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
RENT REVENUE53200016512421651242
ELDERLY CARE SERVICES623000496777496777
FieldValueIRS element (for citing)
Total Program Service Revenue2148019TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column69TotalRevenueColumn
Exclusion$69ExclusionAmount

Other Revenue Misc OtherRevenueMisc

FieldValueIRS element (for citing)
DescriptionMISCELLANEOUSDescription
Business Code900099BusinessCode
Total Revenue Column12190TotalRevenueColumn
Related Or Exempt Function Income12190RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Other Revenue12190TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column2168288TotalRevenueColumn
Related Or Exempt Function Income2160209RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$69ExclusionAmount

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total208353Total
Management And General208353ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total208Total
Management And General208ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total106790Total
Management And General106790ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total57538Total
Management And General57538ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total40789Total
Management And General40789ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total1775Total
Management And General1775ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total8463Total
Management And General8463ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total688Total
Program Services688ProgramServices

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total113745Total
Program Services60255ProgramServices
Management And General53490ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total157969Total
Program Services157969ProgramServices

Interest Interest

FieldValueIRS element (for citing)
Total332039Total
Program Services332039ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total186659Total
Program Services186659ProgramServices

Insurance Insurance

FieldValueIRS element (for citing)
Total39788Total
Program Services39788ProgramServices

Other Expenses OtherExpenses (2 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
ELDERLY CARE EXPENSE772378772378
OVERHEAD ALLOCATIONS133436133436

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total2160618Total
Program Services1549776ProgramServices
Management And General610842ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY154676BOY
EOY233132EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY499970BOY
EOY546152EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY104277BOY
EOY64183EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY30336BOY
EOY30179EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis7077910LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec1329385LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY5910914BOY
EOY5748525EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY341406BOY
EOY336334EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY7041579BOY
EOY6958505EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY117207BOY
EOY140603EOY

Deferred Revenue DeferredRevenue

FieldValueIRS element (for citing)
BOY29037BOY
EOY19953EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY6477580BOY
EOY6403984EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY503914BOY
EOY401290EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY7127738BOY
EOY6965830EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY-86159BOY
EOY-7325EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY-86159BOY
EOY-7325EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY7041579BOY
EOY6958505EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses7670ReconcilationRevenueExpenses
Reconcilation Other Changes71164ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement SeparateXFinancialStatementSeparate
Federal Grant Audit Required1FederalGrantAuditRequired
Federal Grant Audit Performed1FederalGrantAuditPerformed

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org509a2XPubliclySupportedOrg509a2

Gifts Grants Contrib Received509 GiftsGrantsContribReceived509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years1020CurrentTaxYearMinus4Years
Current Tax Year Minus2 Years792CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year5388CurrentTaxYearMinus1Year
Current Tax Year8010CurrentTaxYear
Total15210Total

Gross Receipts From Admissions GrossReceiptsFromAdmissions

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years2091431CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years1873745CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years2089781CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year2510477CurrentTaxYearMinus1Year
Current Tax Year2148019CurrentTaxYear
Total10713453Total

Total509 Total509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years2092451CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years1873745CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years2090573CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year2515865CurrentTaxYearMinus1Year
Current Tax Year2156029CurrentTaxYear
Total10728663Total

Amts Recd From Disqual Persons AmtsRecdFromDisqualPersons

FieldValueIRS element (for citing)
Total0Total

Amts From Subst Contributors AmtsFromSubstContributors

FieldValueIRS element (for citing)
Total0Total

Support From DQ Ps Etc SupportFromDQPsEtc

FieldValueIRS element (for citing)
Total0Total
FieldValueIRS element (for citing)
Public Support Total50910728663PublicSupportTotal509

Gross Investment Income509 GrossInvestmentIncome509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years39005CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years33499CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years727CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year333CurrentTaxYearMinus1Year
Current Tax Year69CurrentTaxYear
Total73633Total

Investment Income And UBTI InvestmentIncomeAndUBTI

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years39005CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years33499CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years727CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year333CurrentTaxYearMinus1Year
Current Tax Year69CurrentTaxYear
Total73633Total

Other Income509 OtherIncome509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years4988CurrentTaxYearMinus4Years
Current Tax Year Minus2 Years5610CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year13395CurrentTaxYearMinus1Year
Current Tax Year12190CurrentTaxYear
Total36183Total

Total Support Total TotalSupportTotal

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years2136444CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years1907244CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years2096910CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year2529593CurrentTaxYearMinus1Year
Current Tax Year2168288CurrentTaxYear
Total10838479Total
FieldValueIRS element (for citing)
Public Support Percentage5090.98990PublicSupportPercentage509
Prior Year Support Percentage0.98880PriorYearSupportPercentage
Investment Income Percentage0.00680InvestmentIncomePercentage
Prior Yr Invest Income Percentage0.00800PriorYrInvestIncomePercentage
Thirty Three Percnt Tests CY509XThirtyThreePercntTestsCY509

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis29265OtherCostOrOtherBasis
Book Value29265BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis6835414OtherCostOrOtherBasis
Depreciation1263546Depreciation
Book Value5571868BookValue

Leasehold Improvements LeaseholdImprovements

FieldValueIRS element (for citing)
Other Cost Or Other Basis150230OtherCostOrOtherBasis
Depreciation30334Depreciation
Book Value119896BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis63001OtherCostOrOtherBasis
Depreciation35505Depreciation
Book Value27496BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings5748525TotalOfBookValueLandBuildings

Other Liabilities OtherLiabilities (4 entries)

DescriptionDescriptionAmountAmount
TENANT SECURITY DEPOSITS$56,406
PREMIUM ON BONDS$197,635
AMOUNT DUE TO EBENEZER SOCIETY, A RELATED PARTY$143,771
MANAGEMENT FEE PAYABLE TO EBENEZER MANAGEMENT SERVICE, A RELATED PARTY$3,478
FieldValueIRS element (for citing)
Total Of Amounts401290TotalOfAmounts
Total Revenue2168288TotalRevenue
Total Expenses2160618TotalExpenses
Excess Or Deficit For Year7670ExcessOrDeficitForYear
Other$71,164OtherAmount
Total Adjustments71164TotalAdjustments
Excess Or Deficit Per FS78834ExcessOrDeficitPerFS
Tot Revenue Etc Audited Fincl Stmt2239452TotRevenueEtcAuditedFinclStmt
Other Revenues71164OtherRevenues
Revenue Not Rptd F99071164RevenueNotRptdF990
Revenue Subtotal2168288RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form9902168288TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt2160618TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal2160618ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form9902160618TotalExpensesPerForm990

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (3 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:PART X:IN ACCORDANCE WITH THE STANDARD RELATED TO THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, THE COMPANY ADDRESSES THE DETERMINATION OF WHETHER TAX BENEFITS CLAIMED SHOULD BE RECORDED IN THE FINANCIAL STATEMENTS. UNDER THIS GUIDANCE, THE COMPANY MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERIT OF THE POSITION. EXAMPLES OF TAX POSITIONS INCLUDE THE TAX-EXEMPT STATUS OF THE COMPANY AND VARIOUS POSITIONS RELATED TO THE POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME. THERE ARE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS A LIABILITY DURING 2011. OPEN TAX YEARS SUBJECT TO EXAMINATION BY THE U.S. AND STATE TAXING AUTHORITIES ARE FOR THE YEARS 2008 TO 2010, WHICH STATUES EXPIRES 2011 TO 2013, RESPECTIVELY. THE MEASUREMENT AND DISCLOSURE PRINCIPLES OF THE STANDARD NORMALLY DO NOT AFFECT THE FINANCIAL STATEMENTS OF AN ENTITY THAT IS NOT SUBJECT TO INCOME TAX. HOWEVER, THERE ARE CERTAIN EXCEPTIONS WHERE THE COMPANY WOULD BEAR THE BURDEN OF AN UNCERTAIN TAX POSITION.
PART XI, LINE 8 - OTHER ADJUSTMENTS:FORGIVENESS OF DEBT BY RELATED PARTY 71,164.
PART XII, LINE 2D - OTHER ADJUSTMENTS:FORGIVENESS OF DEBT BY RELATED PARTY 71,164.

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (2 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
STEPHAN GRYGAR
01866970291850008658013984023852400
MARK THOMAS
028554201104010922907468023534043617400

Form990 Schedule J Part III Form990ScheduleJPartIII

FieldValueIRS element (for citing)
IdentifierSUPPLEMENTAL INFORMATIONIdentifier
Return ReferencePART IIIReturnReference
ExplanationMARK THOMAS AND STEPHAN GRYGAR ARE EMPLOYEES OF FAIRVIEW HEALTH SERVICES. THEIR SALARY IS PASSED TO EBENEZER AND IS AN EXPENSE OF CORPORATE EBENEZER. THE PROFIT/(LOSS) ON CORPORATE EBENEZER IS ALLOCATED OUT AS A CORPORATE ALLOCATION ON EACH OWNED SITE.Explanation

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
FORM 990, PART VI, SECTION A, LINE 2MARK THOMAS, STEPHAN GRYGAR: BUSINESS RELATIONSHIP
FORM 990, PART VI, SECTION A, LINE 8BNO COMMITTEES HAVE AUTHORITY TO ACT ON THE BEHALF OF THE ORGANIZATION.
FORM 990, PART VI, SECTION B, LINE 11THE 990 IS REVIEWED BY MARK THOMAS AND STEPHAN GRYGAR BEFORE FILING. THE COMPLETE GOVERNING BODY DOES NOT REVIEW BEFORE FILING.
FORM 990, PART VI, SECTION B, LINE 12CALL POTENTIAL CONFLICTS OF INTEREST OR OTHER MATTERS RELATING TO THE DUTY OF LOYALTY RESPECTING ALL DIRECTORS OR OFFICERS OF FAIRVIEW (OF THE RANK OF SENIOR VICE PRESIDENT OR ABOVE), SHALL BE REPORTED TO THE FAIRVIEW SYSTEM BOARD VIA THE AUDIT AND COMPLIANCE COMMITTEE. ALL ISSUES RELATING TO THE DUTY OF LOYALTY RESPECTING ALL DIRECTORS, TRUSTEES, OR OFFICERS OF A FAIRVIEW DIVISION WITH AN OPERATING BOARD OR A FAIRVIEW SUBSIDIARY SHALL BE REPORTED TO THE BOARD OF TRUSTEES OR DIRECTORS OF THE APPROPRIATE DIVISION OR SUBSIDIARY. THE CHIEF COMPLIANCE OFFICE SHALL MONITOR CONFLICT ISSUES REPORTED AT THE DIVISION AND SUBSIDIARY LEVEL AND PERIODICALLY REPORT TO THE AUDIT AND COMPLIANCE COMMITTEE WITH RESPECT TO SUCH CONFLICTS. ALL POTENTIAL CONFLICTS OR OTHER ISSUES RELATING TO THE DUTY OF LOYALTY RESPECTING ALL OTHER INTERESTED PERSONS SHALL BE REPORTED TO FAIRVIEW'S CHIEF COMPLIANCE OFFICER, (ON IN THE CASES OF DIVISIONS AND SUBSIDIARIES TO THE CEO OF SUCH DIVISION OR SUBSIDIARY), AND IN HIS OR HER DISCRETION TO THE AUDIT AND COMPLIANCE COMMITTEE OF THE FAIRVIEW SYSTEM BOARD. THE CHIEF COMPLIANCE OFFICER, IN CONJUNCTION WITH FAIRVIEW SENIOR MANAGEMENT, SHALL MAKE THE DECISION AS TO WHETHER A POTENTIAL CONFLICT OF INTEREST IS AN ACTUAL CONFLICT OF INTEREST WITH RESPECT TO SUCH OTHER PERSONS. IN THE CASE OF A CONFLICT OF INTEREST RELATING TO A DIRECTOR OR TRUSTEE OF A FAIRVIEW DIVISION WITH AN OPERATING BOARD OR A DIRECTOR, OFFICER OR EMPLOYEE OF A FAIRVIEW SUBSIDIARY, DECISIONS RELATING TO THE CONFLICT SHALL BE MADE BY THE DIVISION OR SUBSIDIARY USING GUIDELINES DEVELOPED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE FAIRVIEW SYSTEM BOARD. ALL SUCH MATTERS SHALL BE SUBJECT TO REVIEW BY THE AUDIT AND COMPLIANCE COMMITTEE.
FORM 990, PART VI, SECTION B, LINE 15RAISES ARE BASED ON INCREASE GIVEN FOR REIMBURSEMENT BY THE STATE. THE LAST YEAR IT WAS 1%. ANY INCREASES ABOVE 1% ARE GIVEN BASED ON MARKET RATES FOR POSITION. THEY ARE REVIEWED AND APPROVED BY UPPER MANAGEMENT.
FORM 990, PART VI, SECTION C, LINE 19EBENEZER LAKES ASSISTED LIVING FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY CAN BE OBTAINED UPON REQUEST.
FORM 990, PART VII, SECTION AMARK THOMAS AND STEPHAN GRYGAR ARE EMPLOYEES OF FAIRVIEW HEALTH SERVICES, A RELATED ORGANIZATION. THEY DEVOTE, ON AVERAGE, 40HRS/WEEK TO FAIRVIEW HEALTH SERVICES. THE BOARD MEMBERS LISTED IN PART VII, INCLUDING MARK THOMAS AND STEPHAN GRYGAR, ALSO SERVES AS BOARD MEMBERS OF THE OTHER EBENEZER ORGANIZATIONS AS LISTED IN SCHEDULE R. THEY DEVOTE, ON AVERAGE, 1HR/WEEK TO EACH ORGANIZATION.AVERAGE HOURS DEVOTED TO RELATED ORGANIZATIONS
FORM 990, PART XI, LINE 5:FORGIVENESS OF DEBT BY RELATED PARTY 71,164. TOTAL TO FORM 990, PART XI, LINE 5: 71,164.CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XII, LINE 2C:THE ORGANIZATION DID NOT CHANGE EITHER THE OVERSIGHT PROCESS OF THE AUDIT OR THE SELECTION PROCESS OF THE INDEPENDENT ACCOUNTANT DURING THE TAX YEAR.

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (8 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusDirect Controlling Entity NADirectControllingEntityNAControlled OrgControlledOrgBusiness Name Line1DirectControllingEntityName/BusinessNameLine1
FAIRVIEW HEALTH SERVICES
2450 RIVERSIDE AVENUEMINNEAPOLISMN55454410991680HOSPITAL/HEALTHCARE PROVIDERMN501(C)(3)LINE 3N/A0
EBENEZER SOCIETY
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407410706141NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY
EBENEZER RIDGES ASSISTED LIVING
13810 COMMUNITY DRIVEBURNSVILLEMN55337411964691NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY
EBENEZER RIDGES
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407411287792NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY
EBENEZER SOCIETY FOUNDATION
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407411356565SUPPORT EBENEZER SOCIETYMN501(C)(3)LINE 11C, III-FI0EBENEZER SOCIETY
EBENEZER RIDGE POINT APARTMENTS INC
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407411769727NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY
EBENEZER TOWERS
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407237005359NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY
EBENEZER PARK APARTMENTS
2722 PARK AVENUE SOUTHMINNEAPOLISMN55407411378656NURSING HOME CAREMN501(C)(3)LINE 90EBENEZER SOCIETY

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1EBENEZER MANAGEMENT SERVICES INCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line12722 PARK AVENUE SOUTHAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55407ZIPCode
FieldValueIRS element (for citing)
EIN411567046EIN
Primary ActivityMANAGEMENT SERVICESPrimaryActivity
Legal Domicile StateMNLegalDomicileState
Direct Controlling Entity NAN/ADirectControllingEntityNA
Type Of EntityCTypeOfEntity
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees0SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org0ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (2 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolvedMethod Of Amt DeterminationMethodOfAmtDetermination
EBENEZER MANAGEMENT SERVICES INC
L40789AGREED UPON RATE
EBENEZER SOCIETY
O1967320COST

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