2012-11-13T16:10:49-06:00 2011-12-31 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST STE 2300 MINNEAPOLIS MN 55402 990 2011-01-01 412012560 EBENEZER LAKES ASSISTED LIVING EBEN 6128743460 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 STEPHAN GRYGAR 6128743460 2012-10-26 1 LAWRENCE H MOHR CPA P00447603 6128764500 2011 2016-02-24 21:20:13Z MARK THOMAS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 2168288 0 X WWW.FAIRVIEWEBENEZER.ORG X 1906 MN PROVIDE ASSISTED LIVING FOR THE ELDERLY 10 8 74 19 0 0 5388 8010 2510477 2148019 333 69 13395 12190 2529593 2168288 0 0 0 0 321829 372889 0 0 0 1834718 1787729 2156547 2160618 373046 7670 7041579 6958505 7127738 6965830 -86159 -7325 X EBENEZER 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. 0 0 1549776 2160209 PROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 59 UNITS. 1549776 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 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 1 0 0 0 0 1 12 0 1 74 1 0 0 0 0 0 0 0 0 0 0 X 10 8 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 MN X TERRY HAKES 6128743479 2722 PARK AVENUE MINNEAPOLIS MN 55407 X MAGGIE COLLINS 1.00 X X 0 0 0 KENT EKLUND 1.00 X 0 0 0 STEPHAN GRYGAR 1.00 X X 0 215882 22642 REVEREND RUSSELL HELGESEN 1.00 X 0 0 0 SHARY MULHERE 1.00 X X 0 0 0 PASTOR CHRISTOPHER NELSON 1.00 X 0 0 0 JEANNE RIPLEY 1.00 X 0 0 0 JOHN SELSTAD 1.00 X 0 0 0 MARK THOMAS 1.00 X X 0 405172 31002 DEBORAH PAONE 1.00 X 0 0 0 0 621054 53644 0 0 1 0 0 8010 8010 RENT REVENUE 532000 1651242 1651242 ELDERLY CARE SERVICES 623000 496777 496777 2148019 69 69 MISCELLANEOUS 900099 12190 12190 12190 2168288 2160209 0 69 208353 208353 208 208 106790 106790 57538 57538 40789 40789 1775 1775 8463 8463 688 688 113745 60255 53490 157969 157969 332039 332039 186659 186659 39788 39788 ELDERLY CARE EXPENSE 772378 772378 OVERHEAD ALLOCATIONS 133436 133436 2160618 1549776 610842 0 154676 233132 499970 546152 104277 64183 30336 30179 7077910 1329385 5910914 5748525 341406 336334 7041579 6958505 117207 140603 29037 19953 6477580 6403984 503914 401290 7127738 6965830 X -86159 -7325 -86159 -7325 7041579 6958505 X 7670 71164 X X 0 1 1 X 1 1 X 1020 792 5388 8010 15210 2091431 1873745 2089781 2510477 2148019 10713453 2092451 1873745 2090573 2515865 2156029 10728663 0 0 0 10728663 39005 33499 727 333 69 73633 39005 33499 727 333 69 73633 4988 5610 13395 12190 36183 2136444 1907244 2096910 2529593 2168288 10838479 0.98990 0.98880 0.00680 0.00800 X 29265 29265 6835414 1263546 5571868 150230 30334 119896 63001 35505 27496 5748525 TENANT SECURITY DEPOSITS 56406 PREMIUM ON BONDS 197635 AMOUNT DUE TO EBENEZER SOCIETY, A RELATED PARTY 143771 MANAGEMENT FEE PAYABLE TO EBENEZER MANAGEMENT SERVICE, A RELATED PARTY 3478 401290 2168288 2160618 7670 71164 71164 78834 2239452 71164 71164 2168288 0 2168288 2160618 0 2160618 0 2160618 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. X 0 0 0 0 0 0 0 0 0 STEPHAN GRYGAR 0 186697 0 29185 0 0 0 8658 0 13984 0 238524 0 0 MARK THOMAS 0 285542 0 110401 0 9229 0 7468 0 23534 0 436174 0 0 SUPPLEMENTAL INFORMATION PART III MARK 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. FORM 990, PART VI, SECTION A, LINE 2 MARK THOMAS, STEPHAN GRYGAR: BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEES HAVE AUTHORITY TO ACT ON THE BEHALF OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE 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 12C ALL 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 15 RAISES 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 19 EBENEZER LAKES ASSISTED LIVING FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY CAN BE OBTAINED UPON REQUEST. AVERAGE HOURS DEVOTED TO RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A MARK 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: FORGIVENESS OF DEBT BY RELATED PARTY 71,164. TOTAL TO FORM 990, PART XI, LINE 5: 71,164. 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. FAIRVIEW HEALTH SERVICES 2450 RIVERSIDE AVENUE MINNEAPOLIS MN 55454 410991680 HOSPITAL/HEALTHCARE PROVIDER MN 501(C)(3) LINE 3 N/A 0 EBENEZER SOCIETY 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 410706141 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER RIDGES ASSISTED LIVING 13810 COMMUNITY DRIVE BURNSVILLE MN 55337 411964691 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER RIDGES 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411287792 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER SOCIETY FOUNDATION 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411356565 SUPPORT EBENEZER SOCIETY MN 501(C)(3) LINE 11C, III-FI EBENEZER SOCIETY 0 EBENEZER RIDGE POINT APARTMENTS INC 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411769727 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER TOWERS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 237005359 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER PARK APARTMENTS 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411378656 NURSING HOME CARE MN 501(C)(3) LINE 9 EBENEZER SOCIETY 0 EBENEZER MANAGEMENT SERVICES INC 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411567046 MANAGEMENT SERVICES MN N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 EBENEZER MANAGEMENT SERVICES INC L 40789 AGREED UPON RATE EBENEZER SOCIETY O 1967320 COST