2012-11-15T14:53:44-06:00 2011-12-31 131517563 LOEB & TROPER LLP 655 THIRD AVENUE 12TH FLOOR NEW YORK NY 10017 990 2011-01-01 134034061 AMSTERDAM CONTINUING CARE HEALTH SYSTEM INC AMST 2125753322 1060 AMSTERDAM AVENUE NEW YORK NY 10025 JAMES DAVIS 2125753322 2012-11-14 1 BERNARD GROTELL P01275277 2128674000 2011 2016-02-24 21:20:13Z MARK PANCIRER 1060 AMSTERDAM AVENUE NEW YORK NY 10025 671725 0 X WWW.AMSTERDAMCARES.ORG X 1997 NY AMSTERDAM CONTINUING CARE HEALTH SYSTEM, INC. (HEALTH SYSTEM) IS THE SOLE CORPORATE MEMBER OF AMSTERDAM HOUSE CONTINUING CARE RETIREMENT COMMUNITY, INC. (RETIREMENT COMMUNITY), WHICH WAS ESTABLISHED AS A NOT-FOR-PROFIT CORPORATION ON JANUARY 30, 2004. THE RETIREMENT COMMUNITY IS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). 12 12 2 12 0 0 208147 221889 540000 399000 9344 11629 9154 10486 766645 643004 693 0 0 0 215795 224131 0 0 38449 5156 16305 221644 240436 545001 402568 1835076 2227136 2281654 2282656 -446578 -55520 THE PRIMARY PURPOSE OF THE ORGANIZATION IS TO OBTAIN CONTRIBUTIONS, GRANTS AND HOLD SPECIAL EVENTS TO SUPPORT THE AMSTERDAM NURSING HOME. ANNUALLY, THE ORGANIZATION HOLDS A GOLF OUTING EVENT. 0 0 186469 399000 SUPPORT OF SERVICES FOR THE ELDERLY 186469 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 2 0 2 1 0 0 0 0 0 1 1 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 1 0 0 NY X MARK PANCIRER 2125753322 570 SEVENTH AVENUE 6TH FLOOR NEW YORK NY 10018 X LAWRENCE B THOMPSON 1.00 X X 0 0 0 GEORGE L VAN AMSON 0.30 X X 0 0 0 JOSEPH C HOOPES 0.50 X X 0 0 0 JOSE V TORRES 0.30 X X 0 0 0 THE REVEREND JAMES G CALLAWAY JR 0.30 X 0 0 0 ISABEL M CARDEN 0.30 X 0 0 0 KAREN M HOPKINS MD 0.30 X 0 0 0 JAY H MCDOWELL 0.30 X 0 0 0 REV DEACON FRANK L PETERSON 0.30 X 0 0 0 JAMES J CAMPBELL 0.30 X 0 0 0 DYER S WADSWORTH 0.30 X 0 0 0 FRANCES R OLIVIERI 0.30 X 0 0 0 JAMES DAVIS 15.50 X 180004 447673 44618 MARK PANCIRER 12.50 X 30000 213526 45890 210004 661199 90508 1 0 1 0 0 90898 130991 221889 MANAGEMENT SERVICES TO 561000 399000 399000 399000 11629 11629 37845 90898 28721 9124 9124 MISCELLANEOUS 623000 1362 1362 1362 643004 399000 0 22115 210004 168003 7140 34861 14127 11302 480 2345 1176 1176 1972 1972 1350 1350 11672 5988 4441 1243 135 135 240436 186469 15518 38449 1064721 1555543 6044 6171 121594 121594 642717 543828 1835076 2227136 14054 15056 2267600 2267600 2281654 2282656 X -446578 -55520 -446578 -55520 1835076 2227136 X 402568 -11510 X X 0 1 1 X 0 X 247461 189305 263457 208147 221889 1130259 247461 189305 263457 208147 221889 1130259 455404 674855 15512 18955 19430 9344 11629 74870 7778 9124 16902 250000 2895 1376 1362 255633 1477664 399000 0.45670 0.41250 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: MISC. INCOME MANAGEMENT SERVICE INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 INVESTMENT IN AMSTERDAM SERVICES CORP. (2001) 121594 C 121594 SUBVENTION 1 OTHER RECEIVABLES 410619 CONSTRUCTION IN PROGRESS 126338 DUE FROM GERMAN MASONIC HOME CORPORATION 6870 543828 SUBVENTION -SUBORDINATE NOTE-ACCHS, INC 2267600 2267600 643004 240436 402568 -11510 -11510 391058 8800674 -11510 8169180 8157670 643004 0 643004 34247517 34007081 34007081 240436 0 240436 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: UNCERTAINTY IN INCOME TAXES - HEALTH SYSTEM HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. PERIODS ENDING DECEMBER 31, 2008 AND SUBSEQUENT REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIRECT COST OF SPECIAL EVENT 28,721. RELATED ENTITY REVENUE 8,140,459. PART XIII, LINE 2D - OTHER ADJUSTMENTS: DIRECT COST OF SPECIAL EVENT 28,721. RELATED ENTITY EXPENSES 33,978,360. ANNUAL GOLF OUTING 128743 90898 37845 14555 9775 4391 128743 90898 37845 14555 9775 4391 28721 9124 0 0 0 0 0 0 0 1 0 JAMES DAVIS 170004 337557 10000 110000 0 116 0 17778 0 26840 180004 492291 0 0 MARK PANCIRER 30000 207808 0 0 0 5718 0 14651 0 31239 30000 259416 0 0 PART I, LINE 7 THE BOARD OF DIRECTORS GATHERS COMPARABLE INFORMATION, EVALUATES AND APPROVES A BONUS FOR THE ORGANIZATION'S CEO. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 AS PREPARED BY LOEB & TROPER LLP, ACCOUNTING FIRM, IS PROVIDED TO THE AUDIT COMMITTEE FOR REVIEW AND COMMENTS AND TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 12C A INTERESTED DIRECTOR MEANS ANY AMSTERDAM DIRECTOR WHO HAS AN INTEREST AS A PRINCIPAL, PARTNER, DIRECTOR, OFFICER, EMPLOYEE, AGENT, OR STOCKHOLDER(OTHER THAN A STOCKHOLDER OF A PUBLICLY TRADED CORPORATION WHO STOCK IS WIDELY HELD) OF ANY ENTITY WITH WHICH AMSTERDAM HAS OR CONTEMPLATES TRANSACTING BUSINESS. AN INTERESTED DIRECTOR MUST DISCLOSE THE RELATIONSHIP OR INTEREST IN THE TRANSACTION TO THE BOARD OF DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY.DISCLOSURE SHALL BE MADE TO THE CHAIRMAN OF THE BOARD AS SOON AS THE INTERESTED DIRECTOR BECOME AWARE OF THE POTENTIAL FOR A CONFLICT IN CONNECTION WITH THE TRANSACTION WHO THEN SHALL INFORM THE APPLICABLE BOARD.IF THE CHAIRMAN IS INVOLVED IN THE TRANSACTION, THE CHAIRMAN SHALL ADVISE THE SECRETARY OF THE APPLICABLE AMSTERDAM ENTITY WHO SHALL ARRANGE FOR BOARD DISCLOSURE. NO INTERESTED DIRECTOR SHALL PARTICIPATE IN THE DISCUSSION,DELIBERATIONS AND VOTING REGARDING A TRANSACTION. THE AFFIRMATIVE VOTE OF THE MAJORITY OF ALL THE DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY,EXCLUDED IN SUCH COUNTS THE INTERESTED DIRECTOR,SHALL BE REQUIRED BEFORE ENTERING INTO THE TRANSACTION. NO TRANSACTION SHALL BE INVALIDATED OR AFFECTED IN ANY WAY IF THIS POLICY IS FOLLOWED. ALL OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST.SAID CONFLICTS ARE ADDRESSED BY MANAGEMENT. FORM 990, PART VI, SECTION B, LINE 15A FORM 990, PART VI, LINE 15: THE ORGANIZATION HAS A PROCESS TO DETERMINE COMPENSATION FOR THE CEO/ EXECUTIVE DIRECTOR WHICH INCLUDES A REVIEW BY A COMPENSATION AND BENEFITS CONSULTANT, THE USE OF COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN THE DELIBERATION AND THE FINAL DECISION. THIS PROCESS WAS LAST UNDERTAKEN IN 2011. THIS PROCESS INCLUDES A REVIEW OF TOTAL COMPENSATION INCLUDING BONUS CONSIDERATION. COMPENSATION OF OTHER KEY EMPLOYEES IS BASED ON AN INFORMAL REVIEW OF COMPARABLE DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, SECTION A, COLUMN B: JAMES DAVIS AND MARK PANCIRER DEVOTED THEIR TIME TO A RELATED ORGANIZATION. JAMES DAVIS DEVOTED 34.50 HOURS AND MARK PANCIRER 37.50 HOURS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -11,510. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART VI, LINE 13 AND 14: THE ORGANIZATION DOES NOT HAVE WRITTEN POLICIES AND PROCEDURES GOVERNING THE ACTIVITIES. HOWEVER, AMSTERDAM CONTINUING CARE HEALTH SYSTEM FOLLOWS THE POLICIES OF RELATED ORGANIZATION OF AMSTERDAM NURSING HOME CORP (1992). AMSTERDAM HOUSE CCRC LLC 1060 AMSTERDAM AVENUE NEW YORK NY 10025 412126554 PROVIDING SKILLED NURSING HOME CARE AND LIVING PROGRAMS TO ELDERLY NY 8115536 325668282 N/A AMSTERDAM CONSULTING LLC 1060 AMSTERDAM AVENUE NEW YORK NY 10025 134034061 ADMINISTRATIVE AND CONSULTING SERVICES TO OTHER FACILITIES NY 397309 1181716 N/A AMSTERDAM SERVICE CORP(S) 1060 AMSTERDAM AVENUE NEW YORK NY 10025 133902473 PROVIDING ADMINISTRATIVE AND CONSULTING SERVICES TO HEALTHCARE FACILITIES NY 9 501(C)(3) AMSTERDAM CONTINUING CARE HEALTH SYSTEM 1 AMSTERDAM NURSING HOME CORP (1992) 1060 AMSTERDAM AVENUE NEW YORK NY 10025 133834710 PROVIDING SKILLED NURSING HOME BEDS AND ADULT DAY CARE SERVICES FOR SENIORS NY 9 501(C)(3) AMSTERDAM CONTINUING CARE HEALTH SYSTEM 1 AMSTERDAM HOUSE CONTINUING CARE RETIREMENT COMMUNITY INC 1060 AMSTERDAM AVENUE NEW YORK NY 10025 113711764 PROVIDING SKILLED NURSING HOME, HOME FOR INDEPENDENT LIVING FOR SENIORS NY 9 501(C)(3) AMSTERDAM CONTINUING CARE HEALTH SYSTEM 1 AMSTERDAM SERVICES CORP 2001 1060 AMSTERDAM AVENUE NEW YORK NY 10025 134184082 ADMINISTRATIVE AND CONSULTING SERVICES TO OTHER FACILITIES NY AMSTERDAM CONTINUING CARE HEALTH SYSTEM C 24923 58511 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0