2012-03-22T13:25:23-05:00 2011-09-30 ATHERTON & ASSOCIATES LLP PO BOX 4339 MODESTO CA 953524339 990 2010-10-01 770562224 COMMUNITY HOSPICE FOUNDATION OF STANISLAUS COUNTY COMM 2095786300 4368 SPYRES WAY MODESTO CA 95356 RICK DAHLSEID CPA 2095786300 2012-03-05 1 RONALD EHRKE 2095774800 X 2010 2016-02-24 21:20:13Z HAROLD A PETERSON III 4368 SPYRES WAY MODESTO CA 95356 1302187 0 X WWW.HOSPICEHEART.ORG X 2002 CA SUPPORT OF COMMUNITY HOSPICE, INC. 21 21 6 79 0 0 665760 780785 0 0 31818 53593 185605 245222 883183 1079600 5332 371635 0 0 236194 203885 0 0 105075 215959 233244 457485 808764 425698 270836 4916907 5229864 94216 273454 4822691 4956410 X THE FOUNDATION EXISTS TO RAISE FUNDS AND AWARENESS OF THE COMMUNITY HOSPICE MISSION. COMMUNITY HOSPICE PROVIDES COMPASSIONATE END-OF-LIFE CARE AND BEREAVEMENT SUPPORT TO PATIENTS AND THEIR FAMILIES REGARDLESS OF ABILITY TO PAY. THE FOUNDATION RAISES FUNDS UTILIZING A NUMBER OF FUNDRAISING AVENUES. 0 0 638474 TO RAISE FUNDS TO SUPPORT THE OPERATIONS OF COMMUNITY HOSPICE, INC., A RELATED NOT-FOR-PROFIT CORPORATION. COMMUNITY HOSPICE, INC., USES THESE FUNDS TO PROVIDE SERVICES AND SUPPORT TO THE TERMINALLY ILL AND THEIR FAMILIES. 638474 1 1 0 0 0 0 0 0 1 1 1 0 1 1 0 1 1 0 0 0 0 0 0 1 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 1 9 0 1 6 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 21 21 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X RICK DAHLSEID CPA 2095786300 4368 SPYRES WAY MODESTO CA 95356 CATHY TUXSON 1.00 X 0 0 0 JANICE LUCERO 1.00 X 0 0 0 LESLIE KALIM MCHUGH 1.00 X 0 0 0 GARY ERVIN 1.00 X 0 0 0 JAMES COGDILL 1.00 X 0 0 0 DR ASHLEY BARBOZA 1.00 X 0 0 0 SALLY COFER-LINDBERG 1.00 X 0 0 0 PATTY DUVAL 1.00 X 0 0 0 RONI EDGMON 1.00 X 0 0 0 VERN FERGEL 1.00 X 0 0 0 DON GAEKLE 1.00 X 0 0 0 MICHAEL C HERRERO 1.00 X 0 0 0 CLARENCE ABID 1.00 X 0 0 0 KIM JOHNSON 1.00 X 0 0 0 GARRAD MARSH 1.00 X 0 0 0 GINA MACHADO 1.00 X 0 0 0 PETER RODRIGUEZ 1.00 X 0 0 0 MERYL SNIDER 1.00 X 0 0 0 JON TREMAYNE 1.00 X 0 0 0 TICIA SODHI 1.00 X 0 0 0 EMILY WIROWEK 1.00 X 0 0 0 HAROLD A PETERSON III 5.00 X 0 201232 22000 RICK DAHLSEID CPA 5.00 X 0 107836 4303 LYNIS CHAFFEY 40.00 X 5569 0 200 0 309068 26303 0 0 1 0 0 74414 706371 74550 780785 53593 53593 449981 74414 222587 227394 227394 15919 15919 15919 MISCELLANEOUS INCOME 900099 1223 1223 LOSS FROM LIMITED PART 900099 686 686 1909 1079600 1223 0 297592 371635 371635 60901 30451 30450 126406 63203 63203 4592 2296 2296 11986 5993 5993 19780 19780 25 25 28029 28029 18000 18000 2691 2691 8458 8458 5774 5774 MANAGEMENT SERVICE FEES 65215 65215 POSTAGE 32827 32827 BANK, CREDIT CARD & PAY 21148 21148 COMPUTER MAINTENANCE 10115 10115 STAFF RECRUITMENT, TRAI 6714 6714 14468 11335 3133 808764 638474 65215 105075 562364 735104 187013 7227 2691 7116 16583 3552 8889 9202 32665 21458 16982 11207 0 0 3751187 4085584 371198 370872 4916907 5229864 36610 53698 57606 219756 94216 273454 X 4402945 4536664 419746 419746 4822691 4956410 4916907 5229864 X 270836 -137117 X X 0 1 1 X 0 X X X 0 0 0 COMMUNITY HOSPICE INC 942638213 9 1 1 1 371635 1 371635 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 440781 -11770 -6509 422502 417600 1253 21928 440781 189918 216266 11416 417600 0 0 8474 7346 1128 24191 14112 10079 11207 LIMITED PARTNERSHIP 2698000 F PUBLICLY TRADED SECURITIES 1387584 F 4085584 INVESTMENT PROPERTY 7800 ENDOWMENT INVESTMENTS 299232 PLEDGES RECEIVABLE RESTRICTED FOR ENDOWMENT 63840 370872 RELATED PARTY PAYABLE 219756 219756 1079600 808764 270836 -137117 -137117 133719 1163222 -137117 222587 85470 1077752 1848 1848 1079600 657868 222587 222587 435281 373483 373483 808764 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE INTENDED USE OF THE ENDOWMENT FUNDS ARE TO FUND FUTURE OPERATING EXPENSES. LINE 2D - COST OF GOODS SOLD FOR FUNDRAISING EVENTS LINE 4B - TRANSFERS MADE TO RELATED PARTIES GALA 243524 37350 206174 24203 51833 50588 GOLF FORE HOSPICE 106361 32769 73592 20733 6039 35177 7 174510 4295 170215 3047 13708 17259 524395 74414 449981 47983 71580 103024 222587 227394 15919 1 0.95000 15919 15919 CA 1 0 0 0 1.00000 RICK DAHLSEID CPA 4368 SPYRES WAY MODESTO CA 95356 0 LYNIS CHAFFEY 60901 REGISTRATION AND OPERATION OF RAFFLES. X 0 1 COMMUNITY HOSPICE INC 4368 SPYRES WAY MODESTO CA 95356 942638213 501(C)(3) 371635 FUNDS RAISED AND REIMBURSED EXPENSES FOR COMMUNITY HOSPICE INC PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL FUNDS ARE DISTRIBUTED TO COMMUNITY HOSPICE, INC. WHICH IS A RELATED ENTITY. X X X X X 0 0 0 0 0 0 0 0 0 HAROLD A PETERSON III 0 201232 0 0 0 0 0 22000 0 0 0 223232 0 230042 X RENT 2500 BASED ON DONORS REPRESENTATION X MISCELLANEOUS 351 BASED ON DONORS REPRESENTATION X DECORATIONS 2460 BASED ON DONORS REPRESENTATION X PRIZES 54655 BASED ON DONORS REPRESENTATION X SIGNAGE 545 BASED ON DONORS REPRESENTATION X FOOD 3566 BASED ON DONORS REPRESENTATION X NON-EE GIFT AWARDS 6900 BASED ON DONORS REPRESENTATION X PHOTOGRAPHY 2700 BASED ON DONORS REPRESENTATION X OFFICE SUPPLIES 874 BASED ON DONORS REPRESENTATION 0 1 0 FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT DUTIES ARE PERFORMED BY CHI MANAGEMENT, INC. WHICH IS A RELATED PARTY EXEMPT ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER (CFO) OBTAINS THE COMPLETED FORM 990 FROM THE PREPARER AND REVIEWS IT FOR ACCURACY AND COMPLETENESS. IF CONSIDERED ACCURATE AND COMPLETE, A MEETING IS SCHEDULED WITH THE CHI FOUNDATION BOARD. THE COMPLETE 990 IS CONVERTED TO A PDF FILE FOR ELECTRONIC STORAGE AND VIEWING. AT THE MEETING OF THE CHI FOUNDATION BOARD, THE FORM 990 IS PROVIDED TO EACH BOARD MEMBER. THE CFO THEN GOES THROUGH EACH PAGE OF THE FORM 990 EXPLAINING THE MAIN PORTION OF THE RETURN AS WELL AS THE SCHEDULES THAT ARE REQUIRED. MEETING NOTES ARE KEPT OF THE MEETING THROUGHOUT THE REVIEW TO CAPTURE ANY COMMENTS OR QUESTIONS THAT ARISE FROM THE BOARD MEMBERS THAT CANNOT BE ANSWERED BY THE CFO. AT THE CONCLUSION OF THE REVIEW, ANY UNANSWERED QUESTIONS WILL BE FORWARDED TO THE PREPARER FOR REPLY. THOSE REPLIES WILL BE ELECTRONICALLY FORWARDED TO THE MEMBERS OF CHI FOUNDATION BOARD FOR COMMENT. ABSENT ANY ADDITIONAL QUESTIONS OF THE PREPARER, THE FORM 990 WILL BE CONSIDERED TO BE COMPLETE AND READY TO FILE WITH THE INTERNAL REVENUE SERVICE. THE CHI FOUNDATION BOARD WILL MOVE TO APPROVE THE FORM 990. THE FORM 990 WILL BE SIGNED BY THE CFO AND FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C ALL EMPLOYEES, VOLUNTEERS, AND MEMBERS OF THE BOARD OF DIRECTORS AND ADVISORY COMMITTEES WILL SIGN A CONFLICT OF INTEREST DOCUMENT UPON EMPLOYMENT, APPOINTMENT, OR REAPPOINTMENT, INDICATING THAT THEY HAVE READ AND UNDERSTOOD THE RELEVANT POLICIES AND THAT THEY WILL OBSERVE THEM. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS APPROVED BY THE INDEPENDENT BOARD OF DIRECTORS WHERE THE VOTE OF EACH MEMBER IS COUNTED. COMPENSATION ANALYSIS OF SIMILARLY SITUATED ORGANIZATIONS (TAXABLE AND TAX-EXEMPT) WITH RESPECT TO SIZE AND RESPONSIBILITIES OF EACH POSITION ARE COMPARED. THIS ANALYSIS IS PREPARED ANNUALLY. THE PROCESS OF ARRIVING AT EACH INDIVIDUAL'S COMPENSATION ARRANGEMENT IS DOCUMENTED IN BOARD MINUTES, PERSONAL ACTION FORMS, AND THE EMPLOYEE'S PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES AVAILABLE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND ANNUAL REPORT TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES AVAILABLE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND ANNUAL REPORT TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -137,117. MEMBERS OF THE BOARD OF DIRECTORS FROM COMMUNITY HOSPICE, INC., CHI MANAGEMENT, INC. AND COMMUNITY HOSPICE FOUNDATION OF STANISLAUS COUNTY MAKE UP THE AUDIT COMMITTEE CHARGED WITH RESPONSIBILITY OF OVERSIGHT IN CONNECTION TO THE AUDITED FINANCIAL STATEMENTS AND SELECTION OF INDEPENDANT AUDITORS. COMMUNITY HOSPICE INC 4368 SPYRES WAY MODESTO CA 95356 942638213 HOSPICE CARE FOR THE TERMINALLY ILL CA 501(C)(3) 509(A)(2) N/A 0 CHI MANAGEMENT INC 4368 SPYRES WAY MODESTO CA 95356 200178425 PROVIDE PROFESSIONAL SERVICES FOR COMMUNITY HOSPICE, INC AND THE HOPE CHEST CA 501(C)(3) 509(A)(2) N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 COMMUNITY HOSPICE INC & CHI MANGEMENT INC M COMMUNITY HOSPICE INC Q 157718 FAIR MARKET VALUE COMMUNITY HOSPICE INC & CHI MANAGEMENT INC N COMMUNITY HOSPICE INC O 213917 FAIR MARKET VALUE