2011-05-16T11:27:17-05:00 2010-09-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-10-01 311608691 APPLE VALLEY VILLA APARTMENTS APPL 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385225 2011-05-10 1 6123764500 2009 2016-02-24 21:20:13Z TIM TUCKER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 3940815 0 X WWW.AUGUSTANACARE.ORG X 1997 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 5 5 60 38 0 0 183075 2792 3462911 3834364 3843 243 22527 103416 3672356 3940815 0 0 1162288 1385761 0 0 2049680 2129921 3211968 3515682 460388 425133 12059169 12203450 9777827 9496975 2281342 2706475 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 2808707 3834364 APPLE VALLEY VILLA APARTMENTS IS A 208-UNIT SENIOR SERVICE AND CONGREGATE HOUSING COMPLEX IN APPLE VALLEY, MINNESOTA. APPLE VALLEY VILLA APARTMENTS SERVED 254 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010, WITH AN ADDITIONAL 109 PEOPLE BEING SERVED BY CATERED LIVING. 2808707 1 0 0 0 0 0 0 1 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 1 0 0 60 1 0 0 0 0 0 0 0 0 0 5 5 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CRAIG KITTELSON - AUGUSTANA CARE SE 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X SCOTT RAMSDALE 1.00 X X 0 0 0 PAUL HARRINGTON 1.00 X X 0 0 0 DON JACOBSON 1.00 X X 0 0 0 TERRENCE MERRITT 1.00 X 0 0 0 LOWELL WILLIAMS 1.00 X 0 0 0 TIM TUCKER 4.50 X 0 316400 62817 CRAIG KITTELSON 4.50 X 0 251192 59945 TIM MIDDENDORF 4.50 X 0 196561 43531 KATHERINE KOPP 4.50 X 0 215248 33372 0 979401 199665 0 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 195401 1 2792 2792 SENIOR APARTMENTS 623000 3167625 3167625 CATERED LIVING 623000 666739 666739 3834364 243 243 MISCELLANEOUS REVENUE 900099 103416 103416 103416 3940815 3834364 0 103659 1146463 851009 295454 24409 16126 8283 132934 100996 31938 81955 59856 22099 195401 195401 2341 2341 16631 16631 117468 99843 17625 30597 30597 97274 74677 22597 477213 477213 4162 4162 3956 3956 513826 513826 322528 322528 42942 42942 DIETARY EXPENSES 269090 269090 NURSING SUPPLIES 17362 17362 DUES AND SUBSCRIPTIONS 5486 5486 ACTIVITIES EXPENSES 4865 4865 MISCELLANEOUS 3393 3393 5386 1316 4070 3515682 2808707 706975 0 675231 911127 122067 172589 60229 59683 11509397 1359230 10367877 10150167 68383 104241 765382 805643 12059169 12203450 424144 442740 8065000 7820000 100551 102947 1109211 1065443 78921 65845 9777827 9496975 X 1317574 1760375 963493 945825 275 275 2281342 2706475 12059169 12203450 X 0 1 1 X 1 1 X 1020021 800 6696 183075 2792 1213384 1732747 2540308 2562923 2937739 3407014 13180731 2752768 2541108 2569619 3120814 3409806 14394115 500 220 720 0 500 220 720 14393395 7908 11677 6455 3843 244 30127 7908 11677 6455 3843 244 30127 261601 404224 502553 547426 530765 2246569 3022277 2957009 3078627 3672083 3940815 16670811 0.86340 0.86280 0.00180 0.00230 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 16 16 275 275 275 1.00000 0 1 1 1330629 1330629 9725887 1115528 8610359 452881 243702 209179 10150167 TENANT SECURITY DEPOSITS 106882 ASSETS UNDER BOND INDENTURE AGREEMENTS 698486 BENEFICIAL INTEREST IN NET ASSETS OF THE FOUNDATION 275 805643 DUE TO(FROM) AFFILIATES 65845 65845 3940815 3515682 425133 0 425133 3925689 17666 17666 3908023 32792 32792 3940815 3482890 0 3482890 32792 32792 3515682 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. Part V, Line 4: Description of Intended Use of Endowment Funds: 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. Part XII, Line 2d - Other Adjustments: NET ASSETS RELEASED FROM RESTRICTIONS: 17666. Part XII, Line 4b - Other Adjustments: BAD DEBT EXPENSE RECOVERY: 32792. Part XIII, Line 4b - Other Adjustments: BAD DEBT EXPENSE RECOVERY: 32792. 0 1 0 0 0 0 0 0 0 TIM TUCKER 0 247016 0 42593 0 26791 0 38049 0 24768 0 379217 0 0 CRAIG KITTELSON 0 185011 0 34507 0 31674 0 29598 0 30347 0 311137 0 0 TIM MIDDENDORF 0 167002 0 21877 0 7682 0 21610 0 21921 0 240092 0 0 KATHERINE KOPP 0 171994 0 28545 0 14709 0 19697 0 13675 0 248620 0 0 Part I, Line 4a 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 - $12,500 KATHERINE KOPP, VICE PRESIDENT OF SENIOR DEVELOPMENT - $9,500 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. 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 4 Changes were made to all governing documents of all legal entities in the organization. Changes included: 1.) Updates for consistency among entities 2.) Updates for changes in state law and ELCA affiliation standards 3.) Updates for improving governance focus on strategic direction and robust leadership 4.) Updates for consistency with third party financing requirements No changes in fundamental inter-entity control relationships or tax exemption considerations were made. 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 THEREFOR; (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 CORPORATION. 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. FORM 990, PART VII, LINE 1A EXPLANATION FOR HOURS WORKED 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. AUGUSTANA APARTMENTS OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608701 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA CARE 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411728753 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 7 N/A AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 CHARITABLE FOUNDATION MN 501(C)(3) 11 - TYPE 1 N/A AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411806946 MANAGEMENT SERVICES MN 501(C)(3) 11 - TYPE 1 N/A AUGUSTANA CHAPEL VIEW HOMES INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 410693953 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA COMMUNITY PARTNERS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411783680 HOME HEALTH CARE SERVICES MN 501(C)(3) 9 N/A AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608696 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA HOME OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311572624 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A OPEN CIRCLE ADULT DAY CENTER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411424801 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA SENIOR DEVELOPMENT INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 481293891 CONSULTING MN N/A C 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 0 0 0