2011-10-04T14:44:17-05:00 2010-12-31 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-01-01 450228055 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY EVAN 6053623100 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 RAYE NAE NYLANDER 6053623100 2011-10-04 1 6123764500 2010 2016-03-07 17:11:31Z DAVID HORAZDOVSKY 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 1163570352 0 X WWW.GOOD-SAM.COM X 1922 ND TO SHARE GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OTHERS IN NEED. 16 9 27923 2739 1450020 -243548 8940807 10379320 903901474 911161236 1143381 14400882 4545910 4169470 918531572 940110908 6127059 2259895 0 0 556013129 557411688 50000 8500 1970814 339951716 345541170 902141904 905221253 16389668 34889655 1396104550 1472935059 746694490 774821895 649410060 698113164 X TO SHARE GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OLDER PERSONS AND OTHERS IN NEED, BELIEVING THAT "IN CHRIST'S LOVE, EVERYONE IS SOMEONE". 0 0 616212896 2259895 737285133 SKILLED NURSING SERVICES - THE SOCIETY HAD 3,908,542 SKILLED NURSING HOME RESIDENT DAYS IN 2010. SKILLED NURSING SERVICES ARE DESIGNED TO MEET THE DAILY LIVING NEEDS OF THE RESIDENTS. THE CARE PROVIDED REQUIRES SKILLED NURSING AND REHABILITATION INTERVENTION. THE CARE PROVIDED IN THIS SETTING IS VERY IMPORTANT, BUT THE SPIRITUAL AND SOCIAL NEEDS OF THE RESIDENTS ARE STILL A VERY IMPORTANT ELEMENT IN THE CARE OF THE ENTIRE PERSON. SKILLED NURSING SERVICES INCLUDE PROFESSIONAL NURSING CARE 24 HOURS A DAY, SEVEN DAYS A WEEK; THERAPY SERVICES; MEDICATION ADMINISTRATION; SPIRITUAL AND RECREATIONAL ACTIVITIES; AND ROOM AND MEALS. 47133178 56393808 ASSISTED LIVING SERVICES - THE SOCIETY HAD 732,065 ASSISTED LIVING RESIDENT DAYS IN 2010. ASSISTED LIVING SERVICES OFFER RESIDENTS DAILY SUPERVISION AND A VARIETY OF SUPPORTIVE SERVICES IN A RESIDENTIAL ENVIRONMENT. SERVICES MAY FEATURE THREE MEALS A DAY, SPIRITUAL AND RECREATIONAL ACTIVITIES, HOUSEKEEPING, LAUNDRY SERVICE, SCHEDULED TRANSPORTATION, 24 HOUR STAFFING, EMERGENCY CALL SYSTEM, LIMITED PERSONAL CARE SERVICES, AND MEDICATION REMINDER/ASSISTANCE. 46260415 55349565 SENIOR LIVING SERVICES - THE SOCIETY HAD 505,579 SENIOR LIVING RESIDENT DAYS IN 2010. CONGREGATE LIVING SERVICES OFFER BASIC SERVICES INCLUDING HOUSING, MEALS, HOUSEKEEPING, AND TRANSPORTATION. ADDITIONAL SERVICES INCLUDE THE SCHEDULING OF SPIRITUAL AND SOCIAL ACTIVITIES THAT ARE PLANNED TO MEET THE ACTIVE SPIRITUAL, SOCIAL AND PHYSICAL NEEDS OF THE RESIDENTS. THE CONGREGATE LIVING ENVIRONMENT FEATURES A VARIETY OF COMMON SPACES SUCH AS MULTI-PURPOSE ROOMS, LIBRARIES, LARGE, COMMON KITCHENS AND DINING ROOMS FOR RESIDENTS TO INTERACT AS A COMMUNITY. 29949389 35833783 HOME HEALTH SERVICES - THE SOCIETY SERVED APPROXIMATELY 6,832 CLIENTS IN 2010 NEEDING HOME HEALTH SERVICES. HOME HEALTH SERVICES PROVIDE A RANGE OF SERVICES FROM VISITS BY PROFESSIONAL NURSES TO MEET MEDICAL CARE REQUIREMENTS TO HOMEMAKER VISITS THAT PROVIDE HOUSEKEEPING SERVICES. GENERALLY THE HOME HEALTH SERVICES ARE PROVIDED TO SENIORS LIVING IN HOUSING OPERATED BY THE SOCIETY. RESIDENTS IN ASSISTED LIVING AND SENIOR LIVING SETTINGS MAY HAVE TEMPORARY NEED TO ACCESS THE SERVICES OF THE SOCIETY'S HOME HEALTH AGENCIES. THESE RESIDENTS MAY BE RECOVERING FROM A SURGERY OR HAVE AN ILLNESS THAT TEMPORARILY PREVENTS THEM FROM PERFORMING A DAILY LIVING TASK. 24667732 29514397 SENIOR LIVING SERVICES - THE SOCIETY HAD 1,322,313 SENIOR LIVING RESIDENT DAYS IN 2010. SENIOR LIVING SERVICES SERVE RESIDENTS NEEDING HOUSING AND OFFER A SECURE CONVENIENT LOCATION WITH OPTIONAL SERVICES SUCH AS MEALS, HOUSEKEEPING AND TRANSPORTATION. SENIOR LIVING HOUSING GENERALLY IS AVAILABLE IN A CAMPUS ENVIRONMENT THAT INCLUDES SPIRITUAL AND SOCIAL ACTIVITIES AS WELL AS MEDICAL ASSISTANCE. SOCIETY PROVIDED MEETING SPACE - ONE HUNDRED AND SIXTY-NINE FACILITY LOCATIONS WERE ABLE TO MAKE AVAILABLE MEETING ROOM SPACE FOR HUNDREDS OF NON-PROFIT OR SERVICE ORGANIZATIONS OR GROUPS TO GATHER TO ACCOMPLISH THEIR PURPOSE IN 2010. AN ESTIMATE OF THE TOTAL NUMBER OF GROUP MEMBERS SERVED IS AT LEAST 243,283 PEOPLE. MEETING SPACE WAS MADE AVAILABLE FOR CHURCH SERVICES, SERVICE CLUBS, SUPPORT GROUP MEETINGS, VOTING LOCATIONS FOR ELECTIONS AND OTHER GROUPS PROVIDING COMMUNITY BENEFITS. COMMUNITY MEALS AND SNACKS - ONE HUNDRED AND TWENTY-FOUR FACILITY LOCATIONS WERE ABLE TO SERVE APPROXIMATELY 135,978 MEALS AND SNACKS IN 2010. THE SOCIETY PROVIDED MEALS AND SNACKS FOR THE COMMUNITY FOR A VARIETY OF PURPOSES INCLUDING NURSING HOME WEEK AND FOUNDER'S DAY CELEBRATIONS, MOTHER'S AND FATHER'S DAY TEAS, VOLUNTEER LUNCHEONS, OPEN HOUSES, HOLIDAY PARTIES AND COMMUNITY FELLOWSHIP MEALS INVITING THE PUBLIC TO JOIN OUR FACILITIES' RESIDENTS IN A MEAL OR SNACK. MEALS ON WHEELS - FIFTY-FOUR FACILITIES PARTICIPATED IN THE MEALS ON WHEELS PROGRAM IN 2010. FACILITIES PREPARED AN ESTIMATED 133,961 MEALS FOR THE MEALS ON WHEELS PROGRAM AND STAFF MEMBERS DELIVERED AN ESTIMATED 25,252 MEALS IN 2010. THE MEALS ON WHEELS PROGRAM PROVIDES HOT, WELL-BALANCED MEALS TO ELDERLY INDIVIDUALS LIVING IN THE COMMUNITIES WHERE THE SOCIETY HAS FACILITIES. HEALTH FAIRS AND OTHER PROGRAM SERVICES - APPROXIMATELY 100,311 COMMUNITY MEMBERS WERE SERVED IN 2010. THE SOCIETY HOSTS A VARIETY OF PROGRAM SERVICES PROVIDING HEALTH INFORMATION FOR SENIORS INCLUDING TOPICS SUCH AS WELLNESS, BLOOD PRESSURE CHECKS, DIABETES TESTING, VULNERABLE ADULTS' EDUCATION, ESTATE PLANNING SEMINARS AND LONG-TERM CARE AWARENESS PROGRAMS. PROGRAMS SUCH AS SENIOR OLYMPICS AND PIANO RECITALS AT THE FACILITIES ARE ALSO INCLUDED TO PROVIDE OPPORTUNITIES FOR YOUTH AND ADULT GROUPS TO VISIT WITH RESIDENTS (I.E. ADOPT-A-GRANDPARENT) AND CRAFTS TO CREATE COMMUNITY. COMMUNITY EVENTS - APPROXIMATELY 146,531 COMMUNITY MEMBERS WERE SERVED IN 2010. SOCIETY'S STAFF MEMBERS DONATED AN ESTIMATED 49,513 VOLUNTEER HOURS REPRESENTING THE SOCIETY IN ADDITION TO PARTICIPATING IN A VARIETY OF OTHER COMMUNITY EVENTS SUCH AS HIGH SCHOOL MENTORING PROGRAMS, FUNDRAISING WALKS FOR CANCER AND ALZHEMER'S, DONATIONS FOR CHRISTMAS GIFTS FOR UNDERPRIVILEGED CHILDREN, TRANSPORTATION OF ELDERLY TO CHURCH AND OTHER COMMUNITY FUNCTIONS AS WELL AS PARTICIPATION IN COMMUNITY FAIRS. 54617121 65348180 764223610 1 1 0 1 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 1 1 0 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 1 1 0 0 1 2515 0 27923 1 1 1 1 CJ 0 0 0 1 1 0 0 0 0 0 X 16 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 1 1 IN IL OK NM MN OR CA X RAYE NAE NYLANDER CFO & TREASURER 6053623100 4800 W 57TH ST SIOUX FALLS SD 57108 DAVID J HORAZDOVSKY 55.00 X X 521501 0 12669 LORI L BUSSLER 40.00 X 75641 0 29166 KIMBERLY SEAR JOHANSEN 40.00 X 129362 0 25254 BRUCE O KALLIS 40.00 X 68734 0 27272 RONALD L KORTEMEYER 40.00 X 80731 0 28646 MICHELE JUFFER 40.00 X 60667 0 32394 JOANNA RANDALL 40.00 X 107495 0 13396 TERESA HILDEBRANDT 40.00 X 87045 0 27813 JOHN C PENN 1.00 X 0 0 0 PATRICIA K HAUGEN 1.00 X X 0 0 0 SUSAN E NICKERSON 1.00 X X 0 0 0 PAUL R BINDER 1.00 X 0 0 0 REV ANDREA DEGROOT 1.00 X 0 0 0 SCOTT PETERS 1.00 X 0 0 0 CHRISTOPHER T JOHNSON 1.00 X 0 0 0 REV JOHN F HOLT 1.00 X 0 0 0 LARRY W WALTER 1.00 X 0 0 0 NEIL GULSVIG 1.00 X 0 0 0 RAYE NAE NYLANDER 40.00 X 259663 0 16369 THOMAS A PETERSON 32.00 X 115339 0 5856 SYLVIA GAUSE 40.00 X 57205 0 17472 ELOYE FARRELL 40.00 X 39900 0 12200 CINDY MOEGENBURG 40.00 X 260016 0 13709 JOE HERDINA 40.00 X 150514 0 24254 MISTY HAM-QUICK 40.00 X 6808 0 989 DEAN MERTZ 40.00 X 261038 0 14369 RUSTAN WILLIAMS 40.00 X 224876 0 25154 THOMAS KAPUSTA 40.00 X 218653 0 7531 DANNY HANSON 40.00 X 163518 0 13769 RANDY FITZGERALD 40.00 X 156348 0 20285 JACCI NICKELL 40.00 X 151795 0 24754 3196849 0 393321 54 0 1 0 AEGIS THERAPIES INC PO BOX 8103 FT SMITH AR 72902 CONTRACT THERAPY 17027259 SOLOMON BUILDERS INC 4539 TROUSDALE DR NASHVILLE TN 37204 CONSTRUCTION - INCLUDES MATERIALS 11795341 HELENSKE DESIGN GROUP LTD 304 10TH ST NORTH FARGO ND 58102 ARCHITECTURE & CONSTRUCTION MGMT 5651477 SAMPSON CONSTRUCTION CO INC 3730 S 14TH STREET LINCOLN NE 68502 CONSTRUCTION - INCLUDES MATERIALS 4162958 CBS CONSTRUCTION SERVICES 11124 ZEALAND AVENUE NORTH CHAMPLIN MN 55316 CONSTRUCTION - INCLUDES MATERIALS 4049803 182 1300065 1027887 8051368 1277820 10379320 RESIDENT ROUTINE CARE 623000 834870862 834870862 ANCILLARY SERVICES 623000 56647008 56647008 EMPLOYEE & GUEST MEALS 623000 6407159 6407159 RENT 623000 2596949 2596949 SURCHARGE 623000 2576916 2576916 8062342 618950 7443392 911161236 8711074 8711074 1115141 172002 1115141 172002 1287143 1287143 205338878 23233337 196098375 26784032 9240503 -3550695 5689808 5689808 697835 517175 180660 180660 86533 59862 26671 26671 ADMINISTRATIVE SERVICE 561000 3294318 1928306 1366012 SHARE CROP REVENUE 110000 84008 84008 INTEREST RATE SWAP ADJ 900099 -238530 -238530 -464800 -464800 2674996 940110908 897929185 1450020 30352383 1240909 1240909 976155 976155 42831 42831 2736624 2736624 463162532 391929120 69895177 1338235 9451606 8006507 1417950 27149 42225199 35769199 6334714 121286 39835727 33745064 5976240 114423 704007 704007 118329 118329 8500 8500 57005432 52647541 4275300 82591 3916686 1391 3905465 9830 95052838 83544799 11467141 40898 1727243 1727243 31583652 31583652 4194013 1620392 2564116 9505 36463 36463 20456525 20305604 148312 2609 60049601 50645439 9241612 162550 12541970 10577815 1930205 33950 EQUIPMENT MAINTENANCE 17762513 15370531 2391982 LICENSE SURCHARGE 13130172 13130172 UNCOLLECTIBLE EXPENSE 4457798 4457798 STAFF DEVELOPMENT 3467547 1897122 1558882 11543 EMPLOYEE/PUBLIC RELATIO 3154358 1761 3147784 4813 16182023 8450982 7728109 2932 905221253 764223610 139026829 1970814 26940895 27557285 5288055 4624468 715211 715211 66664852 72484974 25682032 26568883 4404095 4516168 6187999 5426287 1651078136 812181181 787575783 838896955 386653884 391012296 4159380 4408228 44562230 43367187 37270134 53357117 1396104550 1472935059 95917877 98694320 6286101 5282924 376323853 329746763 94963143 96015116 117651464 173748174 55552052 71334598 746694490 774821895 X 619645626 664592163 14881616 17179118 14882818 16341883 649410060 698113164 1396104550 1472935059 X 34889655 13813449 X 0 1 1 X 1 1 X 13099931 15141414 14266986 8940807 10983028 62432166 812725158 843265625 877901286 904602868 911859071 4350354008 825825089 858407039 892168272 913543675 922842099 4412786174 0 0 0 4412786174 13207892 15151064 9186363 11053276 9998217 58596812 13207892 15151064 9186363 11053276 9998217 58596812 2588074 1791756 990496 1927402 1224976 8522704 841621055 875349859 902345131 926524353 934065292 4479905690 0.98500 0.98500 0.01310 0.01310 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: ADMINISTRATIVE SERVICES LOSS ON EXTINGUISHMENT OF DEBT INTEREST RATE SWAP ADJUSTMENT RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 1 37486 0 0 1 327428 0 1 364914 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: ONE STAFF MEMBER IS DEVOTED FULL TIME TO PUBLIC POLICY ISSUES, INCLUDING LOBBYING ACTIVITIES. AN OUTSIDE REPRESENTATIVE IS ALSO ENGAGED TO ASSIST WITH COORDINATING THIS ACTIVITY. SEVERAL STAFF MEMBERS AND RESIDENTS WRITE LETTERS TO ELECTED OFFICIALS WHICH PROVIDE BACKGROUND AND EXPRESS RECOMMENDED POSITIONS ON SPECIFIC ISSUES. IN ADDITION, PERIODIC CORRESPONDENCE AND PERSONAL VISITS OCCUR BETWEEN STAFF MEMBERS AND ELECTED OFFICIALS TO ADVOCATE PARTICULAR POSITIONS ON ISSUES. IT IS ESTIMATED THAT TWO PERCENT OF ONE AVERAGE STAFF MEMBERS' TIME IS DEVOTED TO THIS ACTIVITY. 0 1 1348000 -16000 -255000 1077000 1277000 51000 -25000 -45000 1348000 1311000 -30000 24000 28000 1277000 0.09800 0.48700 0.41600 0 0 54074656 54074656 1187360001 573947290 613412711 79039202 45075993 33963209 262948525 193157898 69790627 67655752 67655752 838896955 REAL ESTATE TAXES & OTHER LIABILITIES 10586170 UNAMORTIZED BOND PREMIUM 2497447 ANNUITIES PAYABLE 4333412 PAYABLE UNDER INVESTMENT LOAN AGREEMENT 53917569 71334598 940110908 905221253 34889655 10057156 3756293 13813449 48703104 918677938 577037 577037 918100901 22010007 22010007 940110908 900710290 577037 577037 900133253 5088000 5088000 905221253 PART IV, LINE 2B: AS SET FORTH BY FEDERAL AND STATE REGULATIONS, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (SOCIETY) PROVIDES RESIDENT TRUST ACCOUNT (RTA) SERVICES FOR RESIDENTS. THESE RTA FUNDS ARE NOT COMMINGLED WITH SOCIETY FUNDS, ARE ACCESSIBLE FOR RESIDENTS' USE, HAVE DETAILED ACCOUNTING RECORDS MAINTAINED ON AN INDIVIDUAL RESIDENT BASIS, AND FOLLOW BOTH FEDERAL AND STATE REGULATIONS REGARDING THE HANDLING AND DOCUMENTATION OF ACTIVITY. AS RTA FUNDS ARE HELD IN TRUST FOR RESIDENTS, A RESIDENT MAY AUTHORIZE THAT THEIR RTA FUNDS BE RETURNED TO THE RESIDENT OR THEIR DESIGNEE (REPRESENTATIVE PAYEE, FINANCIAL POWER OF ATTORNEY, GUARDIAN, ETC.) AT ANY TIME. ADDITIONALLY, WHEN A RESIDENT IS DISCHARGED FROM A FACILITY, THEIR RTA FUNDS ARE RETURNED TO THE RESIDENT OR THEIR AUTHORIZED DESIGNEE. IF A RESIDENT EXPIRES WITH RTA FUNDS ON HAND, SPECIFIC STATE REGULATIONS ALONG WITH STATE AND/OR FEDERAL AGENCIES GUIDELINES ARE REVIEWED TO ENSURE THESE RTA FUNDS ARE HANDLED APPROPRIATELY. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE SOCIETY'S ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY THE DONOR'S RESTRICTIONS OR THE BOARD'S DESIGNATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: TAX EXEMPT STATUS FOOTNOTE - THE SOCIETY'S U.S. DOMICILED ENTITIES ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OR ARE PASS-THROUGH ENTITIES NOT SUBJECT TO TAX. GOOD SAMARITAN SOCIETY INSURANCE, LTD. IS AN EXEMPTED COMPANY UNDER THE COMPANIES LAW OF THE CAYMAN ISLANDS. THE SOCIETY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE SOCIETY'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE SOCIETY IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE TAX RETURNS FOR THE YEARS 2007 TO 2009 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSE 517,175. GAMING EXPENSE 59,862. PART XII, LINE 4B - OTHER ADJUSTMENTS: INTEREST INCOME 8,711,074. REALIZED GAIN ON SECURITIES 9,240,503. REALIZED LOSS ON SALE OF PROPERTY -3,550,695. INTEREST RATE SWAP MARKET ADJUSTMENT -238,530. LOSS ON EXTINGUISHMENT OF DEBT -464,800. ASSETS RELEASED FOR CAPITAL PURPOSES 5,520,455. REVENUE FROM DISCONTINUED OPERATIONS 2,792,000. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENT FUNDRAISING EXPENSES 517,175. GAMING EXPENSES 59,862. PART XIII, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISCONTINUED OPERATIONS 5,088,000. PART IV, LINE 2A THE SOCIETY HAS HOUSING ENTRY FEES FOR ADMITTANCE INTO HOUSING UNITS AT VARIOUS LOCATIONS. THESE CONTRACTS FOR HOUSING ENTRY FEES VARY BY LOCATION, AND TYPICALLY HAVE VARYING REFUNDABLE PORTIONS UP TO 100% OF THESE ENTRY FEES. THE REFUNDABLE PORTIONS OF THE HOUSING ENTRY FEES ARE REFUNDABLE BASED UPON TIME RESTRICTIONS AND VACANCY OF THE HOUSING UNIT. THE NONREFUNDABLE PORTION OF THE HOUSING ENTRY FEES ARE RECORDED AS DEFERRED REVENUE AND AMORTIZED INTO INCOME OVER THE LIFE EXPECTANCY OF THE RESIDENT AND FULLY RECOGNIZED WHEN THE RESIDENT VACATES ITS UNIT. THE SOCIETY RECORDS A CURRENT PORTION OF HOUSING ENTRANCE FEES THAT IS EXPECTED TO BE REFUNDED IN THE NEXT YEAR. 1 0 0 0 0 0 0 SOUTH AMERICA THE GRANT WAS USED TO OPEN A SECOND SENIOR CENTER AND SOUP KITCHEN IN TUNJA WHICH PURCHASES AND PREPARES FOOD FOR SENIORS IN SOACHA AND TUNJA, UPGRADING OF 3 SHACKS WHERE SENIORS LIVE, PROVISION OF PROGRAMMING FOR SENIORS AND SUPPORT FOR SHORT-TERM DEVELOPMENT WORK. 42831 CHECK 1 0 0 0 0 0 0 0 PROCEDURE FOR MONITORING GRANTS OUTSIDE THE U.S.: SCHEDULE F, PART I, LINE 2: REGULAR CORRESPONDENCE IS RECEIVED FROM THE GRANTEE REGARDING THE PROGRESS OF THEIR INITIATIVES. X X X X X X X 1 MATALE LINE 1101 ALASKAN WAY SUITE 200 SEATTLE WA 98101 CONSULTANT TO DEVELOP MARKETING MATERIALS 0 34000 8500 25500 34000 8500 25500 AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY DC GOLF TOURNAMENT - SIOUX FALLS, SD 35980 35980 6240 2534 GOLF TOURNAMENT - OTTUMWA, IA 23800 23800 2685 6049 2137 146 638055 638055 497530 697835 697835 2685 12289 502201 517175 180660 64050 43259 1079 1575 1 1.00000 22483 5595 6666 1688 0 86533 48854 7745 3263 59862 26671 FL MN 1 0 1 0 1.00000 0.00000 CHARLES HIATT 4800 WEST 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 0 SEE PART IV FOR A LIST THE SOCIETY'S VARIOUS FACILITIES CONDUCT LIMITED CHARITABLE GAMING ACTIVITIES. EACH FACILITY'S ADMINISTRATOR OR EXECUTIVE DIRECTOR IS IN CHARGE OF THAT FACILITY'S CHARITABLE GAMING ACTIVITIES. THEY ARE:TIM SWOBODA - EXECUTIVE DIRECTOR - ST. JAMES, MN - $180ANDREW HEWITT - ADMINISTRATOR - WESTBROOK, MN - $97SUSAN JENSEN - ADMINISTRATOR - MAPLEWOOD, MN - $179LUANN FOOS - EXECUTIVE DIRECTOR - KISSIMMEE, FL - $2,954MARK ANDERSON - EXECUTIVE DIRECTOR - ALBERT LEA, MN - $188ANGEL NORMANDIN - ADMINISTRATOR - CLEARBROOK, MN - $121MICHAEL DEUTH - EXECUTIVE DIRECTOR - BRAINERD, MN - $189TONY LINN - ADMINISTRATOR - LUVERNE, MN - $140 X 0 1 THE CITY OF NELSON 580 S MAIN STREET NELSON NE 68961 476006289 115 9039 BOOK VALUE APARTMENT BUILDING AND LAND THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY IS A 501(C)(3) NONPROFIT CORPORATION WHOSE PURPOSES INCLUDE: TO ENGAGE IN WORK OF A CHARITABLE AND RELIGIOUS NATURE BY PARTICIPATION IN ANY CHARITABLE OR RELIGIOUS ACTIVITY DESIGNED AND CARRIED ON TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. THE DONATION OF THIS PROPERTY TO THE CITY OF NESLON WILL BENEFIT AND PROMOTE THE GENERAL HEALTH OF THE COMMUNITY IN WHICH IT IS LOCATED. FAIRFIELD CARE INC 303 S 1ST STREET FAIRFIELD WA 99012 272904285 501(C)(3) 1187046 BOOK VALUE LAND AND BUILDING THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY IS A 501(C)(3) NONPROFIT CORPORATION WHOSE PURPOSES INCLUDE: TO ENGAGE IN WORK OF A CHARITABLE AND RELIGIOUS NATURE BY PARTICIPATION IN ANY CHARITABLE OR RELIGIOUS ACTIVITY DESIGNED AND CARRIED ON TO PROMOTE THE GENERAL HEALTH OF THE COMMUNITY. THE DONATION OF THIS PROPERTY TO ANOTHER 501(C)(3) ENTITY WILL BENEFIT AND PROMOTE THE GENERAL HEALTH OF THE COMMUNITY IN WHICH IT IS LOCATED. BOISE GOOD SAMARITAN HOUSING INC 4800 WEST 57TH STREET SIOUX FALLS SD 57108 363370371 501(C)(3) 5808 FORGIVENESS OF DEBT BETWEEN RELATED ORGANIZATIONS. SIOUX EMPIRE UNITED WAY 100 N WEST AVENUE SUITE 120 SIOUX FALLS SD 57104 460233701 501(C)(3) 6500 CONTRIBUTION BOISE STATE UNIVERSITY FOUNDATION 2225 UNIVERSITY DRIVE BOISE ID 83706 826010706 501(C)(3) 7050 CONTRIBUTION TO FUND NURSING SCHOLARSHIPS FOR BSU STUDENTS. GRACE UNITED METHODIST CHURCH 520 S HARRISON OLATHE KS 60001 480670634 501(C)(3) 5000 SOCIAL ACCOUNTABILITY GRANT - SHOE FUND. COMMUNITY THREAD 2300 W ORLEANS STREET STILLWATER MN 55082 410967271 501(C)(3) 5000 SOCIAL ACCOUNTABILITY GRANT FOR VOLUNTEERS IN ACTION. PROJECT LINUS LAS CRUCES CHAPTER 305 W BELL AVENUE MESILLA PARK NM 88047 841362696 501(C)(3) 5000 FMV GIFT CARDS SOCIAL ACCOUNTABILITY GRANT TO BUY SUPPLIES FOR BLANKETS. ALLIANCE GOOD SAMARITAN HOUSING INC 4800 WEST 57TH STREET SIOUX FALLS SD 57108 204714573 501(C)(3) 10466 FORGIVENESS OF DEBT BETWEEN RELATED ORGANIZATIONS. 8 1 SCHOLARSHIPS 410 976155 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE SOCIETY PROVIDES SCHOLARSHIPS TO EMPLOYEES WHO ARE ENROLLED IN A QUALIFIED EDUCATION PROGRAM. THE SOCIETY PAYS THE SCHOLARSHIP DIRECTLY TO THE EDUCATIONAL INSTITUTION WHERE THE EMPLOYEE IS ENROLLED. IF AN EMPLOYEE HAS ALREADY PAID THE EXPENSES, THE SOCIETY REQUIRES RECEIPT OF PAYMENT BEFORE REIMBURSEMENT IS MADE TO THE EMPLOYEE. X X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 DAVID J HORAZDOVSKY 400842 0 0 0 120659 0 0 0 16404 0 537905 0 0 0 KIMBERLY SEAR JOHANSEN 94047 0 0 0 35315 0 0 0 26329 0 155691 0 0 0 RAYE NAE NYLANDER 185593 0 0 0 74070 0 0 0 18357 0 278020 0 0 0 CINDY MOEGENBURG 184616 0 0 0 75400 0 0 0 15486 0 275502 0 0 0 JOE HERDINA 120731 0 0 0 29783 0 0 0 25410 0 175924 0 0 0 DEAN MERTZ 187996 0 0 0 73042 0 0 0 16249 0 277287 0 0 0 RUSTAN WILLIAMS 159850 0 0 0 65026 0 0 0 26952 0 251828 0 0 0 THOMAS KAPUSTA 160489 0 0 0 58164 0 0 0 9273 0 227926 0 0 0 DANNY HANSON 125321 0 0 0 38197 0 0 0 15133 0 178651 0 0 0 RANDY FITZGERALD 115864 0 0 0 40484 0 0 0 21522 0 177870 0 0 0 JACCI NICKELL 113971 0 0 0 37824 0 0 0 25890 0 177685 0 0 0 PART I, LINE 1A PART I, LINE 1A: TRAVEL FOR COMPANIONS: PHIL JOHANSEN (SPOUSE OF BOARD MEMBER KIMBERLY SEAR JOHNSON) $690.31 BRADY RANDALL(SPOUSE OF BOARD MEMBER JOANNA RANDALL) $645.53 BOB BUSSLER(SPOUSE OF BOARD MEMBER LORI BUSSLER) $105.40 GARY NESDAHL(SPOUSE OF BOARD MEMBER REV. ANDREA DEGROOT-NESDAHL) $98.75 JANICE GULSVIG (SPOUSE OF BOARD MEMBER NEIL GULSVIG) $105.40 KURT HILDEBRANDT (SPOUSE OF BOARD MEMBER TERESA HILDEBRANDT) $105.40 NANCY PENN (SPOUSE OF BOARD MEMBER JOHN PENN) $98.75 COHFA 840752932 196474P46 2004-08-31 28168375 REFUNDED 1992-1993 AND 2004 BOND ISSUES 0 0 0 COHFA 840752932 1964742TG 2005-11-15 64472262 REFUNDED 1995, 2003, AND 2005 BOND ISSUES 0 0 0 COHFA 840752932 1964745B2 2006-10-31 108145790 REFUNDED 2000 AND 2001 BOND ISSUES 0 0 0 COHFA 840752932 19648AFY6 2007-12-06 23830000 REFUNDED 2003 AND 2006 BOND ISSUES 0 0 0 2528375 28168375 2592970 25154593 420812 2004 1 0 1 1 3677262 64472262 4434247 50708703 1046025 8283287 2007 1 0 1 1 10695790 108145790 7987341 40680468 1365882 58112099 2008 1 1 1 1 23830000 12347000 476600 11006400 2009 1 0 1 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 NA 1 MBIA INC 13.000000000000 1 0 0 0 0 0 NA 1 AIG FINANCIAL PRODUCTS CORP 5.000000000000 1 0 0 0 0 0 NA 0 NA 0 0 0 1 0 NA 0 NA 0 0 COHFA 840752932 19648ANT8 2008-12-11 28305000 REFUNDED 2004 BOND ISSUE 0 0 0 COHFA 840752932 19648APC3 2009-05-27 80414461 REFUNDED 2004 BOND ISSUE 0 0 0 10315000 28305000 27739585 565415 2008 1 0 1 1 80414461 8318835 20713680 1381946 50000000 2010 1 0 1 1 0 0 0 0 1 0 0 0 0 1 0 1 0 NA 0 NA 0 1 0 1 0 NA 0 NA 0 0 TWYLA BRANDSMA FAMILY RELATIONSHIP 22639 SALARY AND BENEFIT COSTS 0 THOMAS FRASER FAMILY RELATIONSHIP 41353 SALARY AND BENEFIT COSTS 0 WILLIAM KORTEMEYER FAMILY RELATIONSHIP 14728 SALARY AND BENEFIT COSTS 0 RYAN MERTZ FAMILY RELATIONSHIP 42780 SALARY AND BENEFIT COSTS 0 X 13424 FAIR MARKET VALUE X 3 55506 FAIR MARKET VALUE X 9 551966 FAIR MARKET VALUE X 2 388650 FAIR MARKET VALUE X 18 22023 FAIR MARKET VALUE X MISCELLANEOUS ITEMS 139 246251 FAIR MARKET VALUE 0 0 1 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE OF THE BOARD SHALL CONSIST OF THE CHAIRPERSON, PRESIDENT, FIRST VICE CHAIRPERSON, AND TWO OTHER AT-LARGE BOARD MEMBERS NOMINATED BY THE EXECUTIVE NOMINATING AD HOC COMMITTEE AND ELECTED BY THE BOARD. NO EMPLOYEE OF THE SOCIETY EXCEPT THE PRESIDENT MAY SERVE ON THE EXECUTIVE COMMITTEE. THE NAMES OF THE NOMINEES FOR THE EXECUTIVE COMMITTEE SHALL BE PRESENTED TO THE BOARD AT THE FIRST MEETING OF THE NEW BOARD AT THE ANNUAL MEETING. THE EXECUTIVE COMMITTEE OF THE BOARD SHALL BE CHAIRED BY THE FIRST VICE CHAIRPERSON WHEN THE CHAIRPERSON IS ABSENT FOR ANY REASON. THE POWERS AND DUTIES OF THE EXECUTIVE COMMITTEE OF THE BOARD OF THE DIRECTORS HAVE FULL AUTHORITY TO ACT AND TO DO ALL THINGS NECESSARY AS PERMITTED BY LAW TO CARRY OUT THE OBJECTIVE AND BUSINESS OF THE SOCIETY WHENEVER THE BOARD IS NOT IN SESSION AND THEY SHALL DEVELOP ADMINISTRATIVE RULES FOR THE IMPLEMENTATION OF THE ARTICLES OF INCORPORATION AND THE BYLAWS. FORM 990, PART VI, SECTION A, LINE 6 VOTING OR NON-VOTING FORM 990, PART VI, SECTION A, LINE 7A VOTING MEMBERS ELECT THE BOARD MEMBERS FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS MUST APPROVE ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED AND APPROVED BY THE BOARD PRIOR TO ITS FILING. THE ORGANIZATION'S OFFICERS AND MANAGEMENT ARE AN INTEGRAL PART OF THE PREPARATION OF THE FORM 990. THEREFORE, THEY WILL HAVE AN ON-GOING REVIEW OF THE INFORMATION AS IT IS PREPARED FOR THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS AND DIRECTORS ARE REQUIRED TO ANNUALLY DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICTS. ALL POTENTIAL DIRECTOR CONFLICTS ARE INVESTIGATED BY THE ORGANIZATION'S CHIEF LEGAL OFFICER. THE CHIEF LEGAL OFFICER REPORTS HIS FINDINGS TO THE BOARD CHAIRPERSON. THE BOARD ULTIMATELY DETERMINES WHETHER OR NOT AN ACTUAL CONFLICT OF INTEREST EXISTS AND THE REMEDIAL STEPS NECESSARY BASED UPON SUCH LEGAL OPINION. THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT COVERS SUBSTANTIALLY ALL EMPLOYEES. ALL EMPLOYEES ARE REQUIRED TO REPORT ANY POTENTIAL CONFLICTS TO THE APPROPRIATE INDIVIDUAL AS INDICATED IN THE POLICY. ALL POTENTIAL CONFLICTS ARE INVESTIGATED TO DETERMINE IF A CONFLICT EXISTS. IF APPROVAL IS GIVEN TO PROCEED WITH THE ACTION, A COPY OF THE APPROVAL IS DOCUMENTED IN THE EMPLOYEE'S PERSONNEL FILE. FORM 990, PART VI, SECTION B, LINE 15A THE SOCIETY'S EMPLOYEE COMPENSATION PLAN IS REVIEWED AND UPDATED EVERY FIVE YEARS BY AN EXTERNAL CONSULTANT. DURING THE REVIEW, THE COMPENSATION IS EVALUATED, UPDATED, AND RECALIBRATED TO BE 100% COMPETITIVE AT THE 50TH PERCENTILE OF THE NATIONAL LABOR MARKET UTILIZING A NATIONALLY RECOGNIZED DATA BASE. THE COMPENSATION PLAN INCLUDES ALL POSITIONS WITHIN THE SOCIETY INCLUDING EXECUTIVE MANAGEMENT, KEY EMPLOYEES, AND OFFICERS. FOR POSITIONS OTHER THAN THE PRESIDENT/CEO, THE RECOMMENDATIONS BY THE EXTERNAL CONSULTANT ARE REVIEWED AND APPROVED BY THE PRESIDENT/CEO OF THE SOCIETY. FOR THE PRESIDENT/CEO POSITION, THE RECOMMENDATIONS ARE APPROVED BY THE BOARD. SEE SCHEDULE J, PART I, LINE 3 FOR ADDITIONAL DETAILS RELATED TO THE PRESIDENT/CEO POSITION. FORM 990, PART VI, SECTION C, LINE 19 THE SOCIETY'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. THE SOCIETY'S FINANCIAL STATEMENTS ARE AVAILABLE THROUGH ITS EXTERNAL WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 10,057,156. TEMPORARILY RESTRICTED CONTRIBUTIONS 9,310,000. TEMPORARILY RESTRICTED NET ASSETS RELEASED FROM RESTRICTIONS -7,748,000. TRANSFER TO FOUNDATION FROM SOCIETY -1,170,000. INCREASE IN INTEREST IN TEMPORARILY RESTRICTED NET ASSETS OF THE FOUNDATION 607,000. LOSS FROM DISCONTINUED OPERATIONS -1,000. CONTRIBUTIONS FOR ENDOWMENT FUNDS AND TRUSTS 1,133,000. INCREASE IN BENEFICIAL INTEREST IN PERPETUAL TRUST 249,000. DECREASE IN INTEREST IN THE PERM. RESTRICTED NET ASSETS OF THE FOUNDATION 1,376,293. TOTAL TO FORM 990, PART XI, LINE 5: 13,813,449. INDEPENDENT BOARD MEMBERS FORM 990, PART VI, SECTION A, LINE 1B EACH AND EVERY DAY THE SOCIETY'S TOP LOCAL LEADER POSITION AT ITS 200+ DECENTRALIZED LOCATIONS CARRYOUT THE SOCIETY'S MISSION BY ASSURING CARE AND SERVICES ARE PROVIDED TO THOSE MOST IN NEED. IN ORDER FOR THE SOCIETY'S BOARD TO STAY CONNECTED WITH ITS MISSION AND TO ASSURE ALL STRATEGIES HAVE LOCAL LEADERSHIP INPUT, THE SOCIETY'S BYLAWS REQUIRE 6 BOARD MEMBERS TO BE SELECTED FROM THE LOCAL LEADERSHIP. INDEPENDENT BOARD MEMBERS PERIODICALLY REVIEW THE BYLAWS FOR THE MAKEUP OF THE BOARD MEMBERS AND CONTINUE TO DETERMINE THAT IT IS EXTREMELY VALUABLE TO INCLUDE LOCAL LEADERSHIP BOARD REPRESENTATION TO PROVIDE THE INPUT FOR SETTING STRATEGIES FOR THE SOCIETY. THE SEVENTH NON-INDEPENDENT BOARD MEMBER IS THE CEO OF THE SOCIETY. SHARING OF HOURS PART VII, SECTION A, LINE 1 THE ORGANIZATION'S OFFICERS AND DIRECTORS SHARE THEIR TIME BETWEEN THE REPORTING ORGANIZAITON AND RELATED ORGANIZATIONS. SEE BELOW FOR ALLOCATION OF HOURS: CEO & PRESIDENT DAVID J HORAZDOVSKY: 55 HOURS GOOD SAMARITAN SOCIETY, 1 HOUR GOOD SAMARITAN FOUNDATION AS CHAIRPERSON DIRECTOR JOHN C. 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