2011-10-06T14:29:07-05:00 2010-12-31 BAKER TILLY VIRCHOW KRAUSE LLP 225 S 6TH ST STE 2300 MINNEAPOLIS MN 55402 990 2010-01-01 412012560 EBENEZER LAKES ASSISTED LIVING EBEN 6128743460 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 STEPHAN GRYGAR 6128743460 2011-10-06 1 LAWRENCE H MOHR CPA 6128764500 2011-09-29 2010 2016-03-07 17:11:31Z STEPHAN GRYGAR 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 2529593 0 X WWW.FAIRVIEWEBENEZER.ORG X 1906 MN PROVIDE ASSISTED LIVING FOR THE ELDERLY 12 9 72 0 0 0 792 5388 2089781 2510477 727 333 5610 13395 2096910 2529593 0 0 0 0 308004 321829 0 0 0 1719400 1834718 2027404 2156547 69506 373046 7004571 7041579 7531421 7127738 -526850 -86159 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 1670205 2523872 PROVIDE ASSISTED LIVING FOR THE ELDERLY AND DISABLED THROUGH A HUD SPONSORED PROGRAM. THE FACILITY HAS 59 UNITS. 1670205 1 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 9 0 1 72 1 0 0 0 0 0 0 0 0 0 0 X 12 9 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 MAGGIE COLLINS 1.00 X 0 0 0 KENT EKLUND 1.00 X X 0 49517 0 STEPHAN GRYGAR 1.00 X X 0 208071 0 PASTOR CHRISTOPHER NELSON 1.00 X 0 0 0 SHARY MULHERE 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 351541 0 REVEREND RUSSELL HELGESON 1.00 X X 0 0 0 DEBORAH PAONE 1.00 X 0 0 0 TRUDI TRYSLA 1.00 X 0 0 0 MARK EUSTIS 1.00 X 0 1311286 156917 0 1920415 156917 0 0 1 0 0 5388 5388 RENT REVENUE 532000 1747215 1747215 SERVICE INCOME 623000 763262 763262 2510477 333 333 MISCELLANEOUS 900099 13395 13395 13395 2529593 2523872 0 333 163047 163047 250 250 158532 158532 45351 45351 8625 8625 4124 4124 48603 34052 14551 82617 82617 335808 335808 183458 183458 ELDERLY CARE EXPENSE 897977 897977 TAXES AND INSURANCE 132169 132169 OVERHEAD ALLOCATIONS 95986 95986 2156547 1670205 486342 0 108549 154676 417334 499970 37729 104277 23795 30336 7056029 1145115 6067982 5910914 349182 341406 7004571 7041579 117771 117207 20204 29037 6547489 6477580 845957 503914 7531421 7127738 X -526850 -86159 -526850 -86159 7004571 7041579 X 373046 67645 X X 0 1 1 X 1 1 X 5184 1020 792 5388 12384 1825486 2091431 1873745 2089781 2510477 10390920 1830670 2092451 1873745 2090573 2515865 10403304 0 0 0 10403304 11027 39005 33499 727 333 84591 11027 39005 33499 727 333 84591 9237 4988 5610 13395 33230 1850934 2136444 1907244 2096910 2529593 10521125 0.98880 0.98740 0.00800 0.00960 X 29265 29265 6819271 1092303 5726968 150230 25657 124573 57263 27155 30108 5910914 TENANT SECURITY DEPOSITS 53038 PREMIUM ON BONDS 203686 AMOUNT DUE TO EBENEZER SOCIETY, A RELATED PARTY 243711 MANAGEMENT FEE PAYABLE TO EBENEZER MANAGEMENT SERVICE, A RELATED PARTY 3479 503914 2529593 2156547 373046 67645 67645 440691 2597238 67645 67645 2529593 0 2529593 2156547 0 2156547 0 2156547 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 SHOURD 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 2010. OPEN TAX YEARS SUBJECT TO EXAMINATION BY THE U.S. AND STATE TAXING AUTHORITIES ARE FOR THE YEARS 2008-2010, 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 WOU'D BEAR THE BURDEN OF AN UNCERTAIN TAX POSITION. PART XI, LINE 8 - OTHER ADJUSTMENTS: FORGIVENESS OF DEBT BY RELATED PARTY 67,645. PART XII, LINE 2D - OTHER ADJUSTMENTS: FORGIVENESS OF DEBT BY RELATED PARTY 67,645. X 0 0 0 0 0 0 0 0 0 STEPHAN GRYGAR 0 172882 0 35189 0 0 0 0 0 0 0 208071 0 0 MARK THOMAS 0 250982 0 0 0 100559 0 0 0 0 0 351541 0 0 MARK EUSTIS 0 843522 0 467764 0 0 0 144102 0 12815 0 1468203 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 EUSTIS, MARK THOMAS, STEVE 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 STEPHEN GRYGAR BEFORE FILING. THE COMPLETE GOVERNING BODY DOESN'T 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 2 YEARS IT HAS BEEN 2%. ANY INCREASES ABOVE 2% 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: FORGIVENESS OF DEBT BY RELATED PARTY 67,645. TOTAL TO FORM 990, PART XI, LINE 5: 67,645. FORM 990, PART XII, LINE 2C THERE HAS BEEN NO CHANGE SINCE THE PY. 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 N/A 0 EBENEZER RIDGES ASSISTED LIVING 13810 COMMUNITY DRIVE BURNSVILLE MN 55337 411964691 NURSING HOME CARE MN 501(C)(3) LINE 9 N/A 0 EBENEZER RIDGES CARE CENTER 2722 PARK AVENUE SOUTH MINNEAPOLIS MN 55407 411287792 NURSING HOME CARE MN 501(C)(3) LINE 9 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0