2011-09-14T15:48:04-05:00 2010-12-31 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-01-01 460422866 THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION EVAN 6053623100 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 JIM KREKELBERG 6053623100 2011-09-12 1 6123764500 2010 2016-03-07 17:11:31Z CHARLES HIATT 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 5566784 0 X N/A X 1992 MN PROVIDING SUPPORT, ASSISTANCE, AND AID FOR THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (ELGSS). 11 7 0 7 0 0 3191846 3866288 0 0 -26722 1106406 0 0 3165124 4972694 433718 1341528 0 0 0 0 0 0 1001933 1647402 1373252 2081120 2714780 1084004 2257914 15828094 19040697 112255 116678 15715839 18924019 X MISSION:THE MISSION OF THE GOOD SAMARITAN FOUNDATION IS TO SUPPORT THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY'S MISSION OF SHARING GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OLDER PERSONS AND OTHERS IN NEED WELL INTO THE FUTURE. THE FOUNDATION GATHERS, GROWS AND PROVIDES THE CHANNELS THROUGH WHICH GIFTS AND GRANTS FLOW TO SUPPORT AND TO IMPROVE THE QUALITY OF LIFE FOR THOSE IN OUR CARE.VISION:THE GOOD SAMARITAN FOUNDATION SUPPORTS THE SOCIETY'S VISION "TO CREATE AN ENVIRONMENT WHERE PEOPLE ARE LOVED, VALUED AND AT PEACE" BY INVITING DONORS TO HELP US SHOW WHAT SENIOR CARE CAN BE. 0 0 1341528 1341528 0 THE FOUNDATION SUPPORTS THE FOUR HALLMARK VALUES OF THE SOCIETY:(1) CHRIST-CENTERED, (2) RESIDENT-CENTERED, (3) STAFF-CENTERED AND (4) COMMUNITY-CENTERED BY SEEKING MAJOR GIFTS WITH INTEGRITY, INNOVATION AND FAITH.THE LEGACY PROMISE:DAY BY DAY, LET'S MAKE A DIFFERENCE;MONTH BY MONTH, LET'S MOTIVATE OTHERS TO SEIZE OPPORTUNITY;YEAR BY YEAR, SEE THINGS CHANGE; ANDIN A LIFETIME OF WORK, LEAVE A LASTING LEGACY WHICH ADVANCESTHE MISSION AND MINISTRY OF GOOD SAMARITAN SOCIETY ANDGOOD SAMARITAN FOUNDATION;SHOWING GOD'S LOVE IN WORD AND DEED. 1341528 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 11 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JIM KREKELBREG TREASURER 6053623100 4800 W 57TH STREET SIOUX FALLS SD 571175038 DAVID J HORAZDOVSKY 1.00 X X 0 521501 12669 JOHN C PENN 1.00 X X 0 0 0 SUSAN NICKERSON 1.00 X X 0 0 0 RICHARD W FRIESS MD 1.00 X 0 0 0 DANIEL L HAMES 1.00 X 0 125706 31565 RICHARD J HAUBENSAK 1.00 X 0 0 0 CLAYTON E JENSEN MD 1.00 X 0 0 0 ORVAL JOHNSON 1.00 X 0 0 0 ROBERT P O'CONNOR 1.00 X 0 0 0 SHARON A ST MARY 1.00 X 0 135892 16369 DENNIS STENE 1.00 X 0 0 0 LISA MELBY 1.00 X 0 108323 29196 JIM SEWICK 1.00 X 0 92034 19373 DR CHARLES M HIATT 40.00 X 0 151152 13369 RAYE NAE NYLANDER 1.00 X 0 259663 16369 SYLVIA GAUSE 1.00 X 0 57205 17472 0 1451476 156382 0 0 1 0 0 3659474 206814 7732 3866288 374850 374850 1325646 594090 731556 731556 731556 4972694 0 0 1106406 1300065 1300065 41463 41463 45041 39526 5515 1140 870 270 19790 3740 16050 145 145 138698 13918 124780 7591 7031 560 36 36 ALLOCATED SALARIES 1113803 270592 843211 OTHER EXPENSES 15200 15200 STAFF DEVELOPMENT 11642 8914 2728 LICENSE & FEES 6200 6200 0 DUES 2765 738 2027 11201 4554 6647 2714780 1341528 371319 1001933 8507 5984 1722874 2632018 712 68 679 644 14092993 16402051 3041 0 15828094 19040697 19325 24556 92930 92122 112255 116678 X 5304621 6530272 377226 983944 10033992 11409803 15715839 18924019 15828094 19040697 X 2257914 950266 X 0 1 1 X 0 X X X 0 0 0 TELGSS 450228055 9 1 1 1 1300065 1 1300065 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 12476733 1375811 828395 36267 14644672 11256062 616000 820000 215329 12476733 11231052 1277693 -1027867 224816 11256062 0.15700 0.77900 0.06400 0 0 712 68 644 644 ANNUITY OBLIGATION 92122 92122 4972694 2714780 2257914 950266 950266 3208180 2263486 950266 950266 1313220 3659474 3659474 4972694 1414715 0 1414715 1300065 1300065 2714780 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE FOUNDATION'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: THE FOUNDATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE 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 FOUNDATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINAITON BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE FOUNDATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE TAX RETURNS FOR THE YEARS 2007-2009 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL AND STATE AUTHORITIES. PART XII, LINE 4B - OTHER ADJUSTMENTS: GIFTS TRANSFFERED FROM AFFILIATE 1,298,996. EXPENSES PAID BY AFFILIATE 2,360,478. PART XIII, LINE 4B - OTHER ADJUSTMENTS: TRANSFERS TO AFFILIATE 1,300,065. 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 4800 W 57TH ST SIOUX FALLS SD 57108 450228055 501(C)(3) 1300065 GIFTS TRANSFERRED TO THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. 1 SCHOLARSHIPS 27 41463 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE FOUNDATION COMMUNICATES A LIST OF RESTRICTIONS TO EACH CENTER AT THE TIME OF DISTRIBUTION. THE ADMINISTRATOR AT EACH LOCATION IS RESPONSIBLE FOR ENSURING THAT THE FUNDS ARE USED IN ACCORDANCE WITH THE FOUNDATION'S DIRECTION. THE ORGANIZATION PROVIDES SCHOLARSHIPS TO EMPLOYEES OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY WHO ARE ENROLLED IN A QUALIFIED EDUCATION PROGAM. THE ORGANIZATION PAYS THE SCHOLARSHIP DIRECTLY TO THE EDUCATION INSTITUTION WHERE THE EMPLOYEE IS ENROLLED. IF THE EMPLOYEE HAS ALREADY PAID THE EXPENSES, THE ORGANIZATION REQUIRES RECEIPT OF PAYMENT BEFORE REIMBURSEMENT IS MADE TO THE EMPLOYEE. 0 0 0 0 0 0 0 0 0 DAVID J HORAZDOVSKY 0 400842 0 0 0 120659 0 0 0 16404 0 537905 0 0 DANIEL L HAMES 0 86379 0 0 0 39327 0 8311 0 32572 0 166589 0 0 SHARON A ST MARY 0 88918 0 0 0 46974 0 0 0 17494 0 153386 0 0 DR CHARLES M HIATT 0 105338 0 0 0 45814 0 0 0 14651 0 165803 0 0 RAYE NAE NYLANDER 0 185593 0 0 0 74070 0 0 0 18357 0 278020 0 0 SUPPLEMENTAL INFORMATION PART III THE COMPENSATION OF THE FOUNDATION'S EXECUTIVE DIRECTOR IS DETERMINED BY THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, THE FOUNDATION'S SOLE MEMBER. THE FOLLOWING WERE USED BY THE SOCIETY TO DETERMINE THE EXECUTIVE DIRECTOR'S COMPENSATION: 1. INDEPENDENT COMPENSATION CONSULTANT 2. COMPENSATION SURVEY OR STUDY FORM 990, PART VI, SECTION A, LINE 6 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY IS THE SOLE MEMBER OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY BOARD OF DIRECTORS APPROVES THE BOARD MEMBER APPOINTMENTS OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7B THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY BOARD OF DIRECTORS APPROVES THE BOARD MEMBER APPOINTMENTS OF THE FOUNDATION AND ANY AMENDMENTS TO THE BY-LAWS. FORM 990, PART VI, SECTION B, LINE 11 ACCOUNTANTS WITH THE ORGANIZATION REVIEWED THE 990 IN DETAIL PRIOR TO IT BEING FILED. ANY QUESTIONS WERE RESOLVED WITH THE TREASURER AND/OR PRESIDENT OF THE ORGANIZATION PRIOR TO THE 990 BEING FILED. A COPY OF THE 990 WAS PROVIDED TO THE ORGANIZATION'S GOVERNING BODY PRIOR TO THE 990 BEING FILED FOR THEIR REVIEW AND APPROVAL. 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 15 THE ORGANIZATION DOES NOT PAY THE OFFICERS OR EXECUTIVE DIRECTOR. THEY ARE COMPENSATED BY A RELATED ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE FOUNDATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAIN ON INVESTMENTS 950,266. TOTAL TO FORM 990, PART XI, LINE 5: 950,266. THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 4800 W 57TH ST SIOUX FALLS SD 57108 450228055 LONG-TERM CARE, AL, SENIOR HOUSING & HOME AND COMMUNITY BASED SERVICES ND 501(C )(3) 9 N/A 0 GOOD SAMARITAN SOCIETY INC 4800 W 57TH ST SIOUX FALLS SD 57108 460349951 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 BOISE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 363370371 LOW-INCOME SENIOR HOUSING SD 501(C )(3) PF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 LOVINGTON GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460392944 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 PROPHETSTOWN GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460392943 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 JASONVILLE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460396355 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 OLATHE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460396398 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 11 - 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