Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| Total | |||||||||
| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3.. | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public Support. Subtract line 5 from line 4. | 0 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 0 | |||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | ||||||
| 11 | Total support (Add lines 7 through 10). | ||||||






| Calendar year(or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 52,929 | 92,996 | 35,697 | 27,786 | 86,136 | 295,544 |
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | 7,333,930 | 7,462,653 | 7,142,980 | 1,108,685 | 11,110 | 23,059,358 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | 7,386,859 | 7,555,649 | 7,178,677 | 1,136,471 | 97,246 | 23,354,902 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | 23,354,902 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 7,386,859 | 7,555,649 | 7,178,677 | 1,136,471 | 97,246 | 23,354,902 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 29,977 | 17,869 | -26,841 | 1,059,473 | 213,365 | 1,293,843 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 29,977 | 17,869 | -26,841 | 1,059,473 | 213,365 | 1,293,843 |
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 24,648,745 | |||||




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 10000104 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt VI-B, Line 12c | Officer and Key employees are required to sign a declaration | |
| annually that they are in compliance with the conflict of | ||
| interest policy. | ||
| Pt VI-B, Line 15 | The Board of Director votes annually on the Administrators | |
| salary. They have a management consultant that advises | ||
| them on the market rate. The salary approvel is documented | ||
| in the Board minutes. | ||
| Pt VI-C, Line 19 | Copies of all policies, Form 990 and governing documents | |
| are available to the public upon request and are maintain | ||
| in the business office on the premises. | ||
| Pt VI-A, Line 6 | Members are volunteers who agree to become members of the | |
| Organization. A member is nominated by a current member | ||
| and is voted in by the current membership. | ||
| Pt VI-A, Line 7a | The members vote annually for the executive board which is the | |
| President, Treasuer, Secretary, and Vice Presidents. | ||
| Pt VI-A, Line 7b | All major decisions dealing with the Organization would | |
| be voted on by a majority of the members. | ||
| Pt VI-B, Line 11a | A copy of the Form 990 is provided to the President and Administrator | |
| for review and signiture. The 990 is provided to other | ||
| members upon request. | ||
| Pt III, Line 3 | In 2009 the organization sold the organization's license to operate | |
| a 96 bed residential skilled care nursing home to another | ||
| entity. The organization also entered into a Lease agreement | ||
| with that entity to lease the historical building and continue to run | ||
| the skilled care nursing home. The purchasing entity plans to build | ||
| a new facility. At that time the organization plans to | ||
| Form 990, Part IX, Line 24f | SIMINARS & TRAINING 149. 149. PAYROLL EXPENSES 762. 0. 762. 0. DONATIONS 900. 0. 900. 0. LICENSES AND TAXES 1316. 1316. 0. 0. BANK CHARGES 1416. 0. 1416. 0. FEES 2191. 2191. MEALS & ENTERTAINMENT 2272. 1136. 1136. 0. MISCELLANEOUS 3286. 3286. | |
| renovate the historical building and reopen as an assisted | ||
| living facility. | ||
| Pt XII, Line 2c | The Executive Board selects the independent accountant | |
| and reviews the monthly compiled statements. |
| Software ID: | 10000104 |
| Software Version: |