Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
WARTBURG LUTHERAN HOME FOR THE AGING INC
Employer identification number
11-1631836
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(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?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
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.
Section B. Total Support
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..
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).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
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.") .
110,273
25,675
1,889,798
2,500
55
2,028,301
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......
19,322,642
16,458,765
10,547,409
3,734,770
178,992
50,242,578
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.
19,432,915
16,484,440
12,437,207
3,737,270
179,047
52,270,879
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
0
c
Add lines 7a and 7b..
0
8
Public Support (Subtract line 7c from line 6.)
52,270,879
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
19,432,915
16,484,440
12,437,207
3,737,270
179,047
52,270,879
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
167,680
260,848
44,256
22,189
18,714
513,687
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
167,680
260,848
44,256
22,189
18,714
513,687
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.)
11,733
34,665
28,095
74,493
13
Total support (Add lines 9, 10c, 11 and 12.).
19,612,328
16,779,953
12,481,463
3,759,459
225,856
52,859,059
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
98.890 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
99.140 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0.970 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
0.740 %
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
WARTBURG LUTHERAN HOME FOR THE AGING INC
Employer identification number
11-1631836
Identifier
Return Reference
Explanation
CHANGES IN PROGRAM SERVICES
FORM 990, PART III, LINE 3
EFFECTIVE JANUARY 1, 2010, THE ORGANIZATION TRANSFERRED ITS LONG-TERM HEALTHCARE PROGRAM OPERATIONS AND ALL RELATED PROGRAM ASSETS, LIABILITIES AND EQUITY TO THE LUTHERAN CENTER AT POUGHKEEPSIE, INC., A RELATED PARTY.
FORM 990, PART VI, SECTION A, LINE 3
MANAGEMENT SERVICES ARE PROVIDED BY THE LUTHERAN CARE NETWORK, INC. (FORMERLY WARTBURG LUTHERAN SERVICES, INC.)
FORM 990, PART VI, SECTION A, LINE 6
THE ORGANIZATION HAS ONE MEMBER, THE LUTHERAN CARE NETWORK, INC. (FORMERLY WARTBURG LUTHERAN SERVICES, INC.), WHO IS ALSO A 501(C)(3) ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A
THE MEMBERS OF THE GOVERNING BOARD ARE APPOINTED BY THE LUTHERAN CARE NETWORK, INC. (FORMERLY WARTBURG LUTHERAN SERVICES, INC.), WHO IS THE SOLE MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7B
THE LUTHERAN CARE NETWORK, INC. (FORMERLY WARTBURG LUTHERAN SERVICES, INC.) IS THE SOLE MEMBER OF THE ORGANIZATION. ALL SIGNIFICANT DECISIONS OF THE GOVERNING BODY ARE SUBJECT TO THE APPROVAL OF THE BOARD OF THE LUTHERAN CARE NETWORK, INC.
FORM 990, PART VI, SECTION B, LINE 11
THE 990 IS REVIEWED BY THE ORGANIZATION'S MANAGEMENT ONCE IT IS RECEIVED FROM THE PREPARER. A COPY IS PROVIDED TO THE BOARD AND UNLESS ANY OBJECTIONS ARE EXPRESSED, IT IS FILED ONCE REVIEWED BY MANAGEMENT.
FORM 990, PART VI, SECTION B, LINE 12C
AT BEGINNING OF EMPLOYEMNT, MANAGEMENT LEVEL EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST AND OUTSIDE ACTIVITES FORM. THE ORGANIZATION ENFORCES THIS POLICY BY ASSESSING AND MONITORING SITUATIONS IN WHICH ANY POTENTIAL CONFLICT OF INTEREST ARISES.
FORM 990, PART VI, SECTION C, LINE 19
NO DOCUMENTS ARE AVAILABLE TO THE PUBLIC OTHER THAN THOSE REQUIRED BY LAW. THOSE DOCUMENTS THAT ARE REQUIRED TO BE AVAILABLE TO THE PUBLIC ARE AVAILABLE UPON REQUEST.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
CHANGE IN VALUE OF PERPETUAL TRUST 29,900. EQUITY TRANSFER -1,677,777. TOTAL TO FORM 990, PART XI, LINE 5: -1,647,877.
FORM 990, PART XI, LINE 2C:
THERE HAS BEEN NO CHANGE IN THE PROCESS FOR REVIEWING AUDITED FINANCIAL STATEMENTS OR THE SELECTION OF AN INDEPENDENT AUDITOR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.