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
THE ESTELLE PEABODY MEMORIAL HOME OF THE SYNOD OF LINCOLN TRAILS OF THE PRE SBYTERIAN CHURCH (USA)
Employer identification number
35-0883511
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.") .
288,766
396,573
833,498
259,400
313,597
2,091,834
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......
15,076,281
16,592,791
16,740,215
17,571,905
16,605,905
82,587,097
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
37,007
178,634
292,152
107,639
615,432
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
15,365,047
17,026,371
17,752,347
18,123,457
17,027,141
85,294,363
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
0
0
0
0
0
8
Public Support (Subtract line 7c from line 6.)
85,294,363
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...
15,365,047
17,026,371
17,752,347
18,123,457
17,027,141
85,294,363
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
499,825
454,852
453,036
274,317
234,070
1,916,100
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
499,825
454,852
453,036
274,317
234,070
1,916,100
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
205,751
207,113
186,228
599,092
13
Total support (Add lines 9, 10c, 11 and 12.).
16,070,623
17,688,336
18,205,383
18,397,774
17,447,439
87,809,555
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
97.140 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
96.720 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
2.180 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
2.532 %
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
OTHER INCOME, SCHEDULE A, PART III, LINE 12, MISCELLANEOUS INCOME RECEIVED IN FURTHERANCE OF THE ORGANIZATION'S TAX EXEMPT PURPOSE: 2006 - $205,751 2007 - $207,113 2008 - $0 2009 - $0 2010 - $186,228,
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
10000128
Software Version:
v2010.1.0
-
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
THE ESTELLE PEABODY MEMORIAL HOME OF THE SYNOD OF LINCOLN TRAILS OF THE PRE SBYTERIAN CHURCH (USA)
Employer identification number
35-0883511
Identifier
Return Reference
Explanation
PROGRAM SERVICE ACCOMPLISHMENTS (CONTINUED FROM PART III)
FORM 990, PART III, LINE 4A
RESIDENTIAL SERVICES: COTTAGE HOMES - THE 57 INDEPENDENT LIVING COTTAGES OFFER THE FREEDOM OF MAINTENANCE-FREE LIVING ALONG WITH THE COMPANY OF INTERESTING NEIGHBORS WHO CHERISH THEIR INDEPENDENCE AND ARE ALWAYS READY TO LEND A HAND. RESIDENTIAL APARTMENTS AND ASSISTED LIVING CENTER - PEABODY OFFERS 124 RESIDENTIAL AND ASSISTED LIVING UNITS, WHICH HAVE A CAPACITY FOR 144 RESIDENTS. THE SOUTH HOUSE RESIDENTIAL APARTMENTS OFFER THE CONVENIENCE OF VARIOUS CAMPUS SERVICES, ALONG WITH THE INDEPENDENCE OF YOUR OWN RESIDENCE. MEMORY ENHANCEMENT CENTER - THE FRANK AND LAURA SMOCK MEMORY ENHANCEMENT CENTER, WHICH HAS 48 LICENSED MEMORY CARE BEDS, IS DESIGNED AROUND A SIMPLE PREMISE: SURROUND RESIDENTS WITH FAMILIAR SETTINGS AND ACTIVITIES THAT WILL HELP THEM MAINTAIN AND EVEN ENHANCE THEIR MEMORIES AND ENJOY LIFE. THE HOMELIKE NEIGHBORHOOD DESIGN INCLUDES LIFE STATIONS WHERE RESIDENTS CAN GARDEN, PLAY MUSIC AND ENJOY SPORTS AND SPORTING MEMORABILIA -- ALL TO ENERGIZE EACH INDIVIDUAL THROUGH THE ENVIRONMENT. FOR THOSE IN THE EARLY TO MIDDLE STAGES OF MEMORY LOSS, THERE IS NO MORE COMPLETE AND APPROPRIATE CARE AVAILABLE IN THE AREA. SKILLED HEALTH CENTER - PEABODY'S HEALTH CENTER HAS 144 LICENSED HEALTH CARE BEDS DESIGNED TO HELP INDIVIDUALS ENJOY A BETTER QUALITY OF LIVING THROUGH LATE LIFE. ADDITIONAL SERVICES PROVIDED: NUTRITIONAL SERVICES - OUR DINING STAFF WORKS CLOSELY WITH THE NURSING SERVICES AND MEDICAL STAFF TO ENSURE SPECIAL DIETARY GOALS ARE ACCOMPLISHED. THROUGH CAREFUL MEDICATION MANAGEMENT AND MONITORING BY OUR NUTRITIONAL AND NURSING STAFF, OUR RESIDENTS CAN OFTEN ENJOY FOODS THEY WERE NOT ABLE TO BEFORE JOINING THE PEABODY FAMILY. THERAPY SERVICES - OUR THERAPIES INCLUDE SPEECH, PHYSICAL, AND OCCUPATIONAL THERAPY, AND ARE AVAILABLE TO BOTH INPATIENT AND OUTPATIENT RESIDENTS. THIS ALLOWS RESIDENTS TO FOREGO THE OFTEN DIFFICULT TASK OF ARRANGING TRANSPORTATION TO AND FROM THERAPY APPOINTMENTS. SOCIAL SERVICES - STAFF SOCIAL WORKERS PROVIDE PEABODY RESIDENTS AND FAMILIES WITH A VARIETY OF SERVICES TO ENSURE THEIR NEEDS AND DESIRES ARE BEING MET ON A DAILY BASIS. SOCIAL SERVICES COORDINATORS PLAY AN ACTIVE ROLE IN THE ADMISSIONS PROCESS, HELPING TO DETERMINE THE BEST LEVEL OF CARE FOR RESIDENTS, AND PROVIDE EMOTIONAL SUPPORT TO BOTH RESIDENTS AND THEIR FAMILIES DURING TIMES OF TRANSITION. SOCIAL SERVICE COORDINATORS ALSO ASSIST WITH SUPPORTIVE COUNSELING TO INCREASE COPING WITH TRANSITIONS AND ADVOCACY TO ENSURE THAT RESIDENTS' RIGHTS ARE RESPECTED. PASTORAL SERVICES - THE PEABODY MEMORIAL CHAPEL HOLDS SERVICES ON A REGULAR SCHEDULE AND IS CONDUCTED IN THE TRADITION OF VARIOUS DENOMINATIONS. BECAUSE OUR PRIMARY IN-HOUSE WORSHIP SERVICE IS CONDUCTED ON SUNDAY AFTERNOON, MANY RESIDENTS ARE ABLE TO ENJOY RETURNING TO THEIR HOME CONGREGATION FOR MORNING WORSHIP. RECREATIONAL SERVICES - RESIDENTS ARE ABLE TO PARTICIPATE IN MANY GROUPS AND "CLUBS" RANGING FROM BIBLE STUDY TO QUILTING TO CONTEMPORARY FICTION TO VETERAN. IN ADDITION, PEABODY ALSO PROVIDES RESIDENTS WITH MANY OFF-CAMPUS EXCURSIONS.
Delegation of management duties
Form 990, Part VI, Section A, Line 3
IN DECEMBER 2010, THE ORGANIZATION ENTERED INTO A MANAGEMENT CONTRACT WITH LIFE CARE SERVICES, LLC (LCS), AN UNRELATED ORGANIZATION, FOR MANAGEMENT AND ADMINISTRATIVE SERVICES THAT EXTENDS THROUGH DECEMBER 2015.
Review of form 990 by governing body
Form 990, Part VI, Section B, Line 11b
THE ORGANIZATION'S MANAGEMENT REVIEWS A COMPLETED DRAFT OF THE FORM 990. A FINAL DRAFT OF THE FULL FORM 990, INCLUDING ALL APPLICABLE SCHEDULES, IS THEN PROVIDED TO EACH MEMBER OF THE ORGANIZATION'S GOVERNING BODY PRIOR TO ITS FILING WITH THE IRS.
Conflict of interest policy
Form 990, Part VI, Section B, Line 12c
EACH OFFICER, BOARD MEMBER, AND ADMINISTRATIVE STAFF COMPLETES AN ANNUAL CONFLICT OF INTEREST QUESTIONNAIRE. ONCE THE QUESTIONNAIRES ARE COMPLETED, THE EXECUTIVE DIRECTOR REVIEWS THE RESPONSES AND DETERMINES WHETHER OR NOT THERE ARE ANY POTENTIAL CONFLICTS OF INTEREST. IF THERE IS A POTENTIAL CONFLICT OF INTEREST, THE EXECUTIVE DIRECTOR AND BOARD PRESIDENT REVIEW THE CORRESPONDING ISSUE AND DETERMINE IF THERE IS AN ACTUAL CONFLICT OF INTEREST. IF AN ACTUAL CONFLICT OF INTEREST IS DETERMINED TO EXIST, THAT PERSON IS EXCLUDED FROM ANY DISCUSSIONS CONCERNING THE CONFLICTING ISSUE AND IS NOT PERMITTED TO VOTE ON ANY DECISIONS REGARDING THE CONFLICTING ISSUE. ANY PURCHASES AND/OR BIDDING PROPOSALS ARE ALSO REVIEWED FOR ANY POTENTIAL CONFLICTS OF INTEREST PRIOR TO SUBMITTING BIDS OR MAKING PURCHASES. THE EXECUTIVE DIRECTOR ATTENDS THE BOARD MEETINGS AS A GUEST TO ENSURE THAT COMPLIANCE WITH THESE GUIDELINES IS FOLLOWED.
Process used to establish compensation of top management official
Form 990, Part VI, Section B, Line 15a
THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWS AND APPROVES THE AMOUNT OF COMPENSATION FOR THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR AND DOCUMENTS THE DELIBERATION AND DECISION IN THE BOARD MEETING MINUTES. THE BOARD OF DIRECTORS UTILIZES INDIANA OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (IOSHA) WAGE SURVEYS FOR COMPARABILITY TO DETERMINE THE BASIS FOR THE AMOUNT OF COMPENSATION. THIS PROCESS WAS LAST UNDERTAKEN IN 2010. THE PROCESS TO REVIEW THE CEO/EXECUTIVE DIRECTOR'S COMPENSATION IS CURRENTLY UNDER REVIEW WITH THE BOARD OF DIRECTORS. BEGINNING IN DECEMBER 2010, THE ORGANIZATION ENTERED INTO A MANAGEMENT AGREEMENT WITH LIFE CARE SERVICES, LLC (LCS), UNDER WHICH THE NEW CEO/EXECUTIVE DIRECTOR IS PAID BY LCS. THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWED AND APPROVED THE AMOUNT TO BE PAID TO LCS FOR THE CEO/EXECUTIVE DIRECTOR'S COMPENSATION.
Public Disclosure
Form 990, Part VI, Section C, Line 19
GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104. THE ORGANIZATION DOES NOT MAKE THESE DOCUMENTS AVAILABLE TO THE PUBLIC AT THIS TIME.
PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES
FORM 990, PART VI, SECTION B, LINE 15B
THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR REVIEWS AND APPROVES THE COMPENSATION FOR OTHER OFFICERS. THE CEO/EXECUTIVE DIRECTOR UTILIZES INDIANA OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (IOSHA) AND AMERICAN ASSOCIATION OF HOMES AND SERVICES FOR THE AGING (AAHSA) WAGE SURVEYS FOR COMPARABILITY TO DETERMINE THE BASIS FOR THE AMOUNT OF COMPENSATION. THIS REVIEW PROCESS IS COMPLETED ANNUALLY AND WAS LAST DONE IN JANUARY 2010.
Average hours worked per week for related organization
Form 990, Part VII, Section A, Column B
CHOD BOXELL - DEVOTED APPROXIMATELY TWO HOURS PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. JEFFREY BRASIE - DEVOTES APPROXIMATELY TWO HOURS PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. JUDY MOORE - DEVOTES APPROXIMATELY ONE HOUR PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. BARBARA HANCHER - DEVOTES APPROXIMATELY ONE HOUR PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. IYVONNE SCHUMAKER - DEVOTES APPROXIMATELY TWO HOURS PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. JEFF JARECKI - DEVOTES APPROXIMATELY TWO HOURS PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION. JULIE WANNER - DEVOTED APPROXIMATELY TWO HOURS PER WEEK TO THE PEABODY HOME FOUNDATION, A RELATED TAX-EXEMPT ORGANIZATION.
OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, AND HIGHEST COMPENSATED EMPLOYEES
FORM 990, PART VII, SECTION A
DURING PART OF 2010, JULIE WANNER SERVED AS THE ORGANIZATION'S INTERIM CEO/EXECUTIVE DIRECTOR THROUGH A MANAGEMENT AGREEMENT WITH LIFE CARE SERVICES, LLC (LCS), AN INDEPENDENT MANAGEMENT AND CONSULTING FIRM. THE ORGANIZATION PAID LCS DIRECTLY FOR HER SERVICES DURING 2010. JEFF JARECKI SERVED AS THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR THROUGH DECEMBER OF 2010 THROUGH A MANAGEMENT AGREEMENT WITH LIFE CARE SERVICES, LLC (LCS), AN INDEPENDENT MANAGEMENT AND CONSULTING FIRM. THE ORGANIZATION PAID LCS DIRECTLY FOR HIS SERVICES DURING 2010.
Other changes in net assets or fund balances
Form 990, Part XI, Line 5
NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - 218847;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.