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
TRUSTEES OF THE CHURCH HOME AND INFIRMARY (D/B/A EPISCOPAL CHURCH HOME)
Employer identification number
61-0461720
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.") .
2,201,542
809,662
332,506
373,519
294,579
4,011,808
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......
14,213,481
15,377,659
16,331,556
16,421,135
17,299,284
79,643,115
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.
16,415,023
16,187,321
16,664,062
16,794,654
17,593,863
83,654,923
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
1,315,000
417,400
100,000
1,832,400
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..
1,315,000
417,400
100,000
1,832,400
8
Public Support (Subtract line 7c from line 6.)
81,822,523
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...
16,415,023
16,187,321
16,664,062
16,794,654
17,593,863
83,654,923
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
276,588
394,893
249,028
182,131
172,101
1,274,741
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
276,588
394,893
249,028
182,131
172,101
1,274,741
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.)
87,293
91,263
297,306
86,368
83,593
645,823
13
Total support (Add lines 9, 10c, 11 and 12.).
16,778,904
16,673,477
17,210,396
17,063,153
17,849,557
85,575,487
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
95.610 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
95.250 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
1.490 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
1.610 %
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
TRUSTEES OF THE CHURCH HOME AND INFIRMARY (D/B/A EPISCOPAL CHURCH HOME)
Employer identification number
61-0461720
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 3
MANAGEMENT OF THE DIETARY AND THERAPY SERVICES AT THE EPISCOPAL CHURCH HOME ARE PROVIDED BY OUTSIDE CONTRACTED ORGANIZATIONS.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS REVIEWED AND APPROVED BY THE CEO AND CFO. THE 990 IS THEN PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD FOR REVIEW AND APPROVAL. IT IS THEN MADE AVAILABLE TO THE FULL BOARD IF THEY CHOOSE TO REVIEW.
FORM 990, PART VI, SECTION B, LINE 12C
MEMBERS OF THE BOARD OF TRUSTEES MUST COMPLETE AND SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT ANNUALLY AT THE BEGINNING OF THE FISCAL YEAR OR IN CONNECTION WITH THE ANNUAL AUDIT AND MORE FREQUENTLY WHEN ASKED TO DO SO. THE CEO REVIEWS ANY CONTRACTS OR AGREEMENTS PERTAINING TO BOARD MEMBERS OR THEIR FAMILIES. IF THE CEO DETERMINES THAT THERE IS ANY CONFLICT, THE CEO WILL INFORM THE PRESIDENT OF THE BOARD TO DETERMINE IF THE POTENTIAL CONFLICT SHOULD BE PRESENTED TO THE ENTIRE BOARD. IF AN ISSUE ARISES OF NON-COMPLIANCE, THEN CHANGES ARE MADE TO ACHIEVE COMPLIANCE. THE CEO IS MONITORED BY THE PRESIDENT OF THE BOARD.
FORM 990, PART VI, SECTION B, LINE 15A
1. THE COMPENSATION OF THE PERSON IS REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE OF THE ORGANIZATION PROVIDED THAT PERSONS WITH CONFLICTS OF INTEREST WITH RESPECT TO THE COMPENSATION ARRANGEMENT AT ISSUE ARE NOT INVOLVED IN THE REVIEW AND APPROVAL. 2. THE COMPENSATION OF THE PERSON IS REVIEWED AND APPROVED USING DATA AS TO COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. 3. WRITTEN DOCUMENTATION IS PROVIDED FROM THE EXECUTIVE COMITTEE REGARDING DECISIONS ON THE COMPENSATION ARRANGEMENT.
FORM 990, PART VI, SECTION C, LINE 18
EPISCOPAL CHURCH HOME MAKES ITS FORM 990 AVAILABLE UPON REQUEST. IN ADDITION, THEY DO DIRECT FORM 990 INQUIRIES TO THE GUIDESTAR WEBSITE AS WELL.
FORM 990, PART VI, SECTION C, LINE 19
THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS OF EPISCOPAL CHURCH HOME ARE MADE AVAILABLE TO THE PUBLIC ONLY UPON REQUEST.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 914,553.
REVIEW PROCESS OF AUDIT REPORT:
FORM 990, PART XI, LINE 2C:
THE CEO AND CFO REVIEW A DRAFT OF THE AUDIT REPORT IN DETAIL. THE DRAFT COPY OF THE AUDIT REPORT IS PRESENTED TO THE AUDIT AND CORPORATE COMPLIANCE COMMITTEE. AFTER THE DRAFT AUDIT REPORT HAS BEEN APPROVED, THE FINAL AUDIT REPORT IS PRESENTED TO THE FULL BOARD OF DIRECTORS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.