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. | ||||||
| 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). | ||||||






| 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 | 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...... | ||||||
| 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. | ||||||
| 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.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2006 | (b) 2007 | (c) 2008 | (d) 2009 | (e) 2010 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 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.). | ||||||




| Facts And Circumstances Test |
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| SCH A: PART I QUESTION 3: ^ AS NOTED IN THE INSTRUCTIONS FOR SCHEDULE A, THE DEFINITION OF HOSPITAL FOR SCHEDULE A IS DIFFERENT FROM THE DEFINITION FOR SCHEDULE H. ACCORDINGLY, THE ORGANIZATION IS NOT REQUIRED TO FILE SCHEDULE H AS IT DOES NOT MEET THE DEFINITION OF HOSPITAL FOR THE PURPOSES OF SCHEDULE H. |
| Explanation |
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Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| FORM 990, PART I, LINE 6: 20 DIFFERENT VOLUNTEERS CONDUCT CHURCH SERVICES FOR THE PATIENTS. FORM 990, PART VI, SECTION A, LINE 2: LARRY LUTTRELL, DIRECTOR, AND BEVERLY LUTTRELL, ADMINISTRATOR, ARE HUSBAND AND WIFE. FORM 990, PART VI, SECTION A, QUESTION 11: THE RETURN PREPARER EMAILS A COPY OF THE COMPLETED FORM 990 TO EACH VOTING BOARD MEMBER PRIOR TO FILING. ALONG WITH THE FORM 990, THE RETURN PREPARER EMAILS A SUMMARY OUTLINE PROVIDING GUIDANCE FOR BOARD REVIEW OF THE FORM 990. IT IS REQUESTED THAT BOARD MEMBERS REVIEW FORM 990 AND COMPILE QUESTIONS. THE RETURN PREPARER IS AVAILABLE TO MEET WITH GOVERNING BOARD TO REVIEW THE FORM 990 AND ADDRESS ANY QUESTIONS. CHANGES ARE MADE IF NECESSARY AND CORRECTED FORM 990 IS REDISTRIBUTED FOR REVIEW AND APPROVAL FOR FILING. FORM 990, PART VI, SECTION B, QUESTION 12C: THE ORGANIZATON REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THEIR CONFLICT OF INTEREST POLICY BY: REQUIRING EACH OFFICER AND DIRECTOR OR KEY EMPLOYEE TO SIGN A STATEMENT AFFIRMING RECEIPT OF COPY OF POLICY, THAT THEY HAVE READ AND UNDERSTAND IT AND THAT THEY AGREE TO COMPLY WITH THE POLICY. THE ADMINISTRATOR PERIODICALLY REVIEWS THESE TO BE SURE THEY STAY IN COMPLIANCE. CLOSE KNOWLEDGE OF EACH BOARD MEMBER ENABLES THE ORGANIZATION TO BE ASSURED OF COMPLIANCE. RENEWAL OF COMPLIANCE WITH CONFLICT OF INTEREST POLICY TAKES PLACE ANNUALLY. FORM 990, PART VI, SECTION B, QUESTION 15: THE PROCESS FOR DETERMINING COMPENSATION OF THE ADMINISTRATOR AND DIRECTOR OF CHRISTIAN SCIENCE NURSING INCLUDES REVIEW AND APPROVAL BY INDEPENDENT PERSONS, THE GOVERNING BOARD, AND REVIEW OF DATA GATHERED FROM INQUIRIES TO OTHER CHRISTIAN SCIENCE NURING FACILITIES, REVIEW OF COMPENSATION OF PRIOR ADMINISTRATORS AND DIRECTORS OF CHRISTIAN SCIENCE NURSING POSITIONS. SUBSTANTIATION OF THIS REVIEW AND APPROVAL PROCESS IS MADE BY THE GOVERNING BOARD AND IS MADE BY CONTEMPORANEOUSLY DOCUMENTING IN THE ORGANIZATION MINUTES THE DELIBERATIONS AND DECISION. FORM 990, PART VI, SECTION C, QUESTION 19: THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC BY PROVIDING VIEWING TIMES UPON APPOINTMENT AT THE ORGANIZATION'S OFFICE DURING REGULAR BUSINESS HOURS. |
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