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
PRESBYTERIAN RETIREMENT COMMUNITIES NORTHWEST
Employer identification number
91-0666887
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.") .
126,671
13,000
14,701
206,906
361,278
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......
16,252,820
16,063,743
16,481,882
22,080,501
31,989,355
102,868,301
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
164,922
164,922
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.
16,379,491
16,076,743
16,496,583
22,080,501
32,361,183
103,394,501
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.)
103,394,501
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...
16,379,491
16,076,743
16,496,583
22,080,501
32,361,183
103,394,501
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
528,264
523,801
519,253
1,066,106
871,960
3,509,384
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
528,264
523,801
519,253
1,066,106
871,960
3,509,384
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
36,468
19,367
339,571
395,406
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
44,483
44,483
13
Total support (Add lines 9, 10c, 11 and 12.).
16,907,755
16,600,544
17,052,304
23,165,974
33,617,197
107,343,774
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
96.320 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
96.290 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
3.270 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
3.650 %
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
PRESBYTERIAN RETIREMENT COMMUNITIES NORTHWEST
Employer identification number
91-0666887
Identifier
Return Reference
Explanation
FORM 990, PART I, LINE 6:
THERE WERE 17 VOLUNTEER MEMBERS ON THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11
THE PRESIDENT/CEO OF PRESBYTERIAN RETIREMENT COMMUNITIES NORTHWEST REVIEWS THE FORM 990 PRIOR TO SIGNING. THE AUDIT COMMITTEE WILL ALSO REVIEW THE FORM 990 BEFORE IT IS SUBMITTED TO THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
ANNUALLY, A CONFLICT OF INTEREST FORM IS DISTRIBUTED TO THE BOARD OF DIRECTORS AND OFFICERS. THE CEO TYPICALLY REVIEWS THE FORMS AND IDENTIFIES ANY CONFLICTS. IF A CONFLICT IS FOUND, THAT BOARD MEMBER REMOVES HIMSELF OR HERSELF FROM VOTING ON OR DISCUSSING THAT MATTER.
FORM 990, PART VI, SECTION B, LINE 15
THE BOARD USES AN INDEPENDENT COMPENSATION CONSULTANT AND COMPENSATION SURVEY TO ANNUALLY DETERMINE THE CEO AND CFO'S COMPENSATION. THE CEO IS RESPONSIBLE FOR CONDUCTING THE REVIEW OF OTHER OFFICERS' COMPENSATION (EXECUTIVE DIRECTORS). THE LAST REVIEW FOR THE CEO WAS PERFORMED IN DECEMBER 2011.
FORM 990, PART VI, SECTION C, LINE 19
PRESBYTERIAN RETIREMENT COMMUNITIES NORTHWEST MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART VII, SECTION A, COLUMN (B):
THE ESTIMATED AVERAGE HOURS PER WEEK DEVOTED BY THE FOLLOWING INDIVIDUALS TO RELATED ORGANIZATIONS ARE AS LISTED: ROBERT MITCHELL DIRECTOR 0.2 HOURS CAROLE CONGER DIRECTOR 0.0 HOURS JAMES MELHORN DIRECTOR 1.5 HOURS GREG ROBINSON VICE CHAIR 0.5 HOURS GARY HOULAHAN CHAIR 5.0 HOURS PAUL COLLINS DIRECTOR 1.0 HOURS HEATHER JAMES DIRECTOR 2.0 HOURS TOM JOHNSTON DIRECTOR 2.0 HOURS DOUG DIEKEMA DIRECTOR 0.5 HOURS BONNIE BRIAN-CALDWELL DIRECTOR 0.0 HOURS LUCILLE KELLEY DIRECTOR 0.1 HOURS JOHN ESHELMAN DIRECTOR 1.0 HOURS RICHARD MATTHEWS DIRECTOR 2.0 HOURS TOM VALSILATOS DIRECTOR 1.0 HOURS KAY BROWELEIT EX-OFFICIO DIRECTOR 3.0 HOURS REV. SCOTT LUMSDEN EX-OFFICIO DIRECTOR 0.1 HOURS DOUG SETO DIRECTOR 1.0 HOURS TAMERYN CAMPBELL PRESIDENT & CEO 1.0 HOURS FREDERICK MARSH KELLEGREW FORMERPRESIDENT & CEO 1.0 HOURS JEFFREY CRANDALL VICE PRESIDENT 1.0 HOURS PAM PROSKE INTERIM EX-OFFICIO DIRECTOR 0.1 HOURS
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED LOSSES ON INVESTMENTS: -420,518. CHANGE IN VALUE OF INTEREST RATE SWAP- FH, LLC 206,046. ROUNDING 4. TOTAL TO FORM 990, PART XI, LINE 5: -214,468.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.