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) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (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. | 0 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (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.. | 0 | |||||
| 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) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 92,996 | 35,697 | 27,786 | 86,136 | 59,730 | 302,345 |
| 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...... | 7,462,653 | 7,142,980 | 1,108,685 | 11,110 | 34,286 | 15,759,714 |
| 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. | 7,555,649 | 7,178,677 | 1,136,471 | 97,246 | 94,016 | 16,062,059 |
| 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.) | 16,062,059 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 7,555,649 | 7,178,677 | 1,136,471 | 97,246 | 94,016 | 16,062,059 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 17,869 | -26,841 | 1,059,473 | 213,365 | 396,052 | 1,659,918 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 17,869 | -26,841 | 1,059,473 | 213,365 | 396,052 | 1,659,918 |
| 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.). | 17,721,977 | |||||




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 11000175 |
| Software Version: |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Pt VI, Line 12c | Officer and Key employees are required to sign a declaration | |
| annually that they are in compliance with the conflict of | ||
| interest policy. | ||
| Pt VI, Line 15 | The Board of Director votes annually on the Administrators | |
| salary. They have a management consultant that advises | ||
| them on the market rate. The salary approvel is documented | ||
| in the Board minutes. | ||
| Pt VI, Line 19 | Copies of all policies, Form 990 and governing documents | |
| are available to the public upon request and are maintain | ||
| in the business office on the premises. | ||
| Pt VI, Line 6 | Members are volunteers who agree to become members of the | |
| Organization. A member is nominated by a current member | ||
| and is voted in by the current membership. | ||
| Pt VI, Line 7a | The members vote annually for the executive board which is the | |
| President, Treasuer, Secretary, and Vice Presidents. | ||
| Pt VI, Line 7b | All major decisions dealing with the Organization would | |
| be voted on by a majority of the members. | ||
| Pt VI, Line 11a | A copy of the Form 990 is provided to the President and Administrator | |
| for review and signiture. The 990 is provided to other | ||
| members upon request. | ||
| Pt III, Line 3 | In 2009 the organization sold the organization's license to operate | |
| a 96 bed residential skilled care nursing home to another | ||
| entity. The organization also entered into a Lease agreement | ||
| with that entity to lease the historical building and continue to run | ||
| the skilled care nursing home. The purchasing entity plans to build | ||
| a new facility. At that time the organization plans to | ||
| Form 990, Part IX, Line 24f | BANK CHARGES 1201. 1201. LICENSES AND TAXES 1325. 342. 983. MEALS & ENTERTAINMENT 4554. 2277. 2277. MISCELLANEOUS 3479. 2907. 572. PRINTING 3964. 3844. 120. TRAVEL 2178. 2178. COMMUNITY FOUNDATION LOSS 2039. 2039. ROUNDING | |
| renovate the historical building and reopen as an assisted | ||
| living facility. | ||
| Pt XII, Line 2c | The Executive Board selects the independent accountant | |
| and reviews the monthly compiled statements. |
| Software ID: | 11000175 |
| Software Version: |