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? |
|||
|---|---|---|---|---|---|---|---|---|---|
| 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. | ||||||
| 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.. | ||||||
| 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.") . | 0 | 0 | ||||
| 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...... | 0 | 0 | ||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 0 | 0 | ||||
| 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. | 0 | 0 | 0 | 0 | 0 | 0 |
| 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.) | 0 | |||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 0 | 0 | 0 | 0 | 0 | 0 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 0 | 0 | ||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 0 | 0 | 0 | 0 | 0 | 0 |
| 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.) | 0 | |||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | 0 | 0 | 0 | 0 | 0 | 0 |




| Facts And Circumstances Test |
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| Explanation |
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| Software ID: | 11000230 |
| Software Version: | v2011.1.0 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| Significant changes to organizational documents | Form 990, Part VI, Section A, Line 4 | THE ARTICLES OF INCORPORATION WERE AMENDED TO PROPERLY STATE THE INITIAL DIRECTORS AND OFFICERS OF THE CORPORATION. THE ORIGINALLY FILED ARTICLES OF INCORPORATION WERE INCORRECT. |
| Documentation of meetings held by committees of governing body | Form 990, Part VI, Section B, Line 8b | THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. THEREFORE THIS QUESTION IS ANSWERED "NO" WHICH IS CONSISTENT WITH FORM 990 INSTRUCTIONS. |
| Review of form 990 by governing body | Form 990, Part VI, Section B, Line 11b | THE FORM 990 IS REVIEWED BY THE TREASURER IN DETAIL. A COPY OF THE FORM 990 IS PROVIDED TO EVERY MEMBER OF THE GOVERNING BODY PRIOR TO FILING. |
| Conflict of interest policy | Form 990, Part VI, Section B, Line 12c | THE OFFICERS AND DIRECTORS OF THE ORGANIZATION SIGN A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY TO DISCLOSE ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST. THE QUESTIONNAIRE AND RESPONSES ARE DISCUSSED WITH THE BOARD CHAIR. IF AN INDIVIDUAL HAS ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST THE INDIVIDUAL WITH THE CONFLICT IS EXCUSED FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS RELATED TO THE CONFLICT. |
| PROCESS USED TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL | FORM 990, PART VI, LINE 15A | THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS COMPENSATED BY AVOW HOSPICE, INC., A RELATED ORGANIZATION. THE EXECUTIVE COMMITTEE OF AVOW HOSPICE REVIEWS COMPENSATION OF THE PRESIDENT & CEO TO ENSURE COMPENSATION IS REASONABLE AND THEN RECOMMENDS ANY CHANGES TO THE COMPENSATION TO THE BOARD OF DIRECTORS. THE FULL BOARD OF AVOW HOSPICE THEN APPROVES THE COMPENSATION OF THE PRESIDENT & CEO. |
| PROCESS USED TO ESTABLISH COMPENSATION FOR OTHER OFFICERS OR KEY EMPLOYEES | FORM 990, PART VI, LINE 15B | THE ORGANIZATION DOES NOT HAVE OTHER OFFICERS OR KEY EMPLOYEES WHO RECEIVE COMPENSATION FROM AVOW CARE SERVICES, INC. THE COMPENSATION OF THE OTHER OFFICERS, WHO RECEIVE COMPENSATION FROM A RELATED ORGANIZATION (AVOW HOSPICE), IS REVIEWED AND APPROVED BY THE PRESIDENT & CEO OF AVOW HOSPICE. THE PROCESS AND DECISIONS ARE DOCUMENTED IN EACH EMPLOYEE'S FILE IN HUMAN RESOURCES. |
| Governing documents, conflict of interest policy and financial statements available to the public | Form 990, Part VI, Section C, Line 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST FROM THE ORGANIZATION. |
| HOURS DEVOTED TO RELATED ORGANIZATIONS | FORM 990, PART VII, SECTION A | MERRILL BOONE, PAUL MITCHELL, AND KAREN ROLLINS EACH DEVOTE APPROXIMATELY 40 HOURS/WEEK TO AVOW HOSPICE, A RELATED ORGANIZATION. RICHARD BALLO, ROGER LIPITZ, AND MARK J. MOSKOWITZ EACH DEVOTE APPROXIMATELY 2 HOURS/WEEK TO AVOW HOSPICE, A RELATED ORGANIZATION. |
| Other changes in net assets or fund balances | Form 990, Part XI, Line 5 | TRANSFER TO/FROM AFFILIATES - 445000; |
| Software ID: | 11000230 |
| Software Version: | v2011.1.0 |