Form990
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 01-01-2012 , 2012, and ending 12-31-2012
BCheck if applicable:
CName of organization
AGRACE HOSPICECARE INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
5395 E Cheryl Parkway
 
Room/suite
City or town, state or country, and ZIP + 4
Madison, WI53711
D Employer identification number

39-1319537
E Telephone number

G Gross receipts $ 47,936,992
F Name and address of principal officer:
LYNNE MYERS
5395 EAST CHERYL PARKWAY
Madison,WI53711
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.AGRACE.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1978
M State of legal domicile: WI
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: OUR MISSION, "ENHANCING QUALITY OF LIFE AT THE END OF LIFE," LIVES IN THE COMPREHENSIVE, COMPASSIONATE CARE WE PROVIDE TO PATIENTS AND FAMILIES FACED WITH LIFE-LIMITING ILLNESS, HELPING THEM TO LIVE AS FULLY AS THEY CAN. IN 2012 THE ORGANIZATION PROVIDED CHARITY CARE OF APPROXIMATELY $245,000.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 13
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 12
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 641
6 Total number of volunteers (estimate if necessary) ............. 6 1,202
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 1,088,330 938,597
9 Program service revenue (Part VIII, line 2g) ......... 45,132,046 45,440,910
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 220 2,126
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 1,435,488 1,535,037
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 47,656,084 47,916,670
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 46,520 29,703
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 32,269,842 31,610,942
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet657,593    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 14,881,480 14,241,677
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 47,197,842 45,882,322
19 Revenue less expenses. Subtract line 18 from line 12....... 458,242 2,034,348
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 11,080,899 14,701,028
21 Total liabilities (Part X, line 26)............. 4,368,067 4,425,955
22 Net assets or fund balances. Subtract line 21 from line 20..... 6,712,832 10,275,073
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: AGRACE HOSPICECARE, INC.'S MISSION IS TO ENHANCE THE QUALITY OF LIFE AT THE END OF LIFE. AGRACE HOSPICECARE'S VISION IS TO BUILD A COMMUNITY IN WHICH EXCEPTIONAL END-OF-LIFE CARE IS ACCEPTED, EXPECTED AND AVAILABLE TO ALL REGARDLESS OF THEIR AGE, INCOME, RELIGION, ETHNICITY AND/OR CULTURAL BACKGROUND. (CONTINUED IN SCHEDULE O)
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 33,265,832 including grants of $ 29,703 ) (Revenue $ 44,805,493 )
CLINICAL PATIENT CARE - AGRACE HOSPICECARE OFFERS THE MOST COMPREHENSIVE END-OF-LIFE CARE AVAILABLE. PATIENTS AND FAMILIES SERVED BY AGRACE HOSPICECARE ARE PROVIDED THE EXPERT HELP OF A COMPASSIONATE TEAM OF END-OF-LIFE PROFESSIONALS INCLUDING: NURSES, CERTIFIED NURSING ASSISTANTS, SOCIAL WORKERS, CHAPLAINS, VOLUNTEERS, PHYSICIANS, GRIEF COUNSELORS AND PHARMACISTS. THE HOSPICECARE TEAM ASSESSES THE UNIQUE NEEDS OF EACH PATIENT AND FAMILY. WORKING TOGETHER, AGRACE HOSPICECARE STAFF, TRAINED VOLUNTEERS, AND THE PATIENT'S PHYSICIAN DELIVER COMPREHENSIVE CARE FOCUSED ON HELPING THE PATIENT AND THEIR FAMILY LIVE LIFE TO THE FULLEST. IN 2012, THE ORGANIZATION PROVIDED APPROXIMATELY $2,696,000 OF COMMUNITY BENEFIT.
4b (Code:   ) (Expenses $ 1,767,250 including grants of $   ) (Revenue $ 635,420 )
AGRACE HOSPICECARE'S OTHER PROGRAMS INCLUDE THE VOLUNTEER SERVICES PROGRAM, THE FOOD SERVICE PROGRAM AND GRANTS TO SUPPORT RELATED ORGANIZATIONS. IN 2012 MORE THAN 1,200 VOLUNTEERS PROVIDED MORE THAN 70,355 HOURS OF SERVICE. BECAUSE OF THIS SUPPORT, AGRACE HOSPICECARE IS ABLE TO DEFER SOME STAFFING COSTS AND CONTINUE TO PROVIDE COMPASSIONATE, EXPERT CARE TO PATIENTS AND FAMILIES. SOME OF THE VOLUNTEER POSITIONS INCLUDE IN-HOME AND RESIDENTIAL PATIENT AND FAMILY VOLUNTEER; GRIEF SERVICES, ADMINISTRATIVE OFFICE WORK, FLOWER ROOM AND KITCHEN VOLUNTEER; VIGIL PROGRAM; AND AGRACE HOSPICECARE CAMPUS GREETER. (CONTINUED ON SCHEDULE O)
4c (Code:   ) (Expenses $ 809,536 including grants of $   ) (Revenue $   )
GRIEF SERVICES - AGRACE HOSPICECARE'S GRIEF SERVICES PROGRAM PROVIDES SERVICES TO PATIENTS, FAMILY MEMBERS AND COMMUNITY MEMBERS. IN ADDITION TO INDIVIDUAL COUNSELING, AGRACE HOSPICECARE PROVIDES GRIEF SERVICES THROUGH GRIEF SUPPORT GROUPS, HOLIDAY REMEMBRANCE PROGRAMS, MEMORIAL QUILT DEDICATION CEREMONIES AND THE COMMUNITY TRAUMATIC DEATH RESPONSE TEAM. THESE PROGRAMS ARE OFFERED AT NO CHARGE, AND GRIEF SUPPORT GROUPS ARE OPEN TO ANYONE IN THE COMMUNITY EXPERIENCING GRIEF DUE TO A DEATH, NOT JUST TO PATIENTS AND FAMILIES SERVED BY AGRACE HOSPICECARE. IN 2012, AGRACE PROVIDED GRIEF SERVICES TO APPROXIMATELY 4,900 INDIVIDUALS, BOTH CHILDREN AND ADULTS. ALTHOUGH PROVIDING GRIEF SUPPORT IS REQUIRED BY STATE AND FEDERAL REGULATIONS, GRIEF SUPPORT SERVICES ARE NOT COVERED BY INSURANCE, MEDICARE OR MEDICAID REIMBURSEMENT. AGRACE PROVIDES THESE SERVICES BECAUSE THE ORGANIZATION BELIEVES THEY ARE CRITICAL TO HELPING FAMILIES RETURN TO FUNCTIONAL LIVING AFTER THEIR LOSS.
(Code:   ) (Expenses $ 613,205 including grants of $   ) (Revenue $ 58,127 )
COMMUNITY EDUCATION AND OUTREACH - AS THE COMMUNITY'S HOSPICE, AGRACE HOSPICECARE IS DEDICATED TO INCREASING AWARENESS AND UNDERSTANDING OF MATTERS RELATED TO DEATH, DYING, CAREGIVING, GRIEF, AND LOSS. WITH OUR GUIDANCE, OUR NEIGHBORS ARE BETTER PREPARED TO MAKE DECISIONS ABOUT THE CARE THEY OR THEIR LOVED ONES RECEIVE. IN 2012, 17,000 COMMUNITY MEMBERS WERE EDUCATED ABOUT AGRACE THROUGH MORE THAN 740 COMMUNITY PROGRAMS. AGRACE HOSPICECARE CONDUCTS EDUCATIONAL PRESENTATIONS, SEMINARS, CONFERENCES, AND INSERVICE PROGRAMS FOR COMMUNITY GROUPS AND HEALTHCARE PROFESSIONALS. IN 2012, 167 NURSING STUDENTS, MEDICAL STUDENTS, RESIDENTS AND FELLOWS PARTICIPATED IN ROTATIONS AT AGRACE.
4d Other program services (Describe in Schedule O.)
(Expenses $ 613,205 including grants of $   ) (Revenue $ 58,127 )
4e Total program service expensesMediumBullet36,455,823
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part III............................
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part I........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part II...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
Yes
 
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IV..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII .................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV......... Click to see attachment
14b
Yes
 
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IVClick to see attachment
15
Yes
 
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II...
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2.............
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
72
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
641
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
13
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
12
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
 
No
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
 
No
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
 
No
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
Yes
 
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
WI
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletJoyce Zeasman5395 EAST CHERYL PARKWAYMADISONWI53711 (608) 276-4660
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) JOAN BURKE........................................................................
CHAIR
 1.00
.......................   		X   X       0 0 0
(2) LYNNE MYERS........................................................................
PRESIDENT/CEO
 30.00
.......................10.00 		X   X       136,682 0 4,656
(3) SHARON CHAMBERLAIN........................................................................
SECRETARY/VICE CHAIR
 1.00
.......................   		X   X       0 0 0
(4) BRIAN HAPP........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(5) DAVID CULLEN........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(6) DAVID KRUGER........................................................................
DIRECTOR
 1.00
.......................1.00 		X           0 0 0
(7) GERALD LEFERT........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(8) GORDON DERZON........................................................................
DIRECTOR
 1.00
.......................1.00 		X           0 0 0
(9) JEFF GROSSMAN........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(10) JIM BAKKE........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(11) JOHN BUTLER........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(12) MARION WOZNIAK........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(13) MARK WINTER........................................................................
DIRECTOR
 1.00
.......................1.00 		X           0 0 0
(14) MICHAEL FITZPATRICK........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(15) SUSANNA HERRO........................................................................
DIRECTOR
 1.00
.......................   		X           0 0 0
(16) BRUCE AGNEBERG........................................................................
CMO
 40.00
.......................   		    X       257,339 0 24,140
(17) DAN CHIN........................................................................
VP PUBLIC AFFAIRS - PART YEAR
 40.00
.......................   		    X       146,791 0 19,110
Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(18) DENISE GLOEDE........................................................................
VP ACCESS
 40.00
.......................   		    X       132,859 0 8,061
(19) JANE M QUINN........................................................................
VP QUALITY AND COMPLIANCE
 40.00
.......................   		    X       132,259 0 20,836
(20) JOYCE ZEASMAN........................................................................
VP FINANCE
 30.00
.......................10.00 		    X       168,764 0 28,829
(21) JULIA HOUCK........................................................................
VP HR AND L&D/ACTING PRESIDENT
 30.00
.......................10.00 		    X       209,183 0 29,808
(22) JULIE SLATTERY........................................................................
VP CLINICAL SERVICES
 40.00
.......................   		    X       150,244 0 11,024
(23) MARCIA M WHITTINGTON........................................................................
VP FOUNDATION & HOLDINGS
 8.00
.......................40.00 		    X       105,004 70,003 27,085
(24) SUSAN PHILLIPS........................................................................
CEO - PART YEAR
 30.00
.......................10.00 		    X       482,432 0 5,727
(25) DENA GREEN........................................................................
MEDICAL DIRECTOR
 40.00
.......................   		        X   193,606 0 32,650
(26) KATHY WILLIAMS........................................................................
MEDICAL DIRECTOR
 40.00
.......................   		        X   199,489 0 16,164
(27) SUZANNE HOWARD........................................................................
MEDICAL DIRECTOR
 40.00
.......................   		        X   176,163 0 11,238






1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 2,490,815 70,003 239,328
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet13
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
UNIVERSITY OF WI HOSPITALCLINICDRAWER 853MILWAUKEEWI532780853 THERAPIES & IMAGING SVCS 872,801
CHARTWELL MIDWEST-WISCONSINPO BOX 78804MILWAUKEEWI532780804 BIOLOGICAL/INFUSION THERAPY 341,266
RYAN BROTHERS922 SOUTH PARK STMADISONWI53715 AMBULANCE SERVICE 215,364
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet3
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a 200,144
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 534,109
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		204,344
g Noncash contributions included in lines
1a-1f:$ 		5,660
h Total. Add lines 1a-1f.......MediumBullet 938,597
Program Service Revenue Business Code
2a NET PATIENT SERVICE REVENUE 623990 44,805,490 44,805,490    
b FOOD SERVICE 623990 635,420 635,420    
c     0      
d     0      
e     0      
f All other program service revenue . 0 0 0 0
g Total. Add lines 2a–2f........MediumBullet 45,440,910
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 2,126     2,126
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties...........MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss) 0 0
d Net rental income or (loss).......MediumBullet 0      
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss) 0 0
d Net gain or (loss)..........MediumBullet 0      
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ..
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a 28,261
b Less: cost of goods sold ..b 20,322
c Net income or (loss) from sales of inventory..MediumBullet 7,939     7,939
Miscellaneous Revenue Business Code
11a CONTRACTED SERVICES TO AFFILIATES 900099 1,468,968     1,468,968
b OTHER REVENUE 900099 58,130 58,130    
c     0      
d All other revenue .... 0 0 0 0
e Total. Add lines 11a–11d ...... MediumBullet 1,527,098
12 Total revenue. See Instructions......MediumBullet 47,916,670 45,499,040 0 1,479,033
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 29,703 29,703
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 1,487,043 83,452 1,403,591  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 23,625,374 19,283,909 3,853,351 488,114
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 745,457 572,395 153,621 19,441
9 Other employee benefits ....... 3,959,382 3,040,188 815,935 103,259
10 Payroll taxes ........... 1,793,686 1,377,271 369,636 46,779
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 103,050 6,002 97,048  
c Accounting ........... 116,416   116,416  
d Lobbying ........... 16,196   16,196  
e Professional fundraising services. See Part IV, line 17 0  
f Investment management fees ...... 0      
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 221,040 63,297 157,743 0
12 Advertising and promotion .... 510,923 30,834 480,089  
13 Office expenses ....... 396,153 265,296 130,857  
14 Information technology ...... 508,689 395,695 112,994  
15 Royalties .. 0      
16 Occupancy ........... 1,484,590 1,283,575 201,015  
17 Travel ............ 112,316 95,626 16,690  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 133,105 58,843 74,262  
20 Interest ........... 0      
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 3,409 2,666 743  
23 Insurance .............. 219,901 125,220 94,681  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a ROOM AND BOARD EXPENSE 2,163,361 2,163,361    
b MEDICAL SUPPLIES AND EQUIPMENT 2,256,747 2,256,747    
c MEDICATIONS AND INFUSION THERAPIES 2,263,602 2,263,602    
d PATIENT RELATED COSTS 1,926,997 1,926,997    
e All other expenses 1,805,182 1,131,144 674,038 0
25 Total functional expenses. Add lines 1 through 24e 45,882,322 36,455,823 8,768,906 657,593
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720). 0      
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 5,253,205 1 7,944,090
2 Savings and temporary cash investments ......... 276,200 2 276,200
3 Pledges and grants receivable, net ........... 1,000 3  
4 Accounts receivable, net ............. 4,512,189 4 4,282,528
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6 0
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 71,389 8 56,304
9 Prepaid expenses and deferred charges .......... 664,650 9 349,753
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 1,188,137
b Less: accumulated depreciation ..... 10b 1,095,284 96,262 10c 92,853
11 Investments—publicly traded securities .......... 0 11 7,012
12 Investments—other securities. See Part IV, line 11 ..... 0 12 0
13 Investments—program-related. See Part IV, line 11 ..... 0 13 0
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 206,004 15 1,692,288
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 11,080,899 16 14,701,028
Liabilities 17 Accounts payable and accrued expenses ......... 4,214,467 17 4,247,461
18 Grants payable .................   18  
19 Deferred revenue ................ 62,486 19 52,984
20 Tax-exempt bond liabilities .............   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D..   21  
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22 0
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.................... 91,114 25 125,510
26 Total liabilities. Add lines 17 through 25......... 4,368,067 26 4,425,955
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 6,581,259 27 8,631,563
28 Temporarily restricted net assets ........... 131,573 28 1,643,510
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds ........   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ........... 6,712,832 33 10,275,073
34 Total liabilities and net assets/fund balances ........ 11,080,899 34 14,701,028
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
47,916,670
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
45,882,322
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
2,034,348
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
6,712,832
5
Net unrealized gains (losses) on investments ...............
5
-94
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
-22
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
1,528,009
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
10,275,073
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID: 12000266
Software Version: v2012.1.0
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
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
f
g
(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 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 monetary support
Yes No Yes No Yes No
Total                  

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
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........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . 386,549 1,266,679 633,803 1,088,330 938,597 4,313,958
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...... 38,744,774 42,539,018 45,311,566 45,132,046 45,440,910 217,168,314
3 Gross receipts from activities that are not an unrelated trade or business under section 513.. 39,792 41,375 38,282 36,312 28,261 184,022
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. 39,171,115 43,847,072 45,983,651 46,256,688 46,407,768 221,666,294
7a Amounts included on lines 1, 2, and 3 received from disqualified persons... 0 0 0 0 0 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 0 0 0 0 0
c Add lines 7a and 7b.. 0 0 0 0 0 0
8 Public support (Subtract line 7c from line 6.)           221,666,294
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (f) Total
9 Amounts from line 6... 39,171,115 43,847,072 45,983,651 46,256,688 46,407,768 221,666,294
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 15,937 8,720 5,256 2,607 2,126 34,646
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.           0
c Add lines 10a and 10b. 15,937 8,720 5,256 2,607 2,126 34,646
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.) .. 1,276,696 1,380,507 1,417,624 1,419,226 1,528,098 7,022,151
13 Total support. (Add lines 9, 10c, 11, and 12.).. 40,463,748 45,236,299 47,406,531 47,678,521 47,937,992 228,723,091
14
Section C. Computation of Public Support Percentage
15
15
96.910 %
16
16
96.940 %
Section D. Computation of Investment Income Percentage
17
17
0.020 %
18
18
0.020 %
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Explanation
OTHER INCOME, SCHEDULE A, PART III, LINE 12, DESCRIPTION - CONTRACTED SERVICES, COLUMN A - 1234800, COLUMN B - 1323000, COLUMN C - 1377800, COLUMN D - 1392400, COLUMN E - 1468968, COLUMN F - 6796968; DESCRIPTION - OTHER REVENUE, COLUMN A - 41896, COLUMN B - 57507, COLUMN C - 39824, COLUMN D - 26826, COLUMN E - 59130, COLUMN F - 225183;,
 
 
 
Schedule A (Form 990 or 990-EZ) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......................... Arrow Bullet   $    
Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
AGRACE HOSPICECARE INC
  		Employer identification number

39-1319537
Part I
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
     
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
RESTRICTED
 

     
RESTRICTED
RESTRICTED  
RESTRICTED, RESTRICTED   RESTRICTED

$RESTRICTED


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
AGRACE HOSPICECARE INC
  		Employer identification number

39-1319537
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
     
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
(a) No.
from
Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(see instructions) 		(d)
Date received
 
$    
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
AGRACE HOSPICECARE INC
  		Employer identification number

39-1319537
Part III
Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
(a) No.
from
Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
       
 
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet Complete if the organization is described below.SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.










For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group
totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......    
b Total lobbying expenditures to influence a legislative body (direct lobbying) .......    
c Total lobbying expenditures (add lines 1a and 1b) ...................    
d Other exempt purpose expenditures ........................    
e Total exempt purpose expenditures (add lines 1c and 1d) ...............    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
  If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:    
  Not over $500,00020% of the amount on line 1e.    
  Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.    
  Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.    
  Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.    
  Over $17,000,000$1,000,000.    
       
g Grassroots nontaxable amount (enter 25% of line 1f) .................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ......................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
  Calendar year (or fiscal year
beginning in) 		(a) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable amount          
             
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		         
             
c Total lobbying expenditures          
             
d Grassroots nontaxable amount          
             
e Grassroots ceiling amount
(150% of line 2d, column (e))		          
             
f Grassroots lobbying expenditures          
Schedule C (Form 990 or 990-EZ) 2012


Schedule C (Form 990 or 990-EZ) 2012
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
No
Yes
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
Yes
 
2,036
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
Yes
 
953
i
Other activities? ..........................
Yes
 
2,244
j
Total. Add lines 1c through 1i ...............................
5,233
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered “No” OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
Part IV
Supplemental Information
Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
Description of the activities reported on Lines 1a through 1i Schedule C, Part II-B, Line 1 MEMBERSHIP DUES PAID TO NATIONAL HOSPICE AND PALLIATIVE CARE ORGANIZATION ARE ALLOCATED PARTIALLY TO LOBBYING EXPENSES. IN ADDITION, STAFF PARTICIPATED IN ABOUT 4 HOURS OF DIRECT LEGISLATIVE ADVOCACY WITH STATE LEGISLATORS AND/OR STAFFS. STAFF ATTENDED A 2 DAY CONFERENCE FOR AN ORGANIZATION WHOSE MISSION INCLUDES ADVOCACY FOR HOSPICE AND PALLIATIVE CARE. STAFF SERVES ON BOARD OF THIS HOSPICE AND PALLIATIVE CARE ADVOCACY GROUP.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet Attach to Form 990. SchDMd Bullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate contributions to (during year) ...    
3 Aggregate grants from (during year) .....    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ....................... 2a  
b Total acreage restricted by conservation easements .................. 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register .................... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenues included in Form 990, Part VIII, line 1 ........................SchDMd Bullet $ 0
(ii)
Assets included in Form 990, Part X ..............................SchDMd Bullet $ 88,605
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
PROVIDE WELCOMING ENVIRONMENT
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (c)Two years back (d)Three years back (e)Four years back
1a Beginning of year balance .... 62,026 549,776 472,208 460,319  
b Contributions ........ 22,427   14,510 0  
c Net investment earnings, gains, and losses     66,356 11,889  
d Grants or scholarships .....     0 0  
e Other expenditures for facilities
and programs ........ 		  487,750 3,298 0  
f Administrative expenses ....     0 0  
g End of year balance ...... 84,453 62,026 549,776 472,208  
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet100.000 %
c
Temporarily restricted endowment SchDMd Bullet0 %
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
No
(ii) related organizations ........................
3a(ii)
Yes
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................     0
b Buildings ................       0
c Leasehold improvements ............   3,345 3,053 292
d Equipment ................   883,803 879,847 3,956
e Other .................   300,989 212,384 88,605
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 92,853
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other Securities. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b)Book value (c) Method of valuation:
Cost or end-of-year market value
(1)Financial derivatives    
(2)Closely-held equity interests    
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments—Program Related. See Form 990, Part X, line 13.
(a) Description of investment type (b) Book value (c) Method of valuation:
Cost or end-of-year market value








Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1) INTEREST IN NET ASSETS OF AFFILIATE 1,559,292
(2) DUE FROM AFFILIATES 101,961
(3) CASH SURRENDER VALUE OF LIFE INSURANCE 31,035






Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 1,692,288
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes 0
DUE TO AFFILIATE 28,980
SECURITY DEPOSITS 80,000
MERU AGENCY FUNDS 16,530






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 125,510
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains on investments .......... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b....................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities .......... 2a  
b Prior year adjustments .............. 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d...................... 2e  
3 Subtract line 2e from line 1..................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b....................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
Schedule D (Form 990) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0




SCHEDULE F(Form 990)
Department of the Treasury
Internal Revenue Service
Statement of Activities Outside the United States
Right pointing arrow large image Complete if the organization answered "Yes" to Form 990,Part IV, line 14b, 15, or 16.Right pointing arrow large image Attach to Form 990. Right pointing arrow large image See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Part I
General Information on Activities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 14b.
1
For grantmakers. Does the organization maintain records to substantiate the amount of the grants or
assistance, the grantees’ eligibility for the grants or assistance, and the selection criteria used to award
the grants or assistance? ...................................
2
For grantmakers. Describe in Part V the organization’s procedures for monitoring the use of grant funds outside
the United States.
3
Activites per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.)
(a) Region (b) Number of offices in the region (c) Number of employees, agents, and independent contractors in region (d) Activities conducted in region (by type) (e.g., fundraising, program services, investments, grants to recipients located in the region) (e) If activity listed in (d) is a program service, describe specific type of
service(s) in region		 (f) Total expenditures
for and investments
in region
SUB SAHARAN AFRICA 0 0 GRANTMAKING N/A 29,703
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
           
3a Sub-total .....      
b Total from continuation sheets to Part I ...      
c Totals (add lines 3a and 3b) 0 0 29,703
For Paperwork Reduction Act Notice, see the Instructions for Form 990.Cat. No. 50082W Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 2
Part II
Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered “Yes” to Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed.
1 (a) Name of organization (b) IRS code section
and EIN (if applicable)		 (c) Region (d) Purpose of
grant 		(e) Amount of
cash grant 		(f) Manner of
cash
disbursement 		(g) Amount of
of non-cash
assistance 		(h) Description
of non-cash
assistance 		(i) Method of
valuation
(book, FMV,
appraisal, other)
SUB SAHARAN AFRICA SUPPORT EXPENSES 29,703 WIRE TRANSFER 0   N/A
             
             
             
             
             
             
             
             
             
             
             
             
             
             
             
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter ....MediumBullet
1
3
Enter total number of other organizations or entities .......................MediumBullet
0
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012Page 3
Part III
Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 16.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Region (c) Number of recipients (d) Amount of
cash grant 		(e) Manner of cash
disbursement 		(f) Amount of
non-cash
assistance 		(g) Description
of non-cash
assistance 		(h) Method of
valuation
(book, FMV,
appraisal, other)
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 4
Part IV
Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If “Yes,”the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926)......................................
2 Did the organization have an interest in a foreign trust during the tax year? If “Yes,” the organizationmay be required to file Form 3520, Annual Return to Report Transactions with Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A).......................................
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons with Respect to Certain Foreign Corporations. (see Instructions for Form 5471)..............................
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund. (see Instructions for Form 8621)
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons with Respect to Certain Foreign Partnerships. (see Instructions for Form 8865)....................................
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to file Form 5713, International Boycott Report (see Instructions for Form 5713)................................................
Schedule F (Form 990) 2012
Schedule F (Form 990) 2012
Page 5
Part V
Supplemental Information
Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
Identifier ReturnReference Explanation
Procedures for monitoring use of grant funds Schedule F, Part I, Line 2 AGRACE HOSPICECARE, INC. AND THE MERU HOSPICE IN MERU, KENYA, HAVE CREATED A UNIQUE AND IMPORTANT ALLIANCE. BY SHARING KNOWLEDGE AND RESOURCES, THE TWO ORGANIZATIONS WORK TOGETHER TO ALLEVIATE SUFFERING OF THOSE WITH AIDS AND OTHER TERMINAL ILLNESSES IN SUB-SAHARAN AFRICA. BOTH ARE DEDICATED TO ENHANCING THEIR AWARENESS AND UNDERSTANDING ABOUT CARING FOR DYING PATIENTS AND THEIR FAMILIES. AGRACE HOSPICECARE STAFF, VOLUNTEERS AND COMMUNITY MEMBERS ARE COMMITTED TO RAISING DOLLARS TO HELP PAY FOR MERU HOSPICE STAFF SALARIES, HEALTH INSURANCE AND TRAINING. ALSO, MONEY FOR MEDICAL SUPPLIES, VEHICLE EXPENSE, OFFICE RENT, UTILITIES AND DEMONSTRATION KITCHEN GARDEN. THE MERU HOSPICE IN KENYA IS THE ONLY FOREIGN ORGANIZATION THAT RECEIVES GRANTS FROM AGRACE HOSPICECARE. ALL GRANT PROPOSALS ARE PRESENTED TO THE BOARD OF DIRECTORS, AND THE BOARD OF DIRECTORS APPROVES ALL GRANT AWARDS. THE GRANTS TO THE MERU HOSPICE ARE FUNDED FROM DONATIONS THAT WERE GIVEN DIRECTLY TO AGRACE HOSPICECARE IN SPECIFIC SUPPORT OF THE MERU HOSPICE PARTNERSHIP. AGRACE HOSPICECARE HAS A MERU PARTNERSHIP COMMITTEE THAT MONITORS THE ACTIVITY OF THE MERU HOSPICE. THE MERU PARTNERSHIP COMMITTEE REQUIRES THE MERU HOSPICE TO SUBMIT SEMI-ANNUAL FINANCIAL STATEMENTS, ANNUAL BUDGETS, ANNUAL STATISTICAL REPORTS, AND AN ANNUAL NARRATIVE OF ACCOMPLISHMENTS. THESE STATEMENTS ARE REVIEWED BY THE MERU PARTNERSHIP COMMITTEE AND AGRACE HOSPICECARE'S VICE PRESIDENT OF FINANCE. A CONTRACT IS UPDATED ANNUALLY AND SPECIFIES THE USE OF THE GRANT FUNDS.
Method used to account for expenditures on organization's financial statements Schedule F, Part I, Line 3 SUB SAHARAN AFRICA: ACCRUAL
Method used to account for expenditures on organization's financial statements Schedule F, Part I, Line 3 SUB SAHARAN AFRICA: ACCRUAL
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
Schedule F (Form 990) 2012
Additional Data


Software ID: 12000266
Software Version: v2012.1.0



Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ................
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)JOYCE ZEASMANVP FINANCE (i)
(ii)		 145,568
0 		22,500
0 		696
0 		6,942
0 		21,887
0 		197,593
0 		0
0
(2)DAN CHINVP PUBLIC AFFAIRS - PART YEAR (i)
(ii)		 103,313
0 		18,360
0 		25,118
0 		0
0 		19,110
0 		165,901
0 		0
0
(3)JANE M QUINNVP QUALITY AND COMPLIANCE (i)
(ii)		 120,916
0 		10,300
0 		1,043
0 		5,447
0 		15,389
0 		153,095
0 		0
0
(4)JULIA HOUCKVP HR AND L&D/ACTING PRESIDENT (i)
(ii)		 173,923
0 		34,440
0 		820
0 		8,314
0 		21,494
0 		238,991
0 		0
0
(5)MARCIA M WHITTINGTONVP FOUNDATION & HOLDINGS (i)
(ii)		 90,812
60,541 		13,909
9,273 		283
189 		4,291
2,861 		11,960
7,973 		121,255
80,837 		0
0
(6)BRUCE AGNEBERGCMO (i)
(ii)		 218,223
0 		36,000
0 		3,116
0 		10,000
0 		14,140
0 		281,479
0 		0
0
(7)SUSAN PHILLIPSCEO - PART YEAR (i)
(ii)		 10,793
0 		0
0 		471,639
0 		0
0 		5,727
0 		488,159
0 		18,169
0
(8)DENA GREENMEDICAL DIRECTOR (i)
(ii)		 192,675
0 		300
0 		631
0 		7,954
0 		24,696
0 		226,256
0 		0
0
(9)JULIE SLATTERYVP CLINICAL SERVICES (i)
(ii)		 133,974
0 		16,000
0 		270
0 		2,720
0 		8,304
0 		161,268
0 		0
0
(10)KATHY WILLIAMSMEDICAL DIRECTOR (i)
(ii)		 198,558
0 		300
0 		631
0 		8,023
0 		8,141
0 		215,653
0 		0
0
(11)SUZANNE HOWARDMEDICAL DIRECTOR (i)
(ii)		 175,019
0 		300
0 		844
0 		0
0 		11,238
0 		187,401
0 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
Severance or change-of-control payment Schedule J, Part I, Line 4a SEVERANCE PAYMENTS MADE DURING 2012 WERE: SUSAN PHILLIPS $455,392 AND DAN CHIN $14,739.
Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b LYNNE MYERS PARTICIPATES IN A 457(F) DEFERRED COMPENSATION PLAN UNDER AGRACE HOSPICECARE, INC.
Schedule J (Form 990) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 AGRACE HOSPICECARE PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER THE ORGANIZATION'S CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. SUCH PATIENTS ARE IDENTIFIED BASED ON FINANCIAL INFORMATION OBTAINED FROM THE PATIENT AT THE TIME THEY ENROLL IN THE PROGRAM OR SUBSEQUENT CHANGES TO THEIR FINANCIAL CIRCUMSTANCES. BECAUSE THE ORGANIZATION DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. AGRACE HOSPICECARE'S MISSION, "ENHANCING QUALITY OF LIFE AT THE END OF LIFE", IS FULFILLED BY THE COMPREHENSIVE, COMPASSIONATE CARE WE PROVIDE TO PATIENTS AND FAMILIES FACED WITH LIFE-LIMITING ILLNESS, HELPING THEM TO LIVE AS FULLY AS THEY CAN UNTIL THE END OF LIFE. IN 2012, THE ORGANIZATION PROVIDED CHARITY CARE OF APPROXIMATELY $245,000. MOST PATIENTS AND FAMILIES WANT TO RECEIVE CARE IN THE HOME. MORE THAN 90 PERCENT OF AGRACE HOSPICECARE SERVICES ARE DELIVERED IN PATIENTS' HOMES OR IN HOMELIKE SETTINGS SUCH AS COMMUNITY-BASED RESIDENTIAL FACILITIES, ASSISTED LIVING FACILITIES AND NURSING HOMES. AGRACE HOSPICECARE ALSO MAKES HOSPICE SERVICES AVAILABLE TO PATIENTS IN HOSPITAL SETTINGS. AGRACE HOSPICECARE PROVIDES ALL LEVELS OF CARE TO OUR PATIENTS AND MAINTAINS AN INPATIENT UNIT FOR ACUTE AND RESPITE CARE IN ADDITION TO HAVING A RESIDENCE ON THE AGRACE CAMPUS.
PROGRAM SERVICE DESCRIPTION FORM 990, PART III, LINE 4B FOOD SERVICE: AGRACE HOSPICECARE EMPLOYS TALENTED CHEFS TO PROVIDE OUR PATIENTS AND FAMILIES COMFORTING MEALS COOKED WITH LOCALLY GROWN, FRESH PRODUCE, MEATS AND HERBS. STAFF DIETICIANS WORK WITH THE KITCHEN STAFF TO PREPARE MEALS THAT PROVIDE SUSTENANCE AND COMFORT TO PATIENTS. SOMETIMES A PATIENT WILL NOT BE ABLE TO DIGEST SOLID FOODS, BUT SMALL MEALS CAN BE PREPARED FOR THEM TO ENJOY THE COMFORTS OF THE SMELLS THAT MEALS PROVIDE. IN ADDITION TO PATIENT AND FAMILY MEALS, AGRACE HOSPICECARE FOOD SERVICES MAKES FRESH BAKED GOODS, COFFEE AND TEA AVAILABLE FOR PURCHASE BY STAFF, VOLUNTEERS, GUESTS, EDUCATIONAL EVENT ATTENDEES AND GRIEF SUPPORT GROUPS.
Delegate broad authority to a committee Form 990, Part VI, Section A, Line 1a THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD OF DIRECTORS, EXCEPT THE POWER TO: (A) ELECT OFFICERS OF THE CORPORATION; OR (B) FILL VACANCIES IN THE BOARD OF DIRECTORS OR IN THE EXECUTIVE COMMITTEE; OR (C) AMEND OR REPEAL ANY PROVISION OF THESE BY-LAWS, OR (D) ADOPT PROGRAMS WHICH WOULD INVOLVE CONTINUING ACTIVITY OR SUPPORT BY THE CORPORATION FOR MORE THAN ONE (1) FISCAL YEAR. THE EXECUTIVE COMMITTEE SHALL BE RESPONSIBLE FOR THE ANNUAL EVALUATIONS OF THE PRESIDENT. IN NO EVENT SHALL THE EXECUTIVE COMMITTEE BE AUTHORIZED TO DISSOLVE THE CORPORATION. NO PERSON WHO IS NOT A MEMBER OF THE BOARD OF DIRECTORS MAY SERVE ON THE EXECUTIVE COMMITTEE.
Family/business relationships amongst interested persons Form 990, Part VI, Section A, Line 2 DAVID CULLEN AND MARION WOZNIAK - BUSINESS RELATIONSHIP
Significant changes to organizational documents Form 990, Part VI, Section A, Line 4 THE BYLAWS WERE AMENDED TO INCLUDE THE PRESIDENT/CEO AS AN EX-OFFICIO MEMBER OF THE BOARD WITH VOTING RIGHTS, AND PROVIDES THE AUTHORITY FOR THE PRESIDENT/CEO TO EXECUTE BUSINESS DOCUMENTS.
Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b THE CONTROLLER AND VP OF FINANCE PERFORMED A DETAILED REVIEW OF FORM 990 AND THE RELATED SCHEDULES PRIOR TO FILING THE RETURN. THIS INCLUDED VERIFICATION OF ALL AMOUNTS FOR ACCURACY AND COMPLETENESS. THE FORM AND SCHEDULES WERE ALSO REVIEWED FOR CONTENT, PRESENTATION AND REASONABLENESS. THE ENTIRE FORM 990 IS MADE AVAILABLE TO THE ENTIRE EXECUTIVE LEADERSHIP TEAM AND AN ENTITY SPECIFIC HIGHLIGHTS SUMMARY IS PROVIDED. THE ENTIRE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF DIRECTORS PRIOR TO FILING AND IS ACCOMPANIED BY A 990 HIGHLIGHT SUMMARY. THE AUDIT COMMITTEE REVIEWED THE FORM 990 AND RELATED SCHEDULES FOR REASONABLENESS. REPRESENTATIVES FROM THE ACCOUNTING FIRM OF CROWE HORWATH PREPARED A DETAILED SUMMARY OF THE FORM 990 THAT WAS PRESENTED TO THE BOARD OF DIRECTORS BY CROWE HORWATH.
Conflict of interest policy Form 990, Part VI, Section B, Line 12c DIRECTORS, OFFICERS AND KEY EMPLOYEES (INTERESTED PERSONS) ARE REQUIRED TO ANNUALLY REVIEW THE ORGANIZATION'S CODE OF CONDUCT, INCLUDING THE CONFLICT OF INTEREST POLICY/STATEMENT. INTERESTED PERSONS ARE REQUIRED TO DISCLOSE POTENTIAL OR ACTUAL CONFLICTS WITH THE ORGANIZATION IN WRITING VIA THE ANNUAL QUESTIONNAIRE DISTRIBUTED ELECTRONICALLY TO EACH INTERESTED PERSON. IF A CONFLICT OF INTEREST IS DISCOVERED THAT WAS NOT DISCLOSED BY THE INTERESTED PERSON, THE ISSUE WOULD BE DIRECTED TO THE EXECUTIVE COMMITTEE FOR RESOLUTION. THE EXECUTIVE COMMITTEE IS CHARGED WITH REGULAR REVIEW OF THE INTERESTED PERSONS PRACTICES AND QUESTIONNAIRES REGARDING CONFLICTS OF INTEREST AND SUGGESTS IMPROVEMENTS AS NEEDED. THE CONFLICT OF INTEREST QUESTIONNAIRES ARE REVIEWED BY THE CONTROLLER AND GOVERNANCE COORDINATOR. THE CONTROLLER AND GOVERNANCE COORDINATOR DETERMINE WHETHER A POTENTIAL CONFLICT EXISTS BASED ON THE COMPLETED QUESTIONNAIRES SUBMITTED BY EACH INTERESTED PERSON.
Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a EACH YEAR THE ORGANIZATION GATHERS MARKET DATA FOR DETERMINING COMPENSATION OF THE CHIEF EXECUTIVE OFFICER. THIS INCLUDES BENCHMARKS OF NATIONAL, REGIONAL, AND LOCAL COMPENSATION THAT ARE PROVIDED FROM INDEPENDENT COMPENSATION SURVEYS. IN FEBRUARY OF EACH YEAR, THE VICE PRESIDENT OF WORKFORCE DEVELOPMENT PRESENTS THIS INFORMATION TO THE EXECUTIVE COMMITTEE OF THE BOARD, ALONG WITH A 990 ANALYSIS OF SIMILAR SIZED NON-PROFIT HOSPICES. BASED ON THIS INFORMATION, THE EXECUTIVE COMMITTEE SETS AND APPROVES THE PAY FOR THE CHIEF EXECUTIVE OFFICER FOR THE YEAR AND CONTEMPORANEOUSLY DOCUMENTS THEIR APPROVAL IN WRITING. THIS PROCESS WAS LAST UNDERTAKEN IN FEBRUARY 2013.
Process used to establish compensation of other officers/key employees Form 990, Part VI, Section B, Line 15b EACH YEAR THE ORGANIZATION GATHERS MARKET DATA FOR COMPENSATION OF THE EXECUTIVE LEADERSHIP TEAM. THIS DATA INCLUDES BENCHMARKS OF NATIONAL, REGIONAL, AND LOCAL COMPENSATION THAT ARE PROVIDED FROM INDEPENDENT COMPENSATION SURVEYS. EXECUTIVE LEADERSHIP PAY IS ADJUSTED BASED ON: 1) YEARS OF EXPERIENCE; 2) MARKET DATA FOR THE POSITION; 3) PERFORMANCE; AND 4) MARKET DATA FOR THE 65TH PERCENTILE OF TOTAL COMPENSATION FOR THE POSITION. THE VICE PRESIDENT OF WORKFORCE DEVELOPMENT PRESENTS THE MARKET DATA INFORMATION TO THE EXECUTIVE COMMITTEE OF THE BOARD. BASED ON THIS INFORMATION, THE EXECUTIVE COMMITTEE OF THE BOARD APPROVES THE PAY STRUCTURE FOR THE EXECUTIVE LEADERSHIP TEAM AND ALL OTHER EMPLOYEES AND DOCUMENTS THEIR APPROVAL IN WRITING. THIS PROCESS WAS LAST UNDERTAKEN IN FEBRUARY 2013.
Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104. THESE DOCUMENTS MAY BE MADE AVAILABLE TO THE PUBLIC UPON RECEIPT OF A WRITTEN REQUEST.
AVERAGE HOURS PER WEEK FORM 990, PART VII, SECTION A, LINE 1A, COLUMN (B) ALL AGRACE EMPLOYEES REPORTED ON THIS 990 WORK ON AVERAGE A MINIMUM OF 40 HOURS PER WEEK, BUT IN MOST CASES MORE THAN 40 HOURS PER WEEK.
Other changes in net assets or fund balances Form 990 , Part XI, Line 9 CHANGE IN INTEREST IN NET ASSETS OF AFFLIATE - 1496178; NET ASSETS RELEASED FROM RESTRICTION - 31831;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID: 12000266
Software Version: v2012.1.0
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
AGRACE HOSPICECARE INC
 
Employer identification number

39-1319537
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity
(1) AGRACE HOSPICECARE THRIFT STORE LLC
5395 E CHERYL PARKWAY
MADISON,WI53711
30-0001703 		THRIFT STORE WI 816,054 416,878 AGRACE HOSPICECARE FOUNDATION
 










Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1) AGRACE HOSPICECARE FOUNDATION INC

5395 E CHERYL PARKWAY

MADISON,WI53711
 FUNDRAISING WI 501(C)(3) Type I AHCI
 
Yes
 
(2) AGRACE HOSPICECARE HOLDINGS INC

5395 E CHERYL PARKWAY

MADISON,WI53711
 PROPERTY HOLDING WI 501(C)(3) Type I AHCI
 
Yes
 










For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No












Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
Yes
 
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
Yes
 
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
 
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
Yes
 
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
Yes
 
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) AGRACE HOSPICECARE FOUNDATION INC

 C 547,272 REIMBURSEMENT OF ACTUAL EXPENDITURES
(2) AGRACE HOSPICECARE FOUNDATION INC

 N 1,297,752 WAGES OF EMPLOYEES DEDICATED TO FOUNDATION
(3) AGRACE HOSPICECARE HOLDINGS INC

 K 171,216 ESTIMATE OF TIME AND ACTUAL SALARY
(4) AGRACE HOSPICECARE HOLDINGS INC

 J 1,824,636 PER INTER-COMPANY AGREEMENT


Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation

Additional Data


Software ID: 12000266
Software Version: v2012.1.0