TY 2012 Form 990PF

- TIN:

Form990-PF

Department of the Treasury
Internal Revenue Service

Return of Private Foundation

or Section 4947(a)(1) Nonexempt Charitable Trust
Treated as a Private Foundation

Note. The foundation may be able to use a copy of this return to satisfy state reporting requirements.

OMB No. 1545-0052

2012

Open to Public Inspection

For calendar year 2012, or tax year beginning 11-01-2012 , and ending 10-31-2013

Name of foundation
THE CONVERSE HOME INC

Number and street (or P.O. box number if mail is not delivered to street address)272 CHURCH ST Room/suite

City or town, state, and ZIP code
BURLINGTON, VT05401

A Employer identification number

03-0179406

B Telephone number (see instructions)

(802) 862-0401

C If exemption application is pending, check here bullet

G Check all that apply: Initial returnInitial return of a former public charity
Final returnAmended return
Address changeName change

D 1. Foreign organizations, check here ............. bullet

2. Foreign organizations meeting the 85% test,
check here and attach computation ........... bullet

H Check type of organization: Section 501(c)(3) exempt private foundation
Section 4947(a)(1) nonexempt charitable trustOther taxable private foundation

I Fair market value of all assets at end
of year (from Part II, col. (c),
line 16) bullet

$11,827,715J Accounting method: Cash Accrual
Other (specify)
(Part I, column (d) must be on cash basis.)

E If private foundation status was terminated
under section 507(b)(1)(A), check here ......... bullet

F If the foundation is in a 60-month termination
under section 507(b)(1)(B), check here ......... bullet

	Analysis of Revenue and Expenses (The total of amounts in columns (b), (c), and (d) may not necessarily equal the amounts in column (a) (see instructions).)	(a) Revenue and expenses per books		(b) Net investment income	(c) Adjusted net income	(d) Disbursements for charitable purposes (cash basis only)


1	Contributions, gifts, grants, etc., received (attach schedule)	15,065
2	Check
3	Interest on savings and temporary cash investments	1,263		1,263	1,263
4	Dividends and interest from securities......	27,791		27,791	27,791
5a	Gross rents..............
b	Net rental income or (loss)
6a	Net gain or (loss) from sale of assets not on line 10
b	Gross sales price for all assets on line 6a
7	Capital gain net income (from Part IV, line 2)...			14,263
8	Net short-term capital gain.........
9	Income modifications...........
10a	Gross sales less returns and allowances
b	Less: Cost of goods sold....
c	Gross profit or (loss) (attach schedule).....
11	Other income (attach schedule).......		4,282,818		4,282,818
12	Total. Add lines 1 through 11........	4,326,937		43,317	4,311,872
13	Compensation of officers, directors, trustees, etc.
14	Other employee salaries and wages......	2,149,770			2,149,770
15	Pension plans, employee benefits.......	232,563			232,563
16a	Legal fees (attach schedule).........
b	Accounting fees (attach schedule).......		4,250		4,250
c	Other professional fees (attach schedule)....		15,601		15,601
17	Interest...............	498,224			498,224
18	Taxes (attach schedule) (see instructions)		168,362		168,362
19	Depreciation (attach schedule) and depletion...		228,763		228,763
20	Occupancy..............	188,399			188,399
21	Travel, conferences, and meetings.......
22	Printing and publications..........
23	Other expenses (attach schedule).......		572,459		572,459
24	Total operating and administrative expenses.
	Add lines 13 through 23..........	4,058,391		0	4,058,391	0
25	Contributions, gifts, grants paid........	0				0
26	Total expenses and disbursements. Add lines 24 and 25	4,058,391		0	4,058,391	0
27	Subtract line 26 from line 12:
a	Excess of revenue over expenses and disbursements	268,546
b	Net investment income (if negative, enter -0-)			43,317
c	Adjusted net income (if negative, enter -0-)...				253,481

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 11289X Form 990-PF (2012)

Form 990-PF (2012)

Page 2

Part II		Balance Sheets	Beginning of year	End of year
Part II		Balance Sheets	(a) Book Value	(b) Book Value	(c) Fair Market Value
	1	Cash—non-interest-bearing...............	97,216	168,756	168,757
	2	Savings and temporary cash investments..........	317,085	417,608	417,608
	3	Accounts receivable 31,467
		Less: allowance for doubtful accounts	54,531	31,467	31,467
	4	Pledges receivable
		Less: allowance for doubtful accounts
	5	Grants receivable.................
	6	Receivables due from officers, directors, trustees, and other
		disqualified persons (attach schedule) (see page 15 of the
		instructions)....................
	7	Other notes and loans receivable (attach schedule)
		Less: allowance for doubtful accounts
	8	Inventories for sale or use...............
	9	Prepaid expenses and deferred charges...........	28,855	29,382	29,382
	10a	Investments—U.S. and state government obligations (attach schedule)
	b	Investments—corporate stock (attach schedule)........	346,083	545,233	545,233
	c	Investments—corporate bonds (attach schedule)........	301,673	432,421	432,421
	11	Investments—land, buildings, and equipment: basis
		Less: accumulated depreciation (attach schedule)
	12	Investments—mortgage loans..............
	13	Investments—other (attach schedule)...........	257,914	32,034	32,034
	14	Land, buildings, and equipment: basis 9,948,848
		Less: accumulated depreciation (attach schedule) 2,276,572	7,815,110	7,672,276	9,500,000
	15	Other assets (describe )	595,924	670,813	670,813
	16	Total assets (to be completed by all filers—see the
		instructions. Also, see page 1, item I)	9,814,391	9,999,990	11,827,715
	17	Accounts payable and accrued expenses..........	225,550	171,262
	18	Grants payable...................
	19	Deferred revenue..................
	20	Loans from officers, directors, trustees, and other disqualified persons
	21	Mortgages and other notes payable (attach schedule)......	7,704,411	7,558,183
	22	Other liabilities (describe )	294,747	328,161
	23	Total liabilities (add lines 17 through 22)..........	8,224,708	8,057,606
		Foundations that follow SFAS 117, check here
		and complete lines 24 through 26 and lines 30 and 31.
	24	Unrestricted....................	1,579,761	1,932,462
	25	Temporarily restricted................
	26	Permanently restricted................	9,922	9,922
		Foundations that do not follow SFAS 117, check here
		and complete lines 27 through 31.
	27	Capital stock, trust principal, or current funds.........
	28	Paid-in or capital surplus, or land, bldg., and equipment fund
	29	Retained earnings, accumulated income, endowment, or other funds
	30	Total net assets or fund balances (see page 17 of the
		instructions)....................	1,589,683	1,942,384
	31	Total liabilities and net assets/fund balances (see page 17 of
		the instructions)..................	9,814,391	9,999,990

Part III	Analysis of Changes in Net Assets or Fund Balances
1	Total net assets or fund balances at beginning of year—Part II, column (a), line 30 (must agree
	with end-of-year figure reported on prior year’s return)...............	1	1,589,683
2	Enter amount from Part I, line 27a.....................	2	268,546
3	Other increases not included in line 2 (itemize)	3	84,155
4	Add lines 1, 2, and 3..........................	4	1,942,384
5	Decreases not included in line 2 (itemize)	5
6	Total net assets or fund balances at end of year (line 4 minus line 5)—Part II, column (b), line 30.	6	1,942,384

Form 990-PF (2012)

Page 3

Part IV

Capital Gains and Losses for Tax on Investment Income

(a) List and describe the kind(s) of property sold (e.g., real estate, 2-story brick warehouse; or common stock, 200 shs. MLC Co.)		(b) How acquired P—Purchase D—Donation	(c) Date acquired (mo., day, yr.)	(d) Date sold (mo., day, yr.)
1 a	INVESTMENTS HELD BY MERCHANTS TRUST	P	2010-10-31	2013-10-31
b
c
d
e

(e) Gross sales price		(f) Depreciation allowed (or allowable)	(g) Cost or other basis plus expense of sale	(h) Gain or (loss) (e) plus (f) minus (g)
a	14,263	0	0	14,263
b
c
d
e

Complete only for assets showing gain in column (h) and owned by the foundation on 12/31/69				(l) Gains (Col. (h) gain minus col. (k), but not less than -0-) or Losses (from col.(h))
(i) F.M.V. as of 12/31/69		(j) Adjusted basis as of 12/31/69	(k) Excess of col. (i) over col. (j), if any
a	0	0	0	14,263
b
c
d
e

2	Capital gain net income or (net capital loss)	If gain, also enter in Part I, line 7 If (loss), enter -0- in Part I, line 7	2	14,263
3	Net short-term capital gain or (loss) as defined in sections 1222(5) and (6):
	If gain, also enter in Part I, line 8, column (c) (see instructions). If (loss), enter -0- in Part I, line 8 . . . . . . . . . . . . . . . .		3

Part V

Qualification Under Section 4940(e) for Reduced Tax on Net Investment Income

(For optional use by domestic private foundations subject to the section 4940(a) tax on net investment income.)

If section 4940(d)(2) applies, leave this part blank.

Was the foundation liable for the section 4942 tax on the distributable amount of any year in the base period? Yes No

If “Yes,” the foundation does not qualify under section 4940(e). Do not complete this part.

1 Enter the appropriate amount in each column for each year; see page 18 of the instructions before making any entries.
(a) Base period years Calendar year (or tax year beginning in)	(b) Adjusted qualifying distributions	(c) Net value of noncharitable-use assets	(d) Distribution ratio (col. (b) divided by col. (c))
2011
2010
2009
2008
2007

2	Total of line 1, column (d) ......................	2
3	Average distribution ratio for the 5-year base period—divide the total on line 2 by 5, or by the number of years the foundation has been in existence if less than 5 years. . .	3
4	Enter the net value of noncharitable-use assets for 2012 from Part X, line 5.....	4
5	Multiply line 4 by line 3.......................	5
6	Enter 1% of net investment income (1% of Part I, line 27b)...........	6
7	Add lines 5 and 6.........................	7	0
8	Enter qualifying distributions from Part XII, line 4..............	8	0
If line 8 is equal to or greater than line 7, check the box in Part VI, line 1b, and complete that part using a 1% tax rate. See the Part VI instructions.

Form 990-PF (2012)

Page 4

Part VI

Excise Tax Based on Investment Income (Section 4940(a), 4940(b), 4940(e), or 4948—see page 18 of the instructions)

1a	Exempt operating foundations described in section 4940(d)(2), check hereand enter “N/A” on line 1.
	Date of ruling or determination letter: 1986-12-19(attach copy of letter if necessary–see instructions)
b	Domestic foundations that meet the section 4940(e) requirements in Part V, check	1	N/A
	hereand enter 1% of Part I, line 27b...................
c	All other domestic foundations enter 2% of line 27b. Exempt foreign organizations enter 4% of Part I, line 12, col. (b)
2	Tax under section 511 (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-)	2	0
3	Add lines 1 and 2............................	3
4	Subtitle A (income) tax (domestic section 4947(a)(1) trusts and taxable foundations only. Others enter -0-).	4
5	Tax based on investment income. Subtract line 4 from line 3. If zero or less, enter -0- .....	5	0
6	Credits/Payments:

a	2012 estimated tax payments and 2011 overpayment credited to 2012	6a
b	Exempt foreign organizations—tax withheld at source.......	6b
c	Tax paid with application for extension of time to file (Form 8868)	6c
d	Backup withholding erroneously withheld ...........	6d

7	Total credits and payments. Add lines 6a through 6d..............		7
8	Enter any penalty for underpayment of estimated tax. Check hereif Form 2220 is attached.		8
9	Tax due. If the total of lines 5 and 8 is more than line 7, enter amount owed.......		9
10	Overpayment. If line 7 is more than the total of lines 5 and 8, enter the amount overpaid...		10
11	Enter the amount of line 10 to be: Credited to 2013 estimated tax0	Refunded	11

Part VII-A

Statements Regarding Activities

During the tax year, did the foundation attempt to influence any national, state, or local legislation or did

Yes

it participate or intervene in any political campaign? ....................

Did it spend more than $100 during the year (either directly or indirectly) for political purposes (see page 19 of

the instructions for definition)?............................

If the answer is “Yes” to 1a or 1b, attach a detailed description of the activities and copies of any materials

published or distributed by the foundation in connection with the activities.

Did the foundation file Form 1120-POL for this year?.....................

Enter the amount (if any) of tax on political expenditures (section 4955) imposed during the year:

(1) On the foundation. bullet

$ (2) On foundation managers. bullet

Enter the reimbursement (if any) paid by the foundation during the year for political expenditure tax imposed

on foundation managers. bullet

Has the foundation engaged in any activities that have not previously been reported to the IRS?.......

If “Yes,” attach a detailed description of the activities.

Has the foundation made any changes, not previously reported to the IRS, in its governing instrument, articles

of incorporation, or bylaws, or other similar instruments? If “Yes,” attach a conformed copy of the changes....

Did the foundation have unrelated business gross income of $1,000 or more during the year?........

If “Yes,” has it filed a tax return on Form 990-T for this year?...................

Was there a liquidation, termination, dissolution, or substantial contraction during the year?.........

If “Yes,” attach the statement required by General Instruction T.

Are the requirements of section 508(e) (relating to sections 4941 through 4945) satisfied either:

By language in the governing instrument, or

By state legislation that effectively amends the governing instrument so that no mandatory directions

that conflict with the state law remain in the governing instrument?................

Yes

Did the foundation have at least $5,000 in assets at any time during the year? If “Yes,” complete Part II, col. (c), and Part XV.

Yes

Enter the states to which the foundation reports or with which it is registered (see instructions)

If the answer is “Yes” to line 7, has the foundation furnished a copy of Form 990-PF to the Attorney

General (or designate) of each state as required by General Instruction G? If “No,” attach explanation .

Yes

Is the foundation claiming status as a private operating foundation within the meaning of section 4942(j)(3)

or 4942(j)(5) for calendar year 2012 or the taxable year beginning in 2012 (see instructions for Part XIV)?

If “Yes,” complete Part XIV.............................

Yes

Did any persons become substantial contributors during the tax year? If “Yes,” attach a schedule listing their names and addresses.

At any time during the year, did the foundation, directly or indirectly, own a controlled entity within the

meaning of section 512(b)(13)? If "Yes," attach schedule. (see instructions) .............

Did the foundation make a distribution to a donor advised fund over which the foundation or a disqualified person had

advisory privileges? If "Yes," attach statement (see instructions).................

Did the foundation comply with the public inspection requirements for its annual returns and exemption application?

Yes

Website address bullet

www.conversehome.com

The books are in care of bullet

LORRAINE TOMLINSON Telephone no. bullet

(802) 862-0401

Located at bullet

272 CHURCH STBURLINGTONVT ZIP+4 bullet

05401

Section 4947(a)(1) nonexempt charitable trusts filing Form 990-PF in lieu of Form 1041 —Check here......... bullet

and enter the amount of tax-exempt interest received or accrued during the year ...... bullet

At any time during calendar year 2012, did the foundation have an interest in or a signature or other authority over

a bank, securities, or other financial account in a foreign country? .................

See instructions for exceptions and filing requirements for Form TD F 90-22.1. If "Yes", enter the name of the foreign country bullet

Form 990-PF (2012)

Page 5

Part VII-B

Statements Regarding Activities for Which Form 4720 May Be Required

File Form 4720 if any item is checked in the “Yes” column, unless an exception applies.

Yes

During the year did the foundation (either directly or indirectly):

(1) Engage in the sale or exchange, or leasing of property with a disqualified person? YesNo

(2) Borrow money from, lend money to, or otherwise extend credit to (or accept it from)

a disqualified person?.........................YesNo

(3) Furnish goods, services, or facilities to (or accept them from) a disqualified person? YesNo

(4) Pay compensation to, or pay or reimburse the expenses of, a disqualified person? YesNo

(5) Transfer any income or assets to a disqualified person (or make any of either available

for the benefit or use of a disqualified person)?.................YesNo

(6) Agree to pay money or property to a government official? (Exception. Check “No”

if the foundation agreed to make a grant to or to employ the official for a period

after termination of government service, if terminating within 90 days.).........YesNo

If any answer is “Yes” to 1a(1)–(6), did any of the acts fail to qualify under the exceptions described in Regulations

section 53.4941(d)-3 or in a current notice regarding disaster assistance (see page 20 of the instructions)?...

Organizations relying on a current notice regarding disaster assistance check here......... bullet

Did the foundation engage in a prior year in any of the acts described in 1a, other than excepted acts,

that were not corrected before the first day of the tax year beginning in 2012?.............

Taxes on failure to distribute income (section 4942) (does not apply for years the foundation was a private

operating foundation defined in section 4942(j)(3) or 4942(j)(5)):

At the end of tax year 2012, did the foundation have any undistributed income (lines 6d

and 6e, Part XIII) for tax year(s) beginning before 2012?...............YesNo

If “Yes,” list the years bullet

20, 20, 20, 20

Are there any years listed in 2a for which the foundation is not applying the provisions of section 4942(a)(2)

(relating to incorrect valuation of assets) to the year’s undistributed income? (If applying section 4942(a)(2)

to all years listed, answer “No” and attach statement—see instructions.) ..............

If the provisions of section 4942(a)(2) are being applied to any of the years listed in 2a, list the years here.

20, 20, 20, 20

Did the foundation hold more than a 2% direct or indirect interest in any business enterprise at

any time during the year?.........................YesNo

If “Yes,” did it have excess business holdings in 2012 as a result of (1) any purchase by the foundation

or disqualified persons after May 26, 1969; (2) the lapse of the 5-year period (or longer period approved

by the Commissioner under section 4943(c)(7)) to dispose of holdings acquired by gift or bequest; or (3)

the lapse of the 10-, 15-, or 20-year first phase holding period? (Use Schedule C, Form 4720, to determine

if the foundation had excess business holdings in 2012.)....................

Did the foundation invest during the year any amount in a manner that would jeopardize its charitable purposes?

Did the foundation make any investment in a prior year (but after December 31, 1969) that could jeopardize its

charitable purpose that had not been removed from jeopardy before the first day of the tax year beginning in 2012?

During the year did the foundation pay or incur any amount to:

(1) Carry on propaganda, or otherwise attempt to influence legislation (section 4945(e))? YesNo

(2) Influence the outcome of any specific public election (see section 4955); or to carry

on, directly or indirectly, any voter registration drive?...............YesNo

(3) Provide a grant to an individual for travel, study, or other similar purposes? YesNo

(4) Provide a grant to an organization other than a charitable, etc., organization described

in section 509(a)(1), (2), or (3), or section 4940(d)(2)? (see instructions)........YesNo

(5) Provide for any purpose other than religious, charitable, scientific, literary, or

educational purposes, or for the prevention of cruelty to children or animals?........YesNo

If any answer is “Yes” to 5a(1)–(5), did any of the transactions fail to qualify under the exceptions described in

Regulations section 53.4945 or in a current notice regarding disaster assistance (see instructions)? ......

Organizations relying on a current notice regarding disaster assistance check here......... bullet

If the answer is “Yes” to question 5a(4), does the foundation claim exemption from the

tax because it maintained expenditure responsibility for the grant?............YesNo

If “Yes,” attach the statement required by Regulations section 53.4945–5(d).

Did the foundation, during the year, receive any funds, directly or indirectly, to pay premiums on

a personal benefit contract?........................YesNo

Did the foundation, during the year, pay premiums, directly or indirectly, on a personal benefit contract?....

If “Yes” to 6b, file Form 8870.

At any time during the tax year, was the foundation a party to a prohibited tax shelter transaction? YesNo

If yes, did the foundation receive any proceeds or have any net income attributable to the transaction? ....

Form 990-PF (2012)

Page 6

Part VIII

Information About Officers, Directors, Trustees, Foundation Managers, Highly Paid Employees,
and Contractors

1 List all officers, directors, trustees, foundation managers and their compensation (see instructions).
(a) Name and address	(b) Title, and average hours per week devoted to position	(c) Compensation (If not paid, enter -0-)	(d) Contributions to employee benefit plans and deferred compensation	(e) Expense account, other allowances
THOMAS LITTLE	PRESIDENT 3.00	0	0	0
10 EAST ALLEN ST WINOOSKI,VT05404	PRESIDENT 3.00	0	0	0
JUDY STROH	TREASURER 3.00	0	0	0
10 POMFRET LANE ESSEX,VT05452	TREASURER 3.00	0	0	0
JUDY CROUSE	TRUSTEE 2.00	0	0	0
259 BROWNS RIVER ROAD ESSEX JCT,VT05452	TRUSTEE 2.00	0	0	0
ESTELLE DEANE	TRUSTEE 2.00	0	0	0
710 WAKE ROBIN DRIVE SHELBURNE,VT05482	TRUSTEE 2.00	0	0	0
NANCY GOODRICH	TRUSTEE 2.00	0	0	0
3219 WAKE ROBIN DR SHELBURNE,VT05482	TRUSTEE 2.00	0	0	0
TOM HEINRICH	SECRETARY 2.00	0	0	0
261 STONE DRIVE COLCHESTER,VT05446	SECRETARY 2.00	0	0	0
CONNIE FELLION	TRUSTEE 2.00	0	0	0
152 HAYES AVENUE SO BURLINGTON,VT05403	TRUSTEE 2.00	0	0	0
DAN STANYON	TRUSTEE 2.00	0	0	0
196 BURNHAM LANE COLCHESTER,VT05446	TRUSTEE 2.00	0	0	0
JODY LANDON	TRUSTEE 2.00	0	0	0
3 CREEK ROAD ESSEX JCT,VT05452	TRUSTEE 2.00	0	0	0
BONNIE FINNIGAN	TRUSTEE 2.00	0	0	0
35 DUBOIS STREET SOUTH BURLINGTON,VT05403	TRUSTEE 2.00	0	0	0

2 Compensation of five highest-paid employees (other than those included on line 1—see instructions). If none, enter “NONE.”
(a) Name and address of each employee paid more than $50,000	(b) Title, and average hours per week devoted to position	(c) Compensation	(d) Contributions to employee benefit plans and deferred compensation	(e) Expense account, other allowances
COLLEEN IRISH	SUPERVISOR 40.00	59,637	3,940	0
319 ROLLIN IRISH ROAD WESTFORD,VT05494	SUPERVISOR 40.00	59,637	3,940	0
LORRAINE TOMLINSON	BUSINESS DIRECTOR 40.00	53,821	4,742	0
70 WOODBURY ROAD BURLINGTON,VT05401	BUSINESS DIRECTOR 40.00	53,821	4,742	0
JOYCE TOUCHETTE	DIRECTOR 40.00	88,494	10,025	0
15 ARLINGTON STREET ESSEX JCT,VT05452	DIRECTOR 40.00	88,494	10,025	0
EILEEN CURTIS	HEAD NURSE 40.00	83,044	11,187	0
95 STONEWALL LANE CHARLOTTE,VT05445	HEAD NURSE 40.00	83,044	11,187	0
KATHERINE GERAGHTY	NURSE 40.00	59,935	5,073	0
31 VOLZ STREET BURLINGTON,VT05401	NURSE 40.00	59,935	5,073	0
Total number of other employees paid over $50,000...................				6

3 Five highest-paid independent contractors for professional services (see instructions). If none, enter "NONE".
(a) Name and address of each person paid more than $50,000	(b) Type of service	(c) Compensation
NONE

Total number of others receiving over $50,000 for professional services............. bullet

Part IX-A

Summary of Direct Charitable Activities

List the foundation’s four largest direct charitable activities during the tax year. Include relevant statistical information such as the number of organizations and other beneficiaries served, conferences convened, research papers produced, etc.		Expenses
1	OPERATION OF LICENSED ASSISTED LIVING RESIDENCE - 66 RESIDENTS	4,058,391
2


3


4

Form 990-PF (2012)

Page 7

Part IX-B

Summary of Program-Related Investments (see instructions)

Describe the two largest program-related investments made by the foundation during the tax year on lines 1 and 2.		Amount
1


2


All other program-related investments. See page 24 of the instructions.
3

Total. Add lines 1 through 3.......................... bullet

Part X

Minimum Investment Return (All domestic foundations must complete this part. Foreign foundations,
see instructions.)

Fair market value of assets not used (or held for use) directly in carrying out charitable, etc.,

purposes:

Average monthly fair market value of securities...................

957,679

Average of monthly cash balances.......................

500,332

Fair market value of all other assets (see instructions)................

Total (add lines 1a, b, and c).........................

1,458,011

Reduction claimed for blockage or other factors reported on lines 1a and

1c (attach detailed explanation) .............

Acquisition indebtedness applicable to line 1 assets..................

Subtract line 2 from line 1d.........................

1,458,011

Cash deemed held for charitable activities. Enter 1 1⁄2% of line 3 (for greater amount, see

instructions) .............................

21,870

Net value of noncharitable-use assets. Subtract line 4 from line 3. Enter here and on Part V, line 4

1,436,141

Minimum investment return. Enter 5% of line 5..................

71,807

Part XI

Distributable Amount (see instructions) (Section 4942(j)(3) and (j)(5) private operating foundations and certain foreign organizations check here bullet

and do not complete this part.)

Minimum investment return from Part X, line 6....................

Tax on investment income for 2012 from Part VI, line 5......

Income tax for 2012. (This does not include the tax from Part VI.)...

Add lines 2a and 2b............................

Distributable amount before adjustments. Subtract line 2c from line 1............

Recoveries of amounts treated as qualifying distributions................

Add lines 3 and 4............................

Deduction from distributable amount (see instructions).................

Distributable amount as adjusted. Subtract line 6 from line 5. Enter here and on Part XIII,

line 1................................

Part XII

Qualifying Distributions (see instructions)

Amounts paid (including administrative expenses) to accomplish charitable, etc., purposes:

Expenses, contributions, gifts, etc.—total from Part I, column (d), line 26 ..........

Program-related investments—total from Part IX-B..................

Amounts paid to acquire assets used (or held for use) directly in carrying out charitable, etc.,

purposes...............................

126,141

Amounts set aside for specific charitable projects that satisfy the:

Suitability test (prior IRS approval required)....................

Cash distribution test (attach the required schedule) .................

Qualifying distributions. Add lines 1a through 3b. Enter here and on Part V, line 8, and Part XIII, line 4

126,141

Foundations that qualify under section 4940(e) for the reduced rate of tax on net investment

income. Enter 1% of Part I, line 27b (see instructions).................

Adjusted qualifying distributions. Subtract line 5 from line 4..............

126,141

Note: The amount on line 6 will be used in Part V, column (b), in subsequent years when calculating whether the foundation qualifies for
the section 4940(e) reduction of tax in those years.

Form 990-PF (2012)

Page 8

Part XIII

Undistributed Income (see instructions)

		(a) Corpus	(b) Years prior to 2011	(c) 2011	(d) 2012
1 Distributable amount for 2012 from Part XI, line 7					0
2 Undistributed income, if any, as of the end of 2012:
a Enter amount for 2011 only.......
b Total for prior years:20, 20, 20
3 Excess distributions carryover, if any, to 2012:
a From 2007.......
b From 2008.......
c From 2009.......
d From 2010.......
e From 2011.......
fTotal of lines 3a through e.........
4Qualifying distributions for 2012 from Part
XII, line 4: $ 126,141
a Applied to 2011, but not more than line 2a
b Applied to undistributed income of prior years (Election required—see instructions)......
c Treated as distributions out of corpus (Election required—see instructions).........
d Applied to 2012 distributable amount.....					126,141
e Remaining amount distributed out of corpus
5 Excess distributions carryover applied to 2012.
(If an amount appears in column (d), the same amount must be shown in column (a).)
6Enter the net total of each column as indicated below:
a Corpus. Add lines 3f, 4c, and 4e. Subtract line 5
b Prior years’ undistributed income. Subtract line 4b from line 2b ...........
c Enter the amount of prior years’ undistributed income for which a notice of deficiency has been issued, or on which the section 4942(a) tax has been previously assessed......
d Subtract line 6c from line 6b. Taxable amount —see instructions ...........
e Undistributed income for 2011. Subtract line 4a from line 2a. Taxable amount—see instructions .............
f Undistributed income for 2012. Subtract lines 4d and 5 from line 1. This amount must be distributed in 2013 ..........					0
7 Amounts treated as distributions out of corpus to satisfy requirements imposed by section 170(b)(1)(F) or 4942(g)(3) (see instructions) .............
8Excess distributions carryover from 2007 not applied on line 5 or line 7 (see instructions) ...
9Excess distributions carryover to 2013. Subtract lines 7 and 8 from line 6a ......
10 Analysis of line 9:
a Excess from 2008....
b Excess from 2009....
c Excess from 2010....
d Excess from 2011....
e Excess from 2012....

Form 990-PF (2012)

Page 9

Part XIV

Private Operating Foundations (see instructions and Part VII-A, question 9)

1a If the foundation has received a ruling or determination letter that it is a private operating
foundation, and the ruling is effective for 2012, enter the date of the ruling....... bullet

1986-12-19

b Check box to indicate whether the organization is a private operating foundation described in section4942(j)(3) or4942(j)(5)

2a Enter the lesser of the adjusted net income from Part I or the minimum investment return from Part X for each year listed ..........	Tax year	Prior 3 years			(e) Total
	(a) 2012	(b) 2011	(c) 2010	(d) 2009	(e) Total
	71,807	58,875	41,346	45,267	217,295
b 85% of line 2a .........	61,036	50,044	35,144	38,477	184,701
c Qualifying distributions from Part XII, line 4 for each year listed .....	126,141	74,974	84,270	77,565	362,950
d Amounts included in line 2c not used directly for active conduct of exempt activities ....
e Qualifying distributions made directly for active conduct of exempt activities. Subtract line 2d from line 2c ....	126,141	74,974	84,270	77,565	362,950
3 Complete 3a, b, or c for the alternative test relied upon:
a “Assets” alternative test—enter:
(1) Value of all assets ......					0
(2) Value of assets qualifying under section 4942(j)(3)(B)(i)					0
b “Endowment” alternative test— enter 2⁄3 of minimum investment return shown in Part X, line 6 for each year listed...	47,871	39,250	33,765	30,178	151,064
c “Support” alternative test—enter:
(1) Total support other than gross investment income (interest, dividends, rents, payments on securities loans (section 512(a)(5)), or royalties) ....					0
(2) Support from general public and 5 or more exempt organizations as provided in section 4942(j)(3)(B)(iii)....					0
(3) Largest amount of support from an exempt organization					0
(4) Gross investment income					0

Part XV

Supplementary Information (Complete this part only if the organization had $5,000 or more in
assets at any time during the year—see instructions.)

1Information Regarding Foundation Managers:

aList any managers of the foundation who have contributed more than 2% of the total contributions received by the foundation
before the close of any tax year (but only if they have contributed more than $5,000). (See section 507(d)(2).)

bList any managers of the foundation who own 10% or more of the stock of a corporation (or an equally large portion of the
ownership of a partnership or other entity) of which the foundation has a 10% or greater interest.

2Information Regarding Contribution, Grant, Gift, Loan, Scholarship, etc., Programs:

Check here bullet

if the foundation only makes contributions to preselected charitable organizations and does not accept
unsolicited requests for funds. If the foundation makes gifts, grants, etc. (see instructions) to individuals or organizations under
other conditions, complete items 2a, b, c, and d.

aThe name, address, and telephone number of the person to whom applications should be addressed:

bThe form in which applications should be submitted and information and materials they should include:

cAny submission deadlines:

dAny restrictions or limitations on awards, such as by geographical areas, charitable fields, kinds of institutions, or other
factors:

Form 990-PF (2012)

Page 10

Part XV

Supplementary Information (continued)

3 Grants and Contributions Paid During the Year or Approved for Future Payment
Recipient	If recipient is an individual, show any relationship to any foundation manager or substantial contributor	Foundation status of recipient	Purpose of grant or contribution	Amount
Name and address (home or business)		Foundation status of recipient	Purpose of grant or contribution	Amount
aPaid during the year

Total ................................. 3a

bApproved for future payment

Total ................................. 3b

Form 990-PF (2012)

Page 11

Part XVI-A

Analysis of Income-Producing Activities

Enter gross amounts unless otherwise indicated.	Unrelated business income		Excluded by section 512, 513, or 514		(e) Related or exempt function income (See instructions.)
1Program service revenue:	(a) Business code	(b) Amount	(c) Exclusion code	(d) Amount	(e) Related or exempt function income (See instructions.)
aFEES FOR CARE					4,282,818
b
c
d
e
f
gFees and contracts from government agencies
2 Membership dues and assessments....
3Interest on savings and temporary cash investments			14	1,263
4 Dividends and interest from securities....			14	27,791
5 Net rental income or (loss) from real estate:
aDebt-financed property......
bNot debt-financed property.....
6Net rental income or (loss) from personal property
7 Other investment income.....
8Gain or (loss) from sales of assets other than inventory
9 Net income or (loss) from special events:
10 Gross profit or (loss) from sales of inventory..
11 Other revenue: a
b
c
d
e
12 Subtotal. Add columns (b), (d), and (e)..				29,054	4,282,818

13Total. Add line 12, columns (b), (d), and (e)..................

134,311,872

(See worksheet in line 13 instructions to verify calculations.)

Part XVI-B

Relationship of Activities to the Accomplishment of Exempt Purposes

Line No.	Explain below how each activity for which income is reported in column (e) of Part XVI-A contributed importantly to the accomplishment of the foundation’s exempt purposes (other than by providing funds for such purposes). (See instructions.)
1(a)	THE EXEMPT PURPOSE OF THE ORGANIZATION IS THE PROVISION OF HOUSING AND
1(a)	CARE FOR ELDERLY INDIVIDUALS. THE FEES FOR CARE ARE RECEIVED TO HELP
1(a)	SUPPORT THIS ACTIVITY.

Form 990-PF (2012)

Page 12

Part XVII

Information Regarding Transfers To and Transactions and Relationships With Noncharitable Exempt Organizations

Did the organization directly or indirectly engage in any of the following with any other organization described in section

Yes

501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations?

Transfers from the reporting foundation to a noncharitable exempt organization of:

(1) Cash...................................

1a(1)

(2) Other assets.................................

1a(2)

Other transactions:

(1) Sales of assets to a noncharitable exempt organization....................

1b(1)

(2) Purchases of assets from a noncharitable exempt organization..................

1b(2)

(3) Rental of facilities, equipment, or other assets.......................

1b(3)

(4) Reimbursement arrangements...........................

1b(4)

(5) Loans or loan guarantees.............................

1b(5)

(6) Performance of services or membership or fundraising solicitations................

1b(6)

Sharing of facilities, equipment, mailing lists, other assets, or paid employees..............

If the answer to any of the above is “Yes,” complete the following schedule. Column (b) should always show the fair market value
of the goods, other assets, or services given by the reporting foundation. If the foundation received less than fair market value
in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received.

(a) Line No.	(b) Amount involved	(c) Name of noncharitable exempt organization	(d) Description of transfers, transactions, and sharing arrangements

Is the foundation directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527?...........YesNo

If “Yes,” complete the following schedule.

(a) Name of organization	(b) Type of organization	(c) Description of relationship

Sign Here

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 taxpayer or fiduciary) is based on all information of which preparer has any knowledge.
				May the IRS discuss this return with the preparer shown below (see instr.)? Yes No
	Signature of officer or trustee	Date	Title

Paid Preparer Use Only	Print/Type preparer's name	Preparer's Signature	Date	Check if self- employed	PTIN
	Firm's name Firm's address			Firm's EIN
				Phone no.

Form 990-PF (2012)

Additional Data

Software ID:
Software Version:

Form 990PF - Special Condition Description:

Special Condition Description

- TIN:

TY 2012 AccountingFeesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
JULOW & WELTIN AUDIT	4,250		4,250

- TIN:

Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

TY 2012 DepreciationSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description of Property	Date Acquired	Cost or Other Basis	Prior Years' Depreciation	Computation Method	Rate / Life (# of years)	Current Year's Depreciation Expense
LAND	1941-06-01	17,496		N/A	100.00
BUILDING	1941-06-01	104,363	104,363	SL	40.00
VARIOUS 1982-1989	1982-10-31	72,505	72,505	SL	15.00
IMPROVEMENTS	1986-10-31	10,356	10,356	SL	15.00
IMPROVEMENTS - NURSES' STATION	1987-07-22	7,451	7,451	SL	10.00
IMPROVEMENTS	1987-10-31	1,171	1,171	SL	10.00
IMPROVEMENTS	1989-12-31	10,283	10,283	SL	15.00
FURNACE	1990-12-31	9,790	9,790	SL	10.00
STAIRS	1990-12-31	1,483	1,452	SL	15.00
CARPETING	1991-12-31	1,765	1,711	SL	10.00
FURNITURE	1991-12-31	2,784	2,784	SL	7.00
IMPROVEMENTS	1991-12-31	2,855	2,855	SL	15.00
EQUIPMENT	1993-03-10	1,903	1,903	SL	10.00
CHIMNEY RENOVATIONS	1993-09-17	5,291	5,291	SL	10.00
KITCHEN HOOD & SYSTEM	1994-02-01	5,287	5,157	SL	10.00
IMPROVEMENTS	1994-03-01	3,168	2,879	SL	20.00	158
WATER HEATER	1994-09-01	2,796	2,796	SL	7.00
ARCHITECT FEES	1994-10-31	33,999	24,480	SL	25.00	1,360
FURN FIXT & EQUIP	1994-10-31	11,147	11,147	SL	7.00
RENOVATIONS	1995-05-01	314,494	219,775	SL	25.00	12,580
FURN FIXT & EQUIP	1995-05-01	4,338	4,338	SL	7.00
FIRE ALARM SYSTEM	1995-05-01	9,940	9,940	SL	10.00
RENOVATIONS	1996-05-01	115,562	75,896	SL	25.00	4,622
FURN FIXT & EQUIP	1996-05-01	9,118	9,118	SL	10.00
FURN FIXT & EQUIP	1997-05-01	4,240	4,240	SL	10.00
CHIMNEY RENOVATIONS	1997-08-01	15,503	9,466	SL	25.00	620
FURN FIXT & EQUIP	1998-05-01	14,077	14,077	SL	7.00
PAVING	1999-07-06	7,864	7,074	SL	15.00	524
FURN FIXT & EQUIP	1999-05-01	6,625	6,625	SL	10.00
HAND RAILS & SPRINKLER SYSTEM	2000-08-31	2,734	2,684	SL	10.00
CHANDELIER	1999-11-09	1,220	1,108	SL	10.00
MISC	1999-12-31	1,104	974	SL	7.00
BUILDING RENOVATIONS	2001-06-27	1,645	1,247	SL	15.00	110
EQUIPMENT	2001-07-25	28,517	28,517	SL	10.00
AC/DC DETECTORS	2002-08-08	3,817	3,817	SL	7.00
OTHER F,F&E	2002-07-11	1,793	1,793	SL	7.00
FRONT/SIDE PORCH	2002-08-08	8,400	5,740	SL	15.00	560
OTHER IMPROVEMENTS	2002-10-16	4,496	3,000	SL	15.00	300
DOOR ALARM	2003-01-22	4,414	4,300	SL	10.00	110
HOT WATER LINES	2003-07-10	4,815	4,498	SL	10.00	317
WIRING	2003-07-10	3,264	2,035	SL	15.00	218
FURNITURE / FIXTURES	2005-03-31	2,565	2,563	SL	7.00
EXPANSION	2005-07-01	8,170,180	1,198,296	SL	50.00	163,404
EXPANSION	2006-02-01	603,974	81,534	SL	50.00	12,079
FURNITURE & FIXTURES	2006-02-01	1,435	1,384	SL	7.00	51
EXPANSION	2007-03-01	56,309	6,381	SL	50.00	1,126
FURNITURE & FIXTURES	2007-03-01	10,068	8,149	SL	7.00	1,438
ROOF OVER DUMPSTERS	2008-10-10	856	351	SL	10.00	86
MISC FURN & FIXT	2008-02-01	868	826	SL	5.00	42
FURNISHINGS & EQUIPMENT	2009-02-01	15,676	11,756	SL	5.00	3,135
EXPANSION EXPENDITURE	2009-09-08	1,771	111	SL	50.00	35
KEYPAD IN COUNTRY KITCHEN	2008-11-10	2,280	456	SL	20.00	114
2ND FLOOR RENOVATIONS	2010-10-21	1,312	174	SL	15.00	87
FURN, FIXT & EQUIP	2010-03-01	39,452	21,040	SL	5.00	7,890
2007 BUICK	2010-11-30	16,556	6,346	SL	5.00	3,311
FURN, FIXT & EQUIP	2011-02-01	28,606	7,152	SL	7.00	4,087
IMPROVEMENTS	2011-10-05	1,204	87	SL	15.00	80
FURN, FIXT & EQUIP	2012-05-01	35,933	2,567	SL	7.00	5,133
FURN,FIXT & EQUIP	2013-02-01	48,404		SL	7.00	5,186
PORCH CHURCH ST SIDE	2013-10-31	37,525		SL	15.00

- TIN:

TY 2012 InvestmentsCorpBondsSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Name of Bond	End of Year Book Value	End of Year Fair Market Value
BOND MUTUAL FUNDS	432,421	432,421

- TIN:

TY 2012 InvestmentsCorpStockSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Name of Stock	End of Year Book Value	End of Year Fair Market Value
STOCK MUTUAL FUNDS	545,233	545,233

- TIN:

TY 2012 InvestmentsOtherSchedule2

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Category/ Item	Listed at Cost or FMV	Book Value	End of Year Fair Market Value
CERTIFICATES OF DEPOSIT		9,922	9,922
MONEY MARKET		22,112	22,112

- TIN:

TY 2012 LandEtcSchedule2

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Category / Item	Cost / Other Basis	Accumulated Depreciation	Book Value	End of Year Fair Market Value
LAND	17,496		17,496
BUILDING, IMROVEMENTS & EQUIPMENT	9,931,352	2,276,572	7,654,780

- TIN:

TY 2012 OtherAssetsSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Beginning of Year - Book Value	End of Year - Book Value	End of Year - Fair Market Value
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446

- TIN:

TY 2012 OtherAssetsSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Beginning of Year - Book Value	End of Year - Book Value	End of Year - Fair Market Value
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446

- TIN:

TY 2012 OtherAssetsSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Beginning of Year - Book Value	End of Year - Book Value	End of Year - Fair Market Value
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446
SECURITY DEPOSITS	286,374	316,715	316,715
RESERVE FOR REPLACEMENTS	301,177	342,652	342,652
RESIDENTS' PETTY CASH ACCOUNTS	8,373	11,446	11,446

- TIN:

TY 2012 OtherExpensesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Revenue and Expenses per Books	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
SEE SCHEDULE	572,459		572,459

- TIN:

TY 2012 OtherIncomeSchedule2

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Revenue And Expenses Per Books	Net Investment Income	Adjusted Net Income
FEES FOR CARE	4,282,818		4,282,818

- TIN:

TY 2012 OtherIncreasesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Amount
UNREALIZED GAIN ON INVESTMENTS	69,892
REALIZED GAIN ON SALE OF INVESTMENTS	14,263

- TIN:

TY 2012 OtherLiabilitiesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Beginning of Year - Book Value	End of Year - Book Value
SECURITY DEPOSITS	286,374	316,715
RESIDENTS' PETTY CASH HELD IN TRUST	8,373	11,446
SECURITY DEPOSITS	286,374	316,715
RESIDENTS' PETTY CASH HELD IN TRUST	8,373	11,446

- TIN:

TY 2012 OtherLiabilitiesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Description	Beginning of Year - Book Value	End of Year - Book Value
SECURITY DEPOSITS	286,374	316,715
RESIDENTS' PETTY CASH HELD IN TRUST	8,373	11,446
SECURITY DEPOSITS	286,374	316,715
RESIDENTS' PETTY CASH HELD IN TRUST	8,373	11,446

- TIN:

TY 2012 OtherProfessionalFeesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
VARIOUS CONSULTING	15,601		15,601

- TIN:

TY 2012 TaxesSchedule

Name:

THE CONVERSE HOME INC

EIN: 03-0179406

Category	Amount	Net Investment Income	Adjusted Net Income	Disbursements for Charitable Purposes
PAYROLL TAXES	168,362		168,362