Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Sun Health Colonnade
Employer identification number
45-3137352
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
0 %
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
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......
2,048,481
2,048,481
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
2,048,481
2,048,481
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
389,850
389,850
c
Add lines 7a and 7b..
389,850
389,850
8
Public Support (Subtract line 7c from line 6.)
1,658,631
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
2,048,481
2,048,481
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
0
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
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.)
510,255
510,255
13
Total support (Add lines 9, 10c, 11 and 12.).
2,558,736
2,558,736
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
0 %
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
0 %
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Part III Line 12 The amount recorded on line 12 consistes of two items 500,000 was a write-off of a liability for future healthcare for residents. Sun Health Colonnades actuarial consultants determined that Sun Health Colonnade did not require an additional liability for future healthcare of residents. 10,255 was a refund of a utility deposit.
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
11000218
Software Version:
2011.0.0
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
Sun Health Colonnade
Employer identification number
45-3137352
Identifier
Return Reference
Explanation
Form 990 Part VI
3 and 6
The board of directors retains Sun Health Senior Living, LLC, a related entity, to manage the operation of the facility. Sun Health Senior Living, LLC is member owned by Sun Health Services, Sun Health Colonnades sole member.
Form 990 Part VI
7b
Certain reserve powers are maintained by Sun Health Services, as sole member. These reserved powers include the power to elect the board of directors of the organization, to remove any director upon written notice to such director and to the chairman of the board and to hire or terminate the president and chief executive officer of the organization upon written notice to such individual and the chairman.
Form 990 Part VI
11
The return is prepared by management, reviewed by independent accountants and the audit committee and read by the board of directors before filing.
Form 990 Part VI
12c
On an annual basis board members and management staff are required to submit a conflict of interest questionnaire for board and management review, as appropriate. The questionnaire provides specific instructions that the form must be updated if any situation arises during the year that might constitute a conflict. The audit committee has responsibility for intervening, if necessary, on conflict of interest matters. Any individual found to be in conflict will abstain from the decision making process.
Form 990 Part VI
15
The Management Review Committee, as provided in the organizationss by-laws, has a responsibility for the compensation of all senior management. Annually, salaries of senior management are reviewed and approved by the organizations board of directors. The deliberation and decision of the compensation arrangements is contemporaneously substantiated in the organizations minutes. An independent conpensation consultant is retained by the organization periodically to assist with the determination of the compensation and benefits for all senior management. The compensation process was last undertaken in 2012.
Form 990 Part VI
19
Governing documents and conflict of interest policies are generally not made available to the public. Financial statements are available upon request.
Form 990 Part VII
1
Sun Health Colonnade has a management agreement with Sun Health Senior Living, LLC under which the organization pays 5 of gross revenues, with a minimum amount established, as defined in the agreement. In addition, Sun Health Senior Living, LLC employs all of the personnel who work for the organization and incurs other direct costs on behalf of the organization for which the organization reimburses Sun Health Senior Living, LLC based on actual costs incurred. During the period, the organization incurred management fees and reimbursable expenses totalling 1,157,283.
Form 990 Part III
2
Sun Health Colonnade was granted nonprofit status under section 501c3 of the Internal Revenue Code as of June 24, 2011. As such this is the initial year of operations as a nonprofit organization.
Form 990 Part VI
7a
The organization has a board of directors elected to serve a term of three years or until their resignation or removal. The terms of the directors are staggered such that approximately one-third of the directors are elected each year. Directors are eligible to serve a maximum of three consecutive terms without regard to partial terms due to staggering or the filling of vacancies.
Form 990 Part XI
5
Sun Health Colonnade received its IRS determination letter granting exemption under section 501c3 as of June 24, 2011 so this is the initial filing of Form 990. The amounts listed on line 5 of Part XI are the net assets transferred from the Colonnade partnership at that time.
Form 990 Part VII
1a
These individuals devote weekly time to the following organizations William T. Sellner, 40 hours to Sun Health Services, 6 hours to Sun Health Partners, 4 hours to Sun Health Foundation Ronald D. Guziak, 28 hours to Sun Health Services, 20 hours to Sun Health Foundation and 2 hours to Sun Health Partners Sharon Grambow, 15 hours to Sun Health Colonnade, 15 hours to La Loma Senior Living Services, Inc.,15 hours to Sun Health Grandview Terrace, LLP and 5 hours to Sun Health Services. Mr. Guziak and Mr. Sellner devoted 10 hours to the combined senior living entities including Sun Health Grandview Terrace and La Loma Senior Living. The following board members devoted time to Sun Health Services, a related organization Sandra L. Foell, 2 hours and Richard V. Livengood, 2 hours. The following board members devoted time to Sun Health Foundation, a related organization
Darl Bachmann, 6 hours Sandra L. Foell, 5 hours L. Birt Kellam, 2 hours Cathy E. Ross, 2 hours Janis Ryan, 2 hours and Jon Wohler, 2 hours.
Form 990 Part VI Section A Line 3 and 6 The board of directors retains Sun Health Senior Living, LLC, a related entity, to manage the operation of the facility. Sun Health Senior Living, LLC is member owned by Sun Health Services, Sun Health Colonnades sole member. Form 990 Part VI Section A Line 7b Certain reserve powers are maintained by Sun Health Services, as sole member. These reserved powers include the power to elect the board of directors of the organization, to remove any director upon written notice to such director and to the chairman of the board and to hire or terminate the president and chief executive officer of the organization upon written notice to such individual and the chairman. Form 990 Part VI Section A Line 11 The return is prepared by management, reviewed by independent accountants and the audit committee and read by the board of directors before filing. Form 990 Part VI Section A Line 12c On an annual basis board members and management staff are required to submit a conflict of interest questionnaire for board and management review, as appropriate. The questionnaire provides specific instructions that the form must be updated if any situation arises during the year that might constitute a conflict. The audit committee has responsibility for intervening, if necessary, on conflict of interest matters. Any individual found to be in conflict will abstain from the decision making process. Form 990 Part VI Section A Line 15 The Management Review Committee, as provided in the organizationss by-laws, has a responsibility for the compensation of all senior management. Annually, salaries of senior management are reviewed and approved by the organizations board of directors. The deliberation and decision of the compensation arrangements is contemporaneously substantiated in the organizations minutes. An independent conpensation consultant is retained by the organization periodically to assist with the determination of the compensation and benefits for all senior management. The compensation process was last undertaken in 2012. Form 990 Part VI Section A Line 19 Governing documents and conflict of interest policies are generally not made available to the public. Financial statements are available upon request. Form 990 Part VII Section B Line 1 Sun Health Colonnade has a management agreement with Sun Health Senior Living, LLC under which the organization pays 5 of gross revenues, with a minimum amount established, as defined in the agreement. In addition, Sun Health Senior Living, LLC employs all of the personnel who work for the organization and incurs other direct costs on behalf of the organization for which the organization reimburses Sun Health Senior Living, LLC based on actual costs incurred. During the period, the organization incurred management fees and reimbursable expenses totalling 1,157,283. Form 990 Part III Line 2 Sun Health Colonnade was granted nonprofit status under section 501c3 of the Internal Revenue Code as of June 24, 2011. As such this is the initial year of operations as a nonprofit organization. Form 990 Part VI Line 7a The organization has a board of directors elected to serve a term of three years or until their resignation or removal. The terms of the directors are staggered such that approximately one-third of the directors are elected each year. Directors are eligible to serve a maximum of three consecutive terms without regard to partial terms due to staggering or the filling of vacancies. Form 990 Part XI Line 5 Sun Health Colonnade received its IRS determination letter granting exemption under section 501c3 as of June 24, 2011 so this is the initial filing of Form 990. The amounts listed on line 5 of Part XI are the net assets transferred from the Colonnade partnership at that time. Form 990 Part VII Section A Line 1a These individuals devote weekly time to the following organizations William T. Sellner, 40 hours to Sun Health Services, 6 hours to Sun Health Partners, 4 hours to Sun Health Foundation Ronald D. Guziak, 28 hours to Sun Health Services, 20 hours to Sun Health Foundation and 2 hours to Sun Health Partners Sharon Grambow, 15 hours to Sun Health Colonnade, 15 hours to La Loma Senior Living Services, Inc.,15 hours to Sun Health Grandview Terrace, LLP and 5 hours to Sun Health Services. Mr. Guziak and Mr. Sellner devoted 10 hours to the combined senior living entities including Sun Health Grandview Terrace and La Loma Senior Living. The following board members devoted time to Sun Health Services, a related organization Sandra L. Foell, 2 hours and Richard V. Livengood, 2 hours. The following board members devoted time to Sun Health Foundation, a related organization
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.