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
URBAN JACKSONVILLE INC dba AGING TRUE
Employer identification number
23-7024899
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.") ....
1,878,315
2,450,117
1,714,924
1,815,807
1,779,660
9,638,823
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
0
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
4
Total. Add lines 1 through 3..
1,878,315
2,450,117
1,714,924
1,815,807
1,779,660
9,638,823
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)..
0
6
Public Support. Subtract line 5 from line 4.
9,638,823
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..
1,878,315
2,450,117
1,714,924
1,815,807
1,779,660
9,638,823
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
0
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
0
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
701,173
358,528
573,384
430,399
385,435
2,448,919
11
Total support (Add lines 7 through 10).
12,087,742
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
79.740 %
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
79.870 %
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......
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.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
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...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
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.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
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
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
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
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
11000144
Software Version:
2011v1.5
-
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
URBAN JACKSONVILLE INC dba AGING TRUE
Employer identification number
23-7024899
Identifier
Return Reference
Explanation
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
Form 990, Part VI, Line 15b
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
THERE ARE PRESENTLY NO OTHER PAID OFFICERS OF THE ORGANIZATION OR KEY EMPLOYEES AS DEFINED BY THE IRS.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
THE ORGANIZATION HAS A FORMAL CONFLICT OF INTEREST POLICY AND CONFLICT DISCLOSURE PROCEDURE. EACH NEW BOARD MEMBER AND OFFICER RECEIVES AS PART OF THEIR ORIENTATION MATERIALS A COPY OF THE CONFLICT OF INTEREST POLICY AND CONFLICT DISCLOSURE PROCEDURE AND RECEIVES TRAINING ON WHAT CONSTITUTES A CONFLICT OF INTEREST. EACH BOARD MEMBER AND OFFICER MUST COMPLETE AN ANNUAL AFFIRMATION OF COMPLIANCE AND DISCLOSURE STATEMENT, AND AGREES TO REPORT ANY FUTURE POTENTIAL CONFLICTS OF INTEREST TO THE CHAIRMAN OF THE BOARD. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, THE BOARD MEMBER OR OFFICER MUST DISCLOSE ALL MATERIAL FACTS TO THE BOARD OF DIRECTORS FOR THEIR REVIEW AND CONSIDERATION. WHEN A MOTION OR ISSUE IS RAISED IN A BOARD MEETING WHICH CONTAINS POSSIBLE CONFLICTS, THE SPECIFIC BOARD MEMBER MUST ABSTAIN FROM ALL DELIBERATIONS AND VOTING ON THE ISSUE OR TRANSACTION. ALL ACTUAL OR POSSIBLE CONFLICTS OF INTEREST BY OTHER MANAGERS OR EMPLOYEES OTHER THAN BOARD MEMBERS OR OFFICERS MUST BE DISCLOSED TO A COMPLIANCE COMMITTEE, WHO THEN WOULD REPORT ANY SIGNIFICANT ISSUES TO THE BOARD.
Form 990, Part VI, Line 11
Form 990, Part VI, Line 11: Form 990 Review Process
THE FINAL VERSION OF THE FORM 990 IS EMAILED TO, AND REVIEWED BY THE CEO/EXECUTIVE DIRECTOR AND ALL MEMBERS OF THE BOARD OF DIRECTORS BEFORE IT IS FILED.
Client Note 1 - FORM 990 PART III STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTSPROGRAM 1. (EXPENSES $1,516,064)URBAN JACKSONVILLE, INC. IS AN APPROVED ACHC AND MEDICARE CERTIFIED HOME HEALTH AGENCY AND PROVIDES HOME HEALTH SERVICES PRIMARILY TO ELDERLY AND HANDICAPPED PERSONS. SERVICES INCLUDE SKILLED NURSING; PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY; MEDICAL SOCIAL WORK SERVICES; AND HOME HEALTH AIDE SERVICES. DURING THE YEAR ENDED 09/30/2012, 281 CLIENTS WERE SERVED.PROGRAM 2: (EXPENSES $1,332,629)THE MEALS ON WHEELS PROGRAM PROVIDES QUALIFIED ELDERLY OR DISABLED PEOPLE WITH HOT, NUTRITIOUS MEALS DELIVERED TO THEIR HOMES EACH DAY. 249,556 MEALS WERE DELIVERED DURING THE YEAR ENDED 9/30/2012.PROGRAM 3: (EXPENSES $1,136,310)CASE MANAGEMENT SERVICES DETERMINES THE NEEDS OF THE ELDERLY THROUGH AN ASSESSMENT PROCESS, DEVELOPS A PLAN FOR SERVICES WHICH ADDRESSES THESE NEEDS, ARRANGES AND COORDINATES ALL AGREED UPON SERVICES, AND MONITORS THE QUALITY AND EFFECTIVENESS OF THE SERVICES PROVIDED. THE ORGANIZATION PROVIDED 27,414 HOURS OF CASE MANAGEMENT SERVICES DURING THE YEAR ENDED 9/30/2012.ALL OTHER PROGRAMS: (EXPENSES $7,668,074)OTHER PROGRAM SERVICES INCLUDE A NUMBER OF PROGRAMS THAT ARE DESIGNED TO MAINTAIN THE ELDERLY AND DISABLED IN THEIR OWN HOMES FOR AS LONG AS POSSIBLE, AVOIDING PREMATURE INSTITUTIONALIZATION. THIS INCLUDES VARIOUS PROGRAM SERVICES INCLUDING ASSISTED LIVING, HOMEMAKING, MEDICAL TRANSPORTATION, COUNSELING, COMPANIONSHIP, SHOPPING ASSISTANCE, ADULT DAY CARE, RESPITE, SPECIALIZED MEDICAL EQUIPMENT, EMERGENCY ALERT RESPONSE, AND CAREGIVER TRAINING AND SUPPORT.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.