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
HOMESTEAD HEALTH CENTER INC
Employer identification number
48-0862028
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
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.") .
31,137
4,849
7,574
18,457
6,202
68,219
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......
4,306,318
4,274,677
4,399,293
4,064,555
4,375,631
21,420,474
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.
4,337,455
4,279,526
4,406,867
4,083,012
4,381,833
21,488,693
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
1,000
1,000
2,000
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.
584,720
524,882
604,903
986,810
813,962
3,515,277
c
Add lines 7a and 7b..
584,720
524,882
604,903
987,810
814,962
3,517,277
8
Public Support (Subtract line 7c from line 6.)
17,971,416
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...
4,337,455
4,279,526
4,406,867
4,083,012
4,381,833
21,488,693
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
85,743
162,559
85,732
59,111
39,192
432,337
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
85,743
162,559
85,732
59,111
39,192
432,337
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.)
19,244
36,639
32,709
25,974
20,882
135,448
13
Total support (Add lines 9, 10c, 11 and 12.).
4,442,442
4,478,724
4,525,308
4,168,097
4,441,907
22,056,478
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
81.479 %
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
83.730 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
1.960 %
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
2.190 %
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:
Software Version:
-
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
HOMESTEAD HEALTH CENTER INC
Employer identification number
48-0862028
Identifier
Return Reference
Explanation
BUSINESS RELATIONSHIPS
FORM 990, PART VI, SECTION A, LINE 2
JOHN BREWER AND RICK BAILEY HAVE A BUSINESS RELATIONSHIP.
FORM 990 REVIEW PROCESS
FORM 990, PART VI, SECTION B, LINE 11B
AN INDEPENDENT ACCOUNTING FIRM PREPARES THE FORM 990. THE 990 IS THEN REVIEWED BY THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL. ANY QUESTIONS AND CONCERNS THE ORGANIZATION'S OFFICERS AND ACCOUNTING PERSONNEL HAVE ARE ADDRESSED AND ANY CORRECTIONS OR CLARIFICATIONS ARE MADE, IF NEEDED. THE FINAL FORM 990 WITH ALL REQUIRED SCHEDULES IS THEN PROVIDED TO ALL VOTING MEMBERS OF THE BOARD PRIOR TO FILING THE 990 WITH THE IRS.
CONFLICT OF INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12C
AT THE TIME OF ELECTION AND ANNUALLY THEREAFTER, THE ADMINISTRATOR OR HIS/HER DESIGNEE SHALL PROVIDE TO THE OFFICERS AND TO THE BOARD A COPY OF THE CONFLICT OF INTEREST POLICY AND THE APPLICABLE CONFLICT OF INTEREST DISCLOSURE FORM, WHICH SHALL BE COMPLETED TO IDENTIFY ANY RELATIONSHIPS, POSITIONS OR CIRCUMSTANCES WITH RESPECT TO WHICH IT IS BELIEVED A CONFLICT MAY ARISE. EACH OFFICER AND MEMBER OF THE BOARD OF DIRECTORS SHALL DISCLOSE FULLY AND FRANKLY ANY AND ALL ACTUAL OR POTENTIAL CONFLICTS OR DUALITY OF INTEREST OR RESPONSIBILITY, WHETHER INDIVIDUAL, PERSONAL OR BUSINESS, WHICH MAY EXIST. AN OFFICER OR DIRECTOR WITH A POSSIBLE CONFLICT OF INTEREST MUST DISCLOSE TO THE BOARD ALL FACTS KNOWN TO THE OFFICER OR DIRECTOR RESPECTING THE SUBJECT MATTER OF THE TRANSACTION THAT AN ORDINARILY PRUDENT PERSON WOULD REASONABLY BELIEVE TO BE MATERIAL TO A JUDGMENT ABOUT WHETHER OR NOT TO PROCEED WITH THE TRANSACTION. THE OFFICER OR DIRECTOR WITH A POSSIBLE CONFLICT OF INTEREST IS PROHIBITED FROM PARTICIPATION IN ANY BOARD DELIBERATIONS OR DECISIONS RELATED TO THE TRANSACTION.
COMPENSATION REVIEW
FORM 990, PART VI, SECTION B, LINE 15A
PERFORMANCE EVALUATIONS OF EXEMPT STAFF MEMBERS, MORE SPECIFICALLY THOSE LISTED AS OFFICERS OF THE CORPORATION, TAKE PLACE ANNUALLY AND MORE FREQUENTLY IF THE NEED ARISES. THE ANNUAL PERFORMANCE EVALUATIONS ARE DOCUMENTED AND ARE BASED ON THE FOLLOWING EVALUATION CRITERIA: VOLUME OF WORK, QUALITY OF WORK, JOB KNOWLEDGE, JUDGMENT, USE OF EQUIPMENT, LEARNING ABILITY, REGULAR ATTENDANCE, PUNCTUALITY, INITIATIVE & INTEREST, APPEARANCE, RELATIONSHIP WITH STAFF, RELATIONSHIP WITH SUPERVISOR, RELATIONSHIP WITH CLIENTS, CHARACTER & HABITS ANY SALARY ADVANCEMENT INCLUDES MERIT AND COST OF LIVING ADJUSTMENT (COLA). SALARY RANGES ARE ESTABLISHED BASED ON COMPARABLE POSITIONS AT SIMILAR ORGANIZATIONS. AN ANNUAL PERFORMANCE EVALUATION OF THE ADMINISTRATOR IS CONDUCTED BY THE PRESIDENT OF THE BOARD FOLLOWING A DISCUSSION WITH THE BOARD OF DIRECTORS. THE EVALUATION IS BASED ON CRITERIA SIMILAR TO THE CRITERIA LISTED ABOVE. THE RESULTS OF THE EVALUATION AND ANY RAISES OR BONUSES GIVEN ARE APPROVED AND RECORDED IN THE BOARD MINUTES. AN ANNUAL PERFORMANCE EVALUATION OF THE BUSINESS MANAGER, BASED ON THE CRITERIA ABOVE IS CONDUCTED IN WRITING BY THE ADMINISTRATOR.
AVAILABILITY OF DOCUMENTS
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST IN PERSON AT THE FACILITY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.