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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
CEDAR LAKE - CHERRYWOOD INC
Employer identification number
20-0659956
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 supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
If the organization did not check a 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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
29,401
29,436
30,009
27,267
28,025
144,138
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......
22,151
21,196
21,831
24,271
23,513
112,962
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.
51,552
50,632
51,840
51,538
51,538
257,100
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
29,401
29,436
30,009
27,267
28,025
144,138
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
0
c
Add lines 7a and 7b..
29,401
29,436
30,009
27,267
28,025
144,138
8
Public support (Subtract line 7c from line 6.)
112,962
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
51,552
50,632
51,840
51,538
51,538
257,100
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
51
42
20
19
19
151
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
51
42
20
19
19
151
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.)..
51,603
50,674
51,860
51,557
51,557
257,251
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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
43.910 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
42.340 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.060 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.080 %
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
CEDAR LAKE - CHERRYWOOD INC
Employer identification number
20-0659956
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
THE DRAFT OF THE FORM 990 WILL BE REVIEWED BY THE CFO AND DIRECTOR OF FINANCE PRIOR TO SUBMISSION TO THE IRS. THE FORM 990 WILL BE REVIEWED BY THE BOARD OF DIRECTORS AT THE FIRST MEETING POSSIBLE FOLLOWING THE COMPLETION OF THE RETURN, WHICH MAY BE AFTER THE SUBMISSION OF THE RETURN TO THE IRS. THE REVIEW OF THE 990 BY THE BOARD OF DIRECTORS WILL BE DOCUMENTED IN THE MINUTES OF THE BOARD MEETING.
FORM 990, PART VI, SECTION B, LINE 12C
BOARD MEMBERS AND COMMITTEE MEMBERS ARE OBLIGATED TO REPORT ANY POTENTIAL CONFLICT OF INTEREST TO ANY OFFICER OF THE CORPORATION FOR REFERRAL, CONSIDERATION AND RESOLUTION BY THE EXECUTIVE COMMITTEE. IF THE EXECUTIVE COMMITTEE OF THE BOARD DETERMINES THAT A BOARD MEMBER, OFFICER OR COMMITTEE MEMBER HAS FAILED TO PROPERLY DISCLOSE AN ACTUAL OR A POSSIBLE CONFLICT OF INTEREST, THE EXECUTIVE COMMITTEE IS OBLIGATED TO TAKE APPROPRIATE ACTION CONCERNING THE TRANSACTION AND INDIVIDUAL.
FORM 990, PART VI, SECTION B, LINE 15
1. THE COMPENSATION OF THE PERSON IS REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE OF THE ORGANIZATION PROVIDED THAT PERSONS WITH CONFLICTS OF INTEREST WITH RESPECT TO THE COMPENSATION ARRANGEMENT AT ISSUE ARE NOT INVOLVED IN THE REVIEW AND APPROVAL. 2. THE COMPENSATION OF THE PERSON IS REVIEWED AND APPROVED USING DATA AS TO COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. 3. THERE IS CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO THE DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENT.
FORM 990, PART VI, SECTION C, LINE 19
STANDARD PRACTICE IS TO REFER THOSE SEEKING TO REVIEW ANY CEDAR LAKE 990 TO VISIT WWW.GUIDESTAR.ORG TO ACCESS THAT INFORMATION. CEDAR LAKE'S POLICIES, GOVERNING AND FINANCIAL DOCUMENTS ARE MADE AVAILABLE FOR "PUBLIC REVIEW" DURING BUSINESS HOURS UPON REQUEST BUT UNDER OUR CONTROL AND SUPERVISION; THEY ARE NOT DISTRIBUTED FREELY BECAUSE MANY ARE PROPRIETARY IN NATURE. AN ANNUAL REPORT IS MADE WIDELY AVAILABLE TO THE PUBLIC AND PROVIDES SIGNIFICANT AND MEANINGFUL DISCLOSURE FOR THE PUBLIC.
FORM 990, PART XI, LINE 2C, OVERSIGHT OF AUDITORS:
THE PRESIDENT, CFO AND DIRECTOR OF FINANCE REVIEW A DRAFT OF THE AUDIT REPORT IN DETAIL. THE DRAFT COPY OF THE AUDIT REPORT IS PRESENTED TO THE BOARD CHAIR AND TREASURER AND DISCUSSED IN DETAIL WITH THESE REPRESENTATIVES AND MANAGEMENT. AFTER THE DRAFT AUDIT REPORT HAS BEEN APPROVED, THE FINAL AUDIT REPORT IS PRESENTED TO THE FULL BOARD OF DIRECTORS.
FORM 990, PART VII AND SCHEDULE J, PART II
THE PRESIDENT AND CFO ARE EMPLOYEES OF CEDAR LAKE WORKFORCE, LLC. THE ONLY COMPENSATION TO THESE INDIVIDUALS IS PAID TO CEDAR LAKE WORKFORCE, LLC THROUGH CEDAR LAKE LODGE, INC. THE INDIVIDUALS PROVIDE SERVICES TO CEDAR LAKE FOUNDATION, INC., CEDAR LAKE RESIDENCES, INC. AND CEDAR LAKE - HUD FACILITIES VIA A MANAGEMENT CONTRACT WITH CEDAR LAKE LODGE, INC.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.