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
PENNSWOOD VILLAGE
Employer identification number
23-2021541
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.") .
293,538
402,251
334,847
857,022
172,963
2,060,621
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......
25,095,412
25,669,136
26,353,217
26,663,678
25,442,338
129,223,781
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.
25,388,950
26,071,387
26,688,064
27,520,700
25,615,301
131,284,402
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
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.
506,228
506,228
c
Add lines 7a and 7b..
506,228
506,228
8
Public support (Subtract line 7c from line 6.)
130,778,174
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...
25,388,950
26,071,387
26,688,064
27,520,700
25,615,301
131,284,402
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
734,597
725,781
331,881
585,150
694,407
3,071,816
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
734,597
725,781
331,881
585,150
694,407
3,071,816
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.)
..
1,132,169
1,234,866
1,065,713
1,131,605
1,283,342
5,847,695
13
Total support. (Add lines 9, 10c, 11, and 12.)..
27,255,716
28,032,034
28,085,658
29,237,455
27,593,050
140,203,913
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
93.280 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
93.310 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
2.190 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
2.340 %
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
PENNSWOOD VILLAGE
Employer identification number
23-2021541
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
THE ORGANIZATION'S FINANCE COMMITTEE WILL RECEIVE AN ADVANCE COPY OF FORM 990 FOR REVIEW PRIOR TO FILING. THE ORGANIZATION'S FULL BOARD WILL RECEIVE A COPY OF FORM 990 BEFORE THE RETURN IS FILED.
FORM 990, PART VI, SECTION B, LINE 12C
ANNUALLY ALL BOARD MEMBERS AND MANAGEMENT STAFF RECEIVE COPIES OF THE CONFLICT OF INTEREST POLICY AND ARE REQUIRED TO DISCLOSE ANY CONFLICTS THAT MAY EXIST. THIS WOULD INCLUDE CONFLICTS DUE TO FAMILY OR OTHER RELATIONSHIPS. ALL COPIES ARE REVIEWED BY THE EXECUTIVE DIRECTOR AND THE HUMAN RESOURCES DIRECTOR. COPIES OF THE SIGNED ACKNOWLEDGEMENTS FOR STAFF ARE RETAINED IN THE HUMAN RESOURCES OFFICE AND FOR BOARD MEMBERS IN THE EXECUTIVE DIRECTOR'S OFFICE. SHOULD ANY BOARD MEMBER HAVE A CONFLICT, HE OR SHE WOULD RECUSE HIMSELF OR HERSELF FROM ANY DISCUSSIONS AND/OR DECISIONS ON THE CONFLICT. MONITORING OF PROPOSED OR ONGOING TRANSACTIONS FOR POTENTIAL CONFLICTS IS UNDERTAKEN THROUGH INTERNAL CONTROLS ESTABLISHED IN THE FINANCE DEPARTMENT. SPENDING AUTHORITY POLICIES EXIST TO CONTROL WHO HAS THE AUTHORITY TO ENCUMBER PENNSWOOD VILLAGE AND THE EXTENT TO WHICH THEY ARE ABLE TO DO SO. STAFF WITH SPENDING AUTHORITY ARE REQUIRED TO ANNUALLY COMPLETE CONFLICT OF INTEREST STATEMENTS AND TO DISCLOSE ANY CONFLICTS THAT MAY EXIST. STAFF MONITOR PROPOSED AND COMPLETED TRANSACTIONS TO DETERMINE IF A CONFLICT MAY EXIST. ANY CONCERNS ARE BROUGHT TO THE ATTENTION OF THE CFO FOR REVIEW AND ACTION, IF NECESSARY. IF A CONFLICT IS DETERMINED THE CONFLICTING PARTIES WILL BE NOTIFIED AND THE TRANSACTION HALTED. GROSS VIOLATIONS OF THE CONFLICT OF INTEREST MAY RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION.
FORM 990, PART VI, SECTION B, LINE 15
THE ORGANIZATION'S BOARD CONDUCTS AN ANNUAL REVIEW OF THE EXECUTIVE DIRECTOR AND SETS COMPENSATION BASED ON PERFORMANCE WHICH IS CONSISTENT WITH COMPETITIVE SALARY DATA. THE COMPETITIVE SALARY DATA IS PROVIDED BY INDEPENDENT THIRD PARTY COMPENSATION CONSULTANTS AND LEADING AGE, THE NATIONAL ASSOCIATION FOR SENIOR LIVING FACILITIES. THE COMPENSATION REVIEW IS DOCUMENTED IN BOARD MINUTES. THE CFO IS REVIEWED BY THE EXECUTIVE DIRECTOR AND SALARY IS SET ACCORDING TO COMPETITIVE SALARY DATA. THE BOARD REVIEWS AND SETS SALARY OF THE CFO.
FORM 990, PART VI, SECTION C, LINE 19
THE CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS, AND GOVERNING DOCUMENTS ARE PLACED FOR PUBLIC REVIEW IN THE ORGANIZATION'S LIBRARY OR ADMINISTRATIVE OFFICES AND ARE ALSO AVAILABLE UPON REQUEST.
FORM 990, PART XI, LINE 9:
CHANGE IN UNREALIZED GAINS (LOSSES) ON DERIVATIVE FINANCIAL INSTRUMENTS 1,506,850. CHANGE IN VALUE OF SPLIT INTEREST AGREEMENT 95,153.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.