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
MENNO-HAVEN INC
Employer identification number
23-6276101
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.") .
480,295
597,467
397,916
698,096
1,072,972
3,246,746
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......
24,221,786
37,734,090
40,435,759
40,621,935
41,764,636
184,778,206
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
16,132
29,590
43,544
18,527
-5,203
102,590
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.
24,718,213
38,361,147
40,877,219
41,338,558
42,832,405
188,127,542
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
2,690
4,490
3,605
3,210
3,565
17,560
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..
2,690
4,490
3,605
3,210
3,565
17,560
8
Public support (Subtract line 7c from line 6.)
188,109,982
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...
24,718,213
38,361,147
40,877,219
41,338,558
42,832,405
188,127,542
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
167,364
631,151
452,732
693,271
1,804,426
3,748,944
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
167,364
631,151
452,732
693,271
1,804,426
3,748,944
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.)..
24,885,577
38,992,298
41,329,951
42,031,829
44,636,831
191,876,486
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
98.040 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
98.660 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.950 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
1.330 %
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
MENNO-HAVEN INC
Employer identification number
23-6276101
Return Reference
Explanation
FORM 990, PART III, LINE 2
MENNO HAVEN BEGAN AN AT HOME SERVICE CALLED MENNO HAVEN AT HOME BEGINNING JULY 1, 2013. OUR CLIENTS CAN BE INDEPENDENT RESIDENTS OR MEMBERS OF THE COMMUNITY.
FORM 990, PART VI, SECTION A, LINE 2
THE MARKETING DIRECTOR IS DISTANTLY RELATED TO A BOARD MEMBER. THERE HAVE BEEN NO ITEMS THAT WOULD BE CONSIDERED A CONFLICT OF INTEREST.
FORM 990, PART VI, SECTION A, LINE 3
THE ORGANIZATION HAS CONTRACTED WITH A MANAGEMENT COMPANY TO MANAGE AND DIRECT FOOD SERVICES.
FORM 990, PART VI, SECTION A, LINE 7B
MAJOR DECISIONS OF THE GOVERNING BODY ARE APPROVED AND VOTED ON BY OUR BOARD OF DIRECTORS. WRITTEN MINUTES DOCUMENT OUR BOARD OF DIRECTORS MEETINGS, AS WELL AS, ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY.
FORM 990, PART VI, SECTION B, LINE 11
A COPY OF THE FORM 990 WILL BE PROVIDED TO THE BOARD OF DIRECTORS PRIOR TO THE FILING OF THIS FORM.
FORM 990, PART VI, SECTION B, LINE 12C
CONFLICT OF INTEREST FORMS ARE REVIEWED BY THE CEO AND ANY DISCLOSED CONFLICTS ARE DISCUSSED WITH THE EXECUTIVE COMMITTEE OR APPROPRIATE OFFICERS OF THE GOVERNING BODY.
FORM 990, PART VI, SECTION B, LINE 15
COMPENSATION FOR THE CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIALS IS DETERMINED BY A COMPENSATION SURVEY OR STUDY USING PRIMARILY THE LEADING AGE AGENCY WAGE SURVEY OF SIMILAR SIZE FACILITIES. LEADING AGE IS AN ASSOCIATION OF NONPROFIT SENIOR SERVICES IN THE STATE OF PENNSYLVANIA. THE EXECUTIVE COMMITTEE OF THE BOARD ALSO HAS THE LIBERTY TO UTILIZE OTHER SURVEYS OF SIMILAR OPERATIONS IF THEY CHOOSE TO DO SO. COMPENSATION RANGES FOR OTHER OFFICERS AND KEY EMPLOYEES ARE DETERMINED BY A COMPENSATION SURVEY USING THE LEADING AGE PARENT AGENCY WAGE SURVEY. LEADING AGE IS AN ASSOCIATION OF NONPROFIT SENIOR SERVICES IN THE STATE OF PENNSYLVANIA. DISCRESSION OF WHERE THE FALL IN THAT RANGE IS DETERMINED BY THEIR EXPERIENCE AND KNOWLEDGE AND IS DETERMINED BY THEIR SENIOR MANAGER.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGNIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC AT ITS ADMINISTRATIVE OFFICES LOCATED AT 2011 SCOTLAND AVE., CHAMBERSBURG, PA 17201.
FORM 990, PART XI, LINE 9:
CHANGE IN FAIR VALUE OF DERIVATIVES 5,327,969. CHANGE IN VALUE OF PERPETUAL TRUST 236,386.
FORM 990, PART XI, LINE 2C:
THE ORGANIZATION'S FINANCE COMMITTE IS RESPONSIBLE FOR THE OVERSIGHT OF THIS CONSOLIDATED AUDIT AND MAKES RECOMMENDATIONS FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT WHICH IS APPRROVED BY THE FULL BOARD OF DIRECTORS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.