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
AMSTERDAM NURSING HOME CORP (1992)
Employer identification number
13-3834710
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.") .
2,857
88,503
52,777
6,682,692
322,216
7,149,045
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......
54,305,948
57,503,099
54,803,742
54,781,112
56,860,160
278,254,061
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.
54,308,805
57,591,602
54,856,519
61,463,804
57,182,376
285,403,106
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.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
285,403,106
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...
54,308,805
57,591,602
54,856,519
61,463,804
57,182,376
285,403,106
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
113,402
74,656
49,330
27,462
22,513
287,363
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
113,402
74,656
49,330
27,462
22,513
287,363
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.)
..
317,090
287,028
630,695
603,200
724,854
2,562,867
13
Total support. (Add lines 9, 10c, 11, and 12.)..
54,739,297
57,953,286
55,536,544
62,094,466
57,929,743
288,253,336
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
99.010 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
98.950 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.100 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.130 %
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
AMSTERDAM NURSING HOME CORP (1992)
Employer identification number
13-3834710
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
A COPY OF THE FORM 990 AS PREPARED BY LOEB & TROPER LLP, ACCOUNTING FIRM, IS PROVIDED TO THE AUDIT COMMITTEE FOR REVIEW AND COMMENTS AND TO THE FULL BOARD.
FORM 990, PART VI, SECTION B, LINE 12C
A INTERESTED DIRECTOR MEANS ANY AMSTERDAM DIRECTOR WHO HAS AN INTEREST AS A PRINCIPAL, PARTNER, DIRECTOR, OFFICER, EMPLOYEE, AGENT, OR STOCKHOLDER(OTHER THAN A STOCKHOLDER OF A PUBLICLY TRADED CORPORATION WHO STOCK IS WIDELY HELD) OF ANY ENTITY WITH WHICH AMSTERDAM HAS OR CONTEMPLATES TRANSACTING BUSINESS. AN INTERESTED DIRECTOR MUST DISCLOSE THE RELATIONSHIP OR INTEREST IN THE TRANSACTION TO THE BOARD OF DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY.DISCLOSURE SHALL BE MADE TO THE CHAIRMAN OF THE BOARD AS SOON AS THE INTERESTED DIRECTOR BECOME AWARE OF THE POTENTIAL FOR A CONFLICT IN CONNECTION WITH THE TRANSACTION WHO SHALL INFORM THE APPLICABLE BOARD.IF THE CHAIRMAN IN INVOLVED IN THE TRANSACTION, THE CHAIRMAN SHALL ADVISE THE SECRETARY OF THE APPLICABLE AMSTERDAM ENTITY WHO SHALL ARRANGE FOR BOARD DISCLOSURE. NO INTERESTED DIRECTOR SHALL PARTICIPATE IN THE DISCUSSION,DELIBERATIONS AND VOTING REGARDING A TRANSACTION. THE AFFIRMATIVE VOTE OF THE MAJORITY OF ALL THE DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY,EXCLUDED IN SUCH COUNTS THE INTERESTED DIRECTOR,SHALL BE REQUIRED BEFORE ENTERING INTO THE TRANSACTION. NO TRANSACTION SHALL BE INVALIDATED OR AFFECTED IN ANY WAY IF THIS POLICY IS FOLLOWED. ALL OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST. SAID CONFLICTS ARE ADDRESSED BY MANAGEMENT.
FORM 990, PART VI, SECTION B, LINE 15A
FORM 990, PART VI, LINE 15: THE ORGANIZATION HAS A PROCESS TO DETERMINE COMPENSATION FOR THE CEO/ EXECUTIVE DIRECTOR WHICH INCLUDES A REVIEW BY A COMPENSATION AND BENEFITS CONSULTANT, THE USE OF COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN THE DELIBERATION AND THE FINAL DECISION. THIS PROCESS WAS LAST UNDERTAKEN IN 2013. THIS PROCESS INCLUDES A REVIEW OF TOTAL COMPENSATION INCLUDING BONUS CONSIDERATION.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART IX, LINE 11G
PHARMACEUTICAL, PHYSICAL THERAPY AND HUMAN RESOURCE CONSULTING: PROGRAM SERVICE EXPENSES 7,439,442. MANAGEMENT AND GENERAL EXPENSES 423,277. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,862,719.
FORM 990, PART X, LINE 15
OTHER RECEIVABLES $52,755 OTHER ASSETS $147,530 DUE FORM THIRD PARTY PAYOR $3,026,064 SUBVENTION CERTIFICATE FROM $3 ACCHS, INC. TOTAL-OTHER ASSETS $3,226,352
FORM 990, PART XII, LINE 2C:
FORM 990, PART XI, LINE 2C: THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM PRIOR YEARS.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.