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
HOSPICE OF THE TWIN CITIES INC
Employer identification number
03-0464240
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.") .
34,182
28,326
29,748
31,821
34,636
158,713
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......
8,816,348
7,623,117
7,377,465
7,156,014
5,813,756
36,786,700
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.
8,850,530
7,651,443
7,407,213
7,187,835
5,848,392
36,945,413
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.)
36,945,413
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...
8,850,530
7,651,443
7,407,213
7,187,835
5,848,392
36,945,413
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
26,430
29,379
15,992
56,106
72,185
200,092
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
26,430
29,379
15,992
56,106
72,185
200,092
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.)..
8,876,960
7,680,822
7,423,205
7,243,941
5,920,577
37,145,505
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
99.460 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.490 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.540 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.510 %
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
HOSPICE OF THE TWIN CITIES INC
Employer identification number
03-0464240
Return Reference
Explanation
FORM 990, PART III, LINE 2
HOSPICE OF THE TWIN CITIES IS PARTNERING WITH MVNA ON A NEW PROGRAM, ADVANCED ILLNESS MANAGEMENT (AIM). AIM IS A PROFESSIONAL HEALTH CARE CONSULTATIVE SERVICE PROVIDED IN THE HOME SETTING FOR OLDER ADULTS FOCUSED ON SYMPTOM MANAGEMENT, DISEASE MANAGEMENT EDUCATION, PSYCHOSOCIAL SUPPORT, CONNECTION TO COMMUNITY RESOURCES AND SPIRITUAL CARE. AIM ALSO PROVIDES SUPPORT TO CAREGIVERS. THIS IS A PALLIATIVE CARE PROGRAM.
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF THE CORPORATION SHALL BE THE MVNA, A MINNESOTA NONPROFIT CORPORATION EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED (THE "CODE").
FORM 990, PART VI, SECTION A, LINE 7A
THE MEMBER HAS RESERVED TO ITSELF CERTAIN POWERS CONCERNING THE GOVERNANCE OF THE ORGANIZATION. THIS INCLUDES THE APPOINTMENT AND REMOVAL OF THE DIRECTORS OF THE BOARD OF DIRECTORS OF THE ORGANIZATION WITH OR WITHOUT CAUSE AND THE APPROVAL OF THE ELECTION OR APPOINTMENT OF THE CORPORATION'S BOARD OF OFFICERS AND CORPORATE OFFICERS.
FORM 990, PART VI, SECTION A, LINE 7B
THE SOLE MEMBER MUST APPROVE ANY AMENDMENTS MADE TO THE ORGANIZATION'S CERTIFICATE OF INCORPORATION. THE MEMBER HAS RESERVED ITSELF THE FOLLING POWERS CONCERNING THE GOVERNANCE OF THE CORPORATION: THE APPOINTMENT AND REMOVAL OF THE DIRECTORS OF THE BOARD OF DIRECTORS OF THE CORPORATION WITH OR WITHOUT CAUSE; THE APPROVAL OF THE ELECTION OR APPOINTMENT OF THE CORPORATION'S BOARD OFFICERS AND CORPORATE OFFICERS; THE APPROVAL OF ALL AMENDMENTS PROPOSED BY THE CORPORATION'S BOARD OF DIRECTORS OF THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS BEFORE SUCH AMENDMENTS BECOME EFFECTIVE; IN ADDITION THE MEMBER MAY PROPOSE TO THE CORPORATION'S BOARD OF DIRECTORS TO AMEND, REPEAL OR RESTATE ALL OR ANY PORTION OF THE CORPORATION'S ARTICLES OF INCORPORATION OR BYLAWS. IF SUCH PROPOSAL IS ADOPTED BY THE CORPORATION'S BOARD OF DIRECTORS, SUCH AMENDMENT SHALL BE RESUBMITTED TO THE MEMBER'S BOARD OF DIRECTORS FOR FINAL APPROVAL BEFORE SUCH AMENDMENT BECOMES EFFECTIVE; THE APPROVAL OF THE CORPORATION'S STRATEGIC PLANS, CAPITAL BUDGETS, OPERATING BUDGETS AND ENTRY INTO, AND EXIT FROM, ANY LINE OF BUSINESS; THE APPROVAL OF ANY SALE, LEASE, MORTGAGE, ENCUMBRANCE OR TRANSFER OF ANY OF THE CORPORATION'S ASSETS OVER LIMITS ESTABLISHED FROM TIME TO TIME BY RESOLUTION ADOPTED BY THE MEMBER'S BOARD OF DIRECTORS; THE APPROVAL OF THE INCURRENCE OR THE GUARANTEE OF ANY INDEBTEDNESS IN ANY FORM, INCLUDING ALL OPERATING AND CAPITALIZED LEASES AS DEFINED UNDER GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, BY THE CORPORATION OVER LIMITS ESTABLISHED FROM TIME TO TIME BY RESOLUTION ADOPTED BY THE MEMBER'S BOARD OF DIRECTORS BEFORE ANY SUCH INDEBTEDNESS OBLIGATION CAN BECOME LEGALLY BINDING; THE APPROVAL OF CAPITAL EXPENDITURES, WHETHER BUDGETED OR UNBUDGETED AS RECOMMENDED BY THE CORPORATION, IN EXCESS OF LIMITS ESTABLISHED FROM TIME; THE APPROVAL OF THE CORPORATION'S ACQUISITION OF AN INTEREST IN A SUBSIDIARY OR JOINT VENTURE; THE APPROVAL OF CONTRACTS WHICH OBLIGATE THE CORPORATION TO EXPEND FUNDS IN EXCESS OF LIMITS ESTABLISHED FROM TIME TO TIME BY RESOLUTION ADOPTED BY THE MEMBER'S BOARD OF DIRECTORS; DEVELOPMENT OF POLICIES REGARDING THE IMPLEMENTATION OF ANY OF THE RESERVED POWERS DESCRIBED ABOVE.
FORM 990, PART VI, SECTION B, LINE 11
THE BOARD OF DIRECTORS IS SENT AN ELECTRONIC COPY OF THE FORM 990 FOR REVIEW PRIOR TO A BOARD MEETING. BOARD MEMBERS HAVE AN OPPORTUNITY TO REVIEW, AND THE CEO AND CFO RESPOND TO INQUIRIES. THIS PROCESS IS COMPLETED PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX EXEMPT PURPOSES. EACH BOARD MEMBER IS REQUIRED TO DISCLOSE ANY CONFLICTS. IF A CONFLICT IS BROUGHT TO THE BOARD'S ATTENTION OR IT BECOMES AWARE OF A POTENTIAL CONFLICT, THE BOARD MEMBER MUST REMOVE HIMSELF/HERSELF FROM THE MEETING WHILE INDEPENDENT BOARD MEMBERS VOTE ON THE TRANSACTION OR ARRANGEMENT.
FORM 990, PART VI, SECTION C, LINE 18
THE FORM 1023 IS AVAILABLE UPON REQUEST. THE FORM 990 IS AVAILABLE UPON REQUEST AND AVAILABLE ONLINE AT WWW.GUIDESTAR.ORG.
FORM 990, PART VI, SECTION C, LINE 19
THE FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.