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
ALZHEIMERS FAMILY SERVICES INC
Employer identification number
59-3394242
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.") ....
86,611
91,359
65,429
156,151
174,079
573,629
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
0
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
4
Total. Add lines 1 through 3
86,611
91,359
65,429
156,151
174,079
573,629
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)..
20,439
6
Public support. Subtract line 5 from line 4.
553,190
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..
86,611
91,359
65,429
156,151
174,079
573,629
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
729
439
11
7
7
1,193
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
0
0
0
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
119,289
84,634
89,529
3,600
4,660
301,712
11
Total support (Add lines 7 through 10).
876,534
12
Gross receipts from related activities, etc. (see instructions)
..................
12
0
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
63.110 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
65.240 %
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
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......
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.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
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...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
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.)..
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
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
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:
13000248
Software Version:
2013v3.1
-
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
ALZHEIMERS FAMILY SERVICES INC
Employer identification number
59-3394242
Return Reference
Explanation
FORM 990, PART III, LINE 1, ORGANIZATION'S MISSION
(CONTINUED FROM PART III, LINE 1) CAREGIVERS CAN BE A SPOUSE, AN ADULT CHILD, OR EVEN A FRIEND. AFS PROVIDES CURRENT AND UPDATED KNOWLEDGE AND TREATMENT INFORMATION TO THE FAMILY. SERVICES ARE PROVIDED COMMENSURATE WITH THE CAPABILITIES OF THE STAFF AND WITH THE KNOWLEDGE AND APPROVAL OF THE BOARD OF DIRECTORS.
Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee
PURSUANT TO THE ORGANIZATION'S BYLAWS, ARTICLE IX: THE EXECUTIVE COMMITTEE OF THE BOARD SHALL BE COMPOSED OF THE ELECTED OFFICERS OF THE CORPORATION, THE PRESIDENT & CEO OF COVENANT HOSPICE (A RELATED ORGANIZATION), AND THE IMMEDIATE PAST CHAIRPERSON. THE EXECUTIVE DIRECTOR OF THE CORPORATION WILL BE A NON-VOTING MEMBER OF THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL MAKE RECOMMENDATIONS OF ACTION TO THE BOARD; HAVE POWER TO ACT FOR THE BOARD BETWEEN MEETINGS OF THE BOARD, EXCEPT THAT IT MAY NOT MODIFY ANY ACTION TAKEN BY THE BOARD, NOR AMEND, ADOPT OR REPEAL CORPORATION'S BYLAWS; SUCH ACTIONS SHALL BE REPORTED TO THE BOARD AT ITS NEXT REGULAR MEETING; PERFORM SUCH OTHER DUTIES AS THE BOARD FROM TIME TO TIME MAY DEEM EXPEDIENT; A MAJORITY OF THE COMMITTEE SHALL CONSTITUTE A QUORUM; ESTABLISH AND ADVOCATE SUCH AD HOC COMMITTEES AS NEEDED; PROVIDE FINANCIAL OVERSIGHT OF BUDGETARY AND FISCAL PROCEDURES; ASSURE THAT ADEQUATE FINANCIAL CONTROLS ARE CONSISTENTLY EMPLOYED AND ARRANGE FOR AN INDEPENDENT AUDIT ANNUALLY.
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders
THE SOLE MEMBER IS COVENANT HOSPICE, INC., A RELATED ORGANIZATION.
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body
COVENANT HOSPICE, INC. HAS THE AUTHORITY TO APPROVE THE ELECTION OF ALL BOARD MEMBERS OF ALZHEIMER'S FAMILY SERVICES, INC.
Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders
THE FOLLOWING ACTIONS REQUIRE APPROVAL OF COVENANT HOSPICE, INC.: -THE ELECTION OF BOARD MEMBERS OF ALZHEIMER'S FAMILY SERVICES; -AMENDMENTS TO THE BY-LAWS AND ARTICLES OF INCORPORATION OF THE ORGANIZATION; -ANNUAL CAPITAL AND OPERATING BUDGETS OF THE CORPORATION; -INCURRENCE BY ALZHEIMER'S FAMILY SERVICES OF ANY INDEBTEDNESS NOT ALLOWED FOR IN THE APPROVED OPERATING OR CAPITAL BUDGETS OF THE CORPORATION; -TRANSFER BY THE CORPORATION, DURING ANY FISCAL YEAR, OF ANY ASSETS NOT IN THE ORDINARY COURSE OF BUSINESS; -THE SALE, LEASE, OR OTHER TRANSFER OF, OR THE ENTERING INTO OF ANY PARTNERSHIP, JOINT VENTURE, OR OTHER ARRANGEMENT; -THE MERGER OF THE CORPORATION INTO ANOTHER ENTITY OR OF ANOTHER ENTITY INTO THE CORPORATION, OR THE CONSOLIDATION OF THE CORPORATION AND ANY OTHER ENTITY; -THE LIQUIDATION OR DISSOLUTION OF THE CORPORATION; -ANY AFFILIATION AGREEMENT BETWEEN THE CORPORATION AND COVENANT HOSPICE, INC. AND ANY AMENDMENTS THERETO.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
BOTH STAFF AND DESIGNATED BOARD MEMBERS REVIEW THE RETURN BEFORE SIGNING.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
CONFLICT OF INTEREST STATEMENTS ARE SENT ANNUALLY TO MEMBERS OF THE BOARD OF DIRECTORS, AND ALL KEY STAFF MEMBERS REPORTABLE ON THE FORM 990. THE FORMS ARE REVIEWED FOR RESPONSES INDICATING A POSSIBLE CONFLICT OF INTEREST. IN ADDITION, THE DIRECTOR OF ACCOUNTING REVIEWS TRANSACTIONS WITH VENDORS WITH WHICH THE BOARD MAY BE AFFILIATED TO DETERMINE THAT ALL TRANSACTIONS ARE MADE AT ARM'S LENGTH. IF A POSSIBLE CONFLICT IS IDENTIFIED, THE PERSON WITH A CONFLICT IS PROHIBITED FROM PARTICIPATING IN THE BOARD OF DIRECTORS DELIBERATIONS AND DECISIONS IN THE TRANSACTION.
FORM 990, PART VI, LINE 15A, COMPENSATION OF TOP MANAGEMENT OFFICIAL
THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS COMPENSATED BY COVENANT HOSPICE, INC. COVENANT HOSPICE, INC. PROCURES SALARY COMPARABILITY DATA AND HIRES AN INDEPENDENT FIRM TO DO A SALARY COMPARISON FOR ALL SENIOR ADMINISTRATIVE STAFF. THE SALARY COMPARISON WITH THE INDEPENDENT FIRM IS UNDERTAKEN ANNUALLY. THE CEO'S COMPENSATION IS REVIEWED AND APPROVED BY THE COVENANT HOSPICE BOARD WITH INSIGHT GIVEN FROM THE SALARY COMPARISON OF THE INDEPENDENT FIRM. THIS PROCESS IS DONE ANNUALLY AND IS DOCUMENTED. BECAUSE THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS NOT COMPENSATED BY THE FILING ORGANIZATION, THIS QUESTION IS MARKED "NO" IN ACCORDANCE WITH FORM 990 INSTRUCTIONS.
FORM 990, PART VI, LINE 15B, COMPENSATION OF OTHER OFFICERS
THE ORGANIZATION DOES NOT HAVE ANY OTHER OFFICERS WHO RECEIVE COMPENSATION. THEREFORE THIS QUESTION HAS BEEN ANSWERED "NO" IN ACCORDANCE WITH FORM 990 INSTRUCTIONS.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ARE AVAILABLE ON WRITTEN REQUEST.
Form 990, Part IX, Line 11g, Other Expenses
ADMINISTRATIVE FEES - TOTAL EXPENSE: 104181, PROGRAM SERVICE EXPENSE: 98486, MANAGEMENT AND GENERAL EXPENSES: 4855, FUNDRAISING EXPENSES: 840;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.