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
VISITING NURSE ASSOCIATION OF ENGLEWOOD INC
Employer identification number
32-0352097
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.") .
0
0
0
10,000
8,575
18,575
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......
873,845
7,742,891
9,037,098
17,653,834
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
0
0
873,845
7,752,891
9,045,673
17,672,409
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.)
17,672,409
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...
0
0
873,845
7,752,891
9,045,673
17,672,409
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
188
1,258
1,673
3,119
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
188
1,258
1,673
3,119
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
1,600
1,600
3,200
13
Total support. (Add lines 9, 10c, 11, and 12.)..
0
0
874,033
7,755,749
9,048,946
17,678,728
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
0 %
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:
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
VISITING NURSE ASSOCIATION OF ENGLEWOOD INC
Employer identification number
32-0352097
Return Reference
Explanation
PART VI, SECTION A, LINES 2, 6, 7A & 7B
THE ORGANIZATION IS A NEW JERSEY NONPROFIT CORPORATION FORMED BY ITS TWO (2) MEMBERS, VISITING NURSE ASSOCIATION HEALTH GROUP, INC. AND ENGLEWOOD HOSPITAL AND MEDICAL CENTER. THE ORGANIZATION IS GOVERNED AND CONTROLLED BY A BOARD OF TRUSTEES GENERALLY CONSISTING OF INDIVIDUALS EQUALLY APPOINTED BY ITS TWO (2) MEMBERS. THE TRUSTEES OF THE ORGANIZATION ARE ALSO OFFICERS, DIRECTORS, TRUSTEES OR KEY EMPLOYEES OF THE MEMBER ORGANIZATIONS. THE MEMBERS ALSO MAINTAIN CERTAIN RIGHTS AND POWERS OVER SELECTED DECISIONS MADE BY THE BOARD OF TRUSTEES. SUCH DECISIONS WHICH ARE SUBJECT TO APPROVAL BY THE MEMBERS INCLUDE CHANGES TO THE GOVERNING DOCUMENTS, DISSOLUTION OF THE ORGANIZATION, MERGER OR ASSET ACQUISITION AND/OR DISPOSAL PLANS, BUDGET APPROVALS, DEBT ACQUISITION AND APPOINTMENT OR TERMINATION OF THE CHIEF EXECUTIVE OF THE ORGANIZATION.
PART VI, SECTION B, LINE 11B
THE BOARD OF TRUSTEES OF THE ORGANIZATION HAS DELEGATED RESPONSIBILITY FOR REVIEWING THE FORM 990 TO CERTAIN OFFICERS AND MANAGEMENT OFFICIALS OF THE ORGANIZATION. A COPY OF THE COMPLETED FORM 990 WAS REVIEWED BY THE SELECTED OFFICERS AND MANAGEMENT OFFICIALS OF THE ORGANIZaTION AND PROVIDED TO THE BOARD OF TRUSTEES PRIOR TO SUBMISSION.
PART VI, SECTION B, LINE 15
THE COMPENSATION OF THE CHIEF EXECUTIVE AND OTHER KEY EMPLOYEES OF THE ORGANIZATION IS REVIEWED AND APPROVED BY SELECTED MEMBERS OF THE BOARD OF TRUSTEES AFTER CONSIDERATION OF COMPENSATION ARRANGEMENTS PAID BY SIMILARLY SITUATED ORGANIZATIONS FOR SIMILAR SERVICES, COMPENSATION SURVEYS AND OTHER MATTERS TO DETERMINE THAT NO MORE THAN REASONABLE COMPENSATION IS PAID.
PART VI, SECTION B, LINE 12C
THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY IN PLACE TO ADDRESS ANY AND ALL CONFLICTS THAT ARISE, ARE REPORTED OR ARE OTHERWISE DISCOVERED. ON AN ANNUAL BASIS, ALL MEMBERS OF THE BOARD OF TRUSTEES ALONG WITH ALL MEMBERS OF THE MANAGEMENT TEAM AND CERTAIN OTHER EMPLOYEES ARE PROVIDED A CURRENT COPY OF THE POLICY AND ARE ALSO REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE. THESE QUESTIONNAIRES ARE REVIEWED AND RESOLVED, AS NECESSARY, BY THE BOARD OF TRUSTEES.
PART VI, SECTION C, LINE 19
THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS OF THE ORGANIZATION ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST, ON A DISCRETIONARY BASIS.
PT VI, SECTION A, LINE 3
THE ORGANIZATION HAS ENTERED INTO A MANAGEMENT SERVICES AGREEMENT WITH VISITING NURSE ASSOCIATION HEALTH GROUP, INC. TO PERFORM CERTAIN MANAGEMENT DUTIES. SUCH SERVICES INCLUDE, AMONG OTHER ITEMS, THE PREPARATION OF ANNUAL BUDGETS; THE EXECUTION AND IMPLEMENTATION OF ALL POLICIES AND DIRECTIVES OF THE BOARD OF TRUSTEES; THE ESTABLISHMENT OF RATES AND CHARGES FOR SERVICES RENDERED; THE MAINTENANCE OF ALL PROPER AND APPROPRIATE BOOKS AND RECORDS REGARDING THE BUSINESS AND OPERATIONS; THE PAYMENT OF ALL BILLS FOR SERVICES RENDERED TO THE ORGANIZATION; THE ISSUANCE OF ALL BILLS FOR SERVICES RENDERED; THE PROVISION OF ALL GENERAL ADMINISTRATIVE SERVICES; THE PROPER MAINTENANCE AND IMPLEMENTATION OF ALL NECESSARY AND APPROPRIATE PAYROLL AND HUMAN RESOURCE RECORDS; THE PROVISION OF FINANCIAL AND OTHER REPORTS WITH RESPECT TO THE OPERATIONS OF THE ORGANIZATION; AND THE TIMELY PREPARATION AND SUBMISSION OF COST REPORTS, TAX RETURNS AND OTHER SUCH FILINGS AND SUBMISSIONS AS MAY BE REQUIRED UNDER APPLICABLE LAW.
PT IV, LINE 28
BASED ON THE INSTRUCTIONS TO FORM 990, THE ORGANIZATION BELIEVES THAT PART IV, QUESTION 28 CAN BE ANSWERED NO, AND THAT THE ORGANIZATION DOES NOT NEED TO COMPLETE SCHEDULE L, PART IV. IN THE INTEREST OF COMPLETE DISCLOSURE, HOWEVER, THE FOLLOWING INFORMATION IS PROVIDED: PETER GAYLORD, SHERL BRAND AND JOHN HARZ ARE EMPLOYEES AND OFFICERS OF VISITING NURSE ASSOCIATION HEALTH GROUP, INC. (GROUP). THE GROUP IS AN AFFILIATED NONPROFIT ORGANIZATION THAT IS A FIFTY (50%) PERCENT MEMBER OF THE ORGANIZATION AND PROVIDED MANAGEMENT SERVICES TO THE ORGANIZATION IN THE AMOUNT OF $520,837 IN 2013. THE GROUP IS THE SOLE CORPORATE MEMBER OF VISITING NURSE ASSOCIATION OF CENTRAL JERSEY, INC. (VNACJ). VNACJ PROVIDED SKILLED AND OTHER NURSING SERVICES TO THE ORGANIZATION IN THE AMOUNT OF $35,730 IN 2013.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.