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
GROUP HOMES OF FORSYTH INC
Employer identification number
56-1097900
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.") ....
1,038,654
1,032,862
1,026,101
1,018,270
148,801
4,264,688
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
1,038,654
1,032,862
1,026,101
1,018,270
148,801
4,264,688
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.
4,264,688
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..
1,038,654
1,032,862
1,026,101
1,018,270
148,801
4,264,688
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
1,267
931
83
43
2
2,326
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).
4,267,014
12
Gross receipts from related activities, etc. (see instructions)
..................
12
4,912,428
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
99.950 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
99.900 %
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:
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
GROUP HOMES OF FORSYTH INC
Employer identification number
56-1097900
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
FORM 990 IS PROVIDED TO EACH BOARD MEMBER BY E-MAIL FOR REVIEW PRIOR TO FILING THE ORGANIZATION'S CERTIFIED PUBLIC ACCOUNTANT IS INVITED TO ATTEND THE NEXT BOARD MEETING TO DISCUSS THE 990 IF THERE ARE ANY UNCLEAR ISSUES.
FORM 990, PART VI, SECTION B, LINE 12C
EACH MEMBER OF THE BOARD OF DIRECTORS SIGNS A CONFLICT OF INTEREST POLICY ANNUALLY PURSUANT TO THE BYLAWS. BOARD MEMBERS ARE REQUIRED EACH YEAR TO DISCLOSE ANY CONFLICT OF INTEREST AND SIGN A DISCLOSURE AND CONFIDENTIALITY AGREEMENT.
FORM 990, PART VI, SECTION B, LINE 15A
THE BOARD OF DIRECTORS REVIEWS ALL SALARIES OF UPPER MANAGEMENT. A PERFORMANCE EVALUATION IS COMPLETED FOR EACH INDIVIDUAL, AND THE BOARD FOLLOWS A COMPENSATION PLAN FOR IMPLEMENTING INCREASES. THE ORGANIZATION ALSO PARTICIPATES IN A NATIONAL SURVEY FOR REVIEW OF CHANGES IN THE SALARY MARKET TO REMAIN COMPETITIVE.
FORM 990, PART VI, SECTION C, LINE 19
ALL DOCUMENTS ARE IN THE BOARD OF DIRECTOR'S HANDBOOK; COPIES ARE AVAILABLE UPON REQUEST. THE QUALITY IMPROVEMENT/ QUALITY ASSURANCE COMMITTEE IS RESPONSIBLE FOR THE ANNUAL REVIEW.
FORM 990, EXPLANATION OF THE ORGANIZATION'S MISSION AND PROGRAM SERVICES:
GROUP HOMES OF FORSYTH, INC. HAS BEEN SERVING INTELLECTUAL/DEVELOPMENTAL DISABLED ADULTS SINCE 1974. IT IS OUR BELIEF THAT INDIVIDUALS WHO HAVE DEVELOPMENTAL DISABILITIES HAVE THE INHERENT RIGHT TO STRIVE TO FULFILL THEIR POTENTIAL AS HUMAN BEINGS. WE BELIEVE THAT MANY FROM THIS POPULATION HAVE THE COGNITIVE ABILITY TO LEARN THE SKILLS NECESSARY TO OBTAIN SELF-SUFFICIENCY AND EVENTUALLY BE ABLE TO LIVE INDEPENDENTLY. GHF'S EXPERIENCE IN THIS FIELD WITH THIS TARGET POPULATION IS AN INTERNAL ACCELERATOR. OUR STAFF IS FAMILIAR WITH THE BARRIERS THIS POPULATION FACES AS THEY ARE EQUIPPED WITH THE KNOWLEDGE AND ABILITY TO TEACH AND ASSIST THESE INDIVIDUALS TO TRAVEL THE ROAD TO BECOMING SELF-SUFFICIENT. THE AGENCY HAS EXPERIENCE WITH WRITING PCP PLANS AND DEVELOPING TARGETED GOALS TO INCREASE SKILL BUILDING, CONFIDENCE, AND SATISFACTION. GROUP HOMES OF FORSYTH, INC. IS A PRIVATE, NONPROFIT CORPORATION ESTABLISHED IN 1974 WHICH SERVES THE AREA OF FORSYTH, STOKES, AND DAVIE COUNTY. PRIMARY POPULATION CONSISTS OF DIAGNOSIS OF INTELLECTUAL DEVELOPMENTAL DISABILITIES OR DUAL DIAGNOSIS. GROUP HOMES OF FORSYTH, INC. OPERATES SEVEN (7) GROUP HOMES, SIX IN FORSYTH COUNTY AND ONE IN STOKES COUNTY. RESIDENTS OF THE COMMUNITY HOMES RECEIVE ON-SITE, 24-HOUR DIRECT SUPERVISION AND SUPPORT. THE PRIMARY FOCUS IS TO INTEGRATE INDIVIDUALS INTO THE COMMUNITY INDIVIDUALS WHO CHOOSE SUPPORTED LIVING MAY LIVE IN AN APARTMENT OR HOME THAT THEY LEASE OR OWN OR IN AN APARTMENT OR HOME LEASED BY A THIRD PARTY. THE AGENCY OFFERS FOUR COMPENSATORY EDUCATIONAL CLASSROOMS IN COLLABORATION WITH FORSYTH TECHNICAL COMMUNITY COLLEGE. THE CLASSES ARE ARRANGED ACCORDING TO LEVELS OF COGNITIVE ABILITY AND PREFERENCE. THE PROGRAM OFFERS AN ART/THEATER CURRICULUM, CONTINUING EDUCATION, INDEPENDENT SKILL BUILDING, EMPLOYMENT TRAINING AND SENIOR SERVICE CURRICULUM. IN ADDITION TO HOUSING AND EDUCATION, THE AGENCY PROVIDES NC INNOVATIONS WAIVER. AT THE PRESENT TIME GROUP HOMES OF FORSYTH, INC. SERVES 38 INDIVIDUALS IN THE RESIDENTIAL PROGRAM, 38 INDIVIDUALS IN THE COMPENSATORY PROGRAM AND 80 IN THE COMMUNITY GUIDE PROGRAM. CURRENTLY, THE AGENCY IS LICENSED FOR DAY ACTIVITY THROUGH THE DEPARTMENT OF MENTAL HEALTH LICENSURE AND MAINTAINS CARF ACCREDITATION AND CONTRACT WITH CENTERPOINT HUMAN SERVICES AND PARTNERS BEHAVIORAL HEALTH. ONSITE TRAINER FOR CPR, FIRST AID, NCI, CLIENTS RIGHTS, CONFIDENTIALITY, OSHA, FOOD SAFETY, DOCUMENTATION DATA AND COLLECTION, LICENSED RN AND PHARMACIST MONITORING. 156 INDIVIDUALS SERVED IN ALL 4 PROGRAMS. IN 2010-2012, THERE WAS A TOTAL OF 3 VACANCIES AND 6 CONSUMERS ARE CURRENTLY ON THE WAIT LIST FOR SERVICES. OUR GOAL IS TO CREATE A MEANINGFUL AND EFFECTIVE RETURN OF PREVIOUSLY INSTITUTIONALIZED RESIDENTS INTO THE COMMUNITY; AND TO PREVENT UNNECESSARY INSTITUTIONALIZATION OF THE RESIDENTS OF OUR COMMUNITY WHO HAVE DEVELOPMENTAL DISABILITIES. THIS IS ACCOMPLISHED BY ADMISSION INTO OUR COMMUNITY RESIDENTIAL PROGRAMS WHERE PEOPLE ARE PROVIDED WITH LIFE-SKILLS TRAINING AND AFFORDED AN OPPORTUNITY FOR FULL DEVELOPMENT AND MAXIMUM INDEPENDENCE. ALL CONSUMERS ARE BELOW THE POVERTY LINE OF INCOME AND DO NOT HAVE RESOURCES TO MAKE IT ON THEIR OWN. CONSUMERS ARE PROVIDED PERIODIC PHYSICAL AND DENTAL EXAMINATIONS. OTHER MEDICAL NEEDS, SUCH AS SPEECH AND PHYSICAL THERAPY OR PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT ARE ADDRESSED AS NEEDED THROUGH COMMUNITY SERVICES. THE PRIMARY RESPONSIBILITIES OF GROUP HOMES ARE TO ENSURE THE BASIC NEEDS OF ALL ARE AVAILABLE AND PROTECTED TO ENCOURAGE INDIVIDUALIZED DEVELOPMENT. THE PROGRAM PLAN IS REINFORCED BY TRAINING IN THE HOME AND COMMUNITY. STAFF SHALL ENSURE THAT ACTIVITIES ARE SUITABLE FOR THE AGES, INTERESTS, AND TREATMENT/HABILITATION NEEDS OF THE CLIENTS AND CLIENTS SHALL PARTICIPATE IN THE PLANNING OR DETERMINING OF ACTIVITIES WHICH ARE OF INTEREST TO THE CONSUMER. THE AGENCY PRIDES ITSELF ON HELPING INDIVIDUALS TO BECOME SELF-RELIANT, CONTRIBUTING MEMBERS OF THEIR COMMUNITY BUILT ON RECOGNITION OF SELF-RESPECT, HOPE, AND THE ABILITY TO LOOK FOR THE NEED BEHIND THE PROBLEM. GROUP HOMES IS ACTIVELY MEETING THE NEEDS OF THE COMMUNITY BY PROVIDING HOUSING, TRAINING, AND PROTECTION FOR THOSE WHO MAY OR MAY NOT HAVE SUPPORT TO LIVE A PRODUCTIVE LIFE. WE ARE MEETING THE NEEDS OF MANY IN THE FOLLOWING AREAS OF: HOUSING, MEDICAL CARE, INDEPENDENCE, PERSONAL AND PROFESSIONAL GROWTH, AND THE RIGHT TO LIVE AND FUNCTION IN A COMMUNITY WITH RESPECT AND DIGNITY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.