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
BETHANY LUTHERAN HOMES INC
Employer identification number
39-0909446
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
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
BETHANY LUTHERAN HOMES INC
Employer identification number
39-0909446
Return Reference
Explanation
FORM 990 - ORGANIZATION'S MISSION
BETHANY LUTHERAN HOMES, INC. (THE ORGANIZATION) IS A BENEVOLENT CONTINUUM OF CARE RETIREMENT COMMUNITY COMPRISED OF NUMEROUS FACILITIES AND COMMUNITY OUTREACH PROGRAMS DESIGNED TO MEET THE CARE NEEDS OF THE ELDERLY AND DISABLED IN THE LA CROSSE, WI AREA. BETHANY IS A NON-PROFIT CORPORATION, EXEMPT UNDER INTERNAL REVENUE CODE SECTION 501(C)(3) THROUGH ITS AFFILIATION WITH THE EVANGELICAL LUTHERAN CHURCH OF AMERICA.
FORM 990, PAGE 2, PART III, LINE 4D
COMMUNITY OUTREACH PROGRAMS - PROVIDE AN ARRAY OF SERVICES TO THE COMMUNITY INCLUDING: MOBILE MEALS - DELIVERING OVER 22,000 MEALS ANNUALLY TO THE ELDERLY AND DISABLED IN THEIR HOMES. SAGEN CENTRE - PROVIDE STAFFING AND MANAGEMENT OF A 10 UNIT CBRF WHICH IS OWNED BY GUNDERSEN LUTHERAN, AN AFFILIATED NON-PROFIT ORGANIZATION. INDEPENDENT LIVING APARTMENTS - 20 APARTMENTS PROVIDED 7,231 DAYS OF HOUSING FOR SENIORS IN HOLMEN, WI.
FORM 990, PAGE 6, PART VI, LINE 2
BETHANY LUTHERAN HOMES COULEE BANK DIRECTOR BANK OWNER COMMON BOARD MEMBERSHIP
FORM 990, PAGE 6, PART VI, LINE 6
THE ARTICLES OF INCORPORATION STATES, THE MEMBERSHIP OF THIS CORPORATION CONSISTS OF THE FOLLOWING THREE CLASSES OF VOTING MEMBERS: 1) PUBLIC MEMBERS - CONSISTS OF: ONE MEMBER OF THE CLERGY REPRESENTING EACH MEMBER CHURCH, TWO LAY DELEGATES APPOINTED BY EACH MEMBER CHURCH AND MEMBERS OF THE BOARD OF DIRECTORS. 2) CORPORATE MEMBER - THE SOLE MEMBER OF THIS CLASS IS GUNDERSEN LUTHERAN, INC., A WISCONSIN NON-STOCK, NON-PROFIT CORPORATION. 3) SYNOD MEMBER - THE BISHOP OF THE LACROSSE SYNOD OF THE ELCA OR THE DESIGNEE OF THE SYNOD.
FORM 990, PAGE 6, PART VI, LINE 7A
THE BOARD OF DIRECTORS CONSISTS OF 11 MEMBERS AND IS VESTED WITH POWER TO GOVERN THE AFFAIRS OF THE CORPORATION. EIGHT OF THE BOARD MEMBERS ARE ELECTED BY THE PUBLIC MEMBER CLASS, WHILE THREE BOARD MEMBERS ARE ELECTED OR APPOINTED BY THE CORPORATE MEMBER CLASS. AT LEAST TWO MEMBERS OF THE ENTIRE BOARD OF DIRECTORS SHALL BE MEMBERS OF A MEMBER CHURCH BELONGING TO THE ELCA.
FORM 990, PAGE 6, PART VI, LINE 9
LU CAGIN 738 7TH ST N, SUITE 105 LA CROSSE, WI 54601 DIRK GASTERLAND W5136 KEIL COULEE RD LA CROSSE, WI 54601 CATHY FISCHER 3111 GUNDERSON DR. ONALASKA, WI 54650 JEFF KUMFER 1516 LOSEY BLVD S LA CROSSE, WI 54601 JERRY MILLER N2063 JAY LANE LA CROSSE, WI 54601 BARBARA KRUSE N2445 BRIARWOOD AVE. LA CROSSE, WI 54601 STEVEN TANKE 2130 GRANDVIEW BLVD. ONALASKA, WI 54650 PAMELA MAAS 3190 GUNDERSEN DRIVE, NCA1-03 ONALASKA, WI 54650 ANNE STEKEL 1900 SO. AVE. H03-001 LA CROSSE, WI 54601 RICHARD BERENDES 4817 SOUTH 33RD ST. LA CROSSE, WI 54601
FORM 990, PAGE 6, PART VI, LINE 11B
A DRAFT OF THE FORM 990 IS REVIEWED BY THE BOARD PRESIDENT AND CEO.
FORM 990, PAGE 6, PART VI, LINE 12C
THIS POLICY IS REGULARILY FOLLOWED WITH INSTANCES INVOLVING BOARD MEMBERS AND POTENTIAL CONFLICTS OF INTEREST. SECTION 2.3 OF THE BY-LAWS STATES: A DIRECTOR WHO IS SUBJECT TO A CONFLICT OF INTEREST SHOULD REFRAIN FROM PARTICIPATING IN THE DECISION MAKING PROCESS, AND SHALL, IF REQUESTED BY THE PRESIDENT OR A MAJORITY OF THE BOARD, TEMPORARILY LEAVE THE MEETING IF HIS OR HER PRESENCE INHIBITS THE BOARD'S DISCUSSION.
FORM 990, PAGE 6, PART VI, LINE 15A
EACH YEAR THE EXECUTIVE COMMITTEE OF THE BOARD CONDUCTS A PERFORMANCE REVIEW FOR THE CHIEF EXECUTIVE OFFICER. SALARY AND BENEFIT INFORMATION FROM THE LEADINGAGE AND LEADINGAGE WI ANNUAL SURVEY IS USED TO DETERMINE AN APPROPRIATE SALARY AND BENEFIT RANGE FOR THE CEO. THE EXECUTIVE COMMITTEE APPROVES ANY CHANGES TO THE CEO'S SALARY AND BENEFITS ON AN ANNUAL BASIS. THE PRESIDENT OF THE BOARD EXECUTES ANY COMPENSATION CHANGES IN A WRITTEN LETTER THAT IS GIVEN TO THE HUMAN RESOURCES DIRECTOR OF THE CORPORATION.
FORM 990, PAGE 6, PART VI, LINE 15B
THE PROCESS FOR OTHER KEY EMPLOYEES IS SIMILAR TO THE RESPONSE DESCRIBED IN THE RESPONSE TO QUESTION 15A OF PART VI, SECTION B.
FORM 990, PAGE 6, PART VI, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.