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
THE CHRISTIAN HOME & REHABILITATION CTR
Employer identification number
39-0884514
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.") .
12,204
52,627
21,748
105,339
40,747
232,665
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......
5,873,208
6,161,185
5,401,349
5,080,958
5,199,746
27,716,446
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
33,529
13,846
47,375
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.
5,885,412
6,213,812
5,423,097
5,219,826
5,254,339
27,996,486
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.
574,270
574,270
c
Add lines 7a and 7b..
574,270
574,270
8
Public support (Subtract line 7c from line 6.)
27,422,216
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...
5,885,412
6,213,812
5,423,097
5,219,826
5,254,339
27,996,486
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
15,793
9,035
2,376
270
1,009
28,483
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
15,793
9,035
2,376
270
1,009
28,483
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.)..
5,901,205
6,222,847
5,425,473
5,220,096
5,255,348
28,024,969
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
97.850 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.650 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.100 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.130 %
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
THE CHRISTIAN HOME & REHABILITATION CTR
Employer identification number
39-0884514
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 3
IN 2012, THE HOME ENTERED INTO A MANAGEMENT AGREEMENT WITH AGNESIAN HEALTHCARE, INC., A 501(C)(3) ORGANIZATION. UNDER TERMS OF THE MANAGEMENT AGREEMENT, THE HOME PAYS AGNESIAN HEALTHCARE, INC. 104% OF THE ADMINISTRATORS ANNUAL SALARY AND BENEFITS AND ALSO REIMBURSES AGNESIAN HEALTHCARE, INC. FOR CERTAIN OTHER SUPPORT EXPENSES INCURRED ON BEHALF OF THE HOME. TOTAL EMPLOYEE COMPENSATION UNDER THE AGREEMENT FOR 2013 WAS APPROXIMATELY $117,000.
FORM 990, PART VI, SECTION A, LINE 6
MEMBERS OF THE CORPORATION SHALL BE THE ADULT MEMBERS OF THE FOLLOWING CHURCHES: CHURCHES LOCATED IN WAUPUN, WI; ALTO CHRISTIAN REFORMED CHURCH, ALTO REFORMED CHURCH, BETHEL CHRISTIAN REFORMED CHURCH, EDGEWOOD COMMUNITY CHURCH, EMMANUEL REFORMED CHURCH, FIRST CHRISTIAN REFORMED CHURCH, FIRST REFORMED CHURCH, IMMANUEL LUTHERAN CHURCH, PELLA LUTHERAN CHURCH, ST. JOSEPHS CATHOLIC CHURCH, TRINITY REFORMED CHURCH, AND UNION CONGREGATIONAL CHURCH. CHURCHES LOCATED IN RANDOLPH, WI; FIRST CHRISTIAN REFORMED CHURCH, FIRST REFORMED CHURCH, AND SECOND CHRISTIAN REFORMED CHURCH. BETHEL REFORMED CHURCH IN BRANDON, WI FIRST REFORMED CHURCH IN FREISLAND, WI LIVING HOPE CHRISTIAN REFORMED CHURCH IN FOX LAKE, WI
FORM 990, PART VI, SECTION A, LINE 7A
SPONSORING CHURCHES HAVE THE POWER TO ELECT MEMBERS OF THE GOVERNING BODY.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS REVIEWED BY THE BOARD OF DIRECTORS PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
ANNUALLY THE BOARD REVIEWS TRANSACTIONS FOR POTENTIAL CONFLICT OF INTEREST. BOARD MEMBERS ARE TO NOTIFY THE BOARD PRESIDENT IF ANY SUCH CONFLICTS SHOULD ARISE DURING THEIR TERMS. ONCE A CONFLICT IS IDENTIFIED THE BOARD PRESIDENT WILL DETERMINE THE APPROPRIATE ACTION TO TAKE TO RESOLVE THE CONFLICT. EMPLOYEES SIGN AND ACKNOWLEDGE THAT THEY HAVE RECEIVED A PERSONNEL MANUAL THAT CONTAINS AND EXPLAINS CONFLICTS OF INTEREST SHOULD A CONFLICT OF INTEREST ARISE THEY ARE TO DISCLOSE TO AN OFFICER OF THE CHRISTIAN HOME AS SOON AS POSSIBLE THE EXISTENCE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST SO THAT SAFEGUARDS CAN BE ESTABLISHED TO PROTECT ALL PARTIES.
FORM 990, PART VI, SECTION B, LINE 15
COMPARABILITY DATA WASHA SURVEY OR 3.5% ANNUAL PAY INCREASE. THE PERCENTAGE IS SET BY A PERSONAL COMMITTEE (SUB) OF BOARD MEMBERS WITH APPROVAL BY THE ENTIRE BOARD.
FORM 990, PART VI, SECTION C, LINE 19
UPON REQUEST
FORM 990, PART IX, LINE 11G
OTHER FEES: PROGRAM SERVICE EXPENSES 99,137. MANAGEMENT AND GENERAL EXPENSES 42,525. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 141,662. ANCIL SERV-THERAPY: PROGRAM SERVICE EXPENSES 367,403. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 367,403. ANCIL SERV-PHARMACY: PROGRAM SERVICE EXPENSES 69,092. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 69,092.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.