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.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
ALLIANCE VISITING NURSES
Employer identification number
25-1764544
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
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—2011.
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—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
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) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(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......
1,757,349
5,373,234
6,214,568
5,447,038
5,427,726
24,219,915
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...
0
0
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
0
0
6
Total. Add lines 1 through 5.
1,757,349
5,373,234
6,214,568
5,447,038
5,427,726
24,219,915
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..
0
0
0
0
0
0
8
Public support (Subtract line 7c from line 6.)
24,219,915
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
1,757,349
5,373,234
6,214,568
5,447,038
5,427,726
24,219,915
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
7
95
112
270
95
579
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
7
95
112
270
95
579
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.)
..
9,618
20,715
17,432
603
285
48,653
13
Total support. (Add lines 9, 10c, 11, and 12.)..
1,766,974
5,394,044
6,232,112
5,447,911
5,428,106
24,269,147
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 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
99.797 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
99.746 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
0.002 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
0.003 %
19a
33 1/3% support tests—2012.
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—2011.
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to 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
The other income received in the fiscal year was miscellaneous.
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
12000197
Software Version:
v1.00
-
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.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
ALLIANCE VISITING NURSES
Employer identification number
25-1764544
Identifier
Return Reference
Explanation
F990_P06_S0A_L04
Form 990, Part VI, Section A, Line 4
VNA Alliance has an additional member. That member is Grove City Medical Center.
F990_P06_S0A_L06
Form 990, Part VI, Section A, Line 6
The members/shareholders are Concordia Visiting Nurses, Wesbury United Methodist Retirement Community, St Paul Homes, Meadville Medical Center, and Grove City Medical Center. Each member/shareholder has a 20% membership/share of Alliance Visiting Nurses.
F990_P06_S0A_L07a
Form 990, Part VI, Section A, Line 7a
Each member/shareholder of Alliance Visiting Nurses may elect or appoint a maximum of 3 (three) board members.
F990_P06_S0A_L07b
Form 990, Part VI, Section A, Line 7b
The Meadville Medical Center has reserve powers and certain decisions of the governing body are subject to their approval.
F990_P06_S0B_L11b
Form 990, Part VI, Section B, Line 11b
The Form 990 is prepared and reviewed by the CFO for Concordia Visiting Nurses, a 20% member/shareholder of Alliance Visiting Nurses. The document is then reviewed by others on the accounting management team. The board is sent draft copies of the 990, prior to filing, in order to provide questions, comments and feedback. Questions and comments were addressed accordingly. A copy of the final 990 is made available to all board members.
F990_P06_S0B_L12c
Form 990, Part VI, Section B, Line 12c
The corporate compliance officer for Concordia Lutheran Health and Human Care attends at least 1 (one) board meeting a year. All officers, directors or trustees, and key employees are educated on compliance policies and procedures with the corporate compliance officer. This compliance officer also discusses compliance policy and procedures with the corporate compliance officer employed by Alliance Visiting Nurses. Updates on corporate compliance are addressed in scheduled meetings during the year with all staff (including management). Specific corporate compliance goals and objectives are reviewed and evaluated on an ongoing basis during the year with all staff (including management). Additionally, board members are required to disclose any potential conflict of interest prior to discussion on a topic where a conflict may exist. The Board will determine if a conflict exists and act accordingly, which may include the conflicted board member recusing himself/herself from the discussion and any votes related to the matter.
F990_P06_S0B_L15
Form 990, Part VI, Section B, Line 15
The organization reviews national and state surveys for various not-for-profit organizations. Compensation is then appropriately determined based upon experience and comparing to the benchmarks. The personnel committee reviews the efforts and accomplishments of the CEO and recommends any adjustment to the board for approval. The Alliance Visiting Nurses board of directors has final authority/responsibility for approving any adjustment for the CEO. The CEO was reviewed during the fiscal year associated with this return.
F990_P06_S0C_L19
Form 990, Part VI, Section C, Line 19
Alliance Visiting Nurses publishes an annual report that summarizes the financial and operational accomplishments of the organization, which is forwarded to Alliance Visiting Nurses constituents and is available to the public upon request.
F990_P11_S00_L09
Form 990, Part XI, Line 9
Monies were distributed to the members/shareholders during the year. This is a net amount applicable to the distribution to the original members and the subsequent membership contribution of the new member/shareholder.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
12000197
Software Version:
v1.00
-
TIN:
TY 2012 ReasonableCauseExplanation
Name:
ALLIANCE VISITING NURSES
EIN: 25-1764544
Software ID:12000197
Software Version:v1.00
Explanation:
Additional time was needed to gather information and complete the Form 990.