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
TLR REALTY
Employer identification number
04-3742771
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.
0
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...
0
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
0 %
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.") .
61,623
77,125
95,854
95,708
94,878
425,188
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......
28,514
31,816
31,845
32,571
32,473
157,219
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.
90,137
108,941
127,699
128,279
127,351
582,407
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.
550
1,042
1,190
1,232
4,014
c
Add lines 7a and 7b..
550
1,042
1,190
1,232
4,014
8
Public support (Subtract line 7c from line 6.)
578,393
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...
90,137
108,941
127,699
128,279
127,351
582,407
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
805
455
465
451
483
2,659
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
805
455
465
451
483
2,659
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.)..
585,066
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
98.860 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
99.450 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
0.450 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
0.550 %
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
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
12000225
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.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
TLR REALTY
Employer identification number
04-3742771
Identifier
Return Reference
Explanation
Pt VI, Line 3
All management duties such as tenant screening, fiscal
management, janitorial and facilities management are
contracted for with parent company Gateway Healthcare,
Inc.
Pt VI, Line 6
Gateway Healthcare, Inc. is the sole corporate member
of TLR Realty.
Pt VI, Line 7a
The bylaws of TLR Realty (TLR) confer certain reserved
powers on Gateway Healthcare, Inc. (Gateway) to provide
it with the means of effective oversight, coordination
and support of the system. Powers reserved to Gateway
include: to elect and remove trustees and to approve
the election of and removal of certain officers. At
each annual meeting of TLR's Board of Trustees, a list
is compiled of the names of those persons selected to
serve as Trustees of TLR so that it can be approved and
submitted to Gateway for ratification and election.
Pt VI, Line 7b
Gateway has the responsibility for planning, directing,
and establishing policy to assure the development and
delivery of quality health and social services,
professional education, and biomedical research on an
integrated, cost effective basis with each organization
directly or indirectly owned or controlled by Gateway.
Powers reserved to Gateway, in addition to those noted
above, include: to approve amendment of the Articles
of Incorporation and Bylaws and other Charter documents;
strategic plans; to approve investment policies and any
capital or operating budgets or material non-budgeted
expenditures; and to authorize incurrence or guaranty
of material indebtedness.
Pt VI, Line 11b
The preparation and filing of the Form 990 and supporting
schedules is the responsibility of the Chief Financial Officer (CFO)
and Finance Department of Gateway Healthcare, Inc. and Affiliates (Gateway).
The Form 990 is prepared by the Gateway Finance Department staff upon
completion of the annual independent financial statement audit. A draft of the
Form 990 is then provided to the Lifespan Corporation Tax Compliance Manager
for further review. Once the draft Form 990 is complete, the Gateway CFO
forwards it along with all supporting worksheets to KPMG, which then reviews
the completed form in detail. The CFO answers questions as they arise and
provides information as needed. KPMG provides the CFO with any recommended
changes which are reviewed, and if agreed upon, are incorporated into the return.
The draft form 990 is then provided to the CFO for final management review.
Prior to filing Form 990 with the Internal Revenue Service, the CFO
of Gateway will review the form and discuss the highlights with the
Board. During this meeting any questions and comments will be
addressed. The Form 990 is then finalized to include any changes,
if necessary, based on comments from the Board and the Gateway
CFO is then authorized by the Board to file the Form 990.
Pt VI, Line 12c
Gateway Healthcare, Inc. (Gateway) has a Conflict of
Interest Policy that is applicable to all Gateway
Healthcare affiliates, including TLR Realty (TLR),
and is administered by Gateway's Board Chairperson.
The President/CEO annually distributes conflict of
interest disclosure forms to Board members, Leadership,
and others as determined by the Board. All receiving
these disclosure forms are to complete and return them
as directed. When a conflict or potential conflict is
disclosed, the Board Chair and/or President/CEO are to
determine the appropriate response to the disclosure,
consulting with legal counsel as necessary and
reporting the conflict and response to the Board and to
others, including providers when deemed appropriate.
At anytime that a Board or Leadership member has
knowledge of a real or potential conflict of interest
as defined in Gateway's Bylaws, he/she is to disclose
such to the Board Chair or President/CEO and is not
to vote or in other ways make decisions that relate
to the area of conflict.
Pt VI, Line 15a
The compensation of the President/CEO is determined
by the Gateway Healthcare, Inc. Board of Directors
and is reviewed annually following the annual
performance evaluation process. The Executive
Committee of the Board who is independent of
management and free of any conflicts of interest that
would interfere with their exercise of independent
judgment serves as a compensation committee and
approves the compensation decision in advance of
payment. The Committee reviews the current salary and
compares it to available compensation data for local
non-profits and regional behavioral health providers.
The Committee adequately documents the basis for its
determination concurrently upon making the compensation
decision.
Pt VI, Line 19
The organization makes its governing documents,
conflict of interest policies, financial statements,
and 990 returns available upon request. The
organization will provide copies to those who come to
the administrative office during normal business hours
or request a copy by US mail.
Pt VII, Col (E)
Richard Leclerc is the CEO and Scott DiChristofero is
the CFO of Gateway Healthcare, Inc., the sole corporate
member of TLR Realty. Their compensation is paid
directly from Gateway Healthcare, Inc. and they have
no voting powers on the TLR Realty Board.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.