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
INDIANAPOLIS JEWISH HOME INC
Employer identification number
35-6041299
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.") .
752,660
640,252
684,655
828,858
777,812
3,684,237
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......
12,263,749
13,007,188
13,568,803
14,189,130
11,788,950
64,817,820
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
50,556
52,227
65,663
64,634
23,078
256,158
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
13,066,965
13,699,667
14,319,121
15,082,622
12,589,840
68,758,215
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.
1,179,496
1,179,496
c
Add lines 7a and 7b..
1,179,496
1,179,496
8
Public support (Subtract line 7c from line 6.)
67,578,719
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...
13,066,965
13,699,667
14,319,121
15,082,622
12,589,840
68,758,215
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,277
54
811
142
131,943
134,227
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
1,277
54
811
142
131,943
134,227
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
28,757
45,713
34,174
45,963
154,607
13
Total support. (Add lines 9, 10c, 11, and 12.)..
13,096,999
13,745,434
14,354,106
15,128,727
12,721,783
69,047,049
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
97.873 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.740 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.194 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.010 %
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
INDIANAPOLIS JEWISH HOME INC
Employer identification number
35-6041299
Return Reference
Explanation
FORM 990, PART III, LINE 1
(CONTINUED FROM PART III) HOOVERWOOD, A NON-PROFIT, NON-SECTARIAN ORGANIZATION, GOVERNED BY A DEDIATED BOARD OF DIRECTORS, IS A CONSTITUENT AGENCY OF THE JEWISH FEDERATION OF GREATER INDIANAPOLIS. WITH THE VALUES AND TRADITIONS OF JUDAISM AS ITS FOUNDATION, HOOVERWOOD'S MISSION STATEMENT IS BASED ON FOUR CORE VALUES THAT TOGETHER CONTINUE HOOVERWOOD'S TRADITION OF HEALTHCARE EXCELLENCE. DIGNITY- TO UNDERSTAND OUR RESIDENTS AS INDIVIDUALS WITH THEIR OWN HISTORIES, VALUES, AND CONTRIBUTIONS, AND TO PROVIDE OPPORTUNITIES FOR CONTINUED GROWTH, INDEPENDENCE, AND FEELINGS OF SELF-WORTH. SPIRITUALITY - TO UPHOLD THE BELIEFS AND TRADITIONS OF THE JEWISH FAITH, WHILE PROVIDING FOR THE SPIRITUAL WELL-BEING OF RESIDENTS OF ALL FAITHS. COMMUNITY - TO PROVIDE A HOME-LIKE FRIENDLY ENVIRONMENT TO ALL RESIDENTS AND STAFF. VISION - TO PREPARE FOR THE FUTURE OF THE AGING POPULATION THROUGH A COMMITMENT TO EDUCATION, RESEARCH, AND QUALITY CARE.
FORM 990, PART III, LINE 4A
(CONTINUED FROM PART III, LINE 4A) AS A NON-PROFIT ORGANIZATION, CERTIFIED BY MEDICARE AND MEDICAID, HOOVERWOOD SPECIALIZES IN SHORT-TERM REHABILITATION FOLLOWING A HOSPITALIZATION, SKILLED NURSING CARE, AND MEDICAL SPECIALTIES INCLUDING GERIATRICS, GERIATRIC PSYCHIATRY, DENTISTRY AND PODIATRY. HOOVERWOOD'S DEPARTMENT OF REHABILITATION SERVICES PROVIDES PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPIES ON AN INPATIENT AND OUTPATIENT BASIS. HOOVERWOOD'S INTERDISCIPLINARY TEAM OF NURSES, NURSING ASSISTANTS, SOCIAL WORKERS, DIETITIANS, ACTIVITY STAFF AND THERAPISTS WORK TOGETHER TO COORDINATE RESIDENTS' OVERALL CARE AND PROVIDE ENCOURAGEMENT AND SUPPORT IN ORDER FOR OUR RESIDENTS TO REACH THEIR HIGHEST POTENTIAL. THE HOOVERWOOD TEAM TAKES GREAT PRIDE IN THE IMPRESSIVE NUMBER OF RESIDENTS WHO "GRADUATE" FROM THEIR REHABILITATION PROGRAM AND RETURN HOME TO THEIR PRIOR LEVEL OF FUNCTION AND INDEPENDENCE. HOOVERWOOD'S MEDICAL DIRECTORS ARE BOARD CERTIFIED GERIATRICIANS AND ARE AFFILIATED WITH THE ST. VINCENT CENTER FOR HEALTHLY AGING. OUR MEDICAL DIRECTORS HAVE BEEN PROVIDING MEDICAL CARE, CLINICAL LEADERSHIP, AND EDUCATION AT HOOVERWOOD FOR OVER 20 YEARS. A GERIATRIC NURSE PRACTITIONER IS ALSO A VITAL PART OR OUR CARE MODEL AND VISITS HOOVERWOOD ON A REGULAR BASIS. HOOVERWOOD'S GERIATRIC PSYCHIATRIST, AFFILIATED WITH HANCOCK REGIONAL HOSPITAL, PROVIDES EVALUATION AND TREATMENT OF A VARIETY OF MENTAL HEALTH ISSUES AND ASSISTS THE RESIDENTS AS THEY COPE WITH CHANGES AND CHALLENGES IN THEIR LIVES. HOOVERWOOD'S MEDICAL CLINIC OFFERS A FULL SERVICE, ON-SITE DENTAL CLINIC WITH WEEKLY VISITS FROM A DENTIST AND MONTHLY VISITS FROM A PODIATRIST.
FORM 990, PART VI, QUESTION 1A
THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE OFFICERS OF THE CORPORATION PLUS THE PRESIDENT OF THE HOOVERWOOD GUILD. ALSO A MAXIMUM OF TWO (2) OTHER BOARD MEMBERS MAY BE APPOINTED BY THE PRESIDENT TO THE EXECUTIVE COMMITTEE IN HIS/HER SOLE DISCRETION, BUT NOTHING HEREIN SHALL REQUIRE THE PRESIDENT TO APPOINT SUCH ADDITIONAL MEMBERS TO SAID COMMITTEE. THE IMMEDIATE PAST PRESIDENT AND THE CHAIRMAN OF THE HOOVERWOOD FOUNDATION COMMITTEE SHALL ALSO SERVE ON THE EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL MEET WHEN DETERMINED NECESSARY BY THE PRESIDENT AND THE EXECUTIVE DIRECTOR/ADMINISTRATOR. A MAJORITY OF THE EXECUTIVE COMMITTEE MUST BE PRESENT TO CONSTITUTE A QUORUM. THE EXECUTIVE COMMITTEE SHALL ACT, WHEN NECESSARY, IN BETWEEN REGULAR MEETINGS OF THE BOARD. ALL ACTION OF THE EXECUTIVE COMMITTEE SHALL BE REPORTED TO THE BOARD OF DIRECTORS AT THE BOARD'S NEXT MEETING, EITHER IN REGULAR OR EXECUTIVE SESSION. THE EXECUTIVE COMMITTEE SHALL SPECIFICALLY HANDLE TOP MANAGEMENT LEVEL ISSUES, ADMINISTRATIVE COMPENSATION, SENSITIVE POLITICAL/COMMUNITY ISSUES, SENSITIVE LEGAL ISSUES, AND OTHER SUCH TYPE OF CONFIDENTIAL OR SENSITIVE ISSUES.
FORM 990, PART VI, QUESTION 2
JILL BURNETT IS RELATED TO JANIE MAURER. HEATHER KULWIN IS RELATED TO SHIRLEY KULWIN. EDWARD FREEMAN IS RELATED TO IRVING FREEMAN.
FORM 990, PART VI, QUESTION 7A
THE JEWISH FEDERATION OF GREATER INDIANAPOLIS, INC, THE JEWISH COMMUNITY CENTER ASSOCIATION, THE JEWISH COMMUNITY RELATIONS COUNCIL, AND THE BUREAU OF JEWISH EDUCATION HAVE THE RIGHT TO APPOINT ONE VOTING MEMBER TO THE BOARD.
FORM 990, PART VI, QUESTION 11B
THE FORM 990 IS REVIEWED IN DETAIL BY MANAGEMENT, THEN COPIES ARE PROVIDED TO EVERY MEMBER OF THE GOVERNING BODY BEFORE IT IS FILED WITH THE IRS. THE FORM 990 IS ALSO REVIEWED BY AN INDEPENDENT PUBLIC ACCOUNTING FIRM.
FORM 990, PART VI, QUESTION 12C
ALL DIRECTORS AND OFFICERS ARE REQUIRED TO SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. THE STATEMENTS ARE REVIEWED BY THE CHIEF FINANCIAL OFFICER IF ANY CONFLICTS OF INTEREST ARE NOTED, THE EXECUTIVE DIRECTOR AND PRESIDENT OF THE BOARD ARE NOTIFIED. THE PRESIDENT OF THE BOARD ENSURES THAT ANY BOARD MEMBER WITH AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST ABSTAINS FROM VOTING ON DECISIONS RELATED TO THE CONFLICT.
FORM 990, PART VI, QUESTION 15A & 15B
EACH YEAR, THE COMPENSATION COMMITTEE IS SCHEDULED TO DISCUSS THE COMPENSATION OF THE EXECUTIVE DIRECTOR. THE COMPENSATION COMMITTEE CONSISTS OF MEMBERS FROM THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. THE COMMITTEE USES CURRENT COMPENSATION & FRINGE BENEFIT INFORMATION ALONG WITH OTHER COMPARATIVE DATA, AND PERFORMANCE EVALUATIONS TO ANALYZE COMPENSATION FOR THE EXECUTIVE DIRECTOR. THE DELIBERATION AND DECISION IS CONTEMPORANEOUSLY DOCUMENTED IN THE COMMITTEE MINUTES AFTER A CONSENSUS IS REACHED, THE DECISION IS DISCUSSED WITH THE EXECUTIVE DIRECTOR. THE SAME PROCESS IS ALSO COMPLETED FOR THE CHIEF FINANCIAL OFFICER. THE EXECUTIVE DIRECTOR'S COMPENSATION WAS LAST REVIEWED IN MAY 2013 AND THE CHIEF FINANCIAL OFFICER'S COMPENSATION WAS LAST REVIEWED IN JULY 2013.
FORM 990, PART VI, QUESTION 19
THE FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART VII
BYLAWS STATE THAT ALL PAST PRESIDENTS ARE HONORARY BOARD MEMBERS AND HAVE VOTING RIGHTS.
FORM 990, PART VIII AND IX
ON MAY 10, 2013, THE ORGANIZATION EXECUTED SEPARATE SUBLEASE, MANAGEMENT AND LICENSE AGREEMENTS (AGREEMENTS) WITH HANCOCK REGIONAL HOSPITAL (HRH). THE SUBLEASE RESULTS IN A CHANGE OF OWNERSHIP FOR REGULATORY PURPOSES, WITH THE ORGANIZATION CONTINUING TO MANAGE DAY-TO-DAY OPERATIONS VIA THE MANAGEMENT AGREEMENT. THE AGREEMENTS EXPIRE IN 24 MONTHS AND AUTOMATICALLY RENEW FOR SUCCESSIVE TWO-YEAR TERMS UNLESS TERMINATED BY EITHER PARTY. THE SUBLEASE COVERS ALL REAL AND PERSONAL PROPERTY AND REQUIRES HRH TO REMIT MONTHLY LEASE PAYMENTS OF $88,000 AND PAY ALL EXECUTORY COSTS (TAXES, INSURANCE, UTILITIES, AND MAINTENANCE). THE MANAGEMENT AGREEMENT REQUIRES MONTHLY PAYMENTS BASED UPON NET PATIENT REVENUE AND AN ANNUAL QUALITY INCENTIVE PAYMENT DEPENDENT ON THE FACILITY MEETING CERTAIN QUALITY MEASURES. THE LICENSE AGREEMENT REQUIRES MONTHLY PAYMENTS OF $10,796. EITHER THE ORGANIZATION OR HRH HAS THE ABILITY TO TERMINATE THE AGREEMENTS PRIOR TO THE TERMINATION DATE BY PROVIDING 90 DAYS' NOTICE TO THE OTHER PARTY. AT THE TERMINATION OF THE AGREEMENTS, THE ORGANIZATION AND HRH ARE REQUIRED TO PERFORM CERTAIN ACTIONS AS DEFINED BY THE AGREEMENTS.
FORM 990, PART XI
PRIOR PERIOD INCOME ADJUSTMENT DUE TO RESTATEMENT OF FINANCIAL STATEMENTS -$667,581.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.