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
LUTHERAN HOME AT MOORESTOWN
Employer identification number
21-0643360
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.") .
126,696
66,456
167,383
61,755
76,849
499,139
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......
17,946,046
19,503,983
20,662,314
20,374,434
20,974,796
99,461,573
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.
18,072,742
19,570,439
20,829,697
20,436,189
21,051,645
99,960,712
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.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
99,960,712
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...
18,072,742
19,570,439
20,829,697
20,436,189
21,051,645
99,960,712
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
128,154
82,921
85,211
126,143
60,875
483,304
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
128,154
82,921
85,211
126,143
60,875
483,304
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.)
..
48,923
144,413
115,379
162,327
304,010
775,052
13
Total support. (Add lines 9, 10c, 11, and 12.)..
18,249,819
19,797,773
21,030,287
20,724,659
21,416,530
101,219,068
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
98.760 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
98.810 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.480 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.670 %
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
LUTHERAN HOME AT MOORESTOWN
Employer identification number
21-0643360
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 1
THE COMMITTEE IS MADE UP OF BOARD OFFICERS AND AT-LARGE MEMBERS. ALL OF THE COMMITTEE MEMBERS ARE ON THE GOVERNING BODY. THE COMMITTEE HAS THE AUTHORITY TO ACT ON BEHALF OF THE FULL BOARD, EXCEPT FOR THE FOLLOWING ACTIONS: 1) TO ELECT OR APPOINT ANY TRUSTEE, OR REMOVE ANY OFFICER OR TRUSTEE; 2) TO AMEND OR REPEAL ANY RESOLUTION PREVIOUSLY ADOPTED BY THE BOARD; 3) TO MAKE, ALTER OR REPEAL THE CERTIFICATE OF INCORPORATION OR ANY BYLAW OF THE CORPORATION
FORM 990, PART VI, SECTION A, LINE 6
LUTHERAN SOCIAL MINISTRIES OF NEW JERSEY, INC. ("LSMNJ") IS THE SOLE MEMBER OF LUTHERAN HOME AT MOORESTOWN.
FORM 990, PART VI, SECTION A, LINE 7A
THE MEMBERS OF THE BOARD OF TRUSTEES ARE APPOINTED BY THE MEMBER, LUTHERAN SOCIAL MINISTRIES OF NEW JERSEY. THE MEMBER HAS THE RIGHT TO APPROVE TRUSTEES NOMINATED BY THE NOMINATING COMMITTEE OF THE BOARD OF TRUSTEES.
FORM 990, PART VI, SECTION A, LINE 7B
THE MEMBER, LUTHERAN SOCIAL MINISTRIES OF NEW JERSEY, INC., IN ADDITION TO STATUTORILY RESERVED RIGHTS OF APPROVAL, HAS CERTAIN RESERVED RIGHTS OF APPROVAL SET FORTH IN THE CORPORATION'S BYLAWS, INCLUDING THE RIGHT TO: APPOINT AND REMOVE TRUSTEES, THE CHAIRPERSON AND INDEPENDENT AUDITORS; ADOPT AND AMEND THE CERTIFICATE OF INCORPORATION AND BYLAWS; APPROVE FUNDAMENTAL CHANGES SUCH AS MERGERS, SALE OF SUBSTANTIALLY ALL ASSETS, AND DISSOLUTION; APPROVE BUDGETS, MAJOR POLICIES AND LONG-TERM PLANS; AND APPROVE THE SALE OF PROPERTY, INCURRENCE OF DEBT AND MAJOR GIFTS. THE MEMBER VOTES THROUGH THE ACTION OF ITS BOARD OF TRUSTEES.
FORM 990, PART VI, SECTION B, LINE 11
A COPY OF THE PREPARED FORM 990 WAS PROVIDED TO EACH MEMBER OF THE BOARD OF TRUSTEES. MEMBERS WERE REQUESTED TO SEND QUESTIONS, IF ANY, TO MANAGEMENT. THOSE QUESTIONS THAT WERE ADDRESSED TO MANAGEMENT WERE CONSIDERED AND RESOLVED TO THE SATISFACTION OF EACH BOARD MEMBER.
FORM 990, PART VI, SECTION B, LINE 12C
PURSUANT TO THE ORGANIZATION'S CONFLICT OF INTEREST POLICY, THE BOARD OF TRUSTEES AND SENIOR MANAGEMENT DISCLOSE ACTUAL AND POTENTIAL CONFLICTS ON AN ANNUAL BASIS AND AS THEY ARISE DURING THE YEAR, USING A FORM DISTRIBUTED TO THEM. THESE DISCLOSURES ARE REVIEWED BY THE ORGANIZATION'S GENERAL COUNSEL. IN ADDITION, STAFF ARE TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AS THEY ARISE DURING THE YEAR TO THEIR VICE PRESIDENT/EXECUTIVE DIRECTOR, WHO REVIEWS THE DISCLOSURE WITH THE PRESIDENT AND CEO AND COMPLIANCE OFFICER, IN CONSULTATION WITH THE GENERAL COUNSEL. THE PRESIDENT AND CEO WORKS WITH TRUSTEES AND SENIOR MANAGEMENT TO RESOLVE ANY CONFLICTS THAT ARISE OR, WHERE APPROPRIATE, REFERS THE MATTER TO THE BOARD OF TRUSTEES. THE VICE PRESIDENT/EXECUTIVE DIRECTOR WORKS WITH STAFF TO RESOLVE CONFLICTS OF INTEREST IF THEY ARISE. A CONFLICT OF INTEREST MAY BE RESOLVED IN A NUMBER OF WAYS DEPENDING ON THE CIRCUMSTANCES. FOR EXAMPLE, STAFF MAY BE ASKED TO CHANGE THEIR JOB DUTIES, AN OFFICER MAY HAVE TO WITHDRAW FROM AN EXTERNAL AND CONFLICTING ACTIVITY, OR A TRUSTEE MAY HAVE TO BE EXCUSED FROM A BOARD MEETING WHERE A MATTER INVOLVING THE TRUSTEE IS DISCUSSED AND RESOLVED.
FORM 990, PART VI, SECTION B, LINE 15
SOME OF LUTHERAN HOME AT MOORESTOWN'S SENIOR MANAGEMENT ARE EMPLOYED BY LUTHERAN SOCIAL MINISTRIES OF NEW JERSEY, INC. ("LSMNJ"), A TAX-EXEMPT RELATED ORGANIZATION. FOLLOWING IS THE METHOD USED TO DETERMINE COMPENSATION FOR THOSE SENIOR MANAGEMENT EMPLOYEES. THE BOARD OF TRUSTEES DEVELOPED A PLAN FOR SENIOR MANAGEMENT COMPENSATION THAT MAINTAINS COMPENSATION AT MARKET LEVELS, REWARDS EXCEPTIONAL PERFORMANCE, AND ENCOURAGES LONGEVITY. THE STRUCTURE OF THE PLAN WAS DEVELOPED AND APPROVED BY THE BOARD OF TRUSTEES. THE PLAN INCLUDED AN ASSESSMENT OF COMPARABLE MARKET DATA. THE DELIBERATIONS OF THE BOARD OF TRUSTEES WERE DOCUMENTED AND HAVE BEEN MAINTAINED IN THE FORM OF WRITTEN MINUTES. SALARY SURVEY DATA WAS USED TO DETERMINE COMPENSATION RANGES FOR THE SENIOR MANAGEMENT TEAM ("SMT"), INCLUDING THE PRESIDENT / CHIEF EXECUTIVE OFFICER, CHIEF FINANCIAL OFFICER, CHIEF OPERATING OFFICER, AND GENERAL COUNSEL. THE GOAL IS TO MAINTAIN THE SMT AT MARKET COMPENSATION FOR COMPARABLE POSITIONS AS DEFINED IN THE EXECUTIVE COMPENSATION REVIEW OF THE MARKET FOR COMPARABLE POSITIONS. THE BOARD APPROVES THE PLAN AND DEVELOPS A CEO BASE SALARY AND INCENTIVE COMPENSATION RECOMMENDATION EACH YEAR AT ITS FALL MEETING TO BE APPROVED BY THE BOARD OF TRUSTEES. THE BOARD WILL REVIEW THE SALARY AND INCENTIVES THAT THE CEO DEVELOPS FOR THE SMT.
FORM 990, PART VI, SECTION C, LINE 19
INTERESTED PARTIES MAY OBTAIN A COPY OF THE BYLAWS, ARTICLES OF INCORPORATION, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AT THE CORPORATE OFFICES UPON REQUEST.
FORM 990, PART XI, LINE 9:
CHANGE IN FAIR VALUE OF DERIVATIVE FINANCIAL INSTRUMENTS 437,721. VALUATION GAIN, BENEFICIAL INTEREST IN PERPETUAL TRUSTS 113,013.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.