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
Martha & Mary Health Services
Employer identification number
94-3229627
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.") .
49,636
259,750
309,386
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......
15,621,320
15,747,904
14,805,737
14,498,485
14,883,359
75,556,805
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
137,602
140,431
136,837
119,400
133,334
667,604
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.
15,808,558
15,888,335
14,942,574
14,617,885
15,276,443
76,533,795
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
24,636
66,954
91,590
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..
24,636
66,954
91,590
8
Public support (Subtract line 7c from line 6.)
76,442,205
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...
15,808,558
15,888,335
14,942,574
14,617,885
15,276,443
76,533,795
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
8,620
4,875
4,735
4,192
2,872
25,294
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
8,620
4,875
4,735
4,192
2,872
25,294
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
110,557
102,980
147,732
240,208
244,341
845,818
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.)..
15,927,735
15,996,190
15,095,041
14,862,285
15,523,656
77,404,907
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
98.040 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.030 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.050 %
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
Martha & Mary Health Services
Employer identification number
94-3229627
Return Reference
Explanation
Form 990, Part I, Line 6: Description of Volunteer Activities
Our volunteers are a wonderful validation of the level of support Martha and Mary Health Services receives from the community. The following are some of the areas where our volunteers serve. Volunteers assist with the 50+ activities that are available to the residents each week, from painting and woodworking to one-to-one visits and special outings. They support our horticulture program by watering plants in residents' rooms, helping residents plant and tend their individual outdoor garden boxes and assisting with floral arrangements throughout the facility. Our volunteers participate in the Pet Therapy program by registering their pets and visiting residents. They share musical and vocal talent during chapel services and special music programs. They provide assistance with reading, letter writing and socialization during one-on-one room visits. Specially trained volunteers support our dining room services and assist residents with feeding as needed. We also have volunteer bus drivers, bulk mail assistants, environmental services helpers and Gift Shop clerks. Our Board of Trustees represents a broad spectrum of the community. Their commitment to the ideals of Martha and Mary, when coupled with a solid base of experience, has proven to be key in the quest for excellence within the organization. Our volunteers provided over 17,000 hours of service in 2013 and are invaluable to the success of our many programs. This statistic was primarily derived from the volunteer records maintained by Martha and Mary's Resident Life Services Director with the time and activity detail provided by individual volunteers.
Form 990, Part VI, Section A, line 6
Martha and Mary Health Services is a subsidiary of Martha and Mary Lutheran Services. While Lutheran Services is not defined as a Member or Stock Holder in the organizational documents, Lutheran Services "has the right to participate" in the governance of Health Services and as a result is considered a "Member" for purposes of this section.
Form 990, Part VI, Section A, line 7a
Martha and Mary Lutheran Services, as the parent corporation, elects all Trustees.
Form 990, Part VI, Section A, line 7b
Martha and Mary Health Services is a subsidiary of Martha and Mary Lutheran Services. There are defined "substantial issues" that must be approved by the parent corporation. These "substantial issues" include: a) acquisition or sale of real property, b) corporate borrowing which is or will be secured by a mortgage, deed of trust or other encumbrance on corporate real property, c) dissolving the corporation, d) sale of all or substantially all of the corporation's assets. Approved substantial issues will not have any force or effect without the prior written consent of HUD.
Form 990, Part VI, Section B, line 11
Management reviews the Form 990 prior to the completed form being submitted to the board. A copy of the completed 990 is provided to each board member for their review and comments. A subcommittee of the board undertakes a specific review of the 990 and provides their recommendation for approval to the entire board. The 990 is approved by the board prior to submission to the IRS.
Form 990, Part VI, Section B, line 12c
The organization has not established a conflict of interest policy of its own; however, it has adopted the conflict of interest policy of its parent organization, Martha and Mary Lutheran Services (MMLS). The MMLS conflict of interest policy is as follows: Each year and upon selection of the Board, all Trustees and employee officers are required to complete a form stating that they understand the policy and that there has been no contravention of the policy by themselves or family during the year, or if there was a conflict, it was fully disclosed at the time. In the case of a conflict, trustees will recuse themselves. Trustees and all employees, including employee officers, are required to report any potential conflict of interests whenever they arise. The Governance Committee determines whether conflicts exist, and reviews actual conflicts of interest to determine appropriate action. Also, each year prior to the preparation of the Form 990, all trustees and employee officers who served during the year are provided with a questionnaire specifically tailored to the requirements of Form 990.
Form 990, Part VI, Section B, line 15b
The filing organization does not provide a salary to the CEO. Instead, the CEO receives compensation from the parent organization, Martha and Mary Lutheran Services (MMLS). The Board Personnel Committee sets the compensation package for the CEO utilizing compensation benchmarks and additional parameters related to the constraints of Board-approved budget guidelines. The parent organization sets and pays for the compensation for the Director of Finance. The CEO and HR Director use benchmarks from Leading Age Washington to establish a starting wage and determine a fair and equitable wage range for our Director of Finance position within Martha & Mary. The Board President reviews and signs off on any additional wage increases for the Director of Finance position beyond the starting wage. The Personnel Committee must approve the compensation recommendations by the CEO for the Director of Finance and Administrator. The last compensation review was completed in April 2013.
Form 990, Part VI, Section C, line 19
Our financial information is published in our annual report and is distributed to our supporters and the greater community. Audited financial statements are available upon request. Governing documents and conflict of interest policy are not generally available to the public.
Form 990, Part VI, Section A, Line 8b:
A committee may recommend a course of action to the Board, but would not independently act on behalf of the Board. Committee reports to the Board are integrated into the Board Minutes.
Form 990, Part VII: Additional Reporting Hours Information
For purposes of reporting hours worked by the CEO, Interim CFO, and Director of Finance, all hours worked are reported in the parent corporation - Martha and Mary Lutheran Services.
Form 990, Part XI, line 9:
Transfer from related parties 37,440.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
TY 2013 AffiliatedGroupAttachment
Name:
Martha & Mary Health Services
EIN: 94-3229627
Explanation:
Organizations with 501(h) election:Martha & Mary Lutheran Services EIN 91-0567265PO Box 127Poulsbo, WA 98370-0127Total lobbying expenses to influence a legislative body: $79Other exempt purpose expenditures: $1,980,344Martha & Mary Children's Services EIN 91-1916806PO Box 127Poulsbo, WA 98370-0127Total lobbying expenses to influence a legislative body: $0Other exempt purpose expenditures: $2,752,628Martha & Mary Lutheran Services DBA Ebenezer Services EIN 91-1249343PO Box 127Poulsbo, WA 98370-0127Total lobbying expenses to influence a legislative body: $0Other exempt purpose expenditures: $162,105Organizations without 501(h) election:Martha and Mary Home & Community Services EIN 91-1293400PO Box 127Poulsbo, WA 98370-0127Total lobbying expenses to influence a legislative body: $82Other exempt purpose expenditures: $2,454,880The affiliated group does not have excess lobbying expenditures in 2013.