Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 2,705 | 59,967 | 37,124 | 352,872 | 221,986 | 674,654 |
| 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...... | 428,404 | 5,033,988 | 10,670,170 | 16,132,562 | ||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 9,894 | 9,894 | ||||
| 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. | 2,705 | 498,265 | 37,124 | 5,386,860 | 10,892,156 | 16,817,110 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | 875 | 2,501 | 9,715 | 23,785 | 5,000 | 41,876 |
| 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.. | 875 | 2,501 | 9,715 | 23,785 | 5,000 | 41,876 |
| 8 | Public support (Subtract line 7c from line 6.) | 16,775,234 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 2,705 | 498,265 | 37,124 | 5,386,860 | 10,892,156 | 16,817,110 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 748,797 | 491,669 | 302,453 | 97,703 | 190,046 | 1,830,668 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 748,797 | 491,669 | 302,453 | 97,703 | 190,046 | 1,830,668 |
| 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 VI.) .. | 29,309 | 91,018 | 120,327 | |||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 751,502 | 989,934 | 339,577 | 5,513,872 | 11,173,220 | 18,768,105 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: | MISC REVENUE - 2013 AMOUNT: $ 439. 2014 AMOUNT: $ 5,932. HAIR CARE REVENUE - 2013 AMOUNT: $ 25,605. 2014 AMOUNT: $ 67,780. MEDICAL SUPPLIES REVENUE - 2013 AMOUNT: $ 3,265. 2014 AMOUNT: $ 11,711. PUB/BAR REVENUE - 2014 AMOUNT: $ 5,595. |
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Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | NLCS (RELATED ORGANIZATION) BOARD CHAIR REVEREND MARTHA SIMS HAS A FAMILY RELATIONSHIP WITH AN ORCHARD RIDGE EMPLOYEE. |
| FORM 990, PART VI, SECTION A, LINE 3 | NATIONAL LUTHERAN HOME FOR THE AGED, INC. (EIN 26-2222476), THE PARENT ENTITY, PROVIDES FINANCIAL AND MANAGEMENT FUNCTIONS FOR THE ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 4 | THE BY-LAWS WERE CHANGED TO REFLECT THAT A TOTAL OF UP TO NINE TRUSTEES MAY SERVE ON THE BOARD. THE BY-LAWS WERE ALSO REVISED TO REFLECT A PREFERENCE BUT NOT A REQUIREMENT THAT POTENTIAL TRUSTEES HAVE MEMBERSHIP IN A LUTHERAN CONGREGATION. THE TRUSTEES OF THE PARENT, NATIONAL LUTHERAN HOME FOR THE AGED, INC., MAY APPOINT A COMMITTEE TO IDENTIFY AND NOMINATE TRUSTEE CANDIDATES FOR APPROVAL BY THE PARENT'S FULL BOARD. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION HAS A SINGLE CLASS OF CONSTITUENT MEMBERS WHICH SHALL CONSIST OF THOSE DULY ELECTED MEMBERS OF THE BOARD OF TRUSTEES OF NATIONAL LUTHERAN HOME FOR THE AGED, INC., THE PARENT ORGANIZATION TO THE FILING ENTITY. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE ORGANIZATION'S BOARD HAS ROTATING 3 YEAR TERMS WITH THE POSSIBILITY OF 2 CONSECUTIVE TERMS BEING SERVED. THEN A BREAK OF ONE YEAR MUST OCCUR BEFORE AN INDIVIDUAL SERVES AS A BOARD MEMBER AGAIN. THE ONLY EXCEPTION TO THESE RULES ARE THE BISHOP'S DESIGNEES FROM EACH OF THE CHURCH SYNODS TO WHICH THE ORGANIZATION BELONGS. IF THE BISHOP CHOOSES NOT TO SERVE ON THE BOARD, THEN HE CAN ASSIGN AN INDIVIDUAL TO HIS/HER SEAT AS LONG AS HE/SHE IS BISHOP. |
| FORM 990, PART VI, SECTION A, LINE 7B | APPROVAL OF THE FOLLOWING MATTERS IS RESERVED EXCLUSIVELY TO THE MEMBERSHIP. A) APPROVE THE ROLE AND/OR MISSION STATEMENT, IF ANY B) APPROVE OPERATING AND CAPITAL BUDGETS C) APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS D) APPROVAL OF ALL EXPENDITURES, CONTRACTS OR THE INCURRENCE OF DEBT IN EXCESS OF $100,000 THAT HAVE NOT BEEN INCLUDED IN AN APPROVED OPERATING OR CAPITAL BUDGET E) APPROVAL OF AND RECOMMENDATIONS FOR THE FORMATION OF LEGAL ENTITIES, THE SALE, TRANSFER OR SUBSTANTIAL CHANGE IN USE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS, DIVESTITURES, DISSOLUTIONS, CLOSURES, MERGERS, CONSOLIDATIONS, OR CHANGES IN CORPORATE MEMBERSHIP F) LIQUIDATION, DISSOLUTION, WINDING UP OR ABANDONMENT OF THE CORPORATION G) APPROVAL OF STRATEGIC PLANS H) SELECTION OF THE CORPORATION'S EXECUTIVE DIRECTOR I) SELECTION OF THE AUDITOR FOR THE CORPORATION J) APPROVAL OF ALL DECISIONS REGARDING THE MANAGEMENT OF THE CORPORATION'S INVESTMENT PORTFOLIO |
| FORM 990, PART VI, SECTION B, LINE 11 | THE FINANCE COMMITTEE, ALONG WITH APPROPRIATE STAFF, PERFORMS AN INITIAL REVIEW OF THE FORM 990. UPON APPROVAL, THE FORM 990 IS MADE AVAILABLE TO EACH BOARD MEMBER FOR REVIEW PRIOR TO TRANSMISSION OF THE RETURN TO THE IRS. THE BOARD OF THE PARENT, NATIONAL LUTHERAN HOME FOR THE AGED, INC., WILL RECEIVE A COPY OF THE RETURN PRIOR TO THE IRS FILING AS WELL. |
| FORM 990, PART VI, SECTION B, LINE 12C | BOARD MEMBERS AND KEY EMPLOYEES SIGN A CONFLICT OF INTEREST STATEMENT EVERY YEAR. IF A CONFLICT IS IDENTIFIED, IT IS 1) IDENTIFIED AND DISCUSSED WITH THE BOARD AND 2) REVIEWED AND DOCUMENTED BY MANAGEMENT. IF AN ACTUAL OR POTENTIAL CONFLICT IS IDENTIFIED, THE BOARD MEMBER, OFFICER, OR EMPLOYEE WILL RECUSE HIM OR HERSELF FROM ANY CONVERSATIONS, DECISIONS, OR OTHER ACTIVITIES AND DISCUSSIONS INVOLVING THE CONFLICT. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE BOARD DETERMINES THE COMPENSATION FOR THE CEO THROUGH THE COMBINED USE OF SEVERAL METHODS. THE NLCS EXECUTIVE COMMITTEE SERVES AS A COMPENSATION COMMITTEE WHICH OVERSEES THE PROCESS. COMPENSATION SURVEYS ARE PERFORMED BY AN OUTSIDE HR CONSULTING FIRM, PRM, USING LOCAL MARKET DATA. WRITTEN EMPLOYMENT CONTRACTS ARE ALSO DRAWN. THE CEO, EXECUTIVE DIRECTOR, AND DIRECTOR OF HUMAN RESOURCES USE SALARY SURVEYS TO DETERMINE THE COMPENSATION FOR OTHER OFFICERS AND KEY EMPLOYEES TO ENSURE THEY ARE WITHIN THE LOCAL MARKET RANGE. THE SERVICES THE INDIVIDUAL PROVIDES TO THE ORGANIZATION AND THE TENURE OF THE OFFICER ARE ALSO FACTORS CONSIDERED IN SALARY DETERMINATIONS. ONCE THE EXECUTIVE COMMITTEE GIVES ITS APPROVAL, ITS DECISIONS ARE NOTED AT THE BOARD LEVEL. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
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