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
ACACIA CREEK A MASONIC SENIOR LIVING COMMUNITY AT UNION CITY
Employer identification number
20-4688615
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.") .
17,722
17,722
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......
1,104,378
2,098,667
2,919,074
4,577,552
5,916,819
16,616,490
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.
1,104,378
2,098,667
2,919,074
4,577,552
5,934,541
16,634,212
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.
812,631
493,133
255,140
88,455
1,649,359
c
Add lines 7a and 7b..
812,631
493,133
255,140
88,455
1,649,359
8
Public support (Subtract line 7c from line 6.)
14,984,853
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...
1,104,378
2,098,667
2,919,074
4,577,552
5,934,541
16,634,212
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,411
192,680
254,155
253,611
298,554
1,000,411
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
1,411
192,680
254,155
253,611
298,554
1,000,411
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.)..
1,105,789
2,291,347
3,173,229
4,831,163
6,233,095
17,634,623
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
84.970 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
79.380 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
5.670 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
6.160 %
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
ACACIA CREEK A MASONIC SENIOR LIVING COMMUNITY AT UNION CITY
Employer identification number
20-4688615
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE ORGANIZATION HAS ONE MEMBER, MASONIC HOMES OF CALIFORNIA, A SECTION 501(C)(3) CALIFORNIA NONPROFIT PUBLIC BENEFIT CORPORATION.
FORM 990, PART VI, SECTION A, LINE 7A
THE DIRECTORS OF THIS ORGANIZATION SHALL BE ELECTED BY THE MEMBER AT THE ANNUAL MEETING OF THE MEMBER.
FORM 990, PART VI, SECTION A, LINE 7B
THE MEMBER'S APPROVAL SHALL BE REQUIRED BEFORE THIS ORGANIZATION MAY TAKE ANY OF THE FOLLOWING ACTIONS: ADOPT OR AMEND THE ARTICLES OF INCORPORATION OR BYLAWS OF THE ORGANIZATION ADOPT OR MATERIALLY REVISE THE ANNUAL BUDGET OR LONG RANGE PLAN ADOPT OR REVISE THE ORGANIZATION'S MISSION STATEMENT INCUR ANY DEBT OR ENTER INTO ANY CONTRACT NOT CONTEMPLATED BY THE ANNUAL BUDGET, IF THE DOLLAR AMOUNT EXCEEDS A SUM SPECIFIED BY THE MEMBER, FROM TIME TO TIME, BY RESOLUTION. CREATE A TAXABLE OR TAX-EXEMPT SUBSIDIARY ACQUIRE A CONTROLLING INTEREST IN ANOTHER ENTITY APPOINT OUTSIDE AUDITORS MERGE, DISSOLVE, OR TRANSFER ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S ASSETS.
FORM 990, PART VI, SECTION B, LINE 11
THE SENIOR ACCOUNTANTS PREPARE THE FORM 990 SUPPORTING SCHEDULES/DATA, THEN THE CONTROLLER REVIEWS THE SCHEDULES/DATA AND SUBMITS TO THE TAX CONSULTANT FOR PREPARATION OF THE FORM 990. THE TAX CONSULTANT SUBMITS THE COMPLETED 990 TO THE CONTROLLER AND CFO FOR REVIEW AND APPROVAL. CFO AND TAX CONSULTANT PRESENTED THE FORM 990 TO THE AUDIT COMMITTEE FOR FINAL APPROVAL. THE FORM IS THEN POSTED TO AN INTERNAL WEBSITE ACCESSIBLE TO ALL VOTING MEMBERS OF THE BOARD. ONCE APPROVED, THE CFO SIGNS THE FORM 990 AND FILES WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12C
AS REQUIRED, ANNUALLY, EACH MEMBER OF THE BOARD EXECUTES AND SIGNS A CONFLICT OF INTEREST DISCLOSURE STATEMENT. IN THIS STATEMENT, THE BOARD AND THE BOARD LEVEL COMMITTEE DISCLOSES KNOWN, EXISTING, POTENTIAL AND POSSIBLE CONFLICTS OF INTEREST. IF NO SUCH INTERESTS OR ACTIVITIES EXIST, THE PARTY WRITES THE WORD "NONE" IN THE SPACE PROVIDED. IN ADDITION, THESE STATEMENTS ARE UPDATED WHEN AN INTERESTED PARTY SUBSEQUENTLY BECOMES A MATTER OF BOARD ACTION. THE INTERESTED PARTY DISCLOSES THE CIRCUMSTANCES TO THE PRESIDENT OF THE BOARD OF DIRECTORS. IN THE EVENT THE INTERESTED PARTY IN QUESTION IS THE PRESIDENT OF THE BOARD, THE POTENTIAL CONFLICT IS DISCLOSED TO THE FULL BOARD. THE CONFLICT OF INTEREST DISCLOSURE STATEMENT FOR BOARD AND NON-BOARD COMMITTEE MEMBERS IS SUBMITTED TO THE PRESIDENT OF THE BOARD FOR REVIEW. THE PLANS FOR MITIGATION OF ANY CONFLICT RELATING TO BOARD MEMBERS OR NON-BOARD COMMITTEE MEMBERS ARE PRESENTED BY THE PRESIDENT TO THE BOARD AND THE GRAND MASTER. FOLLOWING THEIR REVIEW, ALL CONFLICT OF INTEREST DISCLOSURE STATEMENTS ARE KEPT ON FILE WITH THE GRAND SECRETARY.
FORM 990, PART VI, SECTION B, LINE 15
BENCHMARKING IS COMPLETED ON ALL POSITIONS BY AN INDEPENDENT THIRD PARTY COMPENSATION CONSULTANT. REVIEW IS DONE BY THE INDEPENDENT VOLUNTEER LEADERSHIP BOARD OF TRUSTEES AND APPROVED BY THE PRESIDENT OF THE BOARD. SALARY BENCHMARKING IS CONDUCTED BY AN INDEPENDENT THIRD PARTY COMPENSATION CONSULTANT UTILIZING NUMEROUS PUBLISHED SALARY SURVEYS FOR EACH POSITION BASED ON TITLE AND JOB DESCRIPTION. COMPENSATION IS SET BY THIS ORGANIZATION FOR THE TOP MANAGEMENT OFFICIAL. COMPENSATION FOR THE OTHER OFFICERS IS ESTABLISHED BY A RELATED ORGANIZATION.
FORM 990, PART VI, SECTION C, LINE 19
THE AUDITED FINANCIAL STATEMENTS, GOVERNING/ORGANIZING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC AT THE CORPORATE OFFICE.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.