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 VILLAGE AT MILLER'S GRANT
Employer identification number
32-0154392
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.") ....
17,000
31,000
48,000
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
17,000
31,000
48,000
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)..
27,080
6
Public support. Subtract line 5 from line 4.
20,920
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..
17,000
31,000
48,000
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).
48,000
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
43.580 %
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
100.000 %
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.") .
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......
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.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
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...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
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.)..
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
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
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 VILLAGE AT MILLER'S GRANT
Employer identification number
32-0154392
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 6
THE SOLE MEMBER OF LUTHERAN VILLAGE AT MILLER'S GRANT IS CARROLL LUTHERAN VILLAGE, A MARYLAND NONSTOCK CORPORATION. SOME LVMG BOARD MEMBERS ARE PARENT BOARD MEMBERS OF CLV OR KEY MANAGEMENT OF CLV.
FORM 990, PART VI, SECTION A, LINE 7A
THE TRUSTEES SHALL BE APPOINTED BY THE MEMBER, CARROLL LUTHERAN VILLAGE; PROVIDED, HOWEVER, THAT GREY ROCK COMMUNITY, INC., A MARYLAND NONSTOCK CORPORATION, SHALL BE ENTITLED TO NOMINATE 4 INDIVIDUALS TO SERVE AS TRUSTEES AND THE MEMBER SHALL APPOINT SUCH INDIVIDUALS NOMINATED BY GREY ROCK AS TRUSTEES.
FORM 990, PART VI, SECTION B, LINE 11
THE FORM 990 IS FIRST REVIEWED BY BOTH THE PRESIDENT/CEO AND VP OF FINANCE. ONCE THEIR REVIEW HAS BEEN COMPLETED THE 990 IS GIVEN TO THE ENTIRE BOARD TO REVIEW PRIOR TO THE RETURN BEING FILED.
FORM 990, PART VI, SECTION B, LINE 12C
LUTHERAN VILLAGE AT MILLER'S GRANT, AS THE WHOLLY OWNED SUBSIDIARY OF CARROLL LUTHERAN VILLAGE, FOLLOWS CAROLL LUTHERAN VILLAGE'S CONFLICT OF INTEREST POLICY. CARROLL LUTHERAN VILLAGE HAS AN ESTABLISHED POLICY AND STANDARDS REGARDING CONFLICT OF INTEREST. MANY BOARD AND COMMITTEE MEMBERS ARE ACTIVE AS COMMUNITY AND BUSINESS LEADERS IN CARROLL COUNTY AND WILL AT TIMES FIND THEMSELVES IN A POSITION WHERE THERE MAY BE A DEGREE OF CONFLICT WITH THE VILLAGE'S BUSINESS. THESE CONFLICTS ARE EXPECTED AND THE FACT THAT THEY WILL REGULARLY OCCUR DOES NOT PRECLUDE SUCH A MEMBER FROM SERVING ON THE BOARD OR COMMITTEE. THE VILLAGE IN FACT NEEDS THE VARIED EXPERTISE OF ITS BOARD AND COMMITTEE VOLUNTEERS AND BELIEVES THAT BOARD POLICY OF DISCLOSURE AND ABSTENTION ASSURES THAT THE VILLAGE'S BUSINESS IS CONDUCTED IN A FAIR AND INDEPENDENT MANNER. THE CARROLL LUTHERAN VILLAGE (CLV) CONFLICT OF INTEREST POLICY APPLIES TO OFFICERS, DIRECTORS, BOARD COMMITTEE MEMBERS AND EMPLOYEES OF CLV, EACH OF WHOM IS CONSIDERED AN INTEREST PERSON. AN ENTITY WITH A CLV TRANSACTION IS ANY INDIVIDUAL OR BUSINESS ORGANIZATION WHICH PROPOSES TO ENTER INTO ANY TRANSACTION WITH CLV INVOLVING: 1) THE SALE, PURCHASE, LEASE OR RENTAL OF ANY PROPERTY OR ASSET, 2) EMPLOYMENT, OR RENDITION OF SERVICES, PERSONAL OR OTHERWISE, 3) THE AWARD OF ANY GRANT, CONTRACT, OR SUBCONTRACT, OR 4) THE INVESTMENT OR DEPOSIT OF ANY FUNDS OF CLV. AN INTERESTED PERSON HAS A FINANCIAL INTEREST IN AN ENTITY IF SUCH PERSON OR AN IMMEDIATE FAMILY MEMBER (INCLUDING ALL LINEAL RELATIVES AND THEIR SPOUSES, SIBLINGS AND THEIR SPOUSES) HAS AN OWNERSHIP INTEREST IN THE ENTITY OR IS AN EMPLOYEE OF OR RECEIVES COMPENSATION FROM THE ENTITY. COMPENSATION INCLUDES ANY DIRECT OR INDIRECT REMUNERATION OR SUBSTANTIAL GIFTS OR FAVORS. AN INTERESTED PERSON HAS A CONFLICT OF INTEREST WHEN THAT PERSON, OR AN IMMEDIATE FAMILY MEMBER, IS, OR HAS A FINANCIAL INTEREST IN, AN ENTITY WITH A CLV TRANSACTION. CONFLICTS OF INTEREST CAN ALSO ARISE IN OTHER INSTANCES. THE TYPES OF ACTIVITIES WHICH MAY CREATE A CONFLICT OF INTEREST INCLUDE: 1) OUTSIDE ACTIVITIES: TO RENDER DIRECTIVE, MANAGERIAL OR CONSULTATIVE SERVICES TO ANY OUTSIDE CONCERN THAT DOES BUSINESS WITH, OR COMPETES WITH, THE SERVICES OF CLV, OR TO RENDER OTHER SERVICES IN COMPETITION WITH CLV. 2) GIFTS, GRATUITIES AND ENTERTAINMENT: TO ACCEPT GIFTS, ENTERTAINMENT OR OTHER FAVORS FROM ANY OUTSIDE CONCERN THAT DOES, OR IS SEEKING TO DO BUSINESS WITH OR IS A COMPETITOR OF CLV. 3) INSIDE INFORMATION: TO DISCLOSE OR USE INFORMATION RELATING TO THE BUSINESS OF CLV FOR THE PERSONAL PROFIT OR ADVANTAGE OF THE INDIVIDUAL OR HIS/HER IMMEDIATE FAMILY. IT IS THE RESPONSIBILITY OF AN INTERESTED PERSON TO APPROPRIATELY DISCLOSE TO CLV ANY POTENTIAL CONFLICTS OF INTEREST. ONCE DISCLOSED, IT IS THE RESPONSIBILITY OF THE CEO/PRESIDENT TO DETERMINE IF A CONFLICT EXISTS. THE GOVERNANCE COMMITTEE OF THE BOARD OF TRUSTEES MAY BE UTILIZED BY THE CEO/PRESIDENT, IF NEEDED TO DETERMINE A POTENTIAL CONFLICT OF INTEREST. IF AN INTERESTED PERSON HAS FAILED TO DISCLOSE A CONFLICT OF INTEREST, APPROPRIATE DISCIPLINARY AND/OR CORRECTIVE ACTION WILL BE TAKEN. THE CONFLICT OF INTEREST POLICY STATEMENT IS REVIEWED ANNUALLY BY THE BOARD OF TRUSTEES AND IS A NORMAL PART OF ALL AGREEMENTS AND/OR CONTRACTS. AN APPROPRIATE STATEMENT FORM IS AVAILABLE AND MUST BE SIGNED AND ON FILE FOR ALL INTERESTED PERSONS.
FORM 990, PART VI, SECTION B, LINE 15
CARROLL LUTHERAN VILLAGE'S (THE FILING ORGANIZATION'S PARENT) BOARD OF TRUSTEES' EXECUTIVE COMMITTEE, INCLUDING THE CHAIRMAN, SERVES AS A COMPENSATION COMMITTEE. WITH THE SUPPORT OF THE VP OF HUMAN RESOURCES, THE COMMITTEE USES A VARIETY OF SURVEYS AND COMPENSATION CONSULTANTS TO DETERMINE A RECOMMENDED COMPENSATION AMOUNT FOR THE PRESIDENT/CEO. THE CARROLL LUTHERAN VILLAGE BOARD REVIEWS AND APPROVES THE COMPENSATION OF THE PRESIDENT/CEO.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS FINANCIAL STATEMENTS, FORM 990, AND OTHER OPERATING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CERTAIN GOVERNING DOCUMENTS AND POLICIES ARE CONSIDERED PROPRIETARY AND ARE NOT GENERALLY DISCLOSED. THE ORGANIZATION IS IN FULL COMPLIANCE WITH ALL REGULATIONS CONCERNING DISCLOSURE AT THE FEDERAL, STATE, AND LOCAL LEVELS.
FORM 990, PART XI, LINE 9:
IMPAIRMENT OF LAND -1,260,000.
FORM 990, PAGE 5, LINES 2A AND 2B:
LUTHERAN VILLAGE AT MILLERS GRANT IS CURRENTLY IN THE MARKETING PHASE OF DEVELOPMENT. ALL COSTS ASSOCIATED WITH THIS PROJECT ARE CURRENTLY BEING CAPITALIZED. THIS IS WHY THERE ARE EMPLOYEES LISTED ON LINE 2A OF PART V BUT NO CORRESPONDING SALARIES BEING REPORTED ON THE STATEMENT OF FUNCTIONAL EXPENSES.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.