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
COLUMBIA VANTAGE HOUSE CORPORATION
Employer identification number
52-1533715
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.") .
21,678
6,814
200
28,692
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......
13,715,319
13,998,725
14,707,426
13,780,137
13,335,615
69,537,222
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.
13,736,997
14,005,539
14,707,426
13,780,337
13,335,615
69,565,914
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.)
69,565,914
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...
13,736,997
14,005,539
14,707,426
13,780,337
13,335,615
69,565,914
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
193,259
349,250
172,234
241,001
125,681
1,081,425
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
193,259
349,250
172,234
241,001
125,681
1,081,425
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.)..
13,930,256
14,354,789
14,879,660
14,021,338
13,461,296
70,647,339
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
98.470 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
98.240 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
1.530 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
1.760 %
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
COLUMBIA VANTAGE HOUSE CORPORATION
Employer identification number
52-1533715
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 1
THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE OFFICERS OF THE CORPORATION AND OTHER TRUSTEES THAT MAY BE NAMED TO THE COMMITTEE BY THE CHAIR. THE EXECUTIVE COMMITTEE: (A) SHALL HAVE AND EXERCISE THE AUTHORITY OF THE BOARD OF TRUSTEES IN THE MANAGEMENT OF THE BUSINESS OF THE CORPORATION AND SHALL: (I) ACT AS AN ETHICS COMMITTEE WHEN NEEDED TO DEVELOP POLICIES AND GUIDELINES FOR HANDLING OF ETHICAL ISSUES AND REVIEW AND GIVE CONSULTATION INVOLVING ETHICAL DIFFICULTIES. (II) CONDUCT PERFORMANCE REVIEW OF PRESIDENT CHIEF EXECUTIVE OFFICER. (III) MONITOR EFFECTIVENESS AND APPROVE INCENTIVE COMPENSATION OF EMPLOYEES UNDER INCENTIVE COMPENSATION PROGRAMS. (IV) REVIEW AND RECOMMEND TO THE BOARD CHANGES TO THE HUMAN RESOURCES POLICY AND BENEFIT PLANS OF THE CORPORATION. (V) SUCH OTHER DUTIES AND FUNCTIONS AS MAY BE ASSIGNED BY THE BOARD. (B) THE EXECUTIVE COMMITTEE, HOWEVER, SHALL NOT HAVE ANY POWER OR THE AUTHORITY AS TO THE FOLLOWING: (I) THE FILLING OF VACANCIES IN THE BOARD OF TRUSTEES. (II) THE ADOPTION, AMENDMENT OR REPEAL OF (THE) BYLAWS OF THE CORPORATION. (III) THE AMENDMENT OR REPEAL OF ANY RESOLUTION OF THE BOARD. (IV) ACTION ON MATTERS ASSIGNED BY (THE) BYLAWS OR RESOLUTION OF THE BOARD OF TRUSTEES TO ANOTHER COMMITTEE OF THE BOARD.
FORM 990, PART VI, SECTION A, LINE 2
DAVID IMRE IS THE SON OF JO ELLEN IMRE. BOTH SERVE AS BOARD MEMBERS FOR COLUMBIA VANTAGE HOUSE CORPORATION.
FORM 990, PART VI, SECTION A, LINE 3
THE COMPANY HAS A MANAGEMENT AGREEMENT WITH LIFE CARE SERVICES LLC OF DES MOINES IA (LCS). LCS PROVIDES SYSTEMS (CLINICAL, FINANCIAL), SUPPORT, COMPLIANCE, AND PLACES ON-SITE THE EXECUTIVE DIRECTOR (WHO ACTS AS THE CHIEF OPERATING OFFICER) AND THE ADMINISTRATOR (WHO IS REQUIRED TO BE A MARYLAND LICENSED NURSING HOME ADMINISTRATOR) AND PROVIDES REGULAR REPORTS TO THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 11
FINANCE COMMITTEE WILL REVIEW THE 990 PRIOR TO FILING AT A MEETING. THE 990 WILL BE DISTRIBUTED TO THE FULL BOARD PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
THE CONFLICT OF INTEREST POLICY APPLIES TO THE BOARD OF DIRECTORS, ALL MEMBERS OF STANDING AND ADVISORY COMMITTEE, ANY BOARD OR COMMITTEE MEMBER'S IMMEDIATE FAMILY OR ANY PERSON ACTING ON THE BOARD OR COMMITTEE MEMBER'S BEHALF. ANNUAL CONFLICT OF INTEREST DISCLOSURES ARE REQUIRED OF ALL BOARD MEMBERS. ALL EMPLOYEES ARE REQUIRED TO REVIEW AND ACKNOWLEDGE IN WRITING THE CONFLICT OF INTEREST POLICY UPON HIRE AND ANNUALLY. AFTER DISCLOSURE OF A POTENTIAL CONFLICT AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, THE INTERESTED PERSON SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A BOARD OR COMMITTEE MEMBER HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM THE BOARD OR COMMITTEE MEMBER OF THE BASIS FOR SUCH BELIEF AND AFFORD SUCH BOARD OR COMMITTEE MEMBER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE.
FORM 990, PART VI, SECTION B, LINE 15
THE PROCESS FOR DETERMINING THE COMPENSATION OF THE CEO, EXECUTIVE DIRECTOR, TOP MANAGEMENT OFFICIAL, OTHER OFFICERS, AND KEY EMPLOYEES IS SET ANNUALLY DURING THE BUDGET PROCESS; DETERMINED BASED ON COMPARITIVE MARKET SURVEY AND PERFORMANCE. THIS PROCESS WAS LAST REVIEWED AND APPROVED IN 2014.
FORM 990, PART VI, SECTION C, LINE 19
COLUMBIA VANTAGE HOUSE PROVIDES THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE UPON REQUEST.
FORM 990, PART XI, LINE 9:
CHANGE DUE TO ADOPTION OF ASU 2012-01 -23,079,272.
FORM 990, PART XII, LINE 2C
THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.