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
SYMMES LIFE CARE INC
Employer identification number
04-2853296
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.") .
56,834
78,488
108,107
101,742
94,048
439,219
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......
20,732,837
21,622,275
21,850,560
22,399,632
23,473,682
110,078,986
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.
20,789,671
21,700,763
21,958,667
22,501,374
23,567,730
110,518,205
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.)
110,518,205
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...
20,789,671
21,700,763
21,958,667
22,501,374
23,567,730
110,518,205
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
548,405
712,071
1,098,243
1,386,637
2,371,665
6,117,021
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
548,405
712,071
1,098,243
1,386,637
2,371,665
6,117,021
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.)
..
26,969
27,593
23,716
30,765
1,845
110,888
13
Total support. (Add lines 9, 10c, 11, and 12.)..
21,365,045
22,440,427
23,080,626
23,918,776
25,941,240
116,746,114
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
94.670 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
95.910 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
5.240 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
3.970 %
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
SYMMES LIFE CARE INC
Employer identification number
04-2853296
Return Reference
Explanation
FORM 990, PART VI, SECTION A, LINE 1
THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE PRESIDENT OF THE CORPORATION, AND THE FOUR ELECTED OFFICERS OF THE CORPORATION. THE EXECUTIVE COMMITTEE SHALL POSSESS AND MAY EXERCISE ALL OF THE POWERS OF THE BOARD OF TRUSTEES IN THE MANAGEMENT OF THE CORPORATION AND THE DIRECTION OF ITS AFFAIRS BETWEEN MEETINGS OF THE BOARD, SUBJECT TO ANY LIMITATIONS IMPOSED ON THE EXECUTIVE COMMITTEE BY LAW, THE ARTICLES OF ORGANIZATION, THESE BYLAWS, OR BY THE BOARD OF TRUSTEES. THE BOARD SHALL HAVE THE POWER TO RESCIND ANY VOTE OR ACTION OF THE EXECUTIVE COMMITTEE, BUT NO SUCH RESCISSION SHALL HAVE RETROACTIVE EFFECT OR INVALIDATE ACTION ALREADY TAKEN IN RELIANCE ON SUCH VOTE OR ACTION. THE EXECUTIVE COMMITTEE SHALL MEET AS OFTEN AS MAY BE NECESSARY TO MEET ITS RESPONSIBILITIES, MEETINGS TO BE CALLED BY THE CHAIR OR THE PRESIDENT OF THE CORPORATION.
FORM 990, PART VI, SECTION B, LINE 11
A DRAFT OF THE 990 WAS REVIEWED BY THE ORGANIZATION'S BOARD OF DIRECTORS PRIOR TO BEING SUBMITTED TO THE INTERNAL REVENUE SERVICE.
FORM 990, PART VI, SECTION B, LINE 12C
THE POLICY & PROCEDURE ON CONFLICTS OF INTEREST AND DISCLOSURE OF CERTAIN INTERESTS COVERS ALL TRUSTEES. ALL NEW TRUSTEES ARE REQUIRED TO REVIEW THIS POLICY AND PROCEDURE AND ACKNOWLEDGE IN WRITING THAT THEY HAVE DONE SO. ANNUALLY, ALL TRUSTEES ARE REQUIRED TO REVIEW THE CONFLICT OF INTEREST POLICY AND COMPLETE A DISCLOSURE FORM IDENTIFYING ANY SITUATION HE/SHE BELIEVES COULD GIVE RISE TO A CONFLICT. THE BOARD CHAIR WILL BE INFORMED OF ALL DISCLOSED POTENTIAL CONFLICTS. PRIOR TO ANY BOARD/COMMITTEE ACTION ON A CONTRACT OR TRANSACTION INVOLVING A CONFLICT OF INTEREST, A TRUSTEE HAVING A CONFLICT OF INTEREST SHALL DISCLOSE ALL FACTS MATERIAL TO THE CONFLICT TO THE BOARD CHAIR WHO SHALL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. TRUSTEES WITH A CONFLICT OF INTEREST WILL NOT PARTICIPATE IN OR BE PERMITTED TO HEAR THE BOARD/COMMITTEE'S DISCUSSION OF THE MATTER EXCEPT TO DISCLOSE MATERIAL FACTS AND TO RESPOND TO QUESTIONS; IF A VOTE IS INVOLVED, THE TRUSTEE SHALL NOT VOTE AND SHALL NOT BE PRESENT IN THE ROOM WHEN THE VOTE IS TAKEN. RESPONSIBLE PERSONS WHO ARE NOT MEMBERS OF THE BOARD OR WHO HAVE A CONFLICT OF INTEREST WITH RESPECT TO A CONTRACT OR TRANSACTION THAT IS NOT THE SUBJECT OF BOARD/COMMITTEE ACTION, SHALL DISCLOSE ANY CONFLICT OF INTEREST TO THE CHAIR. THE RESPONSIBLE PERSON SHALL REFRAIN FROM ANY ACTION THAT MAY AFFECT THE ORGANIZATION'S PARTICIPATION IN SUCH CONTRACT OR TRANSACTION. THIS POLICY WAS LAST REVIEWED IN JANUARY 2014.
FORM 990, PART VI, SECTION B, LINE 15
THE PRESIDENT/CEO COMPLETED A SELF-EVALUATION OF HIS PERFORMANCE WHICH WAS PROVIDED TO MEMBERS OF THE BOARD OF TRUSTEES ALONG WITH THE ANNUAL PERFORMANCE EVALUATION FORM WHICH THEY WERE ASKED TO COMPLETE. COMPLETED PERFORMANCE EVALUATIONS WERE RETURNED TO THE CHAIR OF THE EXECUTIVE COMPENSATION COMMITTEE. THE RESULTS OF THE PERFORMANCE EVALUATION WERE SUMMARIZED AND DISCUSSED WITH THE EXECUTIVE COMPENSATION COMMITTEE INCLUDING THE RESULTS OF THE WAGE AND BENEFITS SURVEY CONDUCTED BY AN EXTERNAL CONSULTANT FOR THE CEO/PRESIDENT ROLE IN MAY, 2013. THE EXECUTIVE COMPENSATION COMMITTEE VOTED TO RECOMMEND THE ANNUAL PAY ADJUSTMENT FOR THE PRESIDENT/CEO. THE FULL BOARD OF TRUSTEES VOTED TO ACCEPT THE RECOMMENDATION. THE PRESIDENT/CEO COMPLETED A PERFORMANCE EVALUATION FOR THE SVP/CCO AND EVP/COO. THE PRESIDENT/CEO SHARED THE RESULTS OF THE PERFORMANCE EVALUATIONS WITH THE EXECUTIVE COMPENSATION COMMITTEE AND RECOMMENDED PAY ADJUSTMENTS FOR THESE POSITIONS BASED ON THE PERFORMANCE EVALUATION AND WAGE AND SALARY SURVEY DATA OBTAINED BY AN EXTERNAL CONSULTANT IN MAY, 2013.
FORM 990, PART VI, SECTION C, LINE 19
AUDITED FINANCIAL STATEMENTS ARE MAINTAINED IN A PUBLIC ROOM. RESIDENTS RECEIVE A COPY YEARLY. AUDITED FINANCIAL STATEMENTS ARE UPLOADED TO THE EMMA WEBSITE FOR THE PUBLIC.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.