Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (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 |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (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) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 250,578 | 230,663 | 706,897 | 6,813,562 | 850,519 | 8,852,219 |
| 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 | 20,666,581 | 20,574,412 | 21,346,664 | 20,093,330 | 15,734,481 | 98,415,468 |
| 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 | 20,917,159 | 20,805,075 | 22,053,561 | 26,906,892 | 16,585,000 | 107,267,687 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 129,567 | 120,001 | 667,587 | 6,939,582 | 311,563 | 8,168,300 |
| 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.. | 129,567 | 120,001 | 667,587 | 6,939,582 | 311,563 | 8,168,300 |
| 8 | Public support. (Subtract line 7c from line 6.) | 99,099,387 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 20,917,159 | 20,805,075 | 22,053,561 | 26,906,892 | 16,585,000 | 107,267,687 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 583,164 | 338,371 | 570,174 | 585,982 | 517,524 | 2,595,215 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 583,164 | 338,371 | 570,174 | 585,982 | 517,524 | 2,595,215 |
| 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.) .. | 258,872 | 286,354 | 315,949 | 903,462 | 12,561 | 1,777,198 |
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 21,759,195 | 21,429,800 | 22,939,684 | 28,396,336 | 17,115,085 | 111,640,100 |
| 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) |
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| 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 0.015 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 0.035 | 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 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2020. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2021. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
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| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | THE ORGANIZATION HAS AN AGREEMENT WITH WASHINGTON AND JANE SMITH HOME TO OVERSEE ITS GENERAL OPERATIONS. THE INITIAL TERM OF THIS AGREEMENT WAS FOR A PERIOD OF ONE (1) YEAR. THIS AGREEMENT RENEWS ANNUALLY THEREAFTER UNLESS TERMINATED IN ACCORDANCE WITH OTHER TERMS AND CONDITIONS CONTAINED THEREIN. FURTHERMORE, CERTAIN SUBORDINATION AND DEFERRAL PROVISIONS APPLY IN CONNECTION WITH PAYMENT OF COMPENSATION TO WASHINGTON AND JANE SMITH HOME. UNDER THE TERMS OF THE AGREEMENT, THE ORGANIZATION MUST COMPENSATE WASHINGTON AND JANE SMITH HOME FOR SERVICES RENDERED. THE AGREEMENT ALSO CONTAINS A PROVISION TO COMPENSATE WASHINGTON AND JANE SMITH HOME FOR SUPPLEMENTAL SERVICES IT MAY PROVIDE ABOVE AND BEYOND THOSE ENUMERATED IN THE AGREEMENT. IN ADDITION, THE ORGANIZATION MUST PAY WASHINGTON AND JANE SMITH HOME AN ADDITIONAL SUM ON A MONTHLY BASIS AS REIMBURSEMENT FOR WASHINGTON AND JANE SMITH HOME'S OVERHEAD EXPENSES RELATED TO THE ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 6 | WASHINGTON AND JANE SMITH COMMUNITY - BEVERLY HAS A SINGLE CLASS OF VOTING MEMBERS AND THE SOLE MEMBER OF THAT CLASS IS WASHINGTON AND JANE SMITH HOME, A RELATED ILLINOIS TAX-EXEMPT ORGANIZATION, WHICH SHALL CONTINUE FROM YEAR-TO-YEAR AS THE SOLE MEMBER OF THE ORGANIZATION. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE ORGANIZATION MUST HAVE APPROVAL OF ITS SOLE MEMBER, WASHINGTON AND JANE SMITH HOME, BEFORE ELECTING OR REMOVING ANY OF THE ORGANIZATION'S TRUSTEES AND OFFICERS. |
| FORM 990, PART VI, SECTION A, LINE 7B | THE ORGANIZATION SHALL NOT TAKE ANY OF THE FOLLOWING ACTIONS WITHOUT THE APPROVAL OF THE SOLE MEMBER: (1) ELECTION AND REMOVAL OF TRUSTEES AND OFFICERS. (2) AMENDMENT OF THE ARTICLES OF INCORPORATION OF THE ORGANIZATION. (3) AMENDMENT OF THE BYLAWS OF THE ORGANIZATION. (4) MERGER, CONSOLIDATION OR DISSOLUTION OF THE ORGANIZATION. (5) THE CREATION OF ANY SUBSIDIARIES OR AFFILIATES OF THE ORGANIZATION. (6) ADOPTION OF THE BUSINESS PLAN APPROVED ANNUALLY BY THE BOARD OF TRUSTEES OF THE ORGANIZATION. (7) ADOPTION OF THE ANNUAL BUDGET APPROVED BY THE ORGANIZATION AND ANY ACTIONS TAKEN BY THE ORGANIZATION WHICH WOULD OR COULD INVOLVE EXPENDITURES WHICH EXCEED ONE HUNDRED AND TEN PERCENT (110%) OF THE APPROVED BUDGETED AMOUNTS FOR SUCH EXPENDITURES. (8) THE SELECTION OF BANKING AFFILIATIONS, ACCOUNTING FIRMS OR LEGAL COUNSEL, AS WELL AS APPROVAL OF THE ENGAGEMENT OF ANY CONSULTANTS NOT SPECIFICALLY PROVIDED IN AN APPROVED BUDGET. (9) THE SELECTION AND RETENTION OF THE EXECUTIVE DIRECTOR OF THE ORGANIZATION. (10) THE MAKING OF CAPITAL EXPENDITURES OR SALE OF ANY CAPITAL ASSETS BY THE ORGANIZATION IN EXCESS OF FIFTY THOUSAND DOLLARS ($50,000) UNLESS PROVIDED IN THE ANNUAL BUDGET. (11) THE SELECTION OF THE MANNER AND LOCATION OF INVESTMENT OF ANY FUNDS. (12) THE EXTENSION OF ANY LOANS BY OR ANY BORROWING BY THE ORGANIZATION |
| FORM 990, PART VI, SECTION B, LINE 11B | THE ORGANIZATION'S INTERNAL MANAGEMENT AND THE FINANCE COMMITTEE REVIEWS THE RETURN WITH ITS PAID TAX PREPARER. AFTER REVIEW, COPIES OF THE FULL FORM 990 ARE MADE AVAILABLE TO ALL TRUSTEES PRIOR TO FILING THE RETURN WITH THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | ANNUALLY ALL TRUSTEES, CORPORATE OFFICERS, EXECUTIVE AND KEY PERSONNAL ARE REQUIRED TO COMPLETE A DISCLOSURE FOR CONFLICTS OF INTEREST. THE DISCLOSURES ARE REVIEWED BY THE CFO WHO DETERMINES IF A POTENTIAL OR ACTUAL CONFLICT OF INTEREST EXISTS. IF A POTENTIAL OR ACTUAL CONFLICT OF INTEREST EXISTS THE TRUSTEE IS REQUIRED TO RECUSE THEMSELVES FROM ANY VOTING, DELIBERATION, OR DECISION ON THE TRANSACTION AT THE BOARD LEVEL. FURTHERMORE, ALL VENDOR PAYMENT ACTIVITY IS REVIEWED BY THE CFO FOR VENDORS THAT MAY BE RELATED TO THE FILING ORGANIZATION. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION RELIES ON WASHINGTON AND JANE SMITH HOME, A RELATED TAX-EXEMPT ORGANIZATION TO DETERMINE THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIALS. THE COMPENSATION COMMITTEE OF WASHINGTON AND JANE SMITH HOME EVALUATES AND ESTABLISHES COMPENSATION AND REVIEWS PROTOCOL FOR THE ORGANIZATION'S CEO AND CFO. ANNUAL COMPENSATION COMPARISONS TO INDUSTRY PROFESSIONALS ARE GATHERED AND REVIEWED ON AN ANNUAL BASIS. DECISIONS ARE DOCUMENTED IN THE COMPENSATION COMMITTEE MEETING MINUTES. THE LAST COMPENSATION REVIEW WAS COMPLETED IN OCTOBER 2020. THE CEO OF WASHINGTON AND JANE SMITH HOME DETERMINES THE ANNUAL COMPENSATION OF ALL OTHER OFFICERS, WITH THE EXCEPTION OF THE CFO, BY COMPARING THE COMPENSATION OF EACH OFFICER AND KEY EMPLOYEES TO PROFESSIONALS PERFORMING SIMILAR SERVICES IN SIMILAR INDUSTRIES ON AN ANNUAL BASIS. THE LAST COMPENSATION REVIEW WAS COMPLETED IN JULY 2020. |
| FORM 990, PART VI, SECTION C, LINE 19 | FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104, AND ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME. |
| FORM 990, PART IX, LINE 11G | NURSING MANAGEMENT, PHARMACY, OTHER CONSULTING: PROGRAM SERVICE EXPENSES 725,190. MANAGEMENT AND GENERAL EXPENSES 3,620. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 728,810. DINING SERVICES: PROGRAM SERVICE EXPENSES 1,637,719. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,637,719. REHABILITATION SERVICES: PROGRAM SERVICE EXPENSES 650,865. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 650,865. MARKETING SERVICES: PROGRAM SERVICE EXPENSES 60,484. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 60,484. |
| FORM 990, PART XI, LINE 9: | CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 2,407,831. |
| Software ID: | |
| Software Version: |