2021-11-15T06:41:19-06:00 2020-12-31 861065772 DELOITTE TAX LLP 50 S 6TH STREET MINNEAPOLIS MN 55402 990 2020-01-01 450228055 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY EVAN 6053623100 PO BOX 5039 RTE 5218 SIOUX FALLS SD 571175039 BILL MARLETTE CFO & TREASURER 6053331000 2021-11-05 1 BILL MARLETTE XXX-XX-XXXX CHRIS MESKIMEN P01314196 6123974000 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z RANDY BURY 4800 W 57TH ST SIOUX FALLS SD 57108 1075704409 0 X WWW.GOOD-SAM.COM X 1922 ND DEDICATED TO SHARING GOD'S LOVE THROUGH THE WORK OF HEALTH, HEALING AND COMFORT. 15 11 27349 258 2457867 0 7572687 97147346 931240540 925626155 11436779 -293270 14148138 11300722 964398144 1033780953 1428847 755357 0 0 572779797 550984958 0 0 498051 464395592 450746967 1038604236 1002487282 -74206092 31293671 1563553743 1376420357 240266985 233699983 1323286758 1142720374 X THE MISSION OF THE GOOD SAMARITAN SOCIETY - TO SHARE GOD'S LOVE THROUGH THE WORK OF HEALTH, HEALING AND COMFORT - IS A LOCAL MISSION. IT PLAYS OUT IN HUNDREDS OF HOMETOWNS ACROSS AMERICA EVERY DAY. 0 0 729324877 755357 694704840 SKILLED NURSING SERVICES - REHABILITATION/SKILLED NURSING SERVICES HAVE BEEN AT THE CORE OF THE SOCIETY'S SERVICES OVER ITS 98-YEAR HISTORY. THE SOCIETY APPROACHES CARE FOR THE SPIRITUAL, EMOTIONAL AND SOCIAL DIMENSIONS OF OUR SKILLED NURSING RESIDENTS IS AS IMPORTANT AS THE PHYSICAL CARE THAT IS PROVIDED TO SOCIETY RESIDENTS EVERY HOUR OF EVERY DAY.SERVICES PROVIDED IN SOCIETY SKILLED NURSING FACILITIES INCLUDE COMPREHENSIVE PROFESSIONAL NURSING CARE; REHABILITATION SERVICES; AS WELL AS A HIGH QUALITY OF RELATED SERVICES SUCH AS DIETARY, RECREATIONAL AND OTHER ACTIVITIES; MEDICATION ADMINISTRATION; AND OTHER SERVICES THAT MEET THE HOLISTIC NEEDS OF THOSE THE SOCIETY IS CALLED TO SERVE.THE SOCIETY IS THE LARGEST NOT-FOR-PROFIT PROVIDER OF REHABILITATION/SKILLED NURSING SERVICES IN THE UNITED STATES. BUT SIZE IS NOT THE SOCIETY'S OBJECTIVE. INSTEAD, SEEKING TO MEET THE NEEDS OF "OLDER PERSONS AND OTHERS IN NEED" TO IMPROVE THEIR WELL-BEING - AS THEY DEFINE IT - REMAINS PARAMOUNT.STATISTICALLY, THE SOCIETY PROVIDED A TOTAL OF 2,453,493 SKILLED NURSING HOME DAYS OF CARE AND SERVICE IN 2020. THE SOCIETY CONTINUES TO REINVEST MUCH OF ITS REVENUE TO BUILD AND REVITALIZE ITS FACILITIES ON CAMPUSES THROUGHOUT THE COUNTRY. 90273299 0 95927377 HOUSING WITH SERVICES - ALSO REFERRED TO AS INDEPENDENT OR SENIOR HOUSING, HOUSING WITH SERVICES HAS BEEN A GROWING PART OF THE SOCIETY'S MINISTRY FOR MANY YEARS. WITH ABOUT 10,000 PEOPLE RETIRING EACH AND EVERY DAY IN THE UNITED STATES - AND WITH EVER-INCREASING NUMBERS OCCURRING IN FUTURE YEARS - THE PROVISION OF SENIOR LIVING/HOUSING WILL TAKE ON INCREASING IMPORTANCE IN YEARS TO COME. THE SOCIETY RECOGNIZES THIS GROWTH AND HAS MADE EXPANSION OF SENIOR LIVING SERVICES AND LOCATIONS A MAJOR PART OF THIS CORPORATE STRATEGIC PLANNING.CAMPUSES FEATURE ATTRACTIVE GROUNDS; A VARIETY OF COMMON SPACE AND MULTI-PURPOSE ROOMS FOR RESIDENT AND FAMILY INTERACTION AND COMMUNITY GATHERINGS; LIBRARIES AND READING ROOMS, LARGE COMMON KITCHENS; CABLE TV AND PHONE SERVICE; AND THE AVAILABILITY OF COMPUTER/INTERNET SERVICES TO ALLOW AND ENCOURAGE ELECTRONIC CONNECTIVITY WITH FAMILY AND FRIENDS. FURTHER, VARIOUS SENIOR LEARNING OPPORTUNITIES ARE PROVIDED ON SENIOR LIVING CAMPUSES IN ADDITION TO THE SPIRITUAL AND SOCIAL PROGRAMS OFFERED IN REHABILITATION/SKILLED NURSING SERVICES AND ASSISTED LIVING. 77295783 0 46526328 ASSISTED LIVING SERVICES - ASSISTED LIVING SERVICES RESPOND TO THE SOCIETY'S RESIDENTS' NEEDS EACH DAY IN A "HOME-LIKE" ENVIRONMENT. IN 2020, THE SOCIETY PROVIDED 1,731,284 RESIDENT DAYS IN ASSISTED LIVING LOCATIONS. THIS IMPORTANT LEVEL OF CARE PROVIDES A VITAL, INTERMEDIATE LEVEL OF CARE FOR INDIVIDUALS WHO ARE NEITHER ABLE TO LIVE INDEPENDENTLY NOR ARE IN NEED OF SKILLED NURSING SERVICES.THE LIST OF SERVICES PROVIDED IN SOCIETY ASSISTED LIVING FACILITIES HIGHLIGHTS AN ENVIRONMENT THAT PROVIDES FOR THE HOLISTIC CARE OF ITS RESIDENTS. SERVICES INCLUDE THREE NUTRITIOUS MEALS A DAY, HOUSEKEEPING, LAUNDRY SERVICE, 24-HOUR STAFFING (IN ADDITION TO EMERGENCY CALL SYSTEMS), SCHEDULED TRANSPORTATION, SPIRITUAL SERVICES, AND MEDICATION ASSISTANCE. COORDINATED SPIRITUAL AND SOCIAL PROGRAMS ARE OFFERED FOR THE TOTAL WELL-BEING OF THE RESIDENTS. 11292794 0 93305571 HOME HEALTH SERVICES - THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY OFFERS LICENSED HOME HEALTH CARE, HOSPICE AND SERVICES@HOME (PRIVATE DUTY) SERVICES IN 18 STATES. THESE AGENCIES PROVIDE SKILLED HEALTH CARE IN A CLIENT'S HOME. SKILLED CARE INCLUDES PROFESSIONAL NURSING CARE, HOME HEALTH AIDE ASSISTANCE, SOCIAL SERVICES AND THERAPISTS TO MEET THE SKILLED-MEDICAL NEEDS OF THE CLIENT. WE PROVIDE CLINICAL SUPERVISION AND TREATMENT FOR THE PERSON ON A SHORT-TERM OR INTERMITTENT BASIS TO MEET HIS OR HER MEDICAL AND PERSONAL NEEDS.THE LICENSED HOSPICE AGENCIES AND GENERAL INPATIENT UNIT PROVIDED SERVICES INCLUDING PHYSICIAN, PROFESSIONAL NURSE, MEDICAL SOCIAL WORKER, CHAPLAIN, BEREAVEMENT SERVICE, HOME HEALTH AIDE, VOLUNTEERS AND THERAPY AS DIRECTED BY THE PATIENT'S CARE PLAN. THE COMPASSIONATE, LOVING CARE AT THE END OF A PERSON'S LIFE PROVIDES THE PATIENT AND THEIR FAMILIES WITH THE SUPPORT AND CARE NEEDED TO MEET THE GOALS OF CARE.SERVICES@HOME, OUR PRIVATE DUTY AGENCIES, TAILORS SERVICES TO SUPPORT SENIORS, WHICH ALLOWS THEM THE CHOICE TO REMAIN HOME WHILE RECEIVING THE COMPASSIONATE CARE AND SERVICES NEEDED. THESE SERVICES INCLUDE MEAL PREPARATION, HOUSEKEEPING, COMPANIONSHIP, PERSONAL HYGIENE AND GROOMING, BATHING, EXERCISE, RESPITE CARE, MEMORY CARE, TRANSPORTATION, APPOINTMENT ESCORT, MEDICATION REMINDERS AND MORE. 11292794 0 93305571 908186753 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 1 0 0 1 30 0 1 27349 1 1 1 1 CJ 0 0 0 0 0 0 0 0 0 0 X 15 11 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 AL AK AR CA CO CT DC FL GA HI IL KS KY LA ME MD MI MN MS NV NH NJ NM NY NC ND OH OK PA RI TN UT WA VA WV WI X BILL MARLETTE CFO & TREASURER 6053331000 2301 EAST 60TH STREET SIOUX FALLS SD 57104 DALE THOMPSON CHAIRPERSON 3.30 0.10 X X 0 0 0 ALAN GARD VICE CHAIRPERSON 3.30 0.10 X X 0 0 0 DAVID AUSTAD DIRECTOR 3.30 0.10 X 0 0 0 DAVID BRECHTELSBAUER DIRECTOR 3.30 0.10 X 0 0 0 NORVAL BUCKNEBERG DIRECTOR 3.30 0.10 X 0 0 0 PATRICIA CAMERO DIRECTOR 50.00 0.10 X 197353 0 11791 JAVIER ESPINOSA DIRECTOR (THRU 7/20) 50.00 0.10 X 126784 0 13175 MARNIE HERRMANN DIRECTOR 3.30 0.10 X 0 0 0 KELBY KRABBENHOFT DIRECTOR (THRU 11/20) 3.30 56.70 X 0 5077342 68524 KELBY KRABBENHOFT SEE SCH J, PART III, LINES 4A-4B 3.30 56.70 X 0 44353819 0 BILL GASSEN III DIRECTOR (START 11/20) 3.30 56.70 X 0 1517211 103667 BILL GASSEN III SEE SCH J, PART III, LINES 4A-4B 3.30 56.70 X 0 1100000 0 LISA MELBY DIRECTOR 50.00 0.10 X 171736 0 24712 SCOTT PETERSEN DIRECTOR 3.30 0.10 X 0 0 0 DARRELL SCHMITH DIRECTOR 3.30 0.10 X 0 0 0 JILL SCHUMANN DIRECTOR 3.30 0.10 X 0 0 0 ELIZABETH CALLAHAN DIRECTOR (START 6/20) 45.00 0.10 X 0 0 0 THOMAS KOOP DIRECTOR (START 6/20) 3.30 0.10 X 0 0 0 TABBITHA COOK DIRECTOR (START 9/20) 50.00 0.10 X 92380 0 4025 ERIC VANDEN HULL VICE PRESIDENT - FINANCE 50.00 5.00 X 0 451164 25363 RANDY BURY PRESIDENT & CEO 58.10 1.90 X 0 1334981 137350 RANDY BURY SEE SCH J, PART III, LINES 4A-4B 58.10 1.90 X 0 359927 0 BILL MARLETTE TREASURER 1.00 59.00 X 0 1749053 31556 BILL MARLETTE SEE SCH J, PART III, LINES 4A-4B 1.00 59.00 X 0 5903232 0 NATHAN SCHEMA VICE PRESIDENT - OPERATION 54.90 0.10 X 330901 0 34104 JOSEPH HERDINA ASSISTANT TREASURER 55.00 0.00 X 29703 0 1484 JOSEPH HERDINA SEE SCH J, PART III, LINES 4A-4B 55.00 0.00 X 476691 0 0 VICTORIA WALKER CHIEF MEDICAL OFFICER 55.00 0.00 X 378812 0 12248 GREGORY WILCOX VP MISSION EFFECT & SR PASTOR 45.00 0.00 X 377892 0 23438 KIMBERLY JOHANSEN VP, HOME & COMMUNITY BASED SERVICES 55.00 0.00 X 306661 0 6987 JULIE RIEKEN STAFF NURSE-RN 91.63 0.00 X 247149 0 18189 DAVID J HORAZDOVSKY FORMER OFFICER & CEO (THRU 12/20) 54.96 0.04 X 0 1176519 29427 DAVID J HORAZDOVSKY SEE SCH J, PART III, LINES 4A-4B 54.96 0.04 X 0 1949651 0 THOMAS SYVERSON FORMER OFFICER EXEC VP 53.12 1.88 X 0 355594 39593 JAN RITTER FORMER KEY EMPLOYEE VP - HR 55.00 0.00 X 0 452707 20618 LINDA STUDER FORMER KEY EMPLOYEE VP - OPERATIONS 55.00 0.00 X 266172 0 22455 DUSTIN SCHOLZ FORMER KEY EMPLOYEE REGIONAL VP 55.00 0.00 X 209136 0 35741 DAN HAMES FORMER KEY EMPLOYEE REGIONAL VP 55.00 0.00 X 232594 0 33793 3443964 65781200 698240 235 1 1 0 FOCUSONE SOLUTIONS LLC 13609 CALIFORNIA STREET OMAHA NE 68154 POOL STAFF SERVICES 27155061 AEGIS THERAPIES INC 1000 FLANNA WAY MAIL DROP 2761 FORT SMITH AR 729192761 CONTRACT THERAPY SERVICES 12776967 INFINITY REHAB 25117 SW PARKWAY AVE SUITE D WILSONVILLE OR 97070 CONTRACT THERAPY SERVICES 5116015 GO TO HEALTHCARE PLACEMENT INC 58 VILLA STREET MANCHESTER TN 37355 NURSING POOL SERVICES 3255490 SUMMIT CARE INC 6830 W 121ST COURT OVERLAND PARK KS 66209 CONTRACT THERAPY SERVICES 3137919 128 6036084 88350878 2760384 2379130 97147346 LTC - ROOM REVENUE 623000 670723104 670723104 LTC - THERAPY SERVICES 623000 136305035 136305035 ANCILLARY & PHARMACY 623000 48608499 48608499 HCBS REVENUE 623000 46313825 46313825 LTC QUALITY INCENTIVES 623000 4269202 4064575 204627 19406490 19406490 925626155 749504 749504 3227565 74032 0 0 3227565 74032 3301597 74032 4774 3222791 40435006 445676 40491786 1431670 -56780 -985994 -1042774 -1042774 ADMINISTRATIVE SERVICE 561000 4763929 2753293 2010636 CAFETERIA/VENDING 722514 2321483 2321483 EMPLOYEE & GUEST MEALS 722514 712422 237830 474592 201291 157369 43922 7999125 1033780953 879797723 2457867 54378017 216406 216406 520033 520033 18918 18918 55113598 54892235 177878 43485 4949037 4929159 15973 3905 382680691 381143658 1235091 301942 16873260 16821648 11605 40007 49415309 44870914 4527831 16564 41953063 40487624 1418115 47324 145397 67184 78213 14742 14742 242329 242329 113249 113249 85660996 85454756 206240 2727271 2717779 4485 5007 8847291 8471033 376204 54 21402 21402 45122519 44106083 1016436 4608312 4607571 594 147 637397 637397 24706468 23401421 1305047 70170134 64295844 5874290 13859319 13392367 466952 INTERCOMPANY PURCHASED 82257422 6348469 75907953 1000 MEDICAL SUPPLIES 74673925 74631997 27138 14790 MINNESOTA CARE TAX 17483906 17483906 UNCOLLECTIBLE EXPENSE 8531125 8222975 308150 10923763 10425974 473963 23826 1002487282 908186753 93802478 498051 69969817 37175068 669146 698764 88088081 94944173 12830247 11817775 2764580 3095991 2413448 1503715 2225993027 1094997721 1139954649 1130995306 214234968 21340893 4986807 4715758 27642000 25474000 44658914 1563553743 1376420357 85485387 49621320 4950078 5487858 143144785 163793885 -9989 2969976 6696724 11826944 240266985 233699983 X 1323049860 1142524503 236898 195871 1323286758 1142720374 1563553743 1376420357 X 31293671 -275488 -211584567 X 0 1 X 1 1 1 X 14047566 13962657 13345039 7572687 97147346 146075295 983921587 978517457 975042383 833953581 925626155 4697061163 351192 313503 309104 10332 984131 998320345 992793617 988696526 841536600 1022773501 4844120589 2062341 2386111 2189986 2672670 6036084 15347192 0 2062341 2386111 2189986 2672670 6036084 15347192 4828773397 12386594 12536105 11331116 107653658 4051102 147958575 12386594 12536105 11331116 107653658 4051102 147958575 13559113 13318418 6950594 11582648 7841756 53252529 1024266052 1018648140 1006978236 960772906 1034666359 5045331693 0.95710 0.95670 0.02930 0.03040 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: ADMINISTRATIVE SERVICES OTHER REVENUE EMPLOYEE GUEST MEALS CAFETERIA/VENDING RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 1 13367 0 0 1 111102 0 1 417092 541561 0 PART II-B, LINE 1: THE FILING ORGANIZATION HAS MEMBERSHIPS IN THE SOUTH DAKOTA ASSOCIATION OF HEALTHCARE ORGANIZATIONS, NORTH DAKOTA LONG TERM CARE ASSOCIATION, AND IOWA HOSPITAL ASSOCIATION. A PERCENTAGE OF MEMBERSHIP DUES PAID TO THESE ORGANIZATIONS RELATE TO LOBBYING EXPENSES. IN ADDITION, THE ORGANIZATION EMPLOYS CERTAIN INDIVIDUALS, AND CONTRACTS WITH VARIOUS LOBBYISTS, TO MONITOR LEGISLATIVE ACTS IMPORTANT TO ALL GOOD SAMARITAN SOCIETY ENTITIES ON BOTH STATE AND NATIONAL LEVELS. OCCASIONALLY, EMPLOYEES AND RESIDENTS SEND MAILINGS TO LEGISLATORS ON ISSUES THAT MAY AFFECT LONG TERM CARE/POST-ACUTE ISSUES. 0 1 X 155625 42301 113324 1951000 1795375 155625 2265000 43000 -236000 121000 1951000 2406000 205000 346000 2265000 2388000 16000 26000 24000 2406000 0.00000 1.00000 0.00000 0 0 148572503 148572503 1685212200 840025526 845186674 1703347 1466997 236350 256593991 189128301 67465690 133910986 64376897 69534089 1130995306 DEFERRED COMPENSATION 5607882 OPERATING LEASE PAYABLE - LT 72246 OTHER NON-CURRENT LIABILITIES 6146816 11826944 X PART IV, LINE 2B: AS SET FORTH BY FEDERAL AND STATE REGULATIONS, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (SOCIETY) PROVIDES RESIDENT TRUST ACCOUNT (RTA) SERVICES FOR RESIDENTS. THESE RTA FUNDS ARE NOT COMMINGLED WITH SOCIETY FUNDS, ARE ACCESSIBLE FOR RESIDENTS' USE, HAVE DETAILED ACCOUNTING RECORDS MAINTAINED ON AN INDIVIDUAL RESIDENT BASIS, AND FOLLOW BOTH FEDERAL AND STATE REGULATIONS REGARDING THE HANDLING AND DOCUMENTATION OF ACTIVITY. AS RTA FUNDS ARE HELD IN TRUST FOR RESIDENTS, A RESIDENT MAY AUTHORIZE THAT THEIR RTA FUNDS BE RETURNED TO THE RESIDENT OR THEIR DESIGNEE (REPRESENTATIVE PAYEE, FINANCIAL POWER OF ATTORNEY, GUARDIAN, ETC.) AT ANY TIME. ADDITIONALLY, WHEN A RESIDENT IS DISCHARGED FROM A FACILITY, THEIR RTA FUNDS ARE RETURNED TO THE RESIDENT OR THEIR AUTHORIZED DESIGNEE. IF A RESIDENT EXPIRES WITH RTA FUNDS ON HAND, SPECIFIC STATE REGULATIONS ALONG WITH STATE AND/OR FEDERAL AGENCIES GUIDELINES ARE REVIEWED TO ENSURE THESE RTA FUNDS ARE MANAGED APPROPRIATELY. THE SOCIETY HAS HOUSING ENTRANCE FEES FOR ADMITTANCE INTO HOUSING UNITS AT VARIOUS LOCATIONS. THESE CONTRACTS FOR HOUSING ENTRANCE FEES VARY BY LOCATION, AND TYPICALLY HAVE VARYING REFUNDABLE PORTIONS UP TO 100% OF THESE ENTRANCE FEES. THE REFUNDABLE PORTIONS OF THE HOUSING ENTRANCE FEES ARE REFUNDABLE BASED UPON TIME RESTRICTIONS AND VACANCY OF THE HOUSING UNIT. THE NONREFUNDABLE PORTION OF THE HOUSING ENTRANCE FEES ARE RECORDED AS DEFERRED REVENUE AND AMORTIZED INTO INCOME OVER THE LIFE EXPECTANCY OF THE RESIDENT AND FULLY RECOGNIZED WHEN THE RESIDENT VACATES ITS UNIT. THE SOCIETY RECORDS A CURRENT PORTION OF HOUSING ENTRANCE FEES THAT IS EXPECTED TO BE REFUNDED IN THE NEXT YEAR. PART V, LINE 4: THE SOCIETY'S ENDOWMENT FUNDS ARE USED AS DIRECTED BY THE DONOR'S RESTRICTIONS OR THE BOARD'S DESIGNATION. PART X, LINE 2: CERTAIN CONTROLLED CORPORATIONS ARE SUBJECT TO INCOME TAXES. DEFERRED INCOME TAX ASSETS AND LIABILITIES ARE RECOGNIZED FOR THE DIFFERENCES BETWEEN THE FINANCIAL AND INCOME TAX REPORTING BASIS OF ASSETS AND LIABILITIES BASED ON ENACTED TAX RATES AND LAWS. A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION. THE DEFERRED INCOME TAX PROVISION OR BENEFIT GENERALLY REFLECTS THE NET CHANGE IN DEFERRED INCOME TAX ASSETS AND LIABILITIES DURING THE YEAR. THE CURRENT INCOME TAX PROVISIONS REFLECTS THE TAX CONSEQUENCES OF REVENUES AND EXPENSES CURRENTLY TAXABLE OR DEDUCTIBLE ON VARIOUS INCOME TAX RETURNS FOR THE YEAR REPORTED. THE SOCIETY DID NOT AN INCOME TAX LIABILITY AT DECEMBER 31, 2020; HOWEVER, SOME RELATED ORGANIZATIONS HAVE ESTABLISHED RESERVES. 1 SOUTH AMERICA 0 0 GRANTS TO ORGANIZATION 18918 0 0 0 0 0 0 18918 0 18918 SOUTH AMERICA THE CONTRIBUTION TO THE EVANGELICAL LUTHERAN CHURCH IN COLUMBIA HELPS PROVIDE SHELTER, FOOD, AND SOCIAL SERVICES SUPPORT TO ELDERS IN TWO LOCATIONS - SOACHA AND TUNJA. 18918 WIRE TRANSFERS 1 0 1 0 1 0 0 0 PART I, LINE 2: THE SOCIETY PROVIDES GRANTS TO ORGANIZATIONS TO SUPPORT VARIOUS CAUSES EACH YEAR. GENERAL CORRESPONDENCE WITH THE RECIPIENTS OF THESE GRANTS IS USED WHEN NEEDED WHILE MONITORING THE USE OF THE GRANTED MONIES. PART III ACCOUNTING METHOD: 1 WORLD MISSION PRAYER LEAGUE 232 CLIFTON AVE MINNEAPOLIS MN 55403 410786986 501(C)(3) 10888 MISSIONARY WORK OF PROVIDING FUNDS TO SUPPORT LAMB HOSPITAL IN BANGLADESH. TEAM PO BOX 1986 GRAPEVINE TX 760991986 362169146 501(C)(3) 21123 MISSIONARY WORK OF PROVIDING FUNDS TO SUPPORT KARANDA MISSION HOSPITAL IN ZIMBABWE. SANFORD HEALTH PO BOX 5039 RTE 5218 SIOUX FALLS SD 57117 311527032 501(C)(3) 139966 SCHOLARSHIPS AND EMPLOYEE CRISIS FUND 3 0 SCHOLARSHIPS 297 520033 PART I, LINE 2 THE SOCIETY PROVIDES GRANTS TO ORGANIZATIONS TO SUPPORT VARIOUS CAUSES EACH YEAR. GENERAL CORRESPONDANCE WITH THE RECIPIENTS OF THESE GRANTS IS USED WHEN NEEDED WHILE MONITORING THE USE OF THE GRANTED MOINES. PART III, COLUMN A: THE SOCIETY PROVIDES SCHOLARSHIPS TO EMPLOYEES WHO ARE ENROLLED IN A QUALIFIED EDUCATION PROGRAM. THE SOCIETY PAYS THE SCHOLARSHIP DIRECTLY TO THE EDUCATIONAL INSTITUTION WHERE THE EMPLOYEE IS ENROLLED. IF AN EMPLOYEE HAS ALREADY PAID THE EXPENSE, THE SOCIETY REQUIRES RECEIPT OF PAYMENT BEFORE REIMBURSEMENT IS MADE TO THE EMPLOYEE. X 1 1 X X X X 1 1 0 0 0 0 0 0 0 PATRICIA CAMERO DIRECTOR 195529 0 300 0 1524 0 4227 0 7564 0 209144 0 0 0 KELBY KRABBENHOFT DIRECTOR (THRU 11/20) 0 3028187 0 1971204 0 77951 0 45148 0 23376 0 5145866 0 0 KELBY KRABBENHOFT SEE SCH J, PART III, LINES 4A-4B 0 0 0 0 0 44353819 0 0 0 0 0 44353819 0 8183861 BILL GASSEN III DIRECTOR (START 11/20) 0 1098215 0 244003 0 174993 0 101820 0 1847 0 1620878 0 0 BILL GASSEN III SEE SCH J, PART III, LINES 4A-4B 0 0 0 1100000 0 0 0 0 0 0 0 1100000 0 0 LISA MELBY DIRECTOR 171160 0 300 0 276 0 8799 0 15913 0 196448 0 0 0 ERIC VANDEN HULL VICE PRESIDENT - FINANCE 0 375219 0 25300 0 50645 0 14250 0 11113 0 476527 0 0 RANDY BURY PRESIDENT & CEO 0 888856 0 280005 0 166120 0 111985 0 25365 0 1472331 0 0 RANDY BURY SEE SCH J, PART III, LINES 4A-4B 0 0 0 0 0 359927 0 0 0 0 0 359927 0 226838 BILL MARLETTE TREASURER 0 1210291 0 317501 0 221261 0 29289 0 2267 0 1780609 0 0 BILL MARLETTE SEE SCH J, PART III, LINES 4A-4B 0 0 0 0 0 5903232 0 0 0 0 0 5903232 0 1662810 NATHAN SCHEMA VICE PRESIDENT - OPERATION 300493 0 30300 0 108 0 8700 0 25404 0 365005 0 0 0 JOSEPH HERDINA ASSISTANT TREASURER 29681 0 0 0 22 0 1484 0 0 0 31187 0 0 0 JOSEPH HERDINA SEE SCH J, PART III, LINES 4A-4B 0 0 0 0 476691 0 0 0 0 0 476691 0 0 0 VICTORIA WALKER CHIEF MEDICAL OFFICER 88521 0 0 0 290291 0 4551 0 7697 0 391060 0 0 0 GREGORY WILCOX VP MISSION EFFECT & SR PASTOR 117536 0 4250 0 256106 0 6415 0 17023 0 401330 0 0 0 KIMBERLY JOHANSEN VP, HOME & COMMUNITY BASED SERVICES 74170 0 0 0 232491 0 1584 0 5403 0 313648 0 0 0 JULIE RIEKEN STAFF NURSE-RN 229348 0 17801 0 0 0 9954 0 8235 0 265338 0 0 0 DAVID J HORAZDOVSKY FORMER OFFICER & CEO (THRU 12/20) 0 784138 0 246501 0 145880 0 14250 0 15177 0 1205946 0 0 DAVID J HORAZDOVSKY SEE SCH J, PART III, LINES 4A-4B 0 0 0 0 0 1949651 0 0 0 0 0 1949651 0 0 THOMAS SYVERSON FORMER OFFICER EXEC VP 0 343862 0 300 0 11432 0 13943 0 25650 0 395187 0 0 JAN RITTER FORMER KEY EMPLOYEE VP - HR 0 143874 0 0 0 308833 0 6903 0 13715 0 473325 0 0 LINDA STUDER FORMER KEY EMPLOYEE VP - OPERATIONS 263857 0 300 0 2015 0 10208 0 12247 0 288627 0 0 0 DUSTIN SCHOLZ FORMER KEY EMPLOYEE REGIONAL VP 184659 0 24357 0 120 0 10788 0 24953 0 244877 0 0 0 DAN HAMES FORMER KEY EMPLOYEE REGIONAL VP 206039 0 26279 0 276 0 6806 0 26987 0 266387 0 0 0 PART I, LINE 1A FIRST CLASS OR CHARTER TRAVEL - FIRST CLASS TRAVEL OR CHARTER TRAVEL IS PROVIDED FOR INDIVIDUALS AS NEEDED AND AS COST APPROPRIATE, IN ACCORDANCE WITH WRITTEN POLICIES. THESE COSTS ARE NOT INCLUDED IN THE W-2'S OF THE INDIVIDUALS AS THEY ARE INCURRED FOR BUSINESS PURPOSES OF THE SOCIETY. PART I, LINES 4A-B PART I, LINE 4A SEVERANCE OR CHANGE OF CONTROL AND LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS LINA 4A - SEVERANCE OR CHANGE OF CONTROL UPON HIRE OR PROMOTION, SELECT OFFICERS AND KEY EMPLOYEES SIGN AN EXECUTIVE SEVERANCE AGREEMENT (THE "AGREEMENT"). THE AGREEMENT PROVIDES THAT THE EXECUTIVE WILL RECEIVE A MULTIPLE OF HIS OR HER SALARY (BASED ON YEARS OF SERVICE OR POSITION) AS A PAYMENT IN THE EVENT OF A DEFINED SEPARATION EVENT, WHICH CAN INCLUDE AN INVOLUNTARY SEPARATION OR AN EMPLOYEE VOLUNTARILY LEAVING FOR A DEFINED CONTRACTUAL REASON. FINAL SEPARATION PAYMENTS MIGHT VARY FROM THE AMOUNT PROVIDED IN THE AGREEMENT AS A RESULT OF NEGOTIATIONS SURROUNDING EARLY RETIREMENTS AND POST-SEPARATION OBLIGATIONS AND INCENTIVES (THE "SEPARATION" PAYMENT). LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS - DEFINED BENEFIT SERP ANNUITY PLAN IN 1983, A DEFINED BENEFIT SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("DB SERP ANNUITY PLAN") WAS ESTABLISHED. THE DB SERP ANNUITY PLAN PROVIDED LIFETIME ANNUITY PAYMENTS TO PLAN PARTICIPANTS BASED ON THEIR HISTORICAL SALARY AND YEARS OF SERVICE. THE ANNUITY BENEFIT WAS DESIGNED TO PROVIDE A SIMILAR BENEFIT AS PROVIDED BY THE QUALIFIED DEFINED BENEFIT PENSION PLAN. AS OF 2020, KELBY KRABBENHOFT AND BILL MARLETTE, WITH 24 AND 31 YEARS OF SERVICE RESPECTIVELY, WERE THE ONLY TWO REMAINING PARTICIPANTS. IN NOVEMBER 2020, THE SANFORD BOARD OF TRUSTEES MADE THE DECISION TO ACCELERATE TERMINATION OF THE DB SERP ANNUITY PLAN TO LIMIT FUTURE FINANCIAL LIABILITY AND BECAUSE SANFORD DOES NOT INTEND TO USE AN AVERAGE PAY/ANNUITY SUPPLEMENTAL STRUCTURE ON A GO FORWARD BASIS. KELBY KRABBENHOFT'S AND BILL MARLETTE'S BENEFIT HAD BEEN PREVIOUSLY ACCRUED FOR AND DISCLOSED AS RETIREMENT AND OTHER DEFERRED COMPENSATION ON HISTORICAL 990 FORMS. AS A RESULT OF THE PLAN TERMINATION, THE TOTAL BENEFIT WAS VESTED AND REPORTABLE AS TAXABLE INCOME ON THE PLAN PARTICIPANTS' W-2S IN 2020. LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS - DEFINED BENEFIT SERP LUMP SUM PLANS AS ALSO REQUIRED BY PLAN TERMINATION RULES, SANFORD TERMINATED ALL OTHER DEFINED BENEFIT SUPPLEMENTAL EXECUTIVE RETIREMENT PLANS. KELBY KRABBENHOFT PARTICIPATED IN A DB SERP LUMP SUM PLAN TIED TO RETENTION AND HIS SUCCESSION PLAN. MARK LUNDEEN PARTICIPATED IN A SEPARATE DB SERP LUMP SUM PLAN TIED TO RETENTION. LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS - DEFINED CONTRIBUTION SERP PLAN SANFORD SPONSORS A DEFINED CONTRIBUTION SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("DC SERP PLAN") FOR SELECT OFFICERS OR KEY EMPLOYEES. THE DC SERP PLAN PROVIDES THAT SANFORD WILL MAKE DISCRETIONARY CONTRIBUTIONS INTO PARTICIPANT ACCOUNTS. CERTAIN OF THE BELOW OFFICERS OR KEY EMPLOYEES WERE PAID AS A RESULT OF A VESTING EVENT WHICH INCLUDE REACHING A PRE-ESTABLISHED RETIREMENT AGE OR A DEFINED SEPARATION EVENT. LINES 4A AND 4B - PAYMENTS THE FOLLOWING INDIVIDUALS RECEIVED SEVERANCE OR CHANGE OF CONTROL PAYMENTS AND/OR SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS: KELBY KRABBENHOFT, 24 YEARS OF SERVICE: SEPARATION $15,000,000 DB SERP ANNUITY AND LUMP SUM PLANS $29,353,819 TOTAL $44,353,819 BILL GASSEN III, 9 YEARS OF SERVICE: RETENTION PLAN AGREEMENT $1,100,000 RANDY BURY, 40 YEARS OF SERVICE: DC SERP PLAN $359,927 BILL MARLETTE: DB SERP ANNUITY PLAN $5,903,232 DAVID J HORAZDOVSKY, 42 YEARS OF SERVICE: SEPARATION $1,949,651 JOSEPH HERDINA, 33 YEARS OF SERVICE: SEPARATION $476,691 BREANNA GOEMBEL FAMILY RELATIONSHIP - DAUGHTER OF LINDA STUDER, FORMER KEY EMPLOYEE 62998 COMPENSATION 0 DEBORAH HAMES FAMILY RELATIONSHIP - WIFE OF DAN HAMES, FORMER KEY EMPLOYEE 101435 COMPENSATION 0 KELLIE SCHOLZ FAMILY RELATIONSHIP - WIFE OF DUSTIN SCHOLZ, FORMER KEY EMPLOYEE 63638 COMPENSATION 0 ROGER SCHOLZ FAMILY RELATIONSHIP - FATHER OF DUSTIN SCHOLZ, FORMER KEY EMPLOYEE 28252 COMPENSATION 0 MARY ELLEN SCHOLZ FAMILY RELATIONSHIP - MOTHER OF DUSTIN SCHOLZ, FORMER KEY EMPLOYEE 17701 COMPENSATION 0 JACOB STUDER FAMILY RELATIONSHIP - SON OF LINDA STUDER, FORMER KEY EMPLOYEE 62250 COMPENSATION 0 CLAUDIA ESPINOSA FAMILY RELATIONSHIP - WIFE OF JAVIER ESPINOSA, DIRECTOR 49372 COMPENSATION 0 ANGELA VANDEN HULL FAMILY RELATIONSHIP - SISTER-IN-LAW OF ERIC VANDEN HULL, OFFICER 55813 COMPENSATION 0 X 5 2379130 FAIR MARKET VALUE 0 0 1 0 PART I, LINE 30B: COLUMN B REPRESENTS THE NUMBER OF CONTRIBUTIONS. FORM 990, PART VI, SECTION A, LINE 2 THE FOLLOWING OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES ARE EMPLOYEES OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, AND ITS RELATED ORGANIZATIONS. MANY OF THESE EMPLOYEES ALSO SERVE ON OTHER RELATED ORGANIZATION BOARDS OR HAVE BUSINESS RELATIONSHIPS WITH EACH OTHER THAT SPAN THE ORGANIZATION AS A WHOLE: PATRICIA CAMERO, JAVIER ESPINOSA, KELBY KRABBENHOFT, BILL GASSEN III, LISA MELBY, TABBITHA COOK, NATHAN SCHEMA, ERIC VANDEN HULL AND RANDY BURY. FORM 990, PART VI, SECTION A, LINE 6 ON JANUARY 1, 2019, SANFORD BECAME THE CLASS A CORPORATE MEMBER OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. AT THAT TIME, THE EXISTING MEMBERSHIP OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (THE "SOCIETY") BECAME THE CLASS B MEMBER THAT RETAINED THE ABILITY TO RECOMMEND MEMBERS OF THE SOCIETY BOARD OF DIRECTORS FOR APPOINTMENT BY THE CLASS A CORPORATE MEMBER, SANFORD. THE SOCIETY BOARD OF DIRECTORS ADMINISTERS THE AFFAIRS OF THE SOCIETY, INCLUDING BUDGET DEVELOPMENT AND PROVIDING ADVICE AND CONSENT TO SANFORD IN SELECTING AND EVALUATING THE SOCIETY PRESIDENT. SOME ACTIONS OF THE SOCIETY BOARD OF DIRECTORS REQUIRE APPROVAL OF THE SANFORD BOARD OF TRUSTEES (SEE PART VI, LINE 7B). FORM 990, PART VI, SECTION A, LINE 7A THE SANFORD BOARD OF TRUSTEES APPOINTS THE BOARD MEMBERS FOR THE BOARD OF DIRECTORS OF THE SOCIETY. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS OF THE SOCIETY BOARD OF DIRECTORS MUST BE APPROVED BY THE SANFORD BOARD OF TRUSTEES: (1) APPROVAL OF THE SOCIETY'S ANNUAL AND LONG-TERM STRATEGIC PLANS; (2) APPROVAL OF THE SOCIETY'S ANNUAL OPERATING AND CAPITAL BUDGET AND FINANCIAL FORECAST; (3) MERGER, CONSOLIDATION, DISSOLUTION, SALE OF SUBSTANTIALLY ALL OF SOCIETY'S ASSETS, OR ANY OF THE SAME ACTIONS WITH RESPECT TO ANY SOCIETY SUBSIDIARY TO THE EXTENT SUCH TRANSACTION WOULD REPRESENT SUBSTANTIALLY ALL OF THE SOCIETY'S ASSETS; (4) AMENDMENT, MODIFICATION OR TERMINATION OF THE ARTICLES OF INCORPORATION OR BYLAWS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED INTERNALLY BY THE TAX DEPARTMENT AND REVIEWED BY EXECUTIVE MANAGEMENT. AN EXTERNAL ACCOUNTING FIRM REVIEWS THE RETURN. THE TAX DEPARTMENT PREPARES RETURN HIGHLIGHTS AND KEY DISCLOSURES FOR THE BOARD OF TRUSTEES MEETING PRIOR TO THE RETURN FILING DATE. BEFORE THE RETURN IS FILED, A COMPLETE COPY IS PROVIDED TO THE CURRENT BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 12C THE ANNUAL CONFLICT OF INTEREST DISCLOSURE PROCESS IS MANAGED BY THE CHIEF COMPLIANCE OFFICER (CCO). THE CCO IS RESPONSIBLE FOR ASSURING THAT ALL COMPLETED FORMS ARE RETURNED IN A TIMELY AND COMPLETE MANNER. CONFLICT OF INTEREST QUESTIONNAIRES ARE SENT TO SYSTEM TRUSTEES, MEMBERS OF THE GOVERNING BOARDS OF SUBSIDIARY ENTITIES, OFFICERS, AND KEY EMPLOYEES FOR ALL ENTITIES SUBJECT TO THE IRS FORM 990 FILINGS. THE DISCLOSURES ARE SUMMARIZED FOR REVIEW BY THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES, PURSUANT TO POLICY. THIS REVIEW ALLOWS: 1) THE BOARD TO ACQUIRE AN AWARENESS OF FINANCIAL RELATIONSHIPS OF BOARD MEMBERS AND KEY MANAGEMENT EMPLOYEES AND CAN INVOKE THE RECUSAL PROCESS ON A CASE-BY-CASE BASIS IF POTENTIAL CONFLICTS ARE IMPLICATED IN BOARD DECISIONS AND DELIBERATIONS, AND, 2) GIVES THE BOARD THE OPPORTUNITY TO SEEK ADDITIONAL INFORMATION AND CLARIFICATION ABOUT DISCLOSURES TO DETERMINE POTENTIAL CONFLICTS OF INTEREST, AND HOW TO MANAGE THEM. FORM 990, PART VI, SECTION B, LINE 15 SANFORD AS THE PARENT ORGANIZATION DOES HAVE A PROCESS FOR DETERMINING COMPENSATION OF THE PERSONS LISTED ON PART VII SECTION A, INCLUDING A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, REVIEW OF COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION FOR SUCH COMPENSATION. THE EXECUTIVE COMPENSATION COMMITTEE OF THE SANFORD BOARD OF TRUSTEES DIRECTLY ENGAGES A NATIONALLY RECOGNIZED INDEPENDENT COMPENSATION CONSULTING FIRM ANNUALLY TO REVIEW THE TOTAL COMPENSATION ARRANGEMENTS OF THE OFFICERS AND EXECUTIVES OF THE ORGANIZATION, INCLUDING THE CEO, AND TO REPORT THE FINDINGS TO THEM FOR DELIBERATION AND ACTION. THE DELIBERATIONS AND ACTIONS ARE RECORDED IN THE MINUTES OF THE SANFORD BOARD OF TRUSTEES. THE MOST RECENT STUDY WAS COMPLETED IN 2020. FORM 990, PART VI, SECTION C, LINE 19 ALTHOUGH THE ORGANIZATION DOES NOT MAINTAIN A WEBSITE WHERE THE PUBLIC CAN ACCESS THESE DOCUMENTS, IT WOULD RESPOND INDIVIDUALLY TO ANY REQUESTS OR INQUIRIES FROM THE PUBLIC FOR THESE DOCUMENTS. FORM 990, PART XI, LINE 9: CAPITAL CONTRIBUTION TO GSS PENNINGTON HOUSING LP -3,370,942. CENTRALIZATION OF OPERATING COSTS -109,011,881. FAIR MARKET VALUE ADJUSTMENT 2,753,100. SANFORD-GOOD SAMARITAN COMMUNITY HEALTH SERVICES, LLC LIQUIDATION 50,859,757. CAPITAL CONTRIBUTION TO HERITAGE -1,669,489. CENTRALIZATION OF INVESTMENTS -151,145,112. 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