2017-05-08T10:47:13-05:00 2015-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2014-07-01 411936717 Living Services Foundation LIVI 7632310410 4000 Lexington Avenue No 201 Shoreview MN 55126 Jennifer Gleason Chief Operating Officer 7632310410 2017-03-25 1 Deb Nelson CPA P01264758 6122536500 2017-03-25 2014 2021-01-29 14:40:06Z X Dennis Kamstra 4000 Lexington Avenue No 201 Shoreview MN 55126 7416486 0 X www.lsfdn.org X 1999 MN To support subsidiaries of Benedictine Health System. 5 4 141 1 0 0 0 0 5644725 7394395 -10861 22091 0 0 5633864 7416486 3950 1067 0 0 1850448 3089168 0 0 0 5194788 5886361 7049186 8976596 -1415322 -1560110 37924589 39744215 42570285 45934786 -4645696 -6190571 X The Foundation is organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of the subsidiaries of Benedictine Living Community of Winsted, Benedictine Living Community of New London, Benedictine Living Community of Mora, Benedictine Living Community of Wahpeton, and Benedictine Living Community of Byron. 1 0 8479658 1067 7394395 The organization owns and provides management oversight to the following wholly owned subsidiaries:Living Services Foundation/Minneota, LLC consists of a 67-bed skilled nursing facility and 33-unit assisted living facility located in Minneota, Minnesota. Living Services Foundation/New London, LLC consists of a 62-bed licensed nursing facility, 36-unit attached apartment center and a 12-unit attached assisted living building located in New London, Minnesota. Living Services Foundation/Winsted, LLC consists of a 70-bed licensed nursing facility and a 16-unit attached memory care assisted living building located in Winsted, Minnesota. Living Services Foundation/Mora, LLC consists of a 80-bed skilled nursing facility, a 35-unit assisted living facility and clinic space located in Mora, Minnesota. Living Services Foundation/Wahpeton, LLC consists of a 32-unit assisted living facility located in Wahpeton, North Dakota.Living Services Foundation/Byron, LLC will consist of 20 units of independent living, 16 units of assisted living, and 14 units of memory care assisted living when construction is complete in the spring of 2016. The project is located in Byron, Minnesota. The organization operates Living Services Foundation - Minneota, but leases the other facilities through the wholly owned subsidiaries to Benedictine Living Community of New London, Benedictine Living Community of Winsted, Benedictine Living Community of Mora, and Benedictine Living Community of Wahpeton and Benedictine Living Community of Byron, which are subsidiaries of Benedictine Health System (BHS), who operates those facilities. 8479658 1 0 0 0 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 17 0 1 141 1 0 0 0 0 0 0 0 0 0 0 0 X 5 4 1 0 1 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 MN X Jennifer Gleason 7632100410 4000 Lexington Avenue Suite 201 Shoreview MN 55126 Robert Sundberg Chair 5.00 0.00 X X 7000 0 0 Rod Pakonen Board Member 5.00 0.00 X 7000 0 0 Kevin Rymanowski Board Member 3.00 2.00 X 0 0 0 Paul Sanders Board Member 5.00 0.00 X 7000 0 0 Dennis Kamstra CEO 40.00 0.00 X X 239125 0 20965 Jennifer Gleason COO/Secretary/Treasurer 40.00 0.00 X 128333 0 6016 388458 0 26981 2 0 1 0 Nor-Son Inc 7900 Hastings Road Baxter MN 56425 Design and Construction Services 1273392 1 Resident Service Reven 623000 4403990 4403990 Lease Revenue 532000 2880521 2880521 Lease Surcharge 532000 53000 53000 56884 56884 7394395 22091 22091 7416486 7394395 0 22091 1067 1067 419859 34482 385377 2285079 2251493 33586 16835 16835 80785 78804 1981 286610 267730 18880 21842 13232 8610 18495 9700 8795 468737 466706 2031 26912 26912 108004 97583 10421 31977 31977 228807 222889 5918 11449 11449 2521980 2521980 1713935 1713935 63792 43078 20714 Food 278622 278622 DHS Surcharge 188605 188605 Supplies 135774 135774 Repairs & Maintenance 26446 26446 40984 40359 625 8976596 8479658 496938 0 578849 55928 430486 447877 51398 86306 42928394 9774061 31438131 33154333 3302206 3593301 2123519 2406470 37924589 39744215 1083622 2318676 40843775 42964479 11431 17101 245000 245000 325000 325000 61457 64530 42570285 45934786 X -4645696 -6190571 -4645696 -6190571 37924589 39744215 -1560110 15235 0 X 0 1 X 1 0 X X 6 Bendictine Living Community of Winsted 274219293 9 1 1754616 0 Bendictine Living Community of New London 274218436 9 1 904770 0 Bendictine Living Community of Mora 274219119 9 1 596711 0 Bendictine Living Community of Wahpeton 454274091 9 1 529651 0 Benedictine Living Community of Byron 471538777 9 1 0 0 Benedictine Health System 411531892 1 1 0 0 6 3785748 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X 1 1 Part IV, Section D, Line 3: Benedictine Health System's CEO appointed one of the Foundation's five Directors, Kevin Rymanowski. In addition to his service on the Foundation's Board, Mr. Rymanowski serves as the Chief Financial Officer of BHS and each of the Supported Organizations. He is actively engaged as a Board member in the Foundation's governance and participates in decisions and discussions at the Board level and with the Foundation's leadership in all aspects of the Foundation's management and use of its income and assets for the benefit of BHS and the Supported Organizations. In this manner, the Supported organizations have a significant voice in the Foundation's management and use of its income and assets. Part IV, Section E, Line 2a: The Foundation holds title to and manages properties used by the Supported Organizations in furtherance of their exempt purposes of providing senior housing and long-term care services with special concern for the underserved and those in need of such services. The Supported Organizations each use the respective properties to provide housing to seniors and offer supportive long-term care services. Part IV, Section E, Line 2b: If these facilities were not owned and managed by the Foundation, the Supported Organizations would own and manage such facilities itself because these activities are critical to the Supported Organizations' ability to carry out their own activities in furtherance of their mission and purposes. Because the Supported Organizations would otherwise conduct these same activities if they were not performed by the Foundation, the Foundation's activities represent an integral part of the activities of the Supported Organizations. Part IV, Section A, Line 11: Benedictine Health System is a Type III Functionally Integrated Supporting Organization and is also recognized within the IRS Group Ruling for Catholic organizations under IRC Section 170(b)(1)(A)(i). 0 1 X 1209322 1209322 35612383 7528185 28084198 2100912 1889104 211808 4005777 356772 3649005 33154333 Unamortized Financing Costs 1736470 Nursing Home Bed License 670000 2406470 Asset retirement obligation 64530 64530 X 7431721 15235 15235 7416486 0 7416486 8976596 0 8976596 0 8976596 Part IV, Line 2b: The Organization acts as custodian for the funds of the residents and holds tenant security deposits. These funds are included in cash and cash equivalents and current liabilities in these financial statements. Part X, Line 2: The Organization is organized as a Minnesota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The subsidiaries maintain exempt status under the Organization's exemption since the Organization is the sole member of each subsidiary. The Organization is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Organization is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and, as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. X X X X X 0 0 0 0 0 0 0 0 0 Dennis Kamstra CEO 239125 0 0 0 0 0 0 0 20965 0 260090 0 0 0 A City of Spicer 416005550 84844VAJ4 2006-12-28 9460519 To purchase a nursing & assisted living facility & clinic in Spicer, MN. 0 0 0 B City of Winsted 416005652 975574AQ7 2010-09-16 16112135 Refinance Series 2008 notes issued in 8/29/2008 & fund new construction. 0 0 0 C City of Mora 416005389 2009-04-30 6258382 To purchase a nursing & assisted living facility in Mora, MN. 0 0 0 D City of Wahpeton 456002178 2011-12-28 5605000 To construct a 32 unit senior housing facility in Wahpeton, ND 0 0 0 A 1110000 9460519 712522 189210 8558787 2007 0 0 1 1 B 375000 16112135 1311331 322243 6170490 8308071 2011 1 0 1 1 C 4858382 6258382 6258382 2009 0 0 1 1 D 170723 5605000 112100 5492900 2013 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0 0 1 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 C 0 0 1 0 0 0 0 0 1 D 0 0 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 Date Rebate Computation Performed Issuer Name: City of Spicer Date the Rebate Computation was Performed: 07/22/2011 Issuer Name: City of Winsted Date the Rebate Computation was Performed: 09/01/2015 Schedule K, Part I, Line A, Column (e): The issue price for Bond A Part I(e) is different than Part II Line 3 due to the bonds being issued at a discount of $139,481. Schedule K, Part I, Line B, Column (e): The issue price for Bond B Part I(e) is different than Part II Line 3 due to the bonds being issued at a discount of $392,865. A City of Mora 416005389 2013-09-06 4851795 Refinance a portion of Series 2009 notes issues in 4/30/2009. 0 0 0 B City of Minneota 416005373 2013-12-31 4397409 To purchase a nursing & assisted living facility in Minneota, MN. 0 0 0 C City of Byron 416008945 2014-12-30 10000000 To construct a new 50 unit senior housing complex in Byron, MN 0 0 0 A 289763 4851795 97035 5059 4749701 2013 1 0 1 1 B 129576 4397409 150000 34437 4212972 2013 0 0 1 1 C 10000000 341344 200000 9458656 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 1 0 0 0 1 B 0 0 0 0 1 0 0 0 1 C 0 0 0 0 1 0 0 0 1 A 1 B 1 C 1 Robert Sundberg Board Member Capital improvements to skilled nursing facility. X 120000 120000 0 1 1 Paul S and Gretchen M Sanders Revocable Trust Entity owned by Board Member Capital improvements to skilled nursing facility. X 125000 125000 0 1 1 245000 Form 990, Part III, line 2 Living Services Foundation/Byron, LLC and Benedictine Living Community of Byron began construction of a 50 unit senior housing campus. The services are not yet available. Form 990, Part VI, Section A, line 2 Dennis Kamstra and Jennifer Gleason have a family relationship. Form 990, Part VI, Section A, line 4 The organization's documents were amended for the addition of BLC Byron as a supporting organization. Form 990, Part VI, Section A, line 7a Benedictine Health Systems may appoint one board member with voting rights. Form 990, Part VI, Section A, line 8b No committees are able to act on behalf of the board. Form 990, Part VI, Section B, line 11 An electronic draft of the Form 990 is distributed to the full board of directors for review and approval prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The Conflict of Interest policy is enforced and consistently monitored. An interested person must disclose the existence of their financial interest to the board considering the proposed transaction or arrangement. The remaining board members then determine if a conflict of interest exists. Corrective action is taken by the board of directors as deemed necessary when a conflict of interest is determined to have occurred. Disclosure of a conflict of interest would prevent that person from taking part in discussions or voting on related issues. Form 990, Part VI, Section B, line 15 The process for determining compensation for the CEO and COO is determined by a compensation survey and study. The compensation is then approved by the independent members of the Board of Directors. The last review took place during the summer of 2014. Form 990, Part VI, Section C, line 19 The Organization makes the governing documents and conflict of interest policy available upon request. Amended Form 990: The organization previously filed its June 30, 2015 Form 990 prior to having issued financial statements with final numbers. The audited financial statements have since been finalized and the organization is filing an amended Form 990 to report the changes in financial figures. Form 990, Part I, Lines 8, 17, 19, 20, 21, and 22: Amounts previously reported on these lines have been udpated according to changes made in Parts VIII, IX, and X. Form 990, Part III, Line 4a: Amounts for expenses and revenue have been updated according to changes made in Parts VIII and IX. Form 990, Part VIII, Line 2b: Lease revenue has been updated to reflect final amount per audited financial statement. Form 990, Part IX, Column (B), Lines 16, 22: Occupancy and depreciation expenses have been updated to reflect final amounts per audited financial statement. Form 990, Part X, End of Year: Lines 4, 10c, 15, 17 and 27 have been updated to reflect final amounts per audited financial statement. Form 990, Part XI: Lines 1, 2, 3, 9 and 10 have been updated to reflect final amounts per audited financial statement. Schedule D, Part VI: Amounts have been updated to reflect final amounts per audited financial statement. Schedule D, Part IX: Unamortized financing costs have been updated to reflect final amount per audited financial statement. Schedule D, Parts XI and XII, Line 1: Total revenue and total expense has been updated to reflect final amounts per audited financial statement. Schedule K, Part II, Lines 1, 4 and 10: Amounts have been updated to reflect final figures per audited financial statements. Schedule K, Part IV, Lines 2 and 3: Responses have been updated to reflect accurate information per Form 8038. Living Services Foundation Mora LLC 110 North 7th Street Mora MN 55051 263614974 Leasing of skilled nursing and assisted living facility. DE 550325 5457178 Living Services Foundation Living Services Foundation New London LLC 100 Glen Oaks Drive New London MN 56273 204504668 Leasing of skilled nursing, assisted and independent living facility. DE 748598 7519687 Living Services Foundation Living Services Foundation Winsted LLC 551 4th Street North Winsted MN 55395 208684862 Leasing of skilled nursing and assisted living facility. DE 1330916 13564713 Living Services Foundation Living Services Foundation Wahpeton LLC 711 14th Avenue North Wahpeton ND 58075 453638196 Leasing of assited living facility. DE 394008 4692855 Living Services Foundation Living Services Foundation Minneota LLC 700 North Monroe Street Minneota MN 56264 263614760 Operation of skilled nursing, assisted lving, and home health agency. DE 4403990 5076430 Living Services Foundation Living Services Foundation Byron LLC 4000 Lexington Avenue Suite 201 Shoreview MN 55126 472337717 New assisted living facility under construction for 2015 opening. DE 0 2779864 Living Services Foundation Bendictine Living Community of Winsted 1995 East Rum River Drive South Cambridge MN 55008 274219293 Skilled nursing care center and memory care assisted living MN 501(c)(3) Line 9 Benedictine Health Systems 0 Bendictine Living Community of New London 1995 East Rum River Drive South Cambridge MN 55008 274218436 Skilled nursing care center, assisted living, and senior apartments. MN 501(c)(3) Line 9 Benedictine Health Systems 0 Bendictine Living Community of Mora 1995 East Rum River Drive South Cambridge MN 55008 274219119 Skilled nursing care center and assisted living facility. MN 501(c)(3) Line 9 Benedictine Health Systems 0 Bendictine Living Community of Wahpeton 1995 East Rum River Drive South Cambridge MN 55008 454274091 Assisted living and basic care facility. MN 501(c)(3) Line 9 Benedictine Health Systems 0 Bendedictine Living Community of Byron 1995 East Rum River Drive South Cambridge MN 55008 471538777 Senior Housing MN 501(c)(3) Line 9 Benedictine Health Systems 0 Benedictine Health System 1995 East Rum River Drive South Cambridge MN 55008 411531892 Health Care System MN 501(c)(3) Line 11c, III-FI 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1