2016-10-31T08:29:29-05:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-01-01 450228055 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY EVAN 6053623100 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 G GRANT TRIBBLE CFO & TREASURER 6053623100 2016-10-24 1 KACIE MCEWEN P01599614 6123764500 2015 2017-02-10 21:41:12Z DAVID HORAZDOVSKY 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 1375796694 0 X WWW.GOOD-SAM.COM X 1922 ND TO SHARE GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OTHERS IN NEED. 15 8 26744 1814 1983035 -1448083 16176540 10478332 951359389 957628372 -3556977 -19326 15626038 13654312 979604990 981741690 7967745 5025188 0 0 582739242 582911761 0 0 2675225 405647249 417963844 996354236 1005900793 -16749246 -24159103 1596273747 1646677636 841786329 942289253 754487418 704388383 X TO SHARE GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OLDER PERSONS AND OTHERS IN NEED, BELIEVING THAT "IN CHRIST'S LOVE, EVERYONE IS SOMEONE."(CONTINUED ON SCHEDULE O) 0 0 614352429 5025188 728768956 SKILLED NURSING SERVICES - REHABILITATION/SKILLED NURSING SERVICES HAVE BEEN AT THE CORE OF THE SOCIETY'S SERVICES OVER ITS 93-YEAR HISTORY. THE SOCIETY APPROACHES CARE FOR THOSE WE SERVE IN A "HOLISTIC" MANNER. IN THAT REGARD, 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 3,215,595 SKILLED NURSING HOME DAYS OF CARE AND SERVICE IN 2015. THE SOCIETY CONTINUES TO REINVEST MUCH OF ITS REVENUE TO BUILD AND REVITALIZE ITS FACILITIES ON CAMPUSES THROUGHOUT THE COUNTRY. 77145969 0 91513576 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 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 ITS CORPORATE STRATEGIC PLANNING.IN 2015, THE SOCIETY RECORDED 1,799,623 SENIOR LIVING DAYS OF SERVICE TO RESIDENTS THROUGHOUT THE COUNTRY. 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. 57271577 0 67937792 ASSISTED LIVING SERVICES - ASSISTED LIVING SERVICES RESPOND TO THE SOCIETY'S RESIDENTS' NEEDS EACH DAY IN A "HOME-LIKE" ENVIRONMENT. IN 2015, THE SOCIETY PROVIDED 685,027 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, AND MEDICATION ASSISTANCE. COORDINATED SPIRITUAL AND SOCIAL PROGRAMS ARE OFFERED FOR THE TOTAL WELL-BEING OF THE RESIDENTS. 62581535 0 74236671 ACROSS MANY OF ITS SETTINGS, THE SOCIETY HAS MADE A SIGNIFICANT INVESTMENT AND COMMITMENT TO THE USE OF TECHNOLOGY IN THE VARIOUS LEVELS OF CARE THAT IT PROVIDES IN ITS SUITE OF SERVICES. MOST NOTABLY, A SENSOR TECHNOLOGY PROGRAM - CALLED LIVINGWELL@HOME - IS BEING ROLLED OUT THROUGHOUT THE SOCIETY'S ASSISTED LIVING LOCATIONS, TOUCHING AND IMPROVING THE CARE OF OVER A THOUSAND INDIVIDUALS. THIS PROGRAM LEVERAGES TECHNOLOGY TO UNOBTRUSIVELY MONITOR RESIDENTS' DAILY LIVING BEHAVIORS AND ACTIVITIES, THUS ALLOWING THEM TO EXTEND AND EVEN CONTROL THEIR INDEPENDENCE WHILE GIVING COMFORT TO FAMILY MEMBERS WHO MAY NOT LIVE CLOSE BY. THIS SOCIETY HAS EXPANDED ITS INVESTMENT TO WORK WITH PRIMARY CARE PHYSICIANS IN CHRONIC DISEASE MANAGEMENT PROGRAMS TO PROVIDE EARLY DETECTION AND EARLY INTERVENTION TO POTENTIAL HEALTHCARE CHANGES. THIS WORK IS PROVING TO REDUCE HOSPITALIZATIONS AND ER VISITS WHILE IMPROVING OVERALL CLINICAL OUTCOMES.HOME HEALTH SERVICES - THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY OFFERS LICENSED HOME HEALTH CARE, HOSPICE AND SERVICES@HOME (PRIVATE DUTY) SERVICES IN 18 STATES. OUR HOME HEALTH CARE AGENCIES SERVED APPROXIMATELY 12,231 CLIENTS IN 2015. 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 CARE FOR 1,125 PATIENTS IN 2015. THE SERVICES PROVIDED INCLUDE 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, PROVIDED CARE FOR 3,230 CLIENTS IN 2015. SERVICES@HOME 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. 62581535 0 74236671 811351510 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 1 0 0 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 0 0 1 2765 0 26744 1 1 1 1 CJ 0 0 0 1 1 0 0 0 0 0 X 15 8 0 0 1 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 G GRANT TRIBBLE CFO & TREASURER 6053623100 4800 W 57TH ST SIOUX FALLS SD 57108 DAVID J HORAZDOVSKY PRESIDENT & CEO 55.40 0.60 X X 755069 0 8430 REV JOHN F HOLT CHAIRPERSON 3.30 1.40 X X 0 0 0 NEIL GULSVIG CHAIRPERSON THROUGH JUNE 2015 3.30 1.40 X X 0 0 0 H THEODORE GRINDAL FIRST VICE CHAIRPERSON 3.30 0.70 X X 0 0 0 DR GWEN WAGSTROM HALAAS MEMBER-EXECUTIVE COMMITTEE 3.30 X 0 0 0 ALAN R GARD MEMBER-EXECUTIVE COMMITTEE 3.30 X 0 0 0 BENJAMIN P ANDERSON DIRECTOR 50.00 0.10 X 100118 0 31631 PATRICIA L CAMERO DIRECTOR 50.00 0.10 X 143599 0 17039 DR LIANE M CONNELLY DIRECTOR THROUGH JUNE 2015 3.30 X 0 0 0 MICHAEL DEUTH DIRECTOR 50.00 0.10 X 133441 0 3856 TERESA HILDEBRANDT DIRECTOR THROUGH JUNE 2015 50.00 0.10 X 92145 0 31562 HEATHER L KRZMARZICK DIRECTOR 50.00 0.10 X 100233 0 37178 CONNIE MARCH-CURTIS DIRECTOR 3.30 0.70 X 0 0 0 GUY MATSON DIRECTOR 50.00 0.10 X 118333 0 35624 JOHN RACEK DIRECTOR 3.30 0.70 X 0 0 0 PHILIP SAMUELSON DIRECTOR THROUGH MAY 2015 50.00 0.10 X 135497 0 9474 JILL A SCHUMANN DIRECTOR 3.30 X 0 0 0 DENNIS STENE DIRECTOR 3.30 0.70 X 0 0 0 SHARON ST MARY DIRECTOR 50.00 0.10 X 149154 0 15731 THOMAS SYVERSON EXECUTIVE VICE PRESIDENT 55.00 0.10 X 344842 0 27176 BERGEN J PETERSON EXECUTIVE VICE PRESIDENT 55.00 X 266809 0 19628 G GRANT TRIBBLE EXECUTIVE VICE PRESIDENT,TREASURER 54.50 0.60 X 319108 0 24626 RAYE NAE NYLANDER EXECUTIVE VICE PRESIDENT,TREASURER, THRU JAN. 2015 3.80 51.20 X 217158 0 15467 JOSEPH HERDINA ASSISTANT TREASURER 55.00 0.10 X 205433 0 27176 THOMAS KAPUSTA SECRETARY 54.50 0.60 X 323936 0 15182 SYLVIA GAUSE ASSISTANT SECRETARY 40.90 0.10 X 67186 0 11294 MISTY HAM-QUICK ASSISTANT SECRETARY - THROUGH JANUARY 2015 45.00 0.60 X 42931 0 16641 DEAN MERTZ VICE PRESIDENT 55.00 X 324654 0 15467 LINDA STUDER VICE PRESIDENT 55.00 X 197608 0 11832 SUSAN RAPER REGIONAL VICE PRESIDENT 55.00 X 193375 0 26979 DAN FOSNESS REGIONAL VICE PRESIDENT 55.00 X 174742 0 18536 JAMES DROPPERS REGIONAL VICE PRESIDENT 55.00 X 177652 0 15417 DAN HAMES REGIONAL VICE PRESIDENT 55.00 X 174432 0 27176 RANDY FITZGERALD REGIONAL VICE PRESIDENT 55.00 X 194123 0 18779 PAT KELLY REGIONAL VICE PRESIDENT 55.00 X 179279 0 8163 RUSTAN WILLIAMS VICE PRESIDENT 55.00 X 345469 0 26876 VICTORIA WALKER CHIEF MEDICAL OFFICER 55.00 X 240429 0 15922 JAMES KREKELBERG VICE PRESIDENT, ACCOUNTING AND CONTROLLER 54.50 0.60 X 190946 0 15467 WALTER WOODS GSS FOUNDATION PRESIDENT 0.10 55.00 X 188598 0 8333 6096299 0 556662 54 0 1 0 AEGIS THERAPIES INC PO BOX 8103 FT SMITH AR 72902 CONTRACT THERAPY SERVICES 23604252 GIL HAUGAN CONSTRUCTION IN C PO BOX 84430 SIOUX FALLS SD 57118 GENERAL CONTRACTOR - INCLUDES MATERIALS 18688616 SOLOMON BUILDERS INC 4539 TROUSDALE DR NASHVILLE TN 37204 GENERAL CONTRACTOR - INCLUDES MATERIALS 9255341 NOR-SON INC 7900 HASTINGS ROAD BAXTER MN 56425 GENERAL CONTRACTOR - INCLUDES MATERIALS 7140220 INFINITY REHAB 25117 SW PARKWAY SUITE D WILSONVILLE OR 97070 CONTRACT THERAPY SERVICES 5761725 214 98077 124205 2432420 682043 7141587 341543 10478332 RESIDENT ROUTINE CARE 623000 850440823 850440823 ANCILLARY SERVICES 623000 87337013 87337013 SURCHARGE 623000 6591956 6591956 NURSING SERVICES 623000 5283980 5283980 RENT 623000 2953346 2953346 5021254 5021254 957628372 5076166 5076166 2608233 207901 0 0 2608233 207901 2816134 207901 2608233 384584615 3982168 376017967 17644308 8566648 -13662140 -5095492 -5095492 1148033 124205 193206 954827 954827 60425 50676 9749 9749 303069 148847 154222 154222 ADMINISTRATIVE SERVICES 561000 5997572 4620722 1376850 EMPLOYEE & GUEST MEALS 722210 5720339 829433 4890906 BARBER & BEAUTY SHOP 623990 676535 676535 -2675066 -223248 -2451818 9719380 981741690 952151761 1983035 17128562 4469293 4469293 467901 467901 87994 87994 5433480 5433480 480803893 387282508 91946356 1575029 10306054 8321853 1950784 33417 48005239 38670122 9177901 157216 38363095 30977136 7261569 124390 1126944 1126944 365305 365305 144000 144000 88251147 80587500 7566892 96755 5190776 1818 5180611 8347 9844715 77374 9722087 45254 14225763 14225763 36974166 36974166 8561496 4701035 3849580 10881 133690 133690 21193458 20935272 253341 4845 70948199 56723805 13957489 266905 15310260 12240708 3011955 57597 MEDICAL SUPPLIES 83179221 83179221 EQUIPMENT MAINTENANCE 18188057 16041476 2146011 570 LICENSE SURCHARGE 16534525 16534525 UNCOLLECTIBLE EXPENSE 7138397 7138397 20653725 7644323 12715383 294019 1005900793 811351510 191874058 2675225 11772939 7138142 805022 822396 1455128 1093258 83614875 90339162 8869842 14801947 4010011 3915804 6795767 10980398 2010524037 1026545692 944470154 983978345 405866749 397405791 4394302 4057824 78078699 78756272 3962454 8243573 42177805 45144724 1596273747 1646677636 102096478 104093755 4453226 4977489 491825048 572196770 97091726 109154941 84841183 82597090 579609 61478668 68689599 841786329 942289253 X 714322706 665110020 21358622 20661845 18806090 18616518 754487418 704388383 1596273747 1646677636 X -24159103 -13645354 -12294578 X 0 1 X 1 1 1 X 11021275 16031754 19112946 16176540 10478332 72820847 945148214 934780394 945993052 952770064 958776405 4737468129 88098 189519 366252 371370 363494 1378733 956257587 951001667 965472250 969317974 969618231 4811667709 0 0 0 4811667709 9182093 8835266 9381581 9069280 7892300 44360520 9182093 8835266 9381581 9069280 7892300 44360520 1743415 9546162 8395068 10242472 7220485 37147602 967183095 969383095 983248899 988629726 984731016 4893175831 0.98330 0.98400 0.00910 0.00960 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: ADMINISTRATIVE SERVICES - 2011 AMOUNT: $ 1,740,083. 2012 AMOUNT: $ 2,718,788. 2013 AMOUNT: $ 2,559,371. 2014 AMOUNT: $ 2,689,769. 2015 AMOUNT: $ 4,620,722. GAINLOSS ON EXTINGUISHMENT OF DEBT - 2011 AMOUNT: $ 3,332. 2012 AMOUNT: $ -3,236,037. 2013 AMOUNT: $ -3,249,071. 2014 AMOUNT: $ -1,354,897. 2015 AMOUNT: $ -4,559,774. OTHER REVENUE - 2012 AMOUNT: $ 10,063,411. 2013 AMOUNT: $ 9,084,768. 2014 AMOUNT: $ 8,907,600. 2015 AMOUNT: $ 7,159,537. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 1 41128 0 0 1 342922 0 1 0 384050 0 PART II-B, LINE 1: ONE STAFF MEMBER IS DEVOTED FULL TIME TO PUBLIC POLICY ISSUES, INCLUDING LOBBYING ACTIVITIES. AN OUTSIDE REPRESENTATIVE IS ALSO ENGAGED TO ASSIST WITH COORDINATING THIS ACTIVITY. SEVERAL STAFF MEMBERS AND RESIDENTS WRITE LETTERS TO ELECTED OFFICIALS WHICH PROVIDE BACKGROUND AND EXPRESS RECOMMENDED POSITIONS ON SPECIFIC ISSUES. IN ADDITION, PERIODIC CORRESPONDENCE AND PERSONAL VISITS OCCUR BETWEEN STAFF MEMBERS AND ELECTED OFFICIALS TO ADVOCATE PARTICULAR POSITIONS ON ISSUES. IT IS ESTIMATED THAT TWO PERCENT OF ONE AVERAGE STAFF MEMBERS' TIME IS DEVOTED TO THIS ACTIVITY. 0 1 X 2289000 -1000 181000 -81000 2388000 2980000 -1109000 13000 -405000 2289000 1966000 617000 -3000 -400000 2980000 1508000 6000 14000 -438000 1966000 1077000 81000 -6000 356000 1508000 0.13400 0.05200 0.81400 0 0 61639244 61639244 1425631479 746851169 678780310 100917356 59875291 41042065 300552521 219819232 80733289 121783437 121783437 983978345 REAL ESTATE TAXES & OTHER LIABILITIES 14187502 UNAMORTIZED BOND PREMIUM 16478314 ANNUITIES PAYABLE 2418490 PAYABLE UNDER INVESTMENT LOAN AGREEMENT 16590284 NON-REFUNDABLE APARTMENT ENTRANCE FEES 19015009 68689599 X 982986441 6678 2160525 2167203 980819238 922452 922452 981741690 1001888513 6678 79745 86423 1001802090 4098703 4098703 1005900793 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 HANDLED APPROPRIATELY. PART V, LINE 4: THE SOCIETY'S ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY THE DONOR'S RESTRICTIONS OR THE BOARD'S DESIGNATION. PART X, LINE 2: TAX EXEMPT STATUS FOOTNOTE - THE SOCIETY'S U.S. DOMICILED ENTITIES ARE EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OR ARE PASS-THROUGH ENTITIES NOT SUBJECT TO TAX. GOOD SAMARITAN SOCIETY INSURANCE, LTD. IS AN EXEMPTED COMPANY UNDER THE COMPANIES LAW OF THE CAYMAN ISLANDS. THE SOCIETY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE SOCIETY'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE SOCIETY IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS FOR OPERATING PURPOSES 2,267,687. OTHER EXPENSES INCLUDED IN REVENUE -107,162. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST INCOME 5,590,551. REALIZED GAIN ON SECURITIES 8,052,263. REALIZED LOSS ON SALE OF PROPERTY -13,662,140. LOSS ON EXTINGUISHMENT OF DEBT -4,559,774. T/R CONTRIBUTIONS 4,383,484. CONTRIBUTIONS FOR ENDOWMENT FUNDS & TRUSTS 94,293. REVENUE FROM DISCONTINUED OPERATIONS 30,451. SPECIAL EVENT FUNDRAISING EXPENSES -193,206. GAMING EXPENSES -50,676. COGS - GIFT SHOP EXPENSES -148,847. TRANSFER FROM FOUNDATION 2,432,420. INVESTMENT IN HCBS, LLC -1,046,367. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 193,206. GAMING EXPENSES 50,676. COGS - GIFT SHOP EXPENSES 148,847. EXPENSES FROM DISCONTINUED OPS -312,984. PART XII, LINE 4B - OTHER ADJUSTMENTS: OTHER EXPENSES INCLUDED IN REVENUE 107,162. TRANSFER TO FOUNDATION 3,991,541. FORM 990, PART IV, LINE 2A PART IV, LINE 2A THE SOCIETY HAS HOUSING ENTRY FEES FOR ADMITTANCE INTO HOUSING UNITS AT VARIOUS LOCATIONS. THESE CONTRACTS FOR HOUSING ENTRY FEES VARY BY LOCATION, AND TYPICALLY HAVE VARYING REFUNDABLE PORTIONS UP TO 100% OF THESE ENTRY FEES. THE REFUNDABLE PORTIONS OF THE HOUSING ENTRY FEES ARE REFUNDABLE BASED UPON TIME RESTRICTIONS AND VACANCY OF THE HOUSING UNIT. THE NONREFUNDABLE PORTION OF THE HOUSING ENTRY 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. 1 0 0 0 0 0 0 0 0 0 SOUTH AMERICA OUR CONTRIBUTION TO THE EVANGELICAL LUTHERAN CHURCH IN COLOMBIA GOES TO SUPPORT THEIR WORK WITH ELDERS IN TWO LOCATIONS - SOACHA AND TUNJA. SPECIFICALLY, OUR CONTRIBUTION HELPS PROVIDE SHELTER, FOOD AND SOCIAL SERVICES FOR ABOUT 50 ELDERS IN SOACHA AND 30 ELDERS IN TUNJA. 61244 WIRE TRANSFERS SOUTH AMERICA THE MONEY GOOD SAMARITAN SENDS TO THE EMMAUS ROAD FOUNDATION GOES TO SUPPORT PRIMARY, SECONDARY AND GRADUATE EDUCATION FOR CHILDREN AND YOUNG ADULTS WHO ARE FINANCIALLY DISADVANTAGED. THE FUNDS GOOD SAMARITAN SENDS TO THE EMMAUS ROAD FOUNDATION GO TO PROVIDE SCHOOL TUITION, SCHOOL UNIFORMS, BOOKS AND MATERIALS FOR CHILDREN IN PRIMARY AND SECONDARY EDUCATION. FUNDS THAT GO TO SUPPORT YOUNG ADULTS FOR GRADUATE EDUCATION HELPS TO PAY FOR TUITION, SCHOOL SUPPLIES INCLUDING BOOKS AND, AT TIMES, COMPUTERS, AND OCCASIONALLY ROOM AND BOARD. MANY OF THE CHILDREN AND YOUNG ADULTS THAT GOOD SAMARITAN HELPS TO SUPPORT ARE PART OF THE FAMILIES OF THE SENIORS WHO ARE PART OF GOOD SAMARITAN'S SENIOR CENTER AND SOUP KITCHEN IN SOACHA, A VERY POOR NEIGHBORHOOD SOUTH OF BOGOTA, COLOMBIA. 26750 WIRE TRANSFERS 2 0 1 0 1 0 0 0 PART I, LINE 2: REGULAR CORRESPONDENCE IS RECEIVED FROM THE GRANTEE REGARDING THE PROGRESS OF THEIR INITIATIVES. BOWLING EVENT 107833 86852 20981 6800 4501 1435 24210 GOLF TOURNAMENT 48609 37353 11256 1584 4252 2526 1226 147 1115796 1115796 146672 1272238 124205 1148033 8384 8753 3961 172108 193206 954827 59404 47158 2562 1 1.00000 1021 729 227 1 0.25000 60425 47887 2789 50676 9749 FL MN 0 THE SOCIETY IS REGISTERED IN THE STATE OF MINNESOTA. IT IS NOT REQUIRED TO BE REGISTERED IN THE STATE OF FLORIDA SO IT HAS NOT REGISTERED IN THAT STATE. 0 1 0 1.00000 WALTER WOODS 4800 WEST 57TH STREET SIOUX FALLS SD 57108 0 SEE PART IV FOR A LIST THE SOCIETY'S VARIOUS FACILITIES CONDUCT LIMITED CHARITABLE GAMING ACTIVITIES. EACH FACILITY'S ADMINISTRATOR OR EXECUTIVE DIRECTOR IS IN CHARGE OF THAT FACILITY'S CHARITABLE GAMING ACTIVITIES. THEY ARE:DAREN RIFE - ADMINISTRATOR - WESTBROOK, MN - $277LUANN FOOS - EXECUTIVE DIRECTOR - KISSIMMEE, FL - $3,375 X 0 SCHEDULE G, PART III, LINE 6, COLUMN C PERCENT OF VOLUNTEER LABOR THE SOCIETY'S VARIOUS FACILITIES CONDUCT LIMITED CHARITABLE GAMING ACTIVITIES AND EACH USES VOLUNTEER LABOR. EACH FACILITY REPORTED A DIFFERENT AMOUNT OF VOLUNTEER LABOR FOR THEIR GAMING ACTIVITIES, THEY ARE: WESTBROOK - 25% 1 WORLD MISSION PRAYER LEAGUE 232 CLIFTON AVE MINNEAPOLIS MN 55403 410786986 501(C)(3) 30942 CONTRIBUTIONS SUPPORT THE WORK OF LAMB HOSPITAL IN BANGLADESH. SPECIFICALLY, OUR CONTRIBUTIONS SUPPORT THE "POOR FUND" WHICH IS MONEY USED FOR OPERATIONS AND MEDICINE FOR THOSE PATIENTS WHO HAVE LITTLE OR NO MONEY. THE CONTRIBUTIONS ARE ALSO USED TO SUPPORT THE WORK OF THE CHAPLAINS IN THE HOSPITAL. TEAM PO BOX 969 WHEATON IL 601890969 362169146 501(C)(3) 29641 CONTRIBUTIONS SUPPORT THE WORK OF THE KARANDA MISSION HOSPITAL IN ZIMBABWE. SPECIFICALLY, OUR CONTRIBUTION HELPS PROVIDE MEDICAL SUPPLIES, MEDICINE, AND GENERAL HOSPITAL COSTS FOR THIS MISSION HOSPITAL WHICH IS LOCATED ABOUT 4 HOURS FROM HARARE, THE CAPITAL OF ZIMBABWE. SIOUX EMPIRE UNITED WAY 1000 N WEST AVE SUITE 120 SIOUX FALLS SD 57104 460233701 501(C)(3) 8500 TO SUPPORT EXEMPT MISION. RAPID CITY GOOD SAMARITAN HOUSING GP INC 4800 W 57TH ST SIOUX FALLS SD 57104 461579750 501(C)(3) 240842 BOOK VALUE LAND CONTRIBUTION OF LAND TO BUILD LOW-INCOME SENIOR HOUSING PROJECT. THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION 4800 W 57TH ST SIOUX FALLS SD 57117 460422866 501(C)(3) 3991541 TO SUPPORT THE GENERAL OPERATIONS AND TRANSFER OF GIFTS TO BE HELD BY THE FOUNDATION. SENIOR COMPANION FUND 1000 N WEST AVE SUITE 260 SIOUX FALLS SD 57104 460379180 501(C)(3) 17499 TO SUPPORT EXEMPT MISION. HELPING KIDS BE KIDS FOUNDATION 2027 WEST WIND RD LAS CRUCES NM 88007 203771479 501(C)(3) 5500 SOCIAL ACCOUNTABILITY GRANT AUBURN CHRISTIAN CHURCH 1100 15TH ST AUBURN NE 68305 470619395 501(A) 5750 SOCIAL ACCOUNTABILITY GRANT CITY OF SELBY 3409 MAIN ST SELBY SD 57472 456000417 CITY OF SELBY 5000 SOCIAL ACCOUNTABILITY GRANT THE HUB SPORT CENTER 19619 E CATALDO AVE LIBERTY LAKE WA 99019 260173199 501(C)(3) 5225 SOCIAL ACCOUNTABILITY GRANT ALTERNATIVES TO VIOLENCE 549 E 8TH ST LOVELAND CO 80537 840886127 501(C)(3) 6900 SOCIAL ACCOUNTABILITY GRANT 11 0 SCHOLARSHIPS 308 466310 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. 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 EXPENSES, THE SOCIETY REQUIRES RECEIPT OF PAYMENT BEFORE REIMBURSEMENT IS MADE TO THE EMPLOYEE. 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FORM 990, PART III, LINE 1 IN 2015, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (THE SOCIETY) CELEBRATED ITS 93RD YEAR OF EXISTENCE SINCE ITS FOUNDING IN A SMALL NORTH DAKOTA COMMUNITY. AS THE SOCIETY RAPIDLY APPROACHES A CENTURY OF SERVICE, MISSION AND MINISTRY, ITS STRATEGIC AND OPERATIONAL WORK IS FOCUSED ON THE GOOD SAMARITAN SOCIETY WAY: - GUIDED BY OUR OBLIGATION (MISSION) TO SHARE GOD'S LOVE, THE SOCIETY IS CHALLENGED TO DO NOTHING LESS THAN TO BE OUTSTANDING IN BOTH OPERATIONS AND STRATEGY. - TO SHARE GOD'S LOVE, THE SOCIETY SEEKS OUT AND FINDS OPPORTUNITIES (OUR STRATEGIC DIRECTION) TO HELP IMPROVE WELL-BEING AND LET PEOPLE LEAD THE LIVES THEY WANT TO LIVE IN THE PLACES WHERE THEY WANT TO BE. - AND THE SOCIETY IS SUCCESSFUL WHEN IT ACHIEVES ITS OUTCOME (VISION) OF CREATING ENVIRONMENTS WHERE PEOPLE FEEL LOVED, VALUED AND AT PEACE. EVERY ONE OF OUR 21,000 STAFF MEMBERS HAS TRAINED IN THE GOOD SAMARITAN SOCIETY WAY. THE CHALLENGE OF MEETING PEOPLE'S NEEDS WHERE THEY ARE COMPELS AND PROPELS THE SOCIETY TO MEET THE CHALLENGES OF THE FUTURE. ALTHOUGH THE SOCIETY'S CONSTANCY AND CONSISTENCY OF MISSION HAS STAYED TRUE, THE ENVIRONMENT SURROUNDING THE ORGANIZATION HAS CHANGED GREATLY OVER THESE PAST 93 YEARS. WE STAND AT A CRITICAL JUNCTURE IN OUR NATION'S HISTORY, AS CONDITIONS OF OUR ECONOMY, DEMOGRAPHICS, SOCIETY AND CULTURE HAVE SEEN REVOLUTIONARY CHANGE. THE SOCIETY RECOGNIZES THESE CHANGING NEEDS AND DEMANDS AND STANDS READY TO SERVE PEOPLE'S NEEDS FOR THE NEXT 100 YEARS. FORM 990, PART VI, SECTION A, LINE 1 THE GOVERNING BODY DELEGATED BROAD AUTHORITY TO THE EXECUTIVE COMMITTEE OF THE BOARD TO ACT ON ITS BEHALF ON MATTERS THAT NEED ATTENTION WHEN THE BOARD IS NOT IN SESSION. ALL ACTIONS OF THE EXECUTIVE COMMITTEE ARE RATIFIED AT THE NEXT SCHEDULED BOARD MEETING. THE EXECUTIVE COMMITTEE IS COMPRISED OF THE FOLLOWING BOARD MEMBERS: CHAIRPERSON, FIRST VICE CHAIRPERSON, THREE OTHER MEMBERS OF THE EXECUTIVE COMMITTEE AND THE PRESIDENT. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED TO STATE THAT UP TO TWO (2) BOARD MEMBER POSITIONS SHALL BE HELD BY MEMBERS OF THE LUTHERAN CHURCH MISSOURI SYNOD. FORM 990, PART VI, SECTION A, LINE 6 THE FOLLOWING ARE ELIGIBLE VOTING MEMBERS OF THE SOCIETY BY VIRTUE OF THEIR RELATIONSHIP WITH THE SOCIETY: 1. ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE SOCIETY WHO ARE MEMBERS OF A CHRISTIAN CHURCH. 2. ALL SOCIETY CORPORATE OFFICERS AND ASSISTANT OFFICERS WHO ARE MEMBERS OF A CHRISTIAN CHURCH. 3. ALL REGIONAL VICE PRESIDENTS WHO ARE MEMBERS OF A CHRISTIAN CHURCH. 4. ALL ADMINISTRATOR/EXECUTIVE DIRECTOR/EXECUTIVE MANAGER EMPLOYEES OF THE SOCIETY WHO ARE MEMBERS OF A CHRISTIAN CHURCH. 5. ALL MEMBERS OF EXECUTIVE LEADERSHIP WHO ARE MEMBERS OF A CHRISTIAN CHURCH. 6. ALL MEMBERS WHO ARE MEMBERS OF A CHRISTIAN CHURCH WHO WERE MEMBERS ON JANUARY 1, 2002, THE DAY OF THE ADOPTION OF THIS AMENDED BYLAW. HOWEVER, VOTING MEMBERSHIP FOR ALL SUCH MEMBERS UNDER THIS ARTICLE II. A. 6. SHALL CEASE, AFTER REASONABLE NOTICE, WHEN SUCH MEMBER FAILS TO VOTE AT THE ANNUAL METING OF THE SOCIETY FOR TWO CONSECUTIVE YEARS. 7. ALL MEMBERS OF THE BOARD OF DIRECTORS OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION WHO ARE MEMBERS OF A CHRISTIAN CHURCH. FORM 990, PART VI, SECTION A, LINE 7A VOTING MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS MUST APPROVE ANY AMENDMENTS TO THE ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED AND APPROVED BY THE BOARD PRIOR TO ITS FILING. THE ORGANIZATION'S OFFICERS AND MANAGEMENT WERE AN INTEGRAL PART OF THE PREPARATION OF THE FORM 990. THEREFORE, THEY HAD AN ON-GOING REVIEW OF THE INFORMATION AS IT WAS PREPARED FOR THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS AND DIRECTORS ARE REQUIRED TO ANNUALLY DISCLOSE INTERESTS THAT COULD GIVE RISE TO CONFLICTS. ALL POTENTIAL DIRECTOR CONFLICTS ARE INVESTIGATED BY THE SOCIETY'S CHIEF LEGAL OFFICER. THE CHIEF LEGAL OFFICER REPORTS HIS FINDINGS TO THE BOARD CHAIR. THE BOARD ULTIMATELY DETERMINES WHETHER OR NOT AN ACTUAL CONFLICT OF INTEREST EXISTS AND THE REMEDIAL STEPS NECESSARY BASED UPON SUCH LEGAL OPINION. THE SOCIETY HAS A CONFLICT OF INTEREST POLICY THAT COVERS SUBSTANTIALLY ALL EMPLOYEES. ALL EMPLOYEES ARE REQUIRED TO REPORT ANY POTENTIAL CONFLICTS TO THE APPROPRIATE INDIVIDUAL AS INDICATED IN THE POLICY. ALL POTENTIAL CONFLICTS ARE INVESTIGATED TO DETERMINE IF A CONFLICT EXISTS. IF APPROVAL IS GIVEN TO PROCEED WITH THE ACTION, A COPY OF THE APPROVAL IS DOCUMENTED IN THE EMPLOYEE'S PERSONNEL FILE. FORM 990, PART VI, SECTION B, LINE 15 THE SOCIETY'S CEO'S TOTAL COMPENSATION PLAN IS DETERMINED BY THE EXECUTIVE EVALUATION AND COMPENSATION COMMITTEE (EECC) OF THE BOARD OF DIRECTORS. AS PART OF THEIR RESPONSIBILITIES, THE EXECUTIVE EVALUATION AND COMPENSATION COMMITTEE SHALL REVIEW AND DETERMINE THE ANNUAL BASE SALARY LEVEL, EMPLOYEE AGREEMENTS IF AND WHEN APPROPRIATE, FRINGE BENEFITS, ANY COMPENSATION INCENTIVES AND SUPPLEMENTAL BENEFITS (THE "COMPENSATION") FOR THE PRESIDENT/CEO. THE COMMITTEE WILL USE BEST EFFORTS TO REVIEW AND DETERMINE THE COMPENSATION IN ACCORDANCE WITH THE IRS REBUTTABLE PRESUMPTION PROCEDURE UNDER IRC 4958. THE COMMITTEE INTENDS TO COMPLY WITH THIS PROCEDURE BY MEETING THE THREE GENERAL REQUIREMENTS LISTED BELOW: (1) THE COMPENSATION SHALL BE APPROVED IN ADVANCE BY THE COMMITTEE WITH NO COMMITTEE MEMBERS HAVING A CONFLICT OF INTEREST AS STATED UNDER IRC 4958. (2) THE DETERMINATION SHALL BE BASED UPON COMPARABLE DATA OF SIMILARLY SITUATED POSITIONS WITH DATA PREFERABLY PROVIDED BY AN OUTSIDE COMPENSATION CONSULTANT. (3) THE REVIEW AND DETERMINATION SHALL BE ADEQUATELY AND TIMELY DOCUMENTED. THE DOCUMENTATION SHALL BE IN SIMILAR FORM AND SUBSTANCE. THE EECC ALSO ENGAGES AN EXTERNAL CONSULTANT, AON-HEWITT TO HELP DETERMINE THE COMPENSATION PACKAGE FOR THE CEO. THE EXTERNAL CONSULTANT IS ENGAGED AS NEEDED BUT AT LEAST EVERY FIVE YEARS. SEE SCHEDULE J, PART 1, LINE 3 FOR ADDITIONAL DETAILS RELATED TO THE PRESIDENT/CEO POSITION. THE SOCIETY'S EMPLOYEE COMPENSATION PLAN IS REVIEWED BY THE EXECUTIVE LEADERSHIP TEAM. DURING THE REVIEW, THE COMPENSATION IS EVALUATED, UPDATED, AND RESET TO BE 100% COMPETITIVE AT THE 50TH PERCENTILE OF THE NATIONAL LABOR MARKET UTILIZING A NATIONALLY RECOGNIZED DATABASE. THE COMPENSATION PLAN INCLUDES ALL NATIONAL CAMPUS POSITIONS WITHIN THE SOCIETY, INCLUDING EXECUTIVE MANAGEMENT, KEY EMPLOYEES AND OFFICERS. THIS EMPLOYEE COMPENSATION PLAN WAS REVIEWED AND UPDATED BY AON-HEWITT AS THE OUTSIDE CONSULTANT. AON-HEWITT PROVIDED A WRITTEN REVIEW BASED UPON CURRENT MARKET CONDITIONS WHICH IS ON FILE. COMPENSATION WAS REVIEWED IN 2011 AND IMPLEMENTED IN 2012 FOR OTHER OFFICERS AND KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 THE SOCIETY'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIALS STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION A, LINE 1B EACH AND EVERY DAY THE SOCIETY'S TOP LOCAL LEADER POSITION AT ITS 200+ DECENTRALIZED LOCATIONS CARRYOUT THE SOCIETY'S MISSION BY ASSURING CARE AND SERVICES ARE PROVIDED TO THOSE MOST IN NEED. IN ORDER FOR THE SOCIETY'S BOARD TO STAY CONNECTED WITH ITS MISSION AND TO ASSURE ALL STRATEGIES HAVE LOCAL LEADERSHIP INPUT, THE SOCIETY'S BYLAWS REQUIRE 6 BOARD MEMBERS TO BE SELECTED FROM THE LOCAL LEADERSHIP. INDEPENDENT BOARD MEMBERS PERIODICALLY REVIEW THE BYLAWS FOR THE MAKEUP OF THE BOARD MEMBERS AND CONTINUE TO DETERMINE THAT IT IS EXTREMELY VALUABLE TO INCLUDE LOCAL LEADERSHIP BOARD REPRESENTATION TO PROVIDE THE INPUT FOR SETTING STRATEGIES FOR THE SOCIETY. THE SEVENTH NON-INDEPENDENT BOARD MEMBER IS THE CEO OF THE SOCIETY. FORM 990, PART XI, LINE 9: INCREASE IN NET ASSETS OF FOUNDATION 2,155,349. DECREASE IN BENEFICIAL INTEREST IN PERPETUAL TRUST -336,000. ACH DEVELOPMENT FUND EQUITY -14,111,678. ROUNDING -2,249. 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