2016-10-31T08:30:24-05:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-01-01 460422866 THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION EVAN 6053623100 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 G GRANT TRIBBLE TREASURER 6053623100 2016-10-24 1 KACIE MCEWEN P01599614 6123764500 2015 2017-02-10 21:41:12Z WALTER WOODS 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 9468254 0 X N/A X 1992 MN PROVIDING SUPPORT, ASSISTANCE, AND AID FOR THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (ELGSS). 13 10 0 13 0 0 7589560 4574579 0 0 1748979 2862386 0 0 9338539 7436965 2612461 2463573 0 0 1417976 1559885 0 0 1175530 232165 228302 4262602 4251760 5075937 3185205 57910408 58316843 127527 130517 57782881 58186326 X MISSION:THE MISSION OF THE GOOD SAMARITAN FOUNDATION IS TO SUPPORT THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY'S MISSION OF SHARING GOD'S LOVE IN WORD AND DEED BY PROVIDING SHELTER AND SUPPORTIVE SERVICES TO OLDER PERSONS AND OTHERS IN NEED WELL INTO THE FUTURE. THE FOUNDATION GATHERS, GROWS AND PROVIDES THE CHANNELS THROUGH WHICH GIFTS AND GRANTS FLOW TO SUPPORT AND TO IMPROVE THE QUALITY OF LIFE FOR THOSE IN OUR CARE.VISION:THE GOOD SAMARITAN FOUNDATION SUPPORTS THE SOCIETY'S VISION "TO CREATE AN ENVIRONMENT WHERE PEOPLE ARE LOVED, VALUED AND AT PEACE" BY INVITING DONORS TO HELP US SHOW WHAT SENIOR CARE CAN BE. 0 0 2463573 2463573 0 THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION ("FOUNDATION") SUPPORTS THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY ("SOCIETY") IN ITS EFFORTS TO CREATE ENVIRONMENTS WHERE PEOPLE FEEL LOVED, VALUED AND AT PEACE. WE RAISE FUNDS IN SUPPORT OF THE SOCIETY'S EFFORTS TO TRANSFORM THE AGING EXPERIENCE IN AMERICA AND SEEK "DONORS" WHO ARE INSPIRED TO JOIN OUR JOURNEY. FURTHERMORE, THE FOUNDATION ENSURES THESE DONATIONS ARE USED WHERE THEY CAN HAVE THE GREATEST IMPACT ON THE BENEFICIARIES OF THE SOCIETY'S EFFORTS. 2463573 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 13 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN AL AK AR CA CO CT DC FL GA HI IL KS KY ME MD MI MS NV NH NM NY NC ND OH OK OR PA RI TN UT VA WA WV WI X G GRANT TRIBBLE TREASURER 6053623100 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 DAVID J HORAZDOVSKY CHAIRPERSON 0.60 55.40 X X 0 755070 8430 NEIL GULSVIG VICE CHAIRMAN - THRU JUNE 2015 0.60 4.10 X X 0 0 0 JOHN H HOLT VICE CHAIRMAN 0.60 4.10 X X 0 0 0 DUANE ANDERSON DIRECTOR 0.60 X 0 0 0 KURT BICKEL DIRECTOR 0.60 X 0 0 0 ROE EIDSNESS DIRECTOR - THRU NOVEMBER 2015 0.60 X 0 0 0 JOYCE FJELLAND DIRECTOR 0.60 X 0 0 0 DAVID LERSETH DIRECTOR 0.60 X 0 0 0 LISA MELBY DIRECTOR 0.60 50.00 X 0 141939 24429 MYRA PEABODY DIRECTOR 0.60 X 0 0 0 GALE POLLOCK DIRECTOR 0.60 X 0 0 0 ALFRED PUTZ DIRECTOR 0.60 X 0 0 0 DARRELL SCHMITH DIRECTOR 0.60 X 0 0 0 JIM SEWICK DIRECTOR 0.60 50.00 X 0 109169 21425 THOMAS VANWYHE DIRECTOR 0.60 X 0 0 0 WALTER WOODS PRESIDENT 55.00 0.10 X 0 188598 8333 DR CHARLES M HIATT PRESIDENT - THRU MAY 2015 55.00 X 0 147008 14500 G GRANT TRIBBLE TREASURER 0.60 54.50 X 0 319108 24626 THOMAS KAPUSTA SECRETARY 0.60 54.50 X 0 323936 15182 MISTY HAM-QUICK ASSISTANT SECRETARY 0.60 45.00 X 0 42931 16641 JIM KREKELBERG ASSISTANT TREASURER 0.60 54.50 X 0 190946 15467 0 2218705 149033 0 0 1 0 0 3991541 583038 4574579 961874 961874 3931801 2031289 1900512 1900512 1900512 7436965 0 0 2862386 2437292 2437292 26281 26281 1559885 484934 1074951 50033 41007 9026 779 629 150 5590 1945 3645 107023 21859 85164 41611 41611 36 36 LICENSE & FEES 12086 12086 STAFF DEVELOPMENT 5978 4066 1912 DUES 3394 2827 567 OTHER EXPENSES 1657 1657 115 115 4251760 2463573 612657 1175530 35089 54726 13812758 13422468 712 246 501 466 44062060 44839183 57910408 58316843 21949 39930 105578 90587 127527 130517 X 40955311 41111118 2541991 2641581 14285579 14433627 57782881 58186326 57910408 58316843 3185205 -2781760 0 X 0 1 X 1 0 X X 1 TELGSS 450228055 9 1 2432420 0 1 2432420 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 19029280 148048 18886 123400 19072814 17270657 1313277 855533 410187 19029280 16069481 490240 1062091 351155 17270657 14909198 604726 1015659 460102 16069481 14644672 467533 232597 435604 14909198 0.11800 0.75700 0.12500 0 0 712 246 466 466 ANNUITY OBLIGATION 90587 90587 X 663664 -2781760 -2781760 3445424 3991541 3991541 7436965 1819340 0 1819340 2432420 2432420 4251760 PART V, LINE 4: THE FOUNDATION'S ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY THE DONOR'S RESTRICTIONS OR THE BOARD'S DESIGNATION. PART X, LINE 2: THE FOUNDATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE FOUNDATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE 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 FOUNDATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE FOUNDATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. PART XI, LINE 4B - OTHER ADJUSTMENTS: GIFTS TRANSFERRED FROM AFFILIATE 175,430. EXPENSES PAID BY AFFILIATE 3,304,019. INVESTMENTS TRANSFERRED FROM AFFILIATE 512,092. PART XII, LINE 4B - OTHER ADJUSTMENTS: TRANSFERS TO AFFILIATE 2,432,420. 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 4800 W 57TH ST SIOUX FALLS SD 57108 450228055 501(C)(3) 2432420 GIFTS TRANSFERRED TO THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. 1 0 SCHOLARSHIPS 22 26281 PART I, LINE 2: THE FOUNDATION COMMUNICATES A LIST OF RESTRICTIONS TO EACH CENTER AT THE TIME OF DISTRIBUTION. THE ADMINISTRATOR AT EACH LOCATION IS RESPONSIBLE FOR ENSURING THAT THE FUNDS ARE USED IN ACCORDANCE WITH THE FOUNDATION'S DIRECTION. THE ORGANIZATION PROVIDES SCHOLARSHIPS TO EMPLOYEES OF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY WHO ARE ENROLLED IN A QUALIFIED EDUCATION PROGAM. THE ORGANIZATION PAYS THE SCHOLARSHIP DIRECTLY TO THE EDUCATION INSTITUTION WHERE THE EMPLOYEE IS ENROLLED. IF THE EMPLOYEE HAS ALREADY PAID THE EXPENSES, THE ORGANIZATION REQUIRES RECEIPT OF PAYMENT BEFORE REIMBURSEMENT IS MADE TO THE EMPLOYEE. 1 0 0 0 0 0 0 0 0 DAVID J HORAZDOVSKY CHAIRPERSON 0 587060 0 0 0 168010 0 0 0 9276 0 764346 0 0 LISA MELBY DIRECTOR 0 114157 0 0 0 27782 0 0 0 25275 0 167214 0 0 WALTER WOODS PRESIDENT 0 166416 0 0 0 22182 0 0 0 9179 0 197777 0 0 DR CHARLES M HIATT PRESIDENT - THRU MAY 2015 0 36452 0 0 0 110556 0 0 0 15345 0 162353 0 0 G GRANT TRIBBLE TREASURER 0 302299 0 0 0 16809 0 0 0 25472 0 344580 0 0 THOMAS KAPUSTA SECRETARY 0 252859 0 0 0 71077 0 0 0 16027 0 339963 0 0 JIM KREKELBERG ASSISTANT TREASURER 0 134217 0 0 0 56729 0 0 0 16312 0 207258 0 0 PART I, LINE 3 THE COMPENSATION OF THE FOUNDATION'S EXECUTIVE DIRECTOR IS DETERMINED BY THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, THE FOUNDATION'S SOLE MEMBER. THE FOLLOWING WERE USED BY THE SOCIETY TO DETERMINE THE EXECUTIVE DIRECTOR'S COMPENSATION: 1. INDEPENDENT COMPENSATION CONSULTANT 2. COMPENSATION SURVEY OR STUDY PART I, LINE 4A THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY PAID DR. CHARLES HIATT SEVERANCE PAYMENTS OF $55,981 AFTER LEAVING THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 6 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY IS THE SOLE MEMBER OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY BOARD OF DIRECTORS APPROVES THE BOARD MEMBER APPOINTMENTS OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7B THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY BOARD OF DIRECTORS APPROVES THE BOARD MEMBER APPOINTMENTS OF THE FOUNDATION AND ANY AMENDMENTS TO THE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 ACCOUNTANTS WITH THE FOUNDATION REVIEWED THE 990 IN DETAIL PRIOR TO IT BEING FILED. ANY QUESTIONS WERE RESOLVED WITH THE TREASURER AND/OR EXECUTIVE DIRECTOR OF THE ORGANIZATION PRIOR TO THE 990 BEING FILED. A COPY OF THE 990 WAS PROVIDED TO THE ORGANIZATION'S GOVERNING BODY PRIOR TO THE 990 BEING FILED FOR THEIR REVIEW AND APPROVAL. 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 FOUNDATION'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 FOUNDATION 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 C, LINE 19 THE FOUNDATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 4800 W 57TH ST SIOUX FALLS SD 57108 450228055 LONG-TERM CARE, AL, SENIOR HOUSING & HOME AND COMMUNITY BASED SERVICES ND 501(C )(3) 9 N/A 0 GOOD SAMARITAN SOCIETY INC 4800 W 57TH ST SIOUX FALLS SD 57108 460349951 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 BOISE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 363370371 LOW-INCOME SENIOR HOUSING SD 501(C )(3) PF THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 LOVINGTON GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460392944 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 PROPHETSTOWN GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460393942 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 JASONVILLE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460396355 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 OLATHE GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 460396398 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 11 - 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TYPE 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 EL PASO GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 272876627 LOW-INCOME SENIOR HOUSING SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 LEA COUNTY GOOD SAMARITAN HOUSING INC 4800 W 57TH ST SIOUX FALLS SD 57108 453946645 LOW-INCOME HOUSING TO ELDERLY & DISABLED SD 501(C )(3) 9 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 SIOUX FALLS DOWNTOWN GOOD SAMARITAN HOUSING GP INC 4800 W 57TH ST SIOUX FALLS SD 57108 452473519 FUTURE GENERAL PARTNER OF LIHTC LIMITED PARTNERSHIP SD 501(C )(3) 11 - TYPE 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 PRESCOTT GOOD SAMARITAN HOUSING GP INC 4800 W 57TH ST SIOUX FALLS SD 57108 275114421 GENERAL PARTNER OF PRESCOTT GOOD SAMARITAN HOUSING, LP SD 501(C )(3) 11 - TYPE 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 GOOD SAMARITAN HOLDINGS LLC 4800 W 57TH ST SIOUX FALLS SD 57108 752979560 OWNER OF GOOD SAMARITAN HERITAGE, LLC SD 501(C )(3) 11 - TYPE 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 0 ADAMS COUNTY GOOD SAMARITAN HOUSING GP INC 4800 W 57TH ST SIOUX FALLS SD 57108 461495572 GENERAL PARTNER OF ADAMS COUNTY GOOD SAMARITAN HOUSING, LP SD 501(C )(3) 11 - 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COLLISTER DRIVE GOOD SAMARITAN HOUSING, LLC, EIN 61-1752929 CHANGED ITS NAME TO COLLISTER DRIVE HOUSING, LLC AND BECAME AN UNRELATED ENTITY EFFECTIVE 7/31/15.