2014-05-15T09:19:48-05:00 2013-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2012-07-01 411936717 LIVING SERVICES FOUNDATION LIVI 7632310410 900 LONG LAKE ROAD NO 130 NEW BRIGHTON MN 55112 JENNIFER KAMSTRA 7632310410 2014-05-15 1 DEB NELSON CPA P01264758 6122536500 2014-05-14 2012 2015-11-30 17:44:51Z DENNIS KAMSTRA 900 LONG LAKE ROAD NO 130 NEW BRIGHTON MN 55112 2793222 0 X N/A X 1999 MN TO SUPPORT SUBSIDIARIES OF BENEDICTINE HEALTH SYSTEM. 5 2 2 4 0 0 92200 15000 1000 2740135 36591 1242 2537951 0 2667742 2756377 0 0 0 0 335421 353854 0 0 0 3475237 3992150 3810658 4346004 -1142916 -1589627 33567590 34790428 35253322 38087772 -1685732 -3297344 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, AND BENEDICTINE LIVING COMMUNITY OF WAHPETON, ALL MINNESOTA NONPROFIT CORPORATIONS THAT ARE DESCRIBED IN SECTIONS 501(C)(3) AND 509(A)(1) (COLLECTIVELY, THE "BENEFICIARY ORGANIZATIONS") 0 0 3858481 2740135 THE ORGANIZATION OWNS AND PROVIDES MANAGEMENT OVERSIGHT TO THE FOLLOWING WHOLLY OWNED SUBSIDIARIES: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 AND 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.THE ORGANIZATION LEASES THESE 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, WHICH ARE SUBSIDIARIES OF BENEDICTINE HEALTH SYSTEM (BHS), WHO OPERATES THE FACILITIES. 3858481 1 1 0 0 0 0 0 0 0 0 1 0 0 0 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 5 0 1 2 1 0 0 0 0 0 0 0 0 0 0 0 X 5 2 1 0 0 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 MN X JENNIFER KAMSTRA 7632100410 900 LONG LAKE ROAD SUITE 130 NEW BRIGHTON MN 55112 PAUL SANDERS 5.00 X X 0 0 0 JENNIFER KAMSTRA 40.00 X X 90000 0 4213 ROD PAKONEN 5.00 X 0 0 0 KEVIN RYMANOWSKI 3.00 2.00 X 0 0 0 ROBERT SUNDBERG 5.00 X 0 0 0 DENNIS KAMSTRA 40.00 X X 219000 0 23865 309000 0 28078 1 0 1 0 COMSTOCK CONTSTRUCTION 4511 15TH AVENUE NORTH FARGO ND 58102 CONSTRUCTION SERVICES 3520521 1 15000 15000 15000 LEASE REVENUE 532000 2605707 2605707 MANAGEMENT FEE 532000 105398 105398 29030 29030 2740135 38087 38087 36845 -36845 -36845 -36845 2756377 2740135 0 1242 336965 23545 313420 16889 1181 15708 5289 5289 24333 24333 101914 101914 10069 10069 16567 16567 223 223 2253504 2253504 1567481 1567481 12770 12770 4346004 3858481 487523 0 83554 62728 1698 2269 310041 126653 121661 36572397 6528215 28504061 30044182 3133901 1359963 3186612 1420695 33567590 34790428 1395152 642224 25314132 36817017 245000 8488294 325000 55744 58531 35253322 38087772 X -1685732 -3297344 -1685732 -3297344 33567590 34790428 -1589627 -21985 0 X 0 1 X 1 0 X X X 0 0 0 BENDICTINE LIVING COMMUNITY OF WINSTED 274219293 9 1 1 1 1784624 BENDICTINE LIVING COMMUNITY OF NEW LONDON 274218436 9 1 1 1 965979 BENDICTINE LIVING COMMUNITY OF MORA 274219119 9 1 1 1 690235 BENDICTINE LIVING COMMUNITY OF WAHPETON 454274091 9 1 1 1 388005 4 3828843 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 909322 909322 32725182 5125427 27599755 1983767 1238402 745365 954126 164386 789740 30044182 ASSET RETIRMENT OBLIGATION 58531 58531 X 2734169 -21985 -223 -22208 2756377 0 2756377 4345781 0 4345781 223 223 4346004 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 LIABILITIES IN INCOME TAX EXPENSE, IF SUCH INTEREST AND PENALTIES ARE INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: TRAVEL EXPENSE MOVED TO EXPENSES. -223. PART XII, LINE 4B - OTHER ADJUSTMENTS: TRAVEL EXPENSE MOVED FROM REVENUE. 223. X X X X 0 0 0 0 0 0 0 0 0 DENNIS KAMSTRA 219000 0 0 0 0 0 0 0 23865 0 242865 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 & ASSITED 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 640000 9460519 712522 189210 8558787 2007 0 0 1 1 B 16112135 1311331 322243 6170490 8308071 2011 1 0 1 1 C 138314 6258382 6258382 2009 0 0 1 1 D 74191 5605000 112100 5492900 2013 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 C 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 D 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 0 0 A 1 B 1 C 1 D 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 VI, SECTION A, LINE 2 DENNIS KAMSTRA AND JENNIFER KAMSTRA HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 7A BENEDICTINE HEALTH SYSTEMS MAY APPOINT ONE BOARD MEMBER. 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 BE APPROVED BY THE INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE LAST REVIEW TOOK PLACE IN 2011 AND THE ORGANIZATION IS PLANNING TO CONDUCT ANOTHER REVIEW 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. LIVING SERVICES FOUNDATION MORA LLC 110 NORTH 7TH STREET MORA MN 55051 263614974 LEASING OF SKILLED NURSING AND ASSISTED LIVING FACILITY. DE 544313 690235 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 773383 969229 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 1289253 1784624 LIVING SERVICES FOUNDATION LIVING SERVICES FOUNDATION WAHPETON LLC 711 14TH AVENUE NORTH WAHPETON ND 58075 453638196 LEASING OF ASSITED LIVING FACILITY. DE 134205 421546 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 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0