2013-11-13T10:50:01-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 3000 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2012-01-01 910573114 FOSS HOME & VILLAGE FOSS 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 DAVID CROUCH 2063641300 2013-11-12 1 STEVE BASS P00004800 4252506100 2013-11-12 2012 2016-02-24 21:20:13Z DAVID CROUCH 13023 GREENWOOD AVE N SEATTLE WA 981337397 19463436 0 X WWW.FOSSCARE.ORG X 1929 WA NURSING HOME & ASSISTED LIVING FACILITY 13 13 360 155 0 0 0 276129 18008295 19036746 48851 80861 7291 855 18064437 19394591 0 0 0 0 13258828 12901811 0 0 108525 4386833 5356522 17645661 18258333 418776 1136258 11822134 14792743 7489943 7900721 4332191 6892022 NURSING HOME AND ASSISTED LIVING FACILITY. 0 0 16185987 19036746 NURSING HOME AND ASSISTED LIVING CARE, INCLUDING A SUBSTANTIAL NUMBER OF MEDICARE & MEDICAID SUPPORTED RESIDENTS/PATIENTS. 52% OF REVENUE IS FROM MEDICARE/MEDICAID AND THE REMAINDER IS FROM PRIVATE PAY RESIDENTS. RATES ARE SET BASED ON MARKET RATES IN THE SEATTLE AREA, AND ARE NECESSARY TO MAKE THE ORGANIZATION VIABLE. 16185987 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 43 0 1 360 1 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WA X PATRICIA UPDEGRAFF 2063641300 13023 GREENWOOD AVE N SEATTLE WA 981337397 DR MARYANN JOHNSTON 2.00 X X 0 0 0 MR ART BATT 2.00 X X 0 0 0 MR CARLOS GUANGORENA 2.00 X X 0 0 0 MS MARTA ACEDO 2.00 X 0 0 0 MS NORMA BEERWEILER 2.00 X 0 0 0 MR JOHN GIENAPP 2.00 X 0 0 0 MS LARRAINE KING 2.00 X 0 0 0 MS JANE JONES 2.00 X 0 0 0 REV MARVIN R JONASEN 2.00 X 0 0 0 MS BEV ROACH 2.00 X 0 0 0 MR PAUL WOLD 2.00 X 0 0 0 MS GAIL SCOTT 2.00 X 0 0 0 MR DAVID CROUCH 40.00 X 180841 0 76241 MS PAT UPDEGRAFF 40.00 X 102640 0 50193 MR JOHN HENRY JR 40.00 X 102453 0 22730 385934 0 149164 3 0 1 0 REHAB SPECIALISTS I 4560 SE INTERNATIONAL WAY STE 100 MILWAUKIE OR 97222 CONTRACT THERAPIST 1090774 TW VANCE COMPANY 720 S 333RD ST STE 200 FEDERAL WAY WA 98003 GENERAL BUILDING CONTRACTOR 106549 2 276129 276129 RESIDENT FEES 623000 18720276 18720276 316470 316470 19036746 80861 80861 69700 68845 855 855 855 19394591 19036746 0 81716 409915 409915 9998841 9191993 769777 37071 561178 516281 39270 5627 1343208 1235250 92130 15828 588669 541420 40632 6617 58540 43540 15000 10074 10074 52226 52226 12886 12886 51693 51693 700324 665308 35016 27117 26534 583 181944 77440 104504 399103 379148 19955 PURCHASED SERVICES 1441699 1271476 170223 SUPPLIES 841640 815503 23754 2383 FOOD 787032 787032 PHARMACY 372317 372317 419927 262745 144652 12530 18258333 16185987 1963821 108525 996627 4127982 2012592 1858149 61530 61401 266533 133181 18857046 11851128 6851293 7005918 467783 135345 1018359 1395141 147417 75626 11822134 14792743 2637965 2877166 153489 4670000 4670000 181978 200066 7489943 7900721 X 4332191 6892022 4332191 6892022 11822134 14792743 X 1136258 109653 1313920 X X 0 1 X 1 0 X 757977 131773 200000 276129 1365879 18235508 18705425 18198386 18015586 19313530 92468435 -2186 4193 57000 58700 69700 187407 18991299 18841391 18455386 18074286 19659359 94021721 0 0 0 94021721 56248 39024 41491 48851 80861 266475 56248 39024 41491 48851 80861 266475 35860 9290 45150 19083407 18889705 18496877 18123137 19740220 94333346 0.99670 0.99600 0.00280 0.00350 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2278535 2278535 10972178 6074905 4897273 4519030 4840112 -321082 1087303 936111 151192 7005918 WELLESLEY INCOME FUND 630416 F WELLINGTON FUND ADMIRAL 764725 F 1395141 RESIDENT TRUST ACCTS 16082 DEPOSITS 153489 ACCRUED INTEREST 30495 200066 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS REPORT THERE ARE NO MATTERS THAT WOULD CREATE UNRELATED BUSINESS INCOME TAX OR CALL INTO QUESTION ITS EXEMPT STATUS. X X X 0 1 0 0 0 0 0 0 0 MR DAVID CROUCH 180841 0 0 0 0 0 60290 0 15951 0 257082 0 0 0 MS PAT UPDEGRAFF 102640 0 0 0 0 0 34261 0 15932 0 152833 0 0 0 PART I, LINE 4B PART I, LINE 4B: DAVID CROUCH $57,673 PAT UPDEGRAFF $32,208 FORM 990, PART VI, SECTION B, LINE 11 DRAFT TAX RETURN DISTRIBUTED AT BOARD MEETING FOR REVIEW AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED AT THE BOARD MEETING AND MEMBERS ARE REQUIRED TO COMPLETE AND SIGN THE FORM FOR PROPER DISCLOSURE. MEMBERS ARE DIRECTED TO NOTIFY THE BOARD DURING THE YEAR IF A CONFLICT OF INTEREST DEVELOPS. FORM 990, PART VI, SECTION B, LINE 15 BOARD OF DIRECTORS REVIEWS DATA ON SALARY FROM SALARY SURVEY COMPILED BY HOPSITAL ASSOCIATION, REVIEWS FROM 990'S OF COMPARABLE ORGANIZAITONS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: TRANSFERS OF NET ASSETS FROM FOSS HOME FOUNDATION 1,313,920. AUDIT COMMITTEE RESPONSIBILITY FORM 990, PART XII, LINE 2C THE AUDIT COMMITTEE HAS OVERSIGHT RESPONSIBILITY FOR THE FINANCIAL STATEMENTS, AND THE SELECTION OF THE INDEPENDENT AUDITOR. THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FOSS FOUNDATION 13023 GREENWOOD AVE N SEATTLE WA 98133 911640102 FUNDRAISING ACTIVITIES TO RAISE FUNDS TO PROVIDE GRANTS TO FOSS HOME & VILLA WA 501(C)(3) LINE 1 FOSS HOME & VILLAGE 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0