2012-05-14T09:43:02-05:00 2011-12-31 560571159 BERNARD ROBINSON & COMPANY LLP PO BOX 19608 GREENSBORO NC 274199608 990 2011-01-01 560529956 MASONIC AND EASTERN STAR HOME OF NORTH CAROLINA INC MASO 3362990031 700 S HOLDEN ROAD GREENSBORO NC 27407 MARK KOLADA 3362990031 2012-05-14 1 LORY H KELLEY P00431638 3362944494 2012-05-02 2011 2016-02-24 21:20:13Z WHITESTONE MARK KOLADA 700 S HOLDEN ROAD GREENSBORO NC 27407 39838877 0 X WWW.MESHHOME.ORG X 1912 NC AS A RETIREMENT COMMUNITY LEADER SINCE 1912, MASONIC AND EASTERN STAR HOME OF NC IS DEVOTED TO EXCELLENCE IN HOSPITALITY WITH TRADITIONAL VALUES PROMOTING FRATERNAL SERVICE, DIGNITY, DEPENDABILITY, AND CHOICE. 20 20 277 100 0 0 1930137 1697836 10861519 12012809 191422 -196722 24657 2176 13007735 13516099 1187973 1314415 0 0 5561008 5898486 0 0 0 5544113 4880782 12293094 12093683 714641 1422416 32028874 54497984 16218450 37095401 15810424 17402583 AS A RETIREMENT COMMUNITY LEADER SINCE 1912, MASONIC AND EASTERN STAR HOME OF NC IS DEVOTED TO EXCELLENCE IN HOSPITALITY WITH TRADITIONAL VALUES PROMOTING FRATERNAL SERVICE, DIGNITY, DEPENDABILITY, AND CHOICE. 0 0 10708356 1314415 12012809 MASONIC AND EASTERN STAR HOME OF NC PROVIDES RESIDENTIAL, HEALTH CARE, AND OTHER RELATED SERVICES TO ELDERLY RESIDENTS. THE HOME OFFERS INDEPENDENT LIVNG, ASSISTED LIVING, AND SKILLED NURSING SERVICES. 10708356 1 1 0 0 0 0 0 0 1 1 1 1 0 1 1 1 0 0 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 0 0 1 0 0 0 0 1 52 0 1 277 1 0 0 0 0 0 0 0 0 0 0 X 20 20 0 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X PHIL HUGHES 3362990031 700 S HOLDEN ROAD GREENSBORO NC 27407 X DEWEY PRESLAR JR 1.00 X 0 0 0 LEWIS LEDFORD 1.00 X 0 0 0 ROBERT E GRESHAM JR 1.00 X 0 0 0 DAVID CRISP 1.00 X 0 0 0 DAVID WICKER JR 1.00 X 0 0 0 JANET DORSETT 1.00 X X 0 0 0 JIM SHEARON 1.00 X 0 0 0 GENE JERNIGAN 1.00 X X 0 0 0 DWIGHT CREWS 1.00 X 0 0 0 ARCHIBALD JARRELL 1.00 X 0 0 0 LINDA BONNER 1.00 X 0 0 0 THOMAS JACKSON 1.00 X 0 0 0 DONNA CHESSER 1.00 X 0 0 0 FRAN SOUTHERN 1.00 X X 0 0 0 DONNA YATES 1.00 X X 0 0 0 MELISSA HOGAN 1.00 X 0 0 0 DICK SLOOP 1.00 X 0 0 0 JACK WALTERS 1.00 X 0 0 0 WAYNE LAMBERTSON SR 1.00 X 0 0 0 FREDERICK HINES WHITTY 1.00 X 0 0 0 MARK KOLADA 40.00 X 0 0 0 0 0 0 0 0 0 1 LIFE CARE SERVICES 800 LOCUST STREET DES MOINES IA 50309 MANAGEMENT OF HOME 636782 SYSCO FOOD SERVICES CHARLOTTE 4500 CORPORATE DR NW CONCORD NC 28027 FOOD SERVICES 559349 HERITAGE HEALTHCARE 536 OLD HOWELL ROAD GREENVILLE SC 29615 OCCUP, PHYSICAL & SPEECH THERAPY 528778 BLUE CROSS & BLUE SHIELD OF NC 3530 TORINGDON WAY CHARLOTTE NC 28277 INSURANCE 525822 ZILLNER MARKETING 8725 ROSEHILL ROAD SUITE 200 LENEXA KS 66215 MARKETING SERVICES 319552 5 688485 1009351 1697836 RESIDENT SERVICES 623000 12012809 12012809 12012809 321294 321294 25804762 26262882 59896 -458120 -59896 -518016 -518016 OTHER INCOME 623000 2176 2176 2176 13516099 12012809 0 -194546 1314415 1314415 4913147 4421463 491684 34926 34926 476143 451064 25079 474270 443026 31244 446101 98103 347998 44527 9226 35301 45568 45568 20351 4209 16142 1197844 1197844 23135 3969 19166 152388 152388 1000570 1000570 148071 597 147474 MEDICAL SERVICES 793094 793094 REPAIRS AND MAINTENANCE 296297 252026 44271 VARIOUS SUPPLIES 295170 273643 21527 MISCELLANEOUS 177799 91812 85987 239867 165981 73886 12093683 10708356 1385327 0 1386816 905439 536572 3665274 747544 933405 31758 34801 211934 326758 38060647 11419247 19842166 26641400 4180770 1762108 5091314 5067554 15161245 32028874 54497984 2276025 1233651 8042572 7063839 5899853 28797911 16218450 37095401 X 8766531 9936678 487463 1118273 6556430 6347632 15810424 17402583 32028874 54497984 X 1422416 169743 X 0 1 1 X 0 X 1149837 1475256 1177302 1930137 1697836 7430368 1149837 1475256 1177302 1930137 1697836 7430368 2356665 5073703 547808 825510 616467 191422 321294 2502501 25828 57208 36569 21091 140696 10073565 51511706 0.50370 0.60510 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 6556430 -208798 6347632 6213730 342700 6556430 5538689 675041 6213730 7277779 -1739090 5538689 1.00000 0 0 55677 55677 35708440 9954798 25753642 2179952 1359364 820588 116578 105085 11493 26641400 ASSETS IN SPLIT INTEREST AGREEMENTS 5067554 F 5067554 BOND INVESTMENTS 15161245 F 15161245 REFUNDABLE ADVANCE FEES 1431211 DEPOSITS ON UNOCCUPIED UNITS 618938 RESIDENT TRUST FUNDS 92126 BONDS PAYABLE 26655636 28797911 13516099 12093683 1422416 398993 -229250 169743 1592159 12371427 398993 -229250 169743 12201684 1314415 1314415 13516099 10779268 0 10779268 1314415 1314415 12093683 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: IT IS THE HOME'S POLICY TO EVALUATE ALL TAX POSITIONS TO IDENTIFY ANY THAT MAY BE CONSIDERED UNCERTAIN. ALL IDENTIFIED MATERIAL TAX POSITIONS ARE ASSESSED AND MEASURED BY A "MORE-LIKELY-THAN-NOT" THRESHOLD TO DETERMINE IF THE TAX POSITION IS UNCERTAIN AND WHAT, IF ANY, THE EFFECT OF THE UNCERTAIN TAX POSITION MAY HAVE ON THE FINANCIAL STATEMENTS. NO MATERIAL UNCERTAIN TAX POSITIONS WERE IDENTIFIED DURING 2011. CURRENTLY, THE STATUTE OF LIMITATIONS REMAINS OPEN SUBSEQUENT TO AND INCLUDING 2008; HOWEVER, NO EXAMINATIONS ARE IN PROGRESS OR ANTICIPATED. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SPLIT INTEREST AGREEMENTS -229,250. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN VALUE OF SPLIT INTEREST AGREEMENTS -229,250. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANTS MADE TO RESIDENTS 1,314,415. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GRANTS MADE TO RESIDENTS 1,314,415. 1 WAIVER OF FEES FOR INDIVIDUALS DUE TO HARDSHIPS. 62 1314415 FMV RESIDENTIAL AND HEALTH SERVICES. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES GRANTS FOR RESIDENTS UNABLE TO AFFORD TO PAY FOR THEIR CARE. THE MAJORITY OF THE GRANT RECIPIENTS ALSO RECEIVE MEDICAID BENEFITS. EACH RESIDENT IS REQUIRED TO CONTRIBUTE AS MUCH AS THEY CAN AFFORD TOWARDS THE COST OF THEIR CARE. THE GRANTS ARE PAID DIRECTLY TO THE VENDORS PROVIDING THE CARE, TO ENSURE THE FUNDS ARE USED APPROPRIATELY. X 0 0 0 0 0 0 0 0 0 SUPPLEMENTAL INFORMATION PART III MARK KOLADA IS THE EXECUTIVE DIRECTOR OF MASONIC AND EASTERN STAR HOME OF NORTH CAROLINA. HOWEVER, MARK KOLADA IS EMPLOYED BY LIFE CARE SERVICES, LLC. (AN UNRELATED ORGANIZATION). MASONIC AND EASTERN STAR HOME OF NC PAYS LIFE CARE SERVICES, LLC. TO MANAGE OPERATIONS OF THE HOME. MARK KOLADA'S SALARY AND BENEFITS ARE PAID BY LIFE CARE SERVICES, LLC. FOR THE 2011 TAX YEAR, LIFE CARE SERVICES, LLC PAID MARK KOLADA MEDICARE WAGES IN THE AMOUNT OF $124,104. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820YJN7 2011-04-28 26642514 0 0 0 26642514 1971475 532850 20264188 3874001 0 0 1 1 0 0 0 0 1 0 1 0 0 0 0 X THE BONDS WERE ISSUED TO PAY FOR CONSTRUCTION OF AN EXPANSION TO THE HOMES' EXISTING FACILITY, REFUNDING CERTAIN INDEBTEDNESS INCURRED TO FINANCE A PORTION OF THE EXPANSION, FUNDING A DEBT SERVICE RESERVE FUND AND PAYING CERTAIN EXPENSES INCURRED IN CONNECTION WITH THE ISSUANCE OF THE BONDS. FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF DIRECTORS HAS CONTRACTED WITH LIFE CARE SERVICES, LLC. TO MANAGE, OPERATE AND MAINTAIN THE RETIREMENT COMMUNITY. THE EXECUTIVE DIRECTOR, MARK KOLADA, IS AN EMPLOYEE OF LIFE CARE SERVICES, LLC. FORM 990, PART VI, SECTION A, LINE 7A THE GRAND MASTER APPOINTS THREE BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS WILL REVIEW THE FORM 990 AS IT IS PRESENTED BY LIFE CARE SERVICES, LLC. THE BOARD OF DIRECTORS WILL ASK ANY PERTINENT QUESTIONS AT THAT TIME. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL MONITORING OF CONFLICT OF INTEREST IS PART OF THE DUTIES OF THE CORPORATE COMPLIANCE COMMITTEE, CHAIRED BY TRACY ARMWOOD. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR CEO, CURRENT OFFICERS, ETC ARE REVIEWED AS A PART OF ANNUAL BUDGET BY THE BOARD OF DIRECTORS, FINANCE COMMITTEE AND PERSONNEL COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST. THE AUDITED FINANCIALS ARE INCLUDED IN ANNUAL DISCLOSURE AS REQUIRED BY DEPARTMENT OF INSURANCE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 398,993. CHANGE IN VALUE OF SPLIT INTEREST AGREEMENTS -229,250. TOTAL TO FORM 990, PART XI, LINE 5: 169,743. GRAND LODGE OF THE AF AND AM OF NC PO BOX 6506 RALEIGH NC 27628 560228750 PROVIDE SUPPORT FOR NC MASONS NC 501(C)(10) 0 GRAND CHAPTER OF THE ORDER OF THE EASTERN STAR OF NC PO BOX 5516 KINSTON NC 28503 560239941 CHARITABLE, EDUCATIONAL AND FRATERNAL NC 501(C)(8) 0 NC MASONIC FOUNDATION INC PO BOX 6506 RALEIGH NC 27628 566049500 RECEIVE DONATIONS AND DISTRIBUTE ALL INCOME TO CHARITABLE ORGANIZATIONS NC 501(C)(3) LINE 11B, II 0 NC EASTERN STAR FOUNDATION INC PO BOX 5516 KINSTON NC 28503 561974972 INVEST FUNDS RAISED TO PROVIDE PERPETUAL FUND TO EASTERN STAR HOME NC 501(C)(3) PF 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 NORTH CAROLINA MASONIC FOUNDATION INC E 4010345 NORTH CAROLINA MASONIC FOUNDATION INC C 95271 NORTH CAROLINA EASTERN STAR FOUNDATION INC C 139694 NC MASONIC FOUNDATION (RUCK FUND) C 179658 SCH R, PART V, QUESTION 2, LINE 1E: AMOUNT INVOLVED IS BEGINNING OF YEAR AMOUNT. AMOUNT WAS PAID OFF BY THE END OF THE YEAR.