2012-09-17T16:19:33-05:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-01-01 460422866 THE EVANGELICAL LUTHERAN GOOD SAMARITAN FOUNDATION EVAN 6053623100 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 JIM KREKELBERG 6053623100 2012-08-27 1 TERRANCE J O'REILLY P00068340 6123764500 2011 2016-02-24 21:20:13Z CHARLES HIATT 4800 WEST 57TH STREET BOX 5038 SIOUX FALLS SD 571175038 4659328 0 X N/A X 1992 MN PROVIDING SUPPORT, ASSISTANCE, AND AID FOR THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (ELGSS). 9 5 0 5 0 0 3866288 2320675 0 0 1106406 1721289 0 0 4972694 4041964 1341528 1213290 0 0 0 0 0 0 1036791 1373252 1399379 2714780 2612669 2257914 1429295 19040697 19480736 116678 173370 18924019 19307366 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 1213290 1213290 0 THE FOUNDATION SUPPORTS THE FOUR HALLMARK VALUES OF THE SOCIETY:(1) CHRIST-CENTERED, (2) RESIDENT-CENTERED, (3) STAFF-CENTERED AND (4) COMMUNITY-CENTERED BY SEEKING MAJOR GIFTS WITH INTEGRITY, INNOVATION AND FAITH.THE LEGACY PROMISE:DAY BY DAY, LET'S MAKE A DIFFERENCE;MONTH BY MONTH, LET'S MOTIVATE OTHERS TO SEIZE OPPORTUNITY;YEAR BY YEAR, SEE THINGS CHANGE; ANDIN A LIFETIME OF WORK, LEAVE A LASTING LEGACY WHICH ADVANCESTHE MISSION AND MINISTRY OF GOOD SAMARITAN SOCIETY ANDGOOD SAMARITAN FOUNDATION;SHOWING GOD'S LOVE IN WORD AND DEED. 1213290 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JIM KREKELBREG TREASURER 6053623100 4800 W 57TH STREET PO BOX 5038 SIOUX FALLS SD 571175038 DAVID J HORAZDOVSKY 1.00 X X 0 618344 23870 SUSAN NICKERSON 1.00 X X 0 0 0 BEN SOMERO 1.00 X 0 98558 34853 JIM SEWICK 1.00 X 0 96026 19033 LISA MELBY 1.00 X 0 142758 31100 RICHARD W FRIESS MD 1.00 X 0 0 0 RICHARD J HAUBENSAK 1.00 X 0 0 0 CLAYTON E JENSEN MD 1.00 X 0 0 0 ORVAL JOHNSON 1.00 X 0 0 0 ROBERT P O'CONNOR 1.00 X 0 0 0 SHARON A ST MARY 1.00 X 0 146241 16820 DENNIS STENE 1.00 X 0 0 0 ROE EIDSNESS 1.00 X 0 0 0 JOY MORRISON 1.00 X 0 0 0 JIM KREKELBERG 1.00 X 0 138081 34024 DR CHARLES M HIATT 40.00 X 0 162021 13320 RAYE NAE NYLANDER 1.00 X 0 284920 13820 SYLVIA GAUSE 1.00 X 0 62247 17187 MISTY HAM-QUICK 1.00 X 0 41600 6167 0 1790796 210194 0 0 1 0 0 2125256 195419 2320675 450537 450537 1888116 617364 1270752 1270752 1270752 4041964 0 0 1721289 1156313 1156313 56977 56977 26835 20998 5837 1367 1367 12769 3206 9563 1389 1389 152138 14841 137297 8064 6074 1990 4637 4637 36 36 ALLOCATED SALARIES 1157979 293452 864527 STAFF DEVELOPMENT 11091 5193 5898 LICENSE & FEES 9968 9968 EMPLOYEE RECRUITMENT 6128 6128 6978 2816 4162 2612669 1213290 362588 1036791 5984 27810 2632018 2945922 712 104 644 608 16402051 16506396 19040697 19480736 16875 63912 7681 13871 92122 95587 116678 173370 X 6530272 6408207 983944 1021823 11409803 11877336 18924019 19307366 19040697 19480736 X 1429295 -1045948 X 0 1 1 X 0 X X X 0 0 0 TELGSS 450228055 9 1 1 1 1156313 1 1156313 RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 14644672 467533 232597 435604 14909198 12476733 1375811 828395 36267 14644672 11256062 616000 820000 215329 12476733 11231052 1277693 -1027867 224816 11256062 0.14000 0.79700 0.06300 0 0 712 104 608 608 ANNUITY OBLIGATION 95587 95587 4041964 2612669 1429295 -1045948 -1045948 383347 870760 -1045948 -1045948 1916708 2125256 2125256 4041964 1456356 0 1456356 1156313 1156313 2612669 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE FOUNDATION'S ENDOWMENT FUNDS WILL BE USED AS DIRECTED BY THE DONOR'S RESTRICTIONS OR THE BOARD'S DESIGNATION. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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. THE TAX RETURNS FOR THE YEARS 2008-2010 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL AND STATE AUTHORITIES. PART XII, LINE 4B - OTHER ADJUSTMENTS: GIFTS TRANSFFERED FROM AFFILIATE 396,296. EXPENSES PAID BY AFFILIATE 1,728,960. PART XIII, LINE 4B - OTHER ADJUSTMENTS: TRANSFERS TO AFFILIATE 1,156,313. 1 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 4800 W 57TH ST SIOUX FALLS SD 57108 450228055 501(C)(3) 1156313 GIFTS TRANSFERRED TO THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. 1 0 SCHOLARSHIPS 34 56977 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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. 0 0 0 0 0 0 0 0 0 DAVID J HORAZDOVSKY 0 503311 0 0 0 115033 0 0 0 27887 0 646231 0 0 LISA MELBY 0 101197 0 0 0 41561 0 8480 0 32128 0 183366 0 0 SHARON A ST MARY 0 99696 0 0 0 46545 0 0 0 17996 0 164237 0 0 JIM KREKELBERG 0 102950 0 0 0 35131 0 9724 0 34981 0 182786 0 0 DR CHARLES M HIATT 0 107137 0 0 0 54884 0 0 0 14623 0 176644 0 0 RAYE NAE NYLANDER 0 206097 0 0 0 78823 0 0 0 15878 0 300798 0 0 SUPPLEMENTAL INFORMATION PART III 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 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 PRESIDENT 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 B, LINE 15 THE FOUNDATION DOES NOT PAY THE OFFICERS OR EXECUTIVE DIRECTOR. THEY ARE COMPENSATED BY A RELATED ORGANIZATION. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,045,948. 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 460392943 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 OLATHE GOOD SAMARITAN HOUSING LP 4800 W 57TH ST SIOUX FALLS SD 57108 205297369 SENIOR HOUSING SD N/A HOBBS GOOD SAMARITAN HOUSING LP 4800 W 57TH ST SIOUX FALLS SD 57108 261817167 SENIOR HOUSING SD N/A HASTINGS VILLAGE GARDENING GOOD SAMARITAN HOUSING LP 4800 W 57TH ST SIOUX FALLS SD 57108 271212511 SENIOR HOUSING SD N/A MILLARD GOOD SAMARITAN HOUSING LP 4800 W 57TH ST SIOUX FALLS SD 57108 271212324 SENIOR HOUSING SD N/A PRESCOTT GOOD SAMARITAN HOUSING LP 4800 W 57TH ST SIOUX FALLS SD 57108 275115281 SENIOR HOUSING SD N/A IDAHO SAMARITAN HOUSING INC 4800 W 57TH STREET SIOUX FALLS SD 57108 460424311 LOW-INCOME SENIOR HOUSING SD N/A C GOOD SAMARITAN SOCIETY INSURANCE LTD PO BOX 69 GT CJ 980379099 INSURANCE CJ N/A C GOOD SAMARITAN HUMANITARIAN SERVICES INC 4800 W 57TH STREET SIOUX FALLS SD 57108 205533741 MANAGEMENT SERVICES, UNBUNDLED SERVICES, UNRELATED BUSINESS SD N/A C HOBBS GOOD SAMARITAN HOUSING GP INC 4800 W 57TH STREET SIOUX FALLS SD 57108 261817059 LOW-INCOME SENIOR HOUSING SD N/A C 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0