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~f ~ ICI ~i ~ i I i i I ~I ' CITY OF DUBLIN Fiscal Year 2010-2011 i~ COMMUNITY GROUP/ORGANIZATION APPLICATION FOR FUNDS COVER PAGE 12-11-09P02:04 RCVD i' i ~I ~i AGENCY NAME: HOPE HOSPICE INC. i, PROPOSED PROJECT/PROGRAM NAME: THE GRIEF SUPPORT CENTER ~i ' FUNDING AMOUNT REQUESTED: $15,000 .I i~ II ~I ~~i li ~I 'I .I I' I~ ~I If /~TTi4C~l~~~11~ 1 a~ ~i ~ ~ i~ Ilk r ,I f~ CITY OF DUBLIN Fiscal Year 2010-2011 ' i.~ APPLICATION FOR FUNDS lI~ fI 1. Please select one expense category: ? Capital C10perating ~ r 2. Applicant Information: Organization/Agency Name: Hope Hospice Inc. Mailing Address: 6377 Clark Avenue, Suite 100 i Street Address: 6377 Clark Avenue, Suite 100 City Dublin State CA Zip 94568 Helen Meier 925-829-8770 helenm e,hopehospice.com Executive Director/Chairperson Work Phone Email Tim Neal 925-484-1345 neals(r.~,4neals.com 1? Board President (if applicable) Work Phone Email Please list the Primary Project Contact Person who would be able to answer questions about this application and ;i ro'ect/ ro ram Burin the fundin eriod. f p J P g, g gp Donna McMillion Director of Development Contact Person for Project/Program Job Title 925-829-8770 donnam ho ehos ice.com 925-829-8770 ~ p p I~ Work Phone Email Fax ~i f ~ Federal Tax Identification No.: 94-2576059 I lir City of Dublin Business License No.: BL-005299 ' 2 s, r, i~ 1! City of Dublin Fiscal Year 2010-2011 ~i j' Application foN Funds h 3. Proposed Project/Program Information ~i t~ Amount of Funds Requested $ 15,000 ;i Proposed Project/Program Name: The Grief Support Center tj I II Proposed Project/Program Date(s): Start 07 / O1 / 2010 and End 06 / 30 / 2011 mo. day yr. mo. day yr. I i~ ~I Please note: City Council Grant Funds are distributed on a reimbursement basis. If your Agency ~i needs a 100% disbursement at the beginning of the Fiscal Year, please indicate this below and provide justification for this need. ? Agency is requesting 100% disbursement at the beginning of the Fiscal Year. Q Agency is not requesting 100% disbursement at the beginning of the Fiscal Year. h ~ Hope Hospice will submit a Request for Reimbursement monthly, beginning September 1, 2010. ~ j I~ ~I ~ ~ f j~ f~ II I , i~ 3 ' ~ ; r ;i ij i l City of Dublin Fiscal Year 2010-2011 4' Application for Funds a. How would the requested funds be used? l ~i Hope Hospice is requesting funds to support our Grief Support Center. These funds will help us continue to provide grief support services for adults, teens, children and families i+ in our area who are facing the loss of a loved one. Our mission is to provide a safe place for children, teens, and adults who are grieving the loss of a family member or friend to i~ express their feelings and begin the process of grief recovery. Our programs are ' thoughtfully designed to help people cope with grief, connect with a caring community, and learn healthy coping skills. Our support services are available to individuals of all ages. We also offer on-going support to caregivers and pre-bereavement support to the children of our hospice families who are facing the loss of a parent or other family i~ member. Our services are available to all members of the community who need grief it support. Grief and loss support is provided free to our hospice families and to many community members who cannot afford to pay. Support is needed to underwrite the costs of our programs and services. (Continued on the attached page 4-A.) 1' ~ b. How would the PROPOSED PROJECT/PROGRAM address an unmet community f I need and improve the quality of life for Dublin residents. Why is this project/program needed? i i~ See attached page 4-B. it j' c. What documentation/data/records support the need for this PROPOSED i~ PROJECT/PROGRAM? 17 Sources for determination of need for affordable, accessible services for seniors and others in Dublin and the Tri-Valley include: , ~j 1. Human Services Needs Assessment for the Tri-Valley, Final Report, May 13, 2003, if prepared by IDF Consulting, San Francisco, CA I~~ 2. A Quiet Crisis in America: A report to Congress by the Commission on Affordable ~ Housing and Health Facility Needs for seniors in the 21st Century, June 30, 2002 ~i 3. California Seniors Overlooked c~ Underserved, The Insight Center for Community , Economic Develo ment, Oakland, CA ©2008 p 4. California's Struggling Seniors, The Insight Center for Community Economic Development, Oakland, CA ©2008 j' i ~ ~ 4 City of Dublin Fiscal Year 2010-2011 Application for Funds 3. Proposed Project/Program Information a. How would the requested funds be used? (continued) The program designed for adults consists of 13 months of grief support, which includes a personal consultation, participation in on-going grief support groups and activities, and regular follow up. The grief support groups offer the opportunity for those who are grieving to help one another as they work through the healing process with the assistance of a trained facilitator. We currently have three groups that meet twice a month in the evening. Each group is designed to meet specific needs: those who have experienced significant loss, those who have experienced a sudden loss (as a result of suicide or an accident, for example), and those who are caring for a loved one who has a chronic or life-limiting illness. An additional, in-depth program called Grief Journeys is offered twice a year for a nominal fee. The program consists of eight group sessions during which participants will share memories, learn strategies for handling the holidays and other life events, and engage in a variety of activities that promote healing. Because children are often unable to communicate effectively using verbal skills, we offer other ways, such as art projects, writing, music, and games to help them express feelings. The program designed specifically for teens and children consists of 1 %2 hour, age- appropriate, time-limited group sessions. Parents and guardians of the grieving children are encouraged to participate in a group session that is conducted at the same time as the children's group. The schedule for the time-limited groups corresponds with the public school calendar. Theme-specific workshops are also held throughout the year (i.e., holidays, Father's Day, Mother's Day) to offer additional support for children and families. Support and educational services are provided to the larger community (i.e., schools, daycare centers, community groups) as needed. We also work with our hospice families prior to the death to prepare children to cope. In addition, the Grief Support Center encompasses outreach in the form of access to a resource database and library filled with materials on life-limiting illness and grief recovery, seminars and workshops, and on-site support. Community involvement in the program includes annual memorial events, seminars, and on-site support for local schools and other organizations as needed. 4-A City of Dublin Fiscal Year 2010-2011 Application for Funds 3. Proposed Project/Program Information b. How would the PROPOSED PROJECT/PROGRAM address an unmet community need and improve the quality of life for Dublin residents? Why is this project/program needed? Hope Hospice's Grief Support Center addresses two key human service needs for residents of Dublin identified in the Human Needs Assessment for the Tri-Valley (2003) as shortcomings of the Human Service Network in the area: lack of affordable, accessible services, including counseling services, and lack of information about available existing services. According to the final report prepared by ICF Consulting, the senior population in the Dublin area grew by 70% and the child population in the Tri-Valley grew by 33% over the past decade. In addition, the number of families living below the federal poverty threshold has increased by 27%. The result of such dramatic population growth combined with the economic downturn is a sharp increase in the demand for accessible and affordable human services for children, families, and seniors. The Needs Assessment report specifically identified seniors as a population that has a greater need for services than previously understood. "Certain groups-such as recent immigrants, those with limited English proficiency, and those with a tendency to isolate themselves-have gone underserved. This problem is especially acute among seniors." This observation is shared by the Insight Center for Community Economic Development which estimates that 54% of seniors living alone in Alameda County are unable to afford their most basic needs. The estimate is based on a measure called the Elder Index, which takes into account more factors than the traditional standard for income eligibility, the Federal Poverty Line. Programs that rely exclusively on the FPL to determine eligibility often deny services to seniors who desperately need them because the cost of living in their area is far above the national average. Dublin has experienced a nearly 80% increase in the number of people who are 65 and over and a significant number of these seniors fall into this category. The Grief Support Center addresses the need for accessible, affordable, and available human services by providing a safe and nurturing place to help those who experience the loss of a loved one better understand and process emotions while learning healthy coping skills. Research has shown that grief support can have a profound effect on recovering from a major loss. Our services are available to all members of the community. Our services are affordable. Grief and loss support is provided free to our hospice families and to many community members who cannot afford to pay. Our services are accessible. While our basic services are provided at the facility in Dublin, trained grief support volunteers are able to meet with families in their homes if necessary and staff can conduct on-site sessions to meet the needs of unique groups. The Center maintains an extensive library ofgrief-related materials and a resource database for help in seeking services that are outside the scope of our mission. Providing grief support services to seniors, adults, teens, children and families in the Tri-Valley communities is consistent with the City of Dublin's mission of ensuring a high quality of life to a balanced, diverse community. 4-B ~o,:- - - - - _ I~~ Il, }u ; ; Y City of Dublin ~j Fiscal Year 2010-2011 4. ~I Application for Funds :i d. Specify the PROPOSED PROJECT/PROGRAM population to be served. The Grief Support Center offers services to adults (19-100+), teens (13-18), and children (6-12) who live in the Tri-Valley, Castro Valley, and San Ramon Valley ii communities who are facing the loss of a loved one. We provide grief support services to.hospice families and to all community members. fi e. Projects/programs must be evaluated to determine if they are being carried out efficiently and if project/program goals are being met. Please describe how you plan to monitor your project/program's success and impact. f I, The effectiveness of the program is measured in several ways. The primary t' assessment comes from evaluation forms completed by participants in the adult group sessions. Similar forms are completed by the children, parents, and volunteers + who participate in the group sessions for children and teens. In addition, facilitators meet after each group to discuss their observations and concerns. Self-reporting by both adults and children and feedback from family members also provide insight , regarding a client's progress towards recovery. Because grief is a process and is unique to each individual, the key measure of success is the changes in attihide and behavior that reflect progress towards recovery. A secondary assessment comes from tracking the number of clients served during each fiscal year. Over the past five i 1~ years, the number of clients served per year has increased an average of 11.55%. ii ` i, f. Specify numbers of clients served by agency, then by PROPOSED ji PROJECT/PROGRAM: ~ A enc Partici ant Information . ~ ~j i Total Number of Partici ants Served b A enc if a licable) 994* i~, Total Number of Dublin Residents Served b A enc (if a licable 70* j, Pro'ect/Pro ram Partici ant Information I,, Total Pro osed Partici ants Served b this Pro'ect/Pro ram 570 Total Number of Dublin Residents Served b this Pro'ect 45 * Numbers based on FY 2008-2009 statistics. I~ i 5 it ij~ c~~-_~-- - _ r? i City ot'Dublin j~ riscal Year 2010-2011 J+ I , Application for Funds 5. Financial Information -Operating Budget t a. Expense Budget FY 2010-2011* THIS PROJECT/ EXPENSE BUDGET ORGANIZATION PROGRAM GRANT REQUEST Personnel Costs 4; Employee Salaries & Benefits 4,464,820.00 385,000.00 15,000.00 Non-Personnel Costs f Services & Supplies 1,295,631.00 22,712.00 j Capital Costs 10,000.00 869.00 Ii Occupancy 374,044.00 32,509.00 Admin/Office 214,475:00 13,339.00 t Fundraising Expenses 20,000 00 0 TOTAL 6,378970.00 454,429.00 15,000.00 Further Comments/Explanations: ~ * The budget data shown are projections based on the FY 2009-2010 budget; the FY 2010-2011 i' budget has not been drafted as of this application date. , I `i~ 11 i !I It I i~ ~i Ij ~j Il 6 'i _ _ _ ___-~J v- ~f I'' City of Dublin Fiscal Year 2010-2011 ~I Application fog Funds b. Revenue Budget ~f FY 2010-2011 REVENUE BUDGET ORGANIZATION PROJECT/PROGRAM Committed/Restricted Funds (s ecify source) Third-Party Medical 5,732,370.00 334,084.00 Reimbursements ' I~ Residual Grant Funds 32,000.00 7,000.00 1~ I~ Non-Committed/Restricted Funds 1 (s ecif source Contributions ~ 190,000.00 Cam ai n Income 60,000.00 Donor Solicitations 80,000.00 S ecial Events 45,000.00 Grants 15,000.00 rl Miscellaneous Income 2,100.00 Pro ram Fees 2,500.00 2,500.00 Restricted Funds 220,000.00 19,121.00 TOTAL 6,378,970.00 367,705.00 i~ Further Comments/Explanations: * The budget data shown are projections based on the FY 2009-2010 budget; the FY 2010-2011 budget has not been drafted as of this application date. ~r I~ Ii i, ~ h ~ (j G~ -City of Dublin Fiscal Year 2010-2011 I ~f it Application for Funds 6. General Agency Information i. a. List all years that Organization has previously received City of Dublin fiinding (not Community Development Block Grant - CDBG). !i j N/A - We have not previously requested funding. 4~ t Ij b. Describe the population(s) served by the Organization. Hope Hospice provides hospice services to adults (19-100+) with life-limiting i~ illness and grief support services to all adults (19-100+), teens (13-18), and children i; (6-12) who reside in the Tri-Valley, Castro Valley, and San Ramon Valley ~ communities. The majority of our hospice patients are over 65 years old and suffer from heart disease, stroke, dementia, and several forms of cancer. I' Iii c. Describe all the services the Organization currently provides to Dublin residents. 4~ See attached page 8-A. ; j ; i 1 i d. Has your agency ever previously received funds from the City of Dublin? If yes, I' j please specify in what Fiscal Years and the amount received each year. I' i 11 No. ~ I~ I I~ ~ l ~ 4 ~i - - - - o City of Dublin Fiscal Year 2010-2011 Application for Funds 6. General Agency Information a. Describe all the services the Organization currently provides to Dublin residents. Hope Hospice provides the following services to Dublin residents: ? Comprehensive hospice care, which includes: • A highly skilled nursing staff (RNs and LVNs) who help patients manage pain and other symptoms • Highly skilled social workers who help patients work through complex issues related to death • Specially trained home health aides who provide personal care, such as bathing. • Specially trained chaplains who offer spiritual support that honors the patient and families beliefs • The supplies and equipment necessary for the patient's comfort and convenience • Complimentary personal services (hair stylist, videographer, etc.) • Specially trained volunteers who can relieve caregivers who need time to care for themselves ? Grief support services, which include: • Grief support counselors who help clients identify grief-related emotions and develop healthy coping skills • Unique grief support sessions for adults, teens, and children • Community seminars on grief-related topics • A resource database • An extensive library of books, CDs, and DVDS and other grief-related materials 8-A n ~J ~ it y III I h ii City of Dublin ~I ~ Fiscal Year 2010-2011 ~I Application for Funds 7. Required Attachments: I ? A. Names of Governing Board; identify current Board officers. ? B. Current total Organization operating budget, including revenue. I Clearly label/identify the program that includes the PROPOSED ~ PROJECT/PROGRAM. 1. ? C. Most recent audit report or tax return (if applicable). i ~e ? D. Resolution, letter or other document providing evidence of I' Board/Organization approval of application, and date approval was granted. ¦ Board/Organization approval may be pending. i~ ? E. Organization's certificate of insurance showing coverage for liability and ~ workers' compensation. i~ F'I ? F. Application Verification Declaration Signature Page. 1~ `1 ? G. Copy of IRS Letter of Determination indicating tax exempt status. iI ~I ~i i .I ~ i li If i 1 i~ ,I "i', fl ll s } j' R~ 9 ; i U is I. HOPE HOSPICE, INC. FINANCIAL STATEMENTS AND INDEPENDENT AUDITOR'S REPORT YEARS ENDED JUNE 30, 2008 AND 2007 Patel & Associates Certified Public Accountant HOPE HOSPICE, INC. .TUNE 30, 2008 AND 2007 TABLE OF CONTENTS PAGE INDEPENDENT AUDITOR' S REPORT 1 FINANCIAL STATEMENTS: Statements of Financial Position June 30, 2008 With Comparative Totals as of June 30, 2007 2 Statements of Activities and Changes in Net Assets For the Year Ended June 30, 2008 With Comparative Totals for the Year Ended June 30, 2007 3 Statements of Cash Flows For the Year Ended June 30, 2008 With Comparative Totals for the Year Ended June 30, 2007 4 Notes to Financial Statements 5 - 12 Patel ~ Associates Telephone: (510) 452-5051 266 17''' Street, Suite 200 Fax: (510) 452-3432 Certified Public Accountant Oakland, California 94612-4124 e-mail: ramesh c~patelcpa.com INDEPENDENT AUDITOR'S REPORT The Board of Directors Hope Hospice, Inc. Dublin, California We have audited the accompanying statements of financial position of Hope Hospice, Inc., (a Non- profit Corporation) as of June 30, 2008 and 2007, and the related statements of activities and cash flows for the years then ended. These financial statements are the responsibility of Hope Hospice, Inc.'s management. Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe ~ that our audits provide a reasonable basis for our opinion. f Irt our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Hope Hospice, Inc. as of June 30, 2008 and 2007, and the changes in its net ! assets and its cash flows for the years then ended in conformity with accounting principles generally ~ accepted in the United States of America. Oakland, California E November 11, 2008 1 HOPE HOSPICE, INC. STATEMENTS OF FINANCIAL POSITION JUNE 30, 2008 WITH COMPARATIVE TOTALS AS OF JUNE 30, 2007 2008 2007 ASSETS Current assets: Cash and cash equivalents $ 2,227,335 $ 1,538,030 Investments 2,118,728 2,279,021 Accounts receivable 1,078,862 688,877 Promises to give 2,502 50,000 Total current assets 5,427,427 4,555,928 Property and equipment: Property and equipment 83,830 65,731 Other assets: Deposits 4,127 4,127 Asset held for sale 325,000 Prepaid insurance 40,544 39,354 Total other assets 369,671 43,481 Total assets $ 5,880,928 $ 4,665,140 LIABILITIES AND NET ASSETS Current liabilities: Accounts payable $ 104,345 $ 89,873 Accrued salaries, vacation and benefits 152,103 ] ] 9,364 Total current liabilities 256,448 209,237 Net assets: Unrestricted: 4,324,761 Designated for computer/marketing upgrade 600,000 Designated for building and capital improvements 3,500,000 Others 1,482,055 Temporarily restricted 42,425 131,142 Total net assets 5,624,480 4,455,903 Total liabilities and net assets $ 5,880,928 $ 4,665,140 The accompanying notes are an integral part of these financial statements 2 HOPE HOSPICE, INC. STATEMENTS OF ACTIVITIES AND CHANGES IN NET ASSETS _FOR THE YEAR ENDED JUNE 30. 2008 WITH COMPARATIVE TOTALS FOR THE YEAR ENDED JUNE 30, 2007 Temporarily Total Unrestricted Restricted 2008 2007 SUPPORT AND REVENUE: Campaign income $ 88,970 $ $ 88,970 _ $ 51,084 Donations 784,954 36,865 821,819 785,505 Fund-raisers 119,405 119,405 81,922 Grants ] 7,150 ] 7,150 106,411 Miscellaneous income 1,211 1,211 9,661 Third party medical reimbursements 4,894,551 4,894,551 3,864,319 Program fees 2,923 2,923 ],860 In-kind donations 30,538 30,538 30,889 Investment earnings/(loss) (97,938) (97,938) 307,325 Satisfaction of program restrictions 125,582 (125,582) Total support and revenue 5,967,346 (88,717) 5,878,629 5,238,976 EXPENSES (Note 11): Program services 4,051,997 4,051,997 3,190,783 Management and general 289,754 289,754 265,365 Fund-raising 368,301 368,301 361,745 Total expenses 4,710,052 4,710,052 3,817,893 Change in net assets 1,257,294 (88,717) 1,168,577 1,421,083 Net assets, beginning of year 4,324,761 131,142 4,455,903 3,034,820 Net assets, end of year $ 5,582,055 $ 42,425 $ 5,624,480 $ 4,455,903 The accompanying notes are an integral part'of these financial statements 3 HOPE HOSPICE, INC. STATEMENTS OF CASH FLOWS FOR THE YEAR ENDED JUNE 30, 2008 WITH COMPARATIVE TOTALS FOR THE YEAR ENDED JUNE 30, 2007 2008 2007 CASH FLOWS FROM OPERATING ACTIVITIES: Change in net assets $ 1,168,577 $ 1,421,083 Adjusnnents to reconcile change in net assets to net cash provided by operating activities: Depreciation 24,415 25,185 Non cash contribution (325,000) Unrealized (gains)/losses 223,143 (214,667) (Increase)decrease in: Accounts receivable (389,985) 7,703 Promise to give 47,498 (31.,250) Inventory 15,893 Prepaid insurance (1,190) (8,8]4) Deposits 3,000 Increase(decrease)in: Accounts payable 14,472 14,123 Accrued salaries, vacation, and benefits 32,739 7,458 Net cash provided by operating activities 794,669' 1,239,7]4 CASH FLOWS FROM INVESTING ACTIVITIES: Purchase of furniture, equipment and leasehold improvements (42,514) (10,913) Purchase of investments (62,850) (688,611) Net cash used by investing activities (105,364) (699,524) Net increase in cash 689,305 540,190 Cash and cash equivalents, beginning of year 1,538,030 997,840 Cash and cash equivalents, end of year $ 2,227,335 $ 1,538,030 Non cash financing and investing transactions In-kind services $ 30,538 $ 30,889 The accompanying notes are an integral part of these financial statements 4 HOPE HOSPICE, INC. NOTES TO FINANCIAL STATEMENTS FOR THE YEARS ENDED JUNE 30, 2008 AND 2007 NOTE 1: SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Nature of Activities Hope Hospice, Inc. (the Organization) was formed for the purpose of providing medical care and emotional support for the terminally ill and their families. The Organization is supported through donor contributions, Medicare and private medical insurance reimbursements. Basis of Accounting The financial statements of the Organization have been prepared on the accrual of accounting and accordingly reflect all significant receivables, payables, and other liabilities. Financial Statement Presentation Financial presentation follows the recommendations of the Financial Accounting Standards in its Statement of Financial Accounting Standards, Financial Statements of Not for-Profit Organizations. The Organization presents information regarding its financial position and activities according to two classes of net assets: unrestricted net assets and temporarily restricted net assets. Description of Program and Supporting Services The following program and supporting services are included in the accompanying financial statements: Patient Care The Patient Care department is responsible for the care of all patients and provides support services for patients and their families. The department provides medical care, home health aides, social workers, pastoral care, and volunteer services. The work of the patient care department is overseen by the medical director, Peter Wong, M.D. Bereavement Provides bereavement support and education for the patient's fanuly/caregiver for 18 months following the death of the patient. The Bereavement program offers on-going support groups without charge for the surrounding community as well as for the families/caregivers. The Organization provides community-wide grief education and support. A fee for materials or for Continuing Education Units (CEUs) for specific R disciplines is sometimes charged for these seminars. 5 Adult Bereavement The Adult bereavement program includes: TLC for parents who have lost children; Share & Care, for spousal survivors; Men in Grief; Tragic Loss Support Group; Caregivers Support Group, and A.L.A.P. for adults who have lost parents. Children's Bereavement The Organization offers support groups for children and teens contiguous with the school year. These groups give the children a safe and nurturing place to learn to process their grief. A parent support group is held contiguous with the children support groups. The coordinator of this program also gives seminars in the community to first responders, teachers, doctors, nurses, firemen, police departments, etc., to help them learn how to help children who have suffered a loss. Management and General Functions necessary to maintain the program to ensure an adequate working environment; provide coordination and articulation of the Organization's program strategy through the Executive Director, secure proper administrative functioning of the Board of Directors; and manage the financial and budgetary responsibilities of the Organization. Fund-raising Provides the structure necessary to encourage and secure financial support from individuals, foundations, and corporations. Donated Assets Donated marketable securities and other noncash donations are recorded as contributions at their estimated fair values at the date of donation. Donated Property and Equipment Donations of property and equipment are recorded as donations at their estimated fair value at the date of donation. Such donations are reported as increases in unrestricted net assets unless the donor has restricted the donated asset to a specific purpose. Assets donated with explicit restrictions regarding their use and conhibutions of cash that must be used to acquire property and equipment are reported as restricted contributions. Absent donor stipulations regarding how long those donated assets must be maintained, the Organization reports expirations of donor restrictions when the donated or acquired assets are placed in service as instructed by the donor. The Organization reclassifies temporarily restricted net assets to unrestricted net assets at that time. i 6 Donated Services and Goods Donated services and goods are reflected in the financial statements at the fair value of the services received. The donations of services, including advertising services, are recognized if the services received (a) create or enhance nonfinancial assets or (b) require specialized skills that are provided by individuals possessing those skills and would,~typically need to be purchased if not provided by donation. Donation of goods are recognized if the value of the goods can be reasonably estimated. Donations of services and goods during the current year consisted of the following: 2008 2007 In-kind donations: Advertising and supplies used in fundraising program $ 1S,S03 $ 14,566 Legal services 1S,03S 16,323 $ 30,538 $ 30,889 In addition, the Organization receives a significant amount of donated services from unpaid volunteers who assist in bereavement, children's bereavement, homecare respite, hospice, development, office and other areas of the Organization. No amounts have been recognized in the statement of activities for these services because the criteria for recognition under SFAS 116 has not been inet. During the years ended June 30, 2008 and 2007, approximately 138 and 133 volunteers contributed 3,046 and 2,645 hours for an estimated value of $59,428 and $49,647 respectively. Income Taxes The Organization is exempt from Federal and State income taxes under Internal Revenue Code Section 501(c)(3) and therefore has made no provision for income taxes. Accounts Receivable The accounts receivable consist of amounts due from Medicare, Medi-Cal, and private insurance for patient services. The Organization computes the allowance for doubtful accounts based on actual uncollectible accounts receivable. Uncollectible accounts over the, history of the Organization have been considered immaterial and inconsistent. Therefore, no amounts have been included for an allowance for doubtful accounts. Functional Allocation of Expenses The costs of providing the Organization's various programs and supporting services have been sununarized on a functional basis in the statement of activities. Accordingly, certain costs have been allocated amount the programs and supporting services benefited. Cash Equivalents For purposes of the statement of cash flows, the Organization considers all unrestricted cash and other highly liquid investments with initial maturities of three months or less to be cash equivalents. 7 Estimates The preparation of financial statements in confornity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect certain reported amounts and disclosures. Accordingly, actual results could differ from those estimates. Property and Equipment All acquisitions of property and equipment and all expenditures for repairs, maintenance, renewals, and betterments that materially prolong the useful lives of the assets, exceeding $2,500, are capitalized. Property and equipment are carried at cost or, if donated, at the approximate fair value at the date of donation. -Depreciation is computed using the straight-line method. Bequests The organization records bequest income at the time it has established a right to such a bequest and the proceeds are measurable. Prior Year Summarized Information The financial statements include certain prior-year summarized comparative information in total but not by net asset class. Such information does not include sufficient detail to constitute a presentation in conformity with accounting principles generally accepted in the United States of America. Accordingly, such information should be read in conjunction with the organization's financial statements for the year ended June 30, 2007, from which the summarized information was derived. Interest and Income Taxes During the year, the Organization paid no interest or income taxes. NOTE 2: INVESTMENTS Investments consist of the following: 2008 2007 Domestic Equities $ 798,763 $ 934,839 International Equities 392,969 431,065 Fixed Income 926,996 913,117 Fair Value Total $ 2,118,728 $ 2,279,021 Investment income $ 125,205 $ 92,658 Net realized/unrealized gains (losses) (223,143) 214,667 Total investment income $ (97,938) $ 307,325 8 NOTE 3: REAL PROPERTY HELD FOR SALE: The organization received land as contribution during the year 2008. The value of the land as per appraisal report was $325,000. Since the organization plans to sell the asset, it has been classified as asset held for sale. NOTE 4: PROPERTY AND EQUIPMENT Property and equipment consist of the following: Beguuiing End of of Year Additions Deletions Year Office funuture $ 23,457 $ ~ $ $ 23,457 Equipment 84,357 29,254 17,544 96,067 Software 57,141 3,347 10,775 49,713 Computer equipment 50,028 9,913 18,158 41,783 214,983 42,514 46,477 211,020 Accumulated depreciation and amortization (149,252) (24,415) (46,477) (127,190) Total $ 65,731 $ 18,099 $ $ 83,830 NOTE 5: SATISFACTION OF PROGRAM RESTRICTIONS Temporarily restricted net assets were expended for the following purposes: 2008 2007 Release of restrictio~is Attendant care $ 6,848 $ 10,334 Children and adult bereavement 67,627 24,996 Vigil volunteer and outreach 1,107 Time restriction 50,000 18,750 Total release of restrictions $ 125,582 $ 54,080 9 NOTE 6: TEMPORARILY RESTRICTED NET ASSETS The temporarily restricted net assets at June 30, 2008 were as follows: 2008 2007 Purpose restricted Attendant Care $ 33,656 $ 6,139 Children and adult bereavement 7,877 75,003 Vigil volunteer and patient gifts and cards 892 Subtotal purpose restricted 42,425 81,142 Time restricted Bequest 50,000 Total temporarily restricted net assets $ 42,425 $ 131,142 NOTE 7: CONCENTRATION OF CREDIT RISK The Organization maintains cash balances in excess of the FDIC limits. At June 30, 2008 and 2007, the uninsured bank balances before reconciling items were approximately $2,149,525 and $1,466,760 respectively. NOTE 8: FAIIt VALUE OF FINANCIAL INSTRUMENTS Due to the short terns nature of their maturities, cash, accounts receivable, prepaid expenses, and accounts payable carrying amounts reflect their fair values. NOTE 9: LEASES The Organization leases its office under anon-cancelable operating lease expiring November 2008. The lease was amended on September 22, 2008 to extend the lease term to March 31, 2009. Monthly rental payments are $11,575 at the present time and increase each November. The Organization leases its mail meter under anon-cancelable operating lease expiring 2010. Monthly payments are $108. Total rent paid during the year was approximately $132,125 10 Future minimum rentals under non-cancelable operating leases are as follows: June 30, 2009 $ 59,171 June 30, 2010 1,296 June 30, 2011 1,186 $ 61,653 The organization is currently in negotiation for a new lease to begin late spring 2009. NOTE 10: 403B PLAN The Organization contributes 3% of salaries to a 403(b) plan for all eligible employees. Employees who work more than 20 hours per week and have been employed at least one year are eligible for the plan. During the years ended June 30, 2008 and 2007, the Organization contributed $60,269 and $47,967 respectively to the plan on behalf of the eligible employees. 11 N01'E 11: TOTAL EXPENSES Expenses incurred were for: Total Management Total Patient Adult Child Program and Fund- Supporting Total Care Bereavement Bereavement Expenses General raising Services 2008 2007 Payroll and Uenefits $ 2,363,523 $ 211,165 90,499 $ 2,665,187 $ 239,667 $ 220,289 $ 459,956 $ 3,125,143 S 2,544,837 Patient medical expenses 842,045 ~ 842,045 14 14 842,059 618,576 Office expenses 198,060 20,077 8,604 226,741 19,475 22,556 42,031 268,772 220,440 Operating and other 272,100 17,449 7,478 297,027 28,889 77,496 106,385 403,412 337,306 Fund-raising 36,886 36,886 36,886 40,660 Depreciation 18,311 1,880 806 20,997 1,709 1,709 3,418 24,4]5 25,185 In-kind expenses 9,365 9,365 9,365 30,889 ~ 3,694,039 $ 250,571 $ 107,387 $ 4,051,997 $ 289,754 $ 368,301 $ 658,055 $ 4,710,052 $ 3.817,893 12 c.__ J _ I ~ ~I I+ If I~ it ~~I ~S Ifs f{ I (I Attachment A r~ Hope Hospice Board of Directors i~ r; 1. ~1 t~ ~ E~ ii li ~I f~ HOPE HOSPICE BOARD OF DIRECTORS November 2, 2009 Kirsten Barranti (Steve) Susan C. Micheletti Sandra Ryan (Kevin) Attorney at Law, RN COO San Ramon Regional Medical 3245 Chardonnay Drive 5556 Carngie Loop Center Pleasanton, CA 94566 Livermore, CA 94550 5630 Stockton Loop (H) (925) 462-4371 (Cell) (925) 922-1960 Livermore, CA 94550 San Ramon (W) (925) 474-0040 (H) (925) 245-1015 Regional Medical Center FAX (925) 474-0042 (W) (925) 275-8222 6001 Norris Canyon Road Email: Kirsten~keblaw~~p.com Cell: (209) 612-4037 San Ramon, CA 94583 Barranti Law Group San Ramon Regional Medical Center (W) (925) 275-8365 5556 Stoneridge Dr., #222 6001 Norris Canyon Road Fax: (925) 275-6165 Pleasanton, CA 94588 San Ramon, CA 94583 Email: Sandra.rYan~tenethealth.com Sue.micheletti cr,tenenthealth.cotn Charles Crohare (Patty) micksu cr,comcast.net Daven Sharma (Anu) Board Treasurer CPA & Certified Financial Plamler 4555 Arroyo Road Tim Neal (Robin) Davis & Company, CPAs Livermore, CA 94550 Board President 1323 Valley Avenue (H) (925) 447-3563 3843 Northwood Court Pleasanton, CA 94566 (Cell) (925) 525-7144 Pleasanton, CA 94588 (H) (925) 600-9721 Fax: (925) 447-2945 (H) (925) 484-1345 (W) (510) 278-0915 Email: Charles@theolivina.com Email: neals cr,4neals.com Fax: (510) 278-9433 Tri-Valley Bank Cell: (510) 757-1013 Vice-President - Margie Perry Email: Dave~daviscocpas.com Relationship Manager Board Vice-President 1756 First Street 12 Starflower Terrace Jennifer Thaete (John) Livermore, CA 94550 San Ratnon, CA 94583 Attorney At Law (W) (925) 791-4369 (H) (925) 314-0425 Abramson &Thaete Fax: (925) 245-9388 Community Bank of the Bay 1840 Fourth Street, Suite 200 Email: ccrohare c ,trivalleybank.com Vice-President Livermore, CA 94550 675 Hartz Avenue (H) (925) 606-6535 David Karlsson, CPA (Penny) Suite 107 (W) (925) 447-3322 485 Tioga Court Danville, CA 94526 Fax: (925) 447-0272 Pleasanton, CA 94566 (925) 838-2902 Email: Jennifer@a-tlaw.com (H) (925) 640-8527 Email: Fax: (925) 417-8782 mperry a,communitybankbay.com Brown & Cold 2440 Camino Ramon Mary Prishtina, RN, OCN Suite 298 (Bashkim) San Ramoti, CA 94583 Board Secretary (W) (925) 271-5519 x11 4330 Montgomery Street Email:davidkarlsson(c~,brownandcold.com Oakland, CA 94611 - (H) (510)655-5312 James B. Kohnen (Patricia) (Cell) (925) 998-7640 Retired Engineer and Educator ValleyCare Health System 7303 Ione Court & Ryan Comer Dublin, CA 94568-1703 Cancer Resource Center (H) (925) 828-3623 5725 W. Las Positas Blvd. Email : Jim483@aol.com Pleasanton, CA 94588 (W) (925) 734-3315 Email: mprishti@valleycare.com F:\DATA\Rosters -Staff & Volunteer\Board Member Roster.doc f ~ - ` i, I~ is ~ li I ~ jlll i f I I~ ij ~ Attachment B ~ ii Hope Hospice l FY 2009-2010* Operating Budget E, II it k~ 1+ I IJ II 11 ~I i '1 Ii{tttt Iii Y~ ~ ~ I(+~ 4 ii ~i I~ I~ (I i~ The FY 2010-2011 budget is not available as of the date of this application. ' `i HOPE HOSPICE, INC. DISCIPLINES BUDGET 2009- 2010 Patient Care Marketing 8 Social Work 8 Grief Support Community Approved Patient Care Pastoral Care ;Center Management Outreach Development Budget Income Medi-Cal Room & Board 263,120.00 263,120.00 Physician Visits 2,500.00 2,500.00 Patient Income 3,978,794.00 464,039.00 :...:.339,084.00 289,051.00 395,778.00 5,466,750.00 Campaign Income 60,000.00 60,000.00 Contributions ` • 190,000.00 190,000.00 Donor Solicitations 80,000.00 80,000.00 Special Events 45,000.00 45,000.00 Grants 15,000.00 15,000.00 Miscellaneous Income 2,100.00 2,100.00 Program Fees 2,500.00 2,500.00 Residual Grant Funds 25,000.00 7,000.00 32,000.00 Board Restricted Funds 139,854.00 20,620.00 19,121.00 12,942.00 14,876.00 12,587.00 220,000.00 Total Income 4,409,268.00 484,659.00 867,705.00 304,093.00 410,654.00 402,587.00 6,378,970.00 Operating Total Salaries + Benefits 2,851,177.00 415,179.00 385,000.00 260,482.00 299,528.00 253,454.00 4,464,820.00 Professional Fees 152,564.00 3,186.67 2,955.03 2,000.19 2,299.00 1,945.10 164,950.00 Rent 177,287.03 26,138.66 24,238.64 16,406.58 18,857.56 15,956.53 278,885.00 Telephone 37,404.55 5,514.81 5;113.94 3,461.51 3,978.62 3,366.56 58,840.00 Alarm System 953.55 140.59 1.30.37 88.24 101.43 85.82 1,500.00 Dues & Memberships 13,985.39 2,061.96 1,912.08 1,294.24 1,487.59 1,258.74 22,000.00 Equipment Rental/Leases 1,090.22 160.74. 149.06 100.89 115.96 98.13 1,715.00 Insurance 25,745.83 3,795.89 3;51'9.96 2,382.58 2,738.52 2,317.23 40,500.00 Insurance Background Checks 444.99 65.61 60.84 41.18 47.33 40.05 700.00 Licenses & Permits 4,672.39 688.88 638.81 432.39 496.99 420.53 7,350.00 Maintenance /Repairs 18,870.10 2,782.15 2,579.92 1,746.29 2,007.16 1,698.38 29,684.00 Medicare Electronic Filing Fees 1,425.00 0.00 . '0.00 0.00 0.00 0.00 1,425.00 Patient Medical Expenses 586,190.00 0.00 ,0.00 0.00 0.00 0.00 586,190.00 Medical Dir. Consultation Visits 2,500.00 0.00 ''0.00 0.00 0.00 0.00 2,500.00 Medi-Cal/Medicare Contractual Adj's 13,406.00 0.00 A.00 0.00 0.00 0.00 13,406.00 Medical Insurance Not Paid 22,750.00 0.00 0.00 0.00 0.00 0.00 22,750.00 Indigent & Uncovered Pt. Receivables 40,000.00 0.00 0.00 0.00 0.00 0.00 40,000.00 Attendant Care for Patients 24,000.00 0.00 0.00 0.00 0.00 0.00 24,000.00 Room & Board Reimbursement 263,120.00 0.00 +.0.00 0.00 0.00 0.00 263,120.00 Postage & Delivery 5,403.45 796.67 738.76 500.05 574.75 486.33 8,500.00 Program Expenses-Bereavement 0.00 0.00 5;000.00 0.00 0.00 0.00 5,000.00 Program Expenses-Patients 2,500.00 0.00 0.00 0.00 0.00 0.00 2,500.00 Mileage 52,600.95 7,755.33 7,1.91.59 4,867.82 5,595.02 4,734.29 82,745.00 Taxes 127.14 18.75 ' 17.38 11.77 13.52 11.44 200.00 Untilities 2,174.09 320.54 - 297.24 201.20 231.25 195.68 3,420.00 Office Costs Advertising /Promotion 0.00 0.00 -0.00 0.00 61,000.00 0.00 61,000.00 Audit 9,535.49 1,405.88 1,303.69 882.44 1,014.27 858.23 15,000.00 Bank Service Charges 858.19 126.53 11'7.33 79.42 91.28 77.24 1,350.00 Books/Publications 7,657.00 1,128.92 1,046.86 708.60 814.45 689.16 12,045.00 Fundraising Expenses 0.00 0.00 0.00 0.00 0.00 20,000.00 20,000.00 Furniture /Equipment 6,356.99 937.26 869.13 588.29 676.18 572.15 10,000.00 Meetings 572.13 84.35 78.22 52.95 60.86 51.49 900.00 Miscellaneous Expenses 13,000.05 1,916.69 1,777.36 1,203.06 1,382.78 1,170.06 20,450.00 Office Supplies 20,342.38 2,999.22 2,781.21 1,882.53 2,163.77 1,830.90 32,000.00 Payroll Fees (Paychex) 4,147.94 611.56 567.11 383.86 441.21 373.33 6,525.00 Printing & Reproduction 12,713.99 1,874.51 1,738.25 1,176.58 1,352.35 1,144.31 20,000.00 Recruitment 6,356.99 937.26 869,13 588.29 676.18 572.15 10,000.00 Training -Staff 20,978.08 3,092.94 2,868.12 1,941.36 2,231.38 1,888.11 33,000.00 Volunteer Recognition & Trng. 6,356.99 937.26 869,13 588.29 676.18 572.15 10,000.00 Total Expenses 4,409,268.00 484,659.00 454,429.00 304,093.00 410,654.00 315,868.00 6,378,970.00 EXCEL F:Secret /Personnel Accounting /09-10 BudgeUDCGBudget-Disciplines-09-10 / 12/3/2009 / 10:48 AM _ _ _ lJ J ~ - `II I~ ~ j~ II l I iI I ~I I~ I ~I ii ~I~ II I. I, I !i I II 'i Attachment C I I. I; Hope Hospice I II l1 FY 2007-2008 Audit* i li ii ~i ~i ,I II } i~- ;I I I~ 4 .I The FY 2008-2009 audit is not available as of the date of this application. Hope Hospice will provide the FY 2008-2009 audit once it is approved. li ~ i~. ~,I: m~~___- ,n ~ J `.I i1 I ~ li I~ !I ~i I Attachment D ' i Hope Hospice ~ Board Resolution i. ~ ~I j I' Ij ~I Vii, n~_~_ _ Board Resolution and Authorization to Request Funding The board of directors of Hope Hospice, Inc. authorizes Helen Meier, Executive Director, to submit a proposal to the City of Dublin for Community Support Grant funding for grief support services in a sum not to exceed $15,000. S Z' 10~~ Tim Neal Date Board President _ ~f jl 1 , 'I ii I~ I~ ~l II' ~i i i ~a I~ it i It 4f Attachment E Hope Hospice ~j Certificates of Insurance R, I f~ f ,I i' F~ i~ I' . r. c - - - - - - - -s.-~.----- , OP ID Z3 DATE(MM/DD/YYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE HOPEH-1 02/26 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE (WC) Heffernan Insurance Brkrs HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1350 Carlback Ave, Suite 200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Walnut Creek CA 94596 Phone:925-934-8500 Fax:925-934-8278 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: AmerlCan Alternative Ins. INSURER B: Ho a HospplCe, Inc. INSURER C: At~n: Ju3ie Reed 6500 Dublin Blvd, #lOO INSURER D: Dublin CA 94568 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXP RATION LIMITS LTR NSR , TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YY DATE MMIDD/YY EACH OCCURRENCE $ lOOOOOO GENERAL LIABILITY j.~ X COMMERCIAL GENERAL LIABILITY VHHG3O5122803 O1/O1/O9 O1/O1/lO PREMISES (Eaoccurence) $ lOOOOOO CLAIMS MADE ? OCCUR MED EXP (Any one person) $ 5 O O O O Retrodate 1/1/91 PERSONALBADVINJURY $ 1000000 X Prof Liab $1M/$3M GENERAL AGGREGATE $ 3000000 PRODUCTS - COMPIOP AGG $ 3 0 0 0 O O O GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY n jE~ Loc ~ Eli Ben. 25/50, 000 AUTOMOBILE LIABILRY ~ COMBINED SINGLE LIMIT $ l O O O O O O j.~ ANY AUTO VHHG305122803 01/01/09 Ol/O1/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ GARAGE LIABILITY ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ 4, 0 0 0, O O O EXCESSfUMBRELLA LIABILITY j~ OCCUR X? CLAIMS MADE VHHLJ505002703 01/01/09 O1/O1/10 AGGREGATE $ 4 r OOO r 000 DEDUCTIBLE RETENTION $ _ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE -POLICY LIMIT $ SPECIAL PROVISIONS below OTHER A Crime vHHP205008003 01/01/09 O1/O1/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT !SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION BLACKHA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 O * DAYS WRRTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE' INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHOR N ACORD 25 (2001/08) ©ACORD CORPORATION 1988. 1 _ ~j ~ECEIi/E~ HEFFERN AN INSURANCE BROKERS . M.me.,.,,~. .P !~A~ 16 X009 uann ameaz+e COPE HOSPICE. January 14, 2009 Hope Hospice, Inc. Attn: Judie Reed 6500 Dublin Blvd, #100 Dublin, CA 94568 RE: Workers' Compensation Renewal Effective 5/1 /09 Dear Judie: Your Workers Compensation policy will be renewing on 05/01/09. Please provide us with your estimated annual payrolls for the classifications listed below. The estimated annual payrolls your current policy is based on are shown for your reference. CLASSIFICATIONS EXPIRING RENEWAL # Full Time # Part Time PAYROLL ESTIMATED Employees Employees PAYROLL 8742 Saleperson outside $999,289 $ 1,039,785. 13 6 8810 Clerical $481,287 $ 528, 564. 8 4 8827 Homemakers Services $1,505,370 $ 1,653,598. 22 4 Note: Employees working over 30 hours per week are considered full Time. Enclosed is a renewal questionnaire for you to please complete, sign and date. Please return the enclosed questionnaire, along with your renewal payroll estimates, to our office by 2/6/09. We will continue to keep you updated on our progress with your renewal. In the meantime, please do not hesitate to contact us should you have any questions or wish to discuss your upcoming renewal further. Thank you. Sincerely, , Ch ` al Jost, Cl'S Account Manager 1350 Carlback Ave. 'Suite 200 " P.O. Box 5608 'Walnut Creek, CA 94596 `Phone 925.934.8500 "Fax 925.934.8278 ' www.heffarouo.com License #0564249 ~I i i ~ ~ ,i i I` to I~ Attachment F F Application Verification Declaration ?fi Signature Page 1f ~ ~l ;i i l ~ i! I) j 11 ~ _ v' J I~ t I I1~ ~I City of Dublin ~ Fiscal Year 2010-2011 {S ;I, fl Application fog Funds ,I ~ j APPLICATION VERIFICATION ~i ji I attest that the information contained in this FY 2010-2011 grant application is accurate and that the fiends requested will not. supplant any other monies secured by the organization. l Attached is a resolution, letter, or other document providing evidence that the Board of Directors ~I approved the application as submitted. Successful applicants are required to submit a summary report as soon as possible after submitting the reimbursement request, but not later than August 31, 2011. Failure to submit a report will result in ineligibility for future funding. i~` '1 j, Signatures: ~`I i o e ~d ecutiv Di for Da e l Board President/Chairperson Date ~i ;1 ~i J' i! ~I I~ j i s, ~ i ii a I pIL~:. - - ~ ~ it III I ~ tj ~ I ~1 'I I~ I I li i~ ~ L J ~ Attachment G Hope Hospice IRS Letter of Determination ~ i~ ,i a i r it ~ry*~j Dep~irtmeul ofthe~ Traasur}~ ~ Internal Revenue Service P.O. Box 2508 In reply refer to: 0248667585 Cincinnati OH 45201 Sep. 29, 2009 LTR 4170C EO 94-2576059 000000 00 00012164 BODC: TE REOEIVE® HOPE HOSPICE SUE FAIRBANKS OC~ a ~ Zddg 6377 CLARK AVE STE 100 DUBLIN CA 94568 HOPE HOSPICE 115981 Person to Contact: Mrs.Pam Skiles Toll Free Telephone Number: 1-877-829-5500 Dear Taxpayer: This is in response to your request of Sep. 18, 2009, regarding the tax-exempt status of Hope Hospice. Our records indicate that a determination letter was issued in August 1979, granting this organization exemption from Federal income tax under section 501(c)(3) of the Internal Revenue Code. Our records also indicate this organization is not a private foundation within the meaning of section 509(a) of the Code because it is described in section(s) 509(a)(1) and 170(b)(1)(A)(vi). Donors may deduct contributions to this organization as provided in section 170 of the Cade. Bequests, legacies, devises, transfers, or gifts to the organization or for its use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. If you have any questions, please call us at the telephone number shown above. Sincerely yours, Michele M. Sullivan, Oper. Mgr. Accounts Management Operations I I i I I 4 b~ a Ho ~ 6377 Clark Avenue, Suite 100 (925) 829-8770 p 1 1OV M Dublin, CA 94568-3024 1 (800) Hospice 1 1 {J www.HopeHospice.com Fax (925) 829-0868 Supporting You with Compassion, Dignity and Excellence December 11, 2009 City Manager's Office City of Dublin 100 Civic Plaza Dublin, CA 94568 Enclosed is our completed Community Group/Organization grant application. We are requesting $15,000 to support our Grief Support Center. We greatly appreciate the time and support city staff provided during the submission process. As required, we have included two copies of the application and one copy of the required documents. If you have any questions or require any additional information, please contact me by email at donnamt~hopehospice.com or by phone at 925-829-8770. Sincerely, Donna McMillion Director of Development Enclosure DMam Hope'~i We have updated our /ook from HOSp CE -T HOPE HOSPICE, INC. FINANCIAL STATEMENTS AND INDEPENDENT AUDITOR'S REPORT FOR THE YEARS ENDED ]UNE 30, 2009 AND 2008 Patel & Associates Certified Public Accountant ,1 ~ i T Y 1 HOPE HOSPICE, INC. JUNE 30, 2009 AND 2008 TABLE OF CONTENTS PAGE INDEPENDENT AUDITOR' S REPORT 1 FINANCIAL STATEMENTS: Statements of Financial Position June 30, 2009 and 2008 2 Statements of Activities and Changes in Net Assets 3 For the Years Ended June 30, 2009 and 2008 Statements of Cash Flows For the Years Ended June 30, 2009 and 2008 4 Notes to Financial Statements 5 - I3 SUPPLEMENTAL SCHEDULE Functional Expenses 14 f 1 Patel & Associates Telephone: (510) 452-5051 266 17"' Street, Suite 200 Fax: (510) 452-3432 Certified Public Accountant Oakland, California 946]2-4124 e-mail: ramesh@patelcpa.com INDEPENDENT AUDITOR'S REPORT The Board of Directors Hope Hospice, Inc. Dublin, California We have audited the accompanying statements of financial position of Hope Hospice, Inc., (a Non- profit Corporation) as of June 30, 2009 and 2008, and the related statements of activities and cash flows for the years then ended. These financial statements are the responsibility of Hope Hospice, Inc.'s management. Our responsibility is to express an opinion on these financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United . States of America: Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe that our audits provide a reasonable basis for our opinion. In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of Hope Hospice, Inc. as of June 30, 2009 and 2008, and the changes in its net assets and its cash flows for the years then ended in conformity with accounting principles generally accepted in the United States of America. Our audits were conducted for the purpose of forming an opinion on the financial statements taken as a whole. The supplemental schedule of functional expenses on page 14 is presented for purposes of additional analysis and is not a required part of the basic financial. statements. Such information has been subjected to the auditing procedures applied in the audits of the basic financial statements and, in our opinion, is fairly stated in all material respects in relation to the basic financial statements taken as a whole. Oakland, California December 10, 2009 1 HOPE HOSPICE, INC. STATEMENTS OF FINANCIAL POSITION JUNE 30, 2009 AND 2008 2009 2008 ASSETS Current assets: Cash and cash equivalents $ 916,198 $ 2,227,335 Investments (Note 2) 3,538,572 2,1 ] 8,728 Accounts receivable, net (Notes 1 and 3) ],157,964 1,078,862 Real property held for sale (Note 5) - 325,000 Other receivables 4,810 .2,502 Prepaid expenses 74,182 40,544 Tota] current assets 5,691,726 5,792,971 Property and equipment (Notes 1 and 4) 229,762 83,830 Other assets: Deposits 37,127 4,127 Total assets $ 5,958,615 $ 5.880,928 LIABILITIES AND NET ASSETS , Current liabilities: Accounts payable $ 111,336 $ 104,345 Accrued salaries, vacation and benefits 300,339 152,103 Total current liabilities 4l 1.675 256,448 Net assets: Unrestricted: Designated for computer/marketing upgrade 260,898 600,000 Designated for building and capital improvements 3,500,000 3,500,000 Undesignated 1,760,481 1,482,055 Temporarily restricted (Note 8) 25,561 42,425 Total net assets 5,546,940 5,624,480 Total liabilities and net assets $ 5,958,615 $ 5,880,928 The accompanying notes are an integral part of these financial statements 2 i ~ HOPE HOSPICE, IIVC. STATEMENTS OF ACTNITiES AND CHANGES IN NET ASSETS FOR THE YEARS ENDED JUNE 30, 2009 AND 2008 2009 2008 Temporazily Temporarily Unrestricted Restricted Total Unrestricted Restricted Total SUPPORT AND REVENUE: Net patient service revenue (Note 6) $ 5,383,005 $ - $ 5,383,005 $ 4,879,976 $ - $ 4,579,976 Donations 395,976 2,750 398,726' 784,954 36,865 821,8]9 Campaign income 68,412 - 68,412 i' 88,970 - 88,970 Fund-raisers 65,119 - 65,119 119,405 - 119,405 In-kind donations 46,869 - 46,869'' 30,538 - 30,538 Grants 26,745 - 26,745~~ 17,]50 - 17,]50 Program fees 2,330 - 2,330 2,923 - 2,923 Miscellaneous income 2,230 - 2,230 1,211 - 1,211 Gain on sale of land (Note 5) 96,811 - 96,811/ - - - Investmentlosses (340,755) - (340,755) ( (97,938) - (97,938) Satisfaction of program restrictions (Note 7) 19,614 (19,614) - 125,582 (125,582) - Total support and revenue 5,766,356 (16,864) 5,749,492 5,952,771 (88.7]7) 5,864,054 EXPENSES: Program services 5,045,128 - 5,045,128 4,037,422 - 4,037,422 Management and general 496,519 - 496,519 289,754 - 289,754 Fund-raising 285.385 - 285,385 368,301 - 368.301 Total expenses 5,827.032 - 5,827,032 4,695,477 - 4,695,477 Change in net assets (60,676) (16,864) (77,540) 1,257,294 (88,717) 1,168,577 Net assets, beginning of year 5,582,055 42,425 5,624,480 4,324,761 131,142 4,455,903 Net assets, end of year $ 5,521,379 $ 25,561 $ 5,546,940 $ 5,582.055 $ 42.425 $ 5.624,480 The accompanying notes are an integral part of these financial statements 3 HOPE HOSPICE, INC. STATEMENTS OF CASH FLOWS FOR THE YEARS ENDED JUNE 30.2009 AND 2008 2009 2008 CASH FLOWS FROM OPERATING ACTIVITIES: Change in net assets $ (77,540) $ 1,168,577 Adjustments to reconcile change in net assets to net cash provided by operating activities: Depreciation 27,936 24,415 Donated real property - (325,000) Gain on sale of real property held for sale (96,811) - Unrealized losses from investments 449,205 223,143 (Increase)decrease in: Accounts receivable (79,102) (389,985) Other receivables (2,308) 47,498 Prepaid expenses (33,638) (1,190) Deposits ~ (33,000) - Increase(decrease)in: Accounts payable 6,991 14,472 Accrued salaries, vacation, and benefits 148,236 32,739 Net cash provided by operating activities 309,969 794,669 CASH FLOWS FROM INVESTING ACTIVITIES: Proceeds from sale of real property held for sale 421,811 - Purchase of property and equipment (173,868) (42,514) Purchase of investments (1,869,049) (62,850) Net cash used by investing activities (1,621,106) (105,364) Net increase (decrease) in cash (1,311,137) 689,305 Cash and cash equivalents, beginning of year 2,227,335 1,538,030 Cash and cash equivalents, end of year $ 9]6,198 $ 2,227,335 The accompanying notes are an integral part of these financial statements 4 HOPE HOSPICE, INC. NOTES TO FINANCIAL STATEMENTS FOR THE YEARS ENDED JUNE 30, 2009 AND 2008 NOTE 1: SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES ' Nature of Activities Hope Hospice, Inc. (the Organization) was formed for the purpose of providing medical care and emotional support for the terminally ill and their families. The Organization is supported through donor contributions, Medicare, Medi-Cal and private medical insurance reimbursements. Basis of Accounting The accompanying financial statements of the Organization have been prepared on the accrual basis in accordance with accounting principles generally accepted in the United States of America. Under this method, revenues are recorded when rights to receive are earned or when services have been provided, and expenditures are recorded when obligation to pay is incurred, and accordingly reflect all significant receivables, payables, and other liabilities. Financial Statement Presentation Financial presentation follows the recommendations of the Financial Accounting Standards Board in its Statement of Financial Accounting Standard No. 117, Financial Statements of Not for-Profit Organizations. The Organization presents information regarding its financial position and activities according to the classes of net assets: unrestricted net assets, temporarily restricted net assets, and permanently restricted net assets. Unrestricted net assets -Net assets that are not subject to donor-imposed stipulations. Temporarily restricted net assets -Net assets subject to donor-imposed stipulations that may or will be met, either by actions of .the Organization and/or passage of time. When a restriction expires, temporarily restricted net assets are reclassified to unrestricted net assets and reported in the statement of activities as net assets released from restrictions. Permanently restricted net assets -Net assets subject to donor-imposed stipulations.that they be maintained permanently by the Organization. Generally, the donors of these assets permit the Organization to use all or part of the income earned on any related investments for genera] or specific purposes. There were no permanently restricted net assets at June 30, 2009. Description of Program and Supporting Services Tlie following program and supporting services are included in the accompanying financial statements: Patient Care The Patient Care department is responsible for the care of all patients and provides support services for patients and their families. The department provides medical care, home health aides, social workers, pastoral care, and volunteer services. The work of the patient care department is overseen by the medical director. Grief Support The Organization provides grief education and support for members of the surrounding community as well as for the patients' families/caregivers. The Grief Support program offers on-going support groups without charge for 13 months following the death of the patient. A fee for materials or for Continuing Education Units (CEUs) for specific disciplines is sometimes charged for these seminars. Adult Grief Support The Adult Grief Support program includes: TLC for parents who have lost children; Share & Care for spousal survivors; Tragic Loss Support Group; Caregivers Support Group, and A.L.A.P. for adults who have lost parents. Children's Grief Support The Organization offers support groups for children and teens contiguous with the school year. These groups give the children a safe and nurturing place to learn to process their grief. A parent support group is held contiguous with the children support groups. The coordinator of this program also gives seminars in the community to first responders, teachers, doctors, nurses, firemen, police departments, etc., to help them learn how to help children who have suffered a loss. Marketing and Community Outreach The Marketing and Community Outreach program provides outreach, education and customer service for the Organization's constituency. Management and General .Functions necessary to maintain the programs to ensure an adequate working environment; provide coordination and articulation of the Organization's program strategy through the Executive Director, secure proper administrative functioning of the Board of Directors; and manage the financial and budgetary responsibilities . of the Organization. Fund-raising , Provides the structure necessary to encourage and secure financial support from individuals, foundations, and corporations. 6 Net Patient Service Revenue The Organization has agreements with third-party payors that provide for payments to the Organization at amounts different from its established rates. Payment arrangements include prospectively determined per diem rates. Net patient service revenue is reported at the estimated net realizable amounts from patients, third-party payors, and others for services rendered, including estimated retroactive adjustments under reimbursement agreements with third-parry payors. Retroactive adjustments are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods, as final settlements are determined. Donated Assets Donations of assets are recorded as donations at their estimated fair value at the date of donation. Such donations are reported as increases in unrestricted net assets unless the donor has restricted the donated asset to a specific purpose. Assets donated with explicit restrictions regarding their use and contributions of cash that must be used to acquire assets are reported as restricted contributions. Absent donor stipulations regarding how long those donated assets must be maintained, the Organization reports expirations of donor restrictions when the donated or acquired assets are placed in service as instructed by the donor. The Organization reclassifies .temporarily restricted net assets to unrestricted net assets at that time. Donated Services and Goods Donated services and goods are reflected in the financial statements at the fair value of the services received. The donations of services, .including advertising services, are recognized if the services received (a) create or .enhance nonfinancial assets or (b) require specialized skills that are provided by individuals possessing those skills and would typically need to be purchased if not provided by donation. Donation of goods are recognized if the value of the goods can be reasonably estimated. Donations of services and goods during the current year consisted of the following: 2009 2008 In-kind donations: Advertising-and supplies used in fundraising program $ 31,341 $ 15,503 Legal services 15,528 15,035 $ 46,869 $ 30,538 Ili addition, the Organization receives, a significant amount of donated services from unpaid volunteers who assist in bereavement, children's bereavement, homecare respite, hospice, development, office and other areas of the Organization. No amounts have been recognized in the statement of activities for these services because the criteria for recognition under SFAS 116 has not been met. During the years ended June 30, 2009 and 2008, approximately 146 and 138 volunteers contributed 3,118 and 3,046 hours for an estimated value of $63,141 and $59,428 respectively. 7 Income Taxes The Organization is exempt from Federal and State income taxes under Internal Revenue Code Section 501(c)(3) and Section 23701d of the California Revenue and Taxation Code, respectively, and therefore has made no provision for income taxes. Accounts Receivable The accounts receivable consist of amounts due from Medicare, Medi-Cal, and private insurance for patient services. The Organization computes the allowance for doubtful accounts based on actual uncollectible accounts receivable. Functional Allocation of Expenses The costs of providing the Organization's various programs and supporting services have been summarized on a functional basis in the statement of activities. Accordingly, certain costs have been allocated among the programs and supporting services benefited. Cash Equivalents For purposes of the statement of cash flows, the Organization considers all unrestricted cash and other highly liquid investments with initial maturities of three months or less to be cash equivalents. Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect certain reported amounts and disclosures. Accordingly, actual results could differ from those estimates. Property and Equipment All acquisitions of property and equipment and all expenditures for repairs, maintenance, renewals, and betterments that materially prolong the useful lives of the assets, exceeding $2,500, are capitalized. Property acid equipment are carried at cost or, if donated, at the approximate fair value at the date of donation. Depreciation and amortization are computed using the straight-line method over the estimated useful lives of the individual assets as follows: Office Furniture 5 years Equipment 5 years . Software 3 years Computer Equipment 5 years 8 Bequests Tlie Organization records bequest income at the time it has established an unconditional right to such a bequest and the proceeds are measurable. Fair Value of Financial Instruments The Organization believes that the carrying value of its financial instruments approximates their fair values. The Organization adopted Financial Accounting Standard Board Statement No. 1S7 Fair Value Measurements (FAS 157) at the beginning of the 2009 fiscal year. FAS 157 applies to all financial assets and liabilities that are being measured and reported on a fair value basis and requires such assets and liabilities to be classified and disclosed in one of the following three categories to enable readers of the financial statements to assess the inputs used to develop those measurement: Level 1 Quoted market prices unadjusted in active markets for identical assets or liabilities. Leve12 Observable market based inputs or unobservable inputs that are corroborated by market data. Level 3 Unobservable inputs that are not corroborated by market data. The financial instrument's categorization within the valuation hierarchy is based upon the lowest level of input that is significant to the fair value measurement. h7 determining fair value, the Organization uses valuation techniques that maximize the use of observable inputs and minimize the use of unobservable inputs to the extent possible, as well as considers nonperformance risk in its assessment of fair value. The methods described above may produce a fair value that may not be indicative of net realizable value, or reflective of future fair values.. Furthermore, while the Organization believes its valuation methods are appropriate and consistent with other market participants, the use of different methodologies or assumptions to determine the fair value of certain financial instruments could result in a different estimate of fair value at the reporting date. See Note 2. New Accounting Pronouncement In June 2006, the FASB released Interpretation No. 48, Accounting for Uncertainty in Income Taxes ("FIN 48"). FIN 48 interprets the guidance in Statement of Financial Accounting Standard No. 109, Accounting for Income Taxes ("SFAS 109"). When FIN 48 is implemented, reporting entities utilize different recognition thresholds and measurement requirements when compared to prior technical literature. On December 30, 2008, the FASB issued FASB Staff Position FIN 48-3, Effective Date of FASB Interpretation No. 48 for Certain Nonpublic Enterprises ("FSP FIN 48-3"). As deferred by the guidance in FSP FIN 48-3, the Organization is not required to implement the provisions of FIN 48 until fiscal years beginning after December 15, 2008. As such, the Organization has not implemented those provisions in the June 30, 2009 financial statements. 9 Since the provisions of FIN 48 have not been implemented in accounting for uncertainty in income taxes, the Organization continues to utilize its prior policy of accounting for these positions, following the guidance in Statement of Financial Accounting Standard No. 5, Accounting for Contingencies ("SFAS 5"). Disclosure is not required of a loss contingency involving an unasserted claim or assessment when there has been no manifestation by a potential claimant of an awareness of a possible claim or assessment unless it is considered probable that a claim will be asserted and there is a reasonable possibility that the outcome will be unfavorable. Using the guidance in SFAS 5, as of June 30, 2009, the Organization has no uncertain tax positions that qualify for either recognition or disclosure in the financial statements. Reclassification Certain accounts in the financial statements for the fiscal year ended June 30, 2008 have been reclassified to conform to the June 30, 2009 financial statement presentation. NOTE 2: INVESTMENTS Investments consist of the following: 2009 2008 Domestic equities $ 671,956 $ 798,763 International equities 284,489 392,969 Fixed income 662,525 813,706 Certificates of deposit 1,917,354 113,159 Other 2,248 131 Fair value total $ 3,538,572 $ 2,118,728 Investment income $ 108,450 $ 125,205 Net realized/unrealizedlosses (449,205) (223,143) Total investment loss $ (340,755) $ (97,938) FAIR VALUE MEASUREMENTS Information related to the Organization's assets measured at fair value on a recurring basis at June 30, 2009 is as follows: Quoted Prices in Active Markets for Identical Significant Other, Fair Assets Observable Inputs Value (Level I) ~ (Level 2) Domestic equities $ 671,956 $ 671,956 - International equities 284,489 284;489 - Fixed income 662,525 662,525 - Certificates of deposit 1,917,354 - 1,917,354 Other 2.248 2.248 Total investments $ 3,538,572 $ 1,621.218 $ 1,917.354 10 Fair values for investments are determined by reference to quoted market prices and other relevant information generated by market transactions. NOTE 3: ACCOUNTS RECEIVABLE Accounts receivable consist of the following: 2009 2008 Medicare $ 996,626 $ 827,595 Medi-Cal 74,307 137,055 Other Private Insurance 147,984 114,21.2 1,218,917 1,078,862 Provision for bad debt (60,953) - Accounts receivable, net $ 1,157,964 $ 1,078,862 NOTE 4: PROPERTY AND EOUII'MENT Property and equipment consist of the following: Beginning End of of Year Additions Deletions Year Office furniture $ 23,457 $ - $ - $ 23,457 Equipment 96,067 2,037 4,335 93,769 Software 49,713 88,410 2,500 135,623 Computer equipment 41,783 83,421 4,889 120,315 211,020 173,868 11,724 373,164 Accumulated depreciation and amortization (127,190) (27,936) (11,724) (143,402) Total $ 83,830 $ 145,932 $ - $ 229,762 NOTE 5: REAL PROPERTY HELD FOR SALE: The Organization received land as a contribution during 2008. The value of the land as per appraisal report was $325,000. Since the Organization planned to sell the asset, it has been classified as an asset held for sale. There were no restrictions from the donor related to the use of the property or the use of the proceeds from its sale. During 2009, the land was sold for $421,811, resulting in a gain of $96,811. 11 NOTE 6: NET PATIENT SERVICE REVENUE Net patient service revenue for the years ended June 30, 2009 and 2008 were as follows: 2009 2008 Gross patient service revenue $ 5,422,054 $ 4,894,551 Provision for contractual adjustments (39,049) (14,575) Net patient service revenue $ 5,383,005 $ 4,879,976 NOTE 7: SATISFACTION OF PROGRAM RESTRICTIONS Temporarily restricted net assets were expended for the following purposes: 2009 2008 Attendant care $ 10,290 $ 6,848 Children and adult bereavement 8,897 67,627 Vigil volunteer, outreach and patient gifts and cards . 427 1,107 Time restriction - 50,000 Tota] release of restrictions $ 19,614. $ 125,582 NOTE 8: TEMPORARILY RESTRICTED NET ASSETS The temporarily restricted net assets consist of the following: 2009 2008 Purpose restricted Attendant Care $ 23,366 $ 33,656 Children and adult bereavement 730 7,877 Vigil volunteer and patient gifts and cards 1,465 892 Total temporarily restricted net assets $ 25,561 $ 42,425 NOTE 9: CONCENTRATION OF CREDIT RISK The Organization maintains significant cash balances above the amount that is insured by the Federal Deposit Insurance Corporation in one financial. institution. At June 30, 2009 and 2008, total of the bank account balances at this one financial institution before reconciling items were $809,549 and $2,231,075, respectively. $250,000 and $100,000 of these amounts were insured for years ended June 30, 2009 and 2008, respectively. It is the opinion of.the management that ,the solvency of the financial institution is not of particular concern at this time. 12 NOTE 10: LEASES The Organization entered into anon-cancelable operating lease on February 2009 for its office space in Dublin, California. The lease commenced in October 2009 and will expire in October 2014. Monthly rental payments are $28,215 at the present time and increase each October. The approximate future minimum rental commitments under the non-cancelable operating lease having remaining terms in excess of one.year as of June 30, 2009, for each of the next five years are: 2010 $ 225,720 2011 344,520 2012 353,430 2013 368,280 2014 386,100 $ 1,678,050 NOTE 11: 403B PLAN The Organization contributes 3% of salaries to a 403(b) plan for all eligible employees. Employees who work more than 20 hours per week and have been employed at least one year are eligible for the plan. During the years ended June 30, 2009 and 2008, the Organization contributed $73,901 and $60,269 respectively to the plan on behalf of the eligible employees. 13 , SUPPLEMENTAL SCI3EDULE FIOPE HOSPICE, INC. SUPPLEMENTAL SCHEDULE -FUNCTIONAL EXPENSES FOR TIIE YEARS ENllED JUNE 30, 2009 AND 2008 Marketing Total Management Patient Adult Child and Community Program and Fund- Total Care Grief Support Grief Support Outreach Expenses General raising 2009 2008 Payroll and benefits $ 2,861,094 $ 300,934 $ 93,968 $ 177,001 $ 3,432,997 $ 273,606 $ 174,215 $ 3,880,818 $ 3,125,143 Patient medical expenses 967,956 - - - 967,956 - - 967,956 827,484 Operating and other 297,218 14,214 4,485 57,310 373,227 170,855 28,233 572,315 382,239 Office expenses 200,870 22,487 5,780 17,215 246,352 34,575 15,370 296,297 268,772 In-kind expenses - - - - - 15,528 31,341 46,869 30,538 Fund-raising - 12 - - 12 - 34,829 34,841 36,886 Depreciation 19,835 2,235 559 1,955 24,584 1,955 1,397 27,936 24,415 $ 4,346,973 $ 339,882 $ 104,792 $ 253,481 $ 5,045,128 $ 496,519 $ 285,385 $ 5,827,032 $ 4,695,477 14 t OMB No. 1545-OD47 J rf Fortrt990 Return of Organization Exempt From Income Tax Under section 501(c), 527, or 4947(aX1) of the Internal Revenue Code 2008 (except black lung benefit trust or private foundation) ~f'~ '~,.s'~-''~~, I'j u~~~-~'~' t~~~,~ a ~ wtr F w'~' Department of the Treasury Internal Revenue Service 'The organization may have to use a copy of this return to satisfy state reporting requirements. i0pen~ o~aPubhe+ nspectlon le.t .v. -s._, atA~ .~kril:^..! Y!d .i.[~'.,.,:.Lf..-.... T..:. For the 2008 calendar year, or tax year beginning 7 / 01 , 2008, and ending 6 / 3 0 2 0 0 9 B Ctteck i( applicable: ~ Employer Identification Number X Addresschange PIRSIab le Hope Hospice, Inc. 94-2576059 or print 6377 Clark Ave. Suite #100 E Telephone number Name change or type. see Dublin, CA 94568 925-829-8770 Initial return specific Instruc- Termination tions. Amended return G Gross receipts ~ 5 , 7 52 , 6 81 . Application pending F Name and address of principal officer: Helen Meter H(a) Is this a group return for affiliates? Yes X No Same As C AbOVe H(b) Are all affiliates included? Yes No If 'No,' attach a list. (see instructions) 1 Tax-exempt status X 501(c) (3 (insert no.) 4947(a)(1) or 527 J Website: ? WWW . h0 ehos ice . com H(c) Group exemption number ~ K Type of organization: X Corporation Trust Association Other' L Year of Formation: 197 9 M State of legal domicile: CA ~P,~rt'cl~ Summa 1 Briefly describe the organization's mission or most significant activities; Hope HOS~1Ce~_ InC_ _waS_fOr'IIled for the purpose of Rrov_idi.nc~ medical care_and ~mo~.ional su~Rort for termin~ll~_ill_ _ _ _ _ _ _ ~~~ients_~nd_theis_f.amilieS~~-------------------------------------- v --------------g------------p ------P---------o----------- 2 Checlc this box ' ~ if the or anization discontinued its o erations or dis osed of more than 25 /o of its assets. ~ 3 Number of voting members of the governing body (Part VI, line 1 a) 3 9 N 4 Number of independent voting members of the governing body (Part VI, line lb) 4 g 5 Total number of employees (Part V, line 2a} 5 66 6 Total number of volunteers estimate it necessar 6 146 ~ ( Y).......... a 7a Total gross unrelated business revenue from Part VIII, line 12, column C 7a 0 . b Net unrelated business taxable income from Form 990-T, line 34 7b 0 . Prior Year Current Year 8 Contributions and grants (Part VIII, line th) 1, 041, 017. 540, 752 . c 9 Program service revenue (Part VIII, line 2g) 4, 879, 976. 5, 385, 335. 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) -97, 938 . -243, 944 . ~ 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, lOc, and l le) 40, 999. 43, 144. 12 Total revenue -add lines 8 through 11 (must equal Part VIII, column (A), line 12).. 5, 864, 054. 5, 725, 287 . 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 14 Benefits paid to or for members (Part IX, column (A), line 4) . h 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 3, 125, 143. 3, 830, 686. m 16a Professional fundraising fees (Part IX, column (A), line l le) y( ~rf x b Total fundraising expenses (Part IX, column (D), line 25) ? 261, 180. ~ ti ~ t~~~;p w 17 Other expenses (Part IX, column (A), lines lla-ltd, llf-24f) 1, 570, 334. 1, 972, 141. 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 4, 695, 477. 5, 802, 827. 19 Revenue less expenses. Subtract line 18 from line 12 1, 168, 577 . -77, 540. o ~ Beginning of Year End of Year m 20 Total assets (Part x, line 16) 5, 880, 928. 5, 958, 615. 21 Total liabilities (Part X, line 26) 256, 448. 411, 675. zLL _ 22 Net assets or fund balances. Subtract line 21 from line 20 5, 624, 480. 5, 546, 940. Partll.l~;~~ Si nature Block Under penalties i perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, d complete. claratio preparer (other than officer) is based on all information of which preparer has any knowledge. Sign ? ~ ~ / C~ Here i nature of offi er D e Helen Meie Executive Director Type or print name and title. Date Check it Preparer's identifying number self ? (see instructions) Paid Preparer's i ernployed ' Pre- signature ? ~fvH~y~,~ N/A parer's Patel & Associates, CPA USe Firm's name (or employed)If ? 266 17th Street, Suite 200 EIN ? N/A Only address, and Oakland, CA 94612-4124 Phone no. (510) 452-5051 . ZIP + a May the IRS discuss this return with the preparer shown above? (see instructions) lnl Yes n No BAA For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. T=,=_a,ol t2t_ t2iz2fos Form 990 (2008) . t Form 99G (2008) Ho e Hos ice, Inc. 94-2576059 Page 2 P~a'rt411f~ Statement of Program Service Accomplishments (see instructions) _ ~ t~, 1 Briefly describe the organization's mission: Hope Hosgice,_Inc. was formed for_the_purpose_of providing_medical_care and emotional_ - - - - support for terminally _i11~?atients and their_families_ 2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ? ~ Yes X? No If 'Yes,' describe these new services on Schedule 0. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services?......... ~ Yes X? No If 'Yes,' describe these changes on Schedule 0. 4 Describe the exempt purpose achievements for each of the organization's three largest program services by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total .expenses, and revenue, if any, for each program service reported. 4a (Code: ; ) (Expenses $ 4, 346, 973. including grants of $ ) (Revenue $ 5, 383, 005. ) Patient Care Program:_____ _ _ This program provides medical care and social services, assigns home health aides and volunteer respite assignments for_terminal~ i11 patients. _427~atients were served _ _ for a total of 25,371 patient_days______ 4b (Code: `!k~') (Expenses $ 444, 674 . including grants of $ ) (Revenue $ 2 , 330. ) T_he A_dult_an_d_Ch_ild_re_n's Grief_Support_Program___ _ _ This program provides_grief support and education for the patient's family/care - - - - giver_for_13 _mon_t_hs_ f_ol_l_owing the_death_o_f_a patient.Su~gort groups and services _fo_r__ children and teens who have suffered a_loss in their family are also available. Over - 500 adult_clients_and_48 children_were_served_durincL this_period.___ 4c (Code: • ; ' , (Expenses $ 2 5 3 , 4 81. including grants of $ ) (Revenue $ ) _M_arketi_ng_and_CommunitY Outreach Program:__ _ _ _ _ This program provides_hospice_education and information to individuals, facilities_ _ _ and the community_ More than 110 presentations were made during this period. 4d Other program services. (Describe in Schedule 0.) (Expenses $ including grants of $ ) (Revenue $ ) 4e Total program service expenses ? $ 5, 045, 128 . (Must equal Part IX, Line 25, column (B).) BAA rE=_AOio2~_ iz~zcios corm 99G (2008) A ' ` Form 990 (2008) Ho e Hos ice, Inc. 94-2576059 Page 3 i.Ptart;ll% :Checklist of Re uired Schedules Yes No 1 Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If 'Yes,' complete Schedule A 1 X 2 Is the organization required to complete Schedule B, Schedule of Contributors? 2 X 3 Did the organization engage in direct or indirect political campaign activities on behalf ofi or in opposition to candidates for public office? If 'Yes,' complete Schedule C, Part l 3 X 4 Section 501(cx3) organizations. Did the organization engage in lobbying activities? If 'Yes,' complete Schedule C, Part It 4 X 5 Section 501(c)(4), 501(c)(5), and 501(cx6) organizations. Is the organization subject to the section b033(e) notice and reporting .requirement and proxy tax? If 'Yes,' complete Schedule C, Part 111 5 6 Did the organization maintain any donor advised funds or any accounts where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If 'Yes,' complete Schedule D, Part l........... 6 X 7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas or historic structures? If 'Yes,' complete Schedule D, Part 11 7 X 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? !f 'Yes,' complete Schedule D, Parflll 8 X 9 Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If 'Yes,' complete Schedule D, PartlV............_ 9 X 10 Did the organization hold assets in term, permanent, or quasi-endowments? If 'Yes,' complete Schedule D, Part V....... 10 X 11 Did the organization report an amount in Part X, lines 10, 12, 13, 15, or 25? !f 'Yes,' complete Schedule D, Parts Vl, VII, VIII, IX, or X as applicable 11 X 12 Did the organization receive an audited financial statement for the year for which it is completing this return that was prepared in accordance with GAAP? If 'Yes.' complete Schedule D, Parts Xl, Xll, and Xlll . 12 X 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If 'Yes,' complete Schedule E 13 X 14a Did the organization maintain an office, employees, or agents outside of the U.S.? 14a X b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, and program service activities outside the U.S.? If 'Yes.' complete Schedule , Part l 14b X 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity Vocated outside the United States? If 'Yes.' complete Schedule F, Parf 1l 15 X 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If 'Yes,' complete Schedule F, Part ill . 16 X 17 Did the organization report more than $15,000 on Part IX, column (A), line l le? If 'Yes,' complete Schedule G, Part l.... 17 X 18 Did the organization report more than $15,000 total on Part VIII, lines 1 c and 8a? If 'Yes.' complete Schedule G, Parf Il.. 18 X 19 Did the organization report more than $15,000 on Part VIII, line 9a? If 'Yes,' complete Schedule G, Part ill 19 X 20 Did the organization operate one or more hospitals? !f 'Yes,' complete Schedule H 20 X 21 Did the organization report mare than ~5,DDD on Part IX, column (A), line 1? If'Yes,' complete Schedule 1, Parts 1 and IL 21 X 22 Did the organization report more than $5,000 on Part IX, column (A), line 2? If 'Yes,' complete Schedule 1, Parts /and ill 22 X 23 Did the organization answer 'Yes' to Part VII, Section A, questions 3, 4, or 5? If 'Yes,' complete Schedule J 23 X 24a Did the organization have atax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, and that was issued after December 31, 2002? If 'Yes,' answer questions 24b-24d and complete Schedule K. If 'No,'go to question 25 24a X b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? 24b c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? 24c d Did the organization act as an 'on behalf of issuer for bonds outstanding at any time during the year? 24d 25a Section 501(c)(3) and 5D1(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If 'Yes,' complete Schedule L, Part l 25a X b Did the organization become aware that it had engaged in an excess benefit transaction with a disqualified person from a prior year? If 'Yes,' complete Schedule L, Part ! . 25b X 26 Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization's tax year. !f 'Yes,' complete Schedule L, Part ll....... 26 X 27 Did the organization provide a grant or other assistance to an officer, director, trustee, Ivey employee, or substantial contributor, or to a person related to such an individual? If 'Yes,' complete Schedule L, Parf 111 27 X BAA Form 990 (2008) T-=P.D103L 1D/13/OB c F r ~ , Form 990 (2008) Hope Hospice, Inc. 94-2576059 Page a Fart' lV Checklist of Re wired Schedules (continued Yes No ~r-= ~ ~ w. nh - 26 During the tax year, did any person who is a current or former officer, director, trustee, or key employee: ~ a Have a direct business relationship with the organization (other than as an officer, director, trustee, or employee), ~~,-N,. or an indirect business relationship through ownership of more than 35% in another entity (individually or collectively - with other person(s) listed in Part VII, Section A)? If 'Yes,' complete Schedule L, Part IV 28a X b Have a family member who had a direct or indirect business relationship with the organization? If 'Yes,' complete Schedule L, ParflV 28b X c Serve as an officer, director, trustee, key employee, partner, or member of an entity (or a shareholder of a professional corporation) doing business with the organization? !f 'Yes,' complete Schedule L, Part IV 28c X 29 Did the organization receive more than $25,000 in non-cash contributions? !f 'Yes,' complete Schedule M 29 X 30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If'Yes,'complete Schedule M 30 X 31 Did the organization liquidate, terminate, or dissolve and cease operations? If 'Yes,' complete Schedule N, Part I........ 31 Y, 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If 'Yes,' complete Schedule N, Partll 32 X 33 Did the orgganization own 100% of an entity disregarded as separate from the organizatiori-under Regulations sections 301.7701-2 and 301.7701.3? If 'Yes,' complete Schedule R, Parf 1 33 X 34 Was the organization related to any tax-exempt or taxable entity? If 'Yes,' complete Schedule R, Parts !I, lll, IV, and V, line 1 34 X 35 Is any related organization a controlled entity within the meaning of section 512(b)(13)? If 'Yes,' complete Schedule R, Part V, line 2 35 X 36 Section 501(c}(3) organizations. Did the organization make any transfers-to an exempt non-charitable related organization? If 'Yes,' complete Schedule R, Par! V, line 2 36 X 37 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If 'Yes,' complete Schedule R, Part Vl 37 X BAA Form 990 (2008) T~=P,07(KL 12!18/08 ` , Form 990 (2008) Hope Hos ice, Inc . 94-2576059 Page 5 . Part;1/~,-~,« Statements Re ardin Other IRS Filin sand Tax Com liance Yes No 1 a Enter the number reported in Box 3 of form 1096, Annual Summary and Transmittal of U.S. t3,„ ~ r4y , Information Returns. Enter -0- if not applicable 1 a 77 b Enter the number of Forms W•2G included in line 1 a. Enter -0- if not applicable 1 b 0 i ~~r~, c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? 1 c X , 2a Enter theyiumber of9em to ees re ortetly n Form W-3,YTransmittal of Wa a and Tax Statements, filed for the 2a 6 6 Py P 9 calendar ear endin with or within the ear covered b this return 1•`,. i~;~=:~ 2b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? . 26 X Note. If the sum of lines la and 2a is greater than 250, you may be required to e-file this return. (see instructions) „t~' ~ ='-~'~`xa 3a Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return? 3a X b If 'Yes' has it filed a Form 990-T for this year? If 'No,' provide an explanation in Schedule O.... ~ 3b 4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? 4a X b If 'Yes,' enter the name of the foreign country: See the instructions for exceptions and filing requirements for Form TD F 9D-22.1, Report of Foreign Bank and Financial Accounts. ~ ~ 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? 5a X ` b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? 5b X c If 'Yes,' to question 5a or 5b, did the organization file Form 8886-T, Disclosure by Tax-Exempt Entity Regarding Prohibited Tax Shelter Transaction? 5c 6a Did the organization solicit any contributions that were not tax deductible? 6a X b If 'Yes,' did the organization include .with every solicitation an express statement that such contributions or gifts were not deductible? 6b 7 Organizations that may receive deductible contributions under section 170(c). a Did ttie organization provide goods or services in exchange for any quid pro quo contribution of more than $75?......... 7a X b If 'Yes,' did the organization notify the donor of the value of the goods or services provided? 7b c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which.it was required to file Form 8282? 7c X d tf 'Yes,' indicate the number of Forms 8282 filed during the year 7d 0 e Did the organization, during the year, receive any funds, directly or indirectly, to pay premiums on a personal ~ benefit contract? 7e X f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 7f X g For all contributions of qualified intellectual property, did the organization file Form 8899 as required? 7g Y, h For all contributions of cars, boats, airplanes, and other vehicles, did the organization file a Form 1098-C as required? 7h X B Section 501(cx3) and other sponsoring organizations maintaining donor advised funds and section 509(a)(3) s~" supporting organizations. Did the supporting organization, or a fund maintained by a sponsoring organization, have excess business holdings at any time during the year? . 8 9 Section 501(c)(3} and other sponsoring organizations maintaining donor advised funds. a Did the organization make any taxable distributions under section 4966? 9a X b Did the organization make any distribution to a donor, donor advisor, or related person? 9b X 10 Section 501(cx7) organizations. Enter: } ` a Initiation fees and capital contributions included on Part VIII, line 12 10a ' , b Gross Receipts, included on Form 990, Part VIII, line 12, for public use of club facilities..... 10b 11 Section 501(cx12) organizations. Enter. ~ ~ { a Gross income from other members or shareholders 11 a 7Yi .~L - b Gross income from other sources (Do not net amounts due or paid to other sources against .a~: ,r~ w -rs~~, amounts due or received from them.) 11 b ..,rw?; 12a Section 4947(a}(1)nnn-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? . 12a b If 'Yes,' enter the amount of tax-exem t interest received or accrued Burin the ear........ 112bI y~'>~ BAA Form 990 (2008) T==AD105L 04/08/09 ~ Form 990 (2008) HO e Hos ice, Inc. 94-2576059 Page 6 'Parti:~`%I.;;~ Governance, Management and Disclosure (Sections A,.B, and C request information abouf policies not required by the internal Revenue Code.) Section A. Governin Bod and Mana ement For each 'Yes' response fo lines 2-7b below, and fora 'No' response to lines 8 or 9b below, describe the circumstances, Yes No processes, or changes in Schedule O. See instructions. ~ c~~~ ~ 1 a Enter the number of voting members of the governing body 1 a 9 ~M1 ' b Enter the number of voting members that are independent 1 b 9 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other ° ,y`: officer, director, trustee or key employee? 2 ~ X 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? 3 X 4 Did the organization make any significant changes to its organizational documents 4 X since the prior Form 990 was filed? 5 Did the organization become aware during the year of a material diversion of the organization's assets? 5 X 6 Does the organization have members or stockholders? 6 X 7a Does the organization have members, stockholders, or other persons who may elect one or more members of the governing body? 7a X b Are any decisions of the governing body subject to approval by members, stockholders, or other persons? 7b X . 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: Y ~ a The governing body? 8a X b Each committee with authority to act on behalf of the governing body? 8b X 9a Does the organization have local chapters, branches, or affiliates? 9a X b If 'Yes,' does the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with those of the organization? 9b 113 Was a copy of the Form 990 provided to the organization's governing body before it was filed? All organizations must describe in Schedule 0 the process, if any, the organization uses to review the Form 990 ...See. SChedule..0...... 10 X 11 Is there any officer, director or trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? !f 'Yes,' provide the names and addresses in Schedule D 11 X Section B. Policies Yes No 12a Does the organization have a written conflict of interest policy? !f 'No,' go to line 13 12a X b Are officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? 12b X c Does the organization regularly and consistently monitor and enforce compliance with the policy? If 'Yes,' describe in Schedule D how this is done...... See .Schedule..0 12c X 13 Does the organization have a written whistleblower policy? 13 X 14 Does the organization have a written document retention and destruction policy? 14 X 15 Did the process for determining compensation of the following persons include a review and approval by independent ~ , ~ ~ persons, comparability data, and contemporaneous substantiation of the deliberation and decision: a The organization's CEO, Executive Director, or top management official? 15a X b Other officers of key employees of the organization?... S.ee..S.Chedule .0 15b X Describe the process in Schedule 0. (see instructions) p4.,,~;, 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable "1 entity during the year? 16a X b If 'Yes,' has the or ariization ado tad a written olic or rocedure re uirin the or anization to evaluate its artici ation i~ • 9 P~ P Y P q 9 9 P P in joint venture arrangements under applicable federal tax law, and taken steps to safeguard the organization's exempt ~~a_, status with respect to such arrangements? 16b Section C. Disclosures 17 List the states with which a copy of this Form 990 is required to be filed ? CA 18 Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you make these available. Check all that apply. Own website ~ Another's website ~ Upon request 19 Describe in Schedule 0 whether (and if so, how) the organization makes its governing documents, conflict of interest policy, and financial statements available to the public. See Schedule 0 20 State the name, physical address, and telephone number of the person ~aho possesses the books and records of the organization: ?Linda Newman 6377 Clark Ave. Suite 100 Dublin CA 94568 925-829-8770 BAA Form 990 (2008) T-=AOIOGL 12/18/08 Form 990 (2008) Hope Hos ice, Inc . 94-2576059 Page 7 %Part`1`/I1~ Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1 a Complete this table for all persons required to be listed. Use Schedule J-2 if additional space is needed. • List all of the organization's current officers, directors, trustees whether individuals or organizations), regardless of amount of compensation, and current key employees. Enter -0- in columns (D), (E~, and (F) if no compensation was paid. • List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) or more than $100,000 from the organization and any related organizations. • List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. • List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this box if the organization did not compensate any officer, director, trustee, or key employee. (A) (B) {c) ~ (D} (E) (F) Name and Title Average Position (check all that apply) Reportable Reportable Estimated hours compensation from compensation from amount of other per week a a N o ~ 3 ~ the organization related organizations compensation _ a ~ ~ (W~2/1a99-MISC) (W~2/1099~MISC) from the a = ~ ~ ~ ~ organization o m ~ ~ m" n and related m ° organizations E ~ - m ~ m ~ ~ ~ m ~ v m a Tim Neal President 1 X 0. 0. 0. Marie Perms Vice President 1 X 0. 0. 0. Charles Crohare Treasurer 1 X 0. 0. 0. Maw Prishtina Secretar 1 X 0. 0. 0. David Karlsson Director 1 X 0. 0. 0. Daven Sharma Director 1 X 0. 0. 0. Esther Becker Director 1 X 0. 0. 0. Jennifer Thaete Director 1 X 0. 0. 0. San_d_r_a_Ryan Director 1 X 0. 0. 0, Helen Meier Executive Direc 37.5 X 117,786. 0. 9,475. _Dar_le_ne_ F_ri_es_en,_ RN _ _ _ _ _ Nurse Su ervisor 37.5 X 117,967. 0. 9,679. Dara Burke, RN Facilit Liaison 37.5 X 104,965. 0. 3,988. Ann Noll, RN Dir. Patient Svcs 37.5 X 105,438. 0. 4,085. --------------------J BAA rEEAOIO~~_ o~./za/o9 Form 990 (2008) , ti 1 ~ ~ Form 990(2008) HOAe Hos ice, Inc. 94-2576059 Page 8 ePart`~V,II# Section A. Officers, Directors, Trustees, Ke Em to ees, and Hi hest Com ensated Em to ess (conf. CA) CB) CE) <F) Average Position (check alf that apply) Reportable Re ortable =stimated Name and Title p hours compensation from com ensation irom amount of other per week > ~ s v? T p a n _ ~ g ,o o the oroanization related organizations compensation ~ a = ~ ~ o ~ ~ (W 2n 099 MISC) (W-2!1099-MISC) from the organization o m ~ ~ m and related m ° ° organizations - ~ ~ ~ ~ m m ~ m ~ m m a 1bTotal ~ 446, 156. 0. 27, 227. 2 Total number of individuals (including those in l a) who received more than $100,000 in reportable compensation from the organization ~ 4 Yes No 3 Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1 a. If 'Yes,' complete Schedule J for such individual . 3 X 4 For any individual listed on line la, is the sum of reportable compensation and other compensation from ~ i,'~ the organization and related organizations greater than $150,000? If 'Yes' complete Schedule J ror such ~ • individual 4 X H« ~ 5 Did any person listed on line la receive or accrue compensation from any unrelated organization for services rendered to the organization? If 'Yes,' complete Schedule J for such person 5 X Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Name and business address Descri tion of Services Compensation i I 2 Total number of independent contractors (including those in 1) who received more than $100,000 in I ~-4,,~.z x ` x ' com °nsation from the oroanization 0 ~r'~ ~ P ,.~«_3aa..,. BAA T_~A.otos~ tondos Form 990 (2008) ~ r Form 990 (2DD8) Hope Hospice, Inc. 94-2576059 Page 9 ~.Pa'rt=1'/.1:11; Statement of Revenue ~ ~~~~,,7a ~ r~,akrr* ~ Total revenue Related or Unrelated Revenue P~" w2 ~ ~~a t~~~`~ exempt business excluded from tax a ~ . function revenue under sections _Y.:~i~~~~_ ~ ~~;~'~~~`~'~ir' 3w~ . revenue 512, 513, or 514 1 a Federated cam ai ns 1 a ` ~ ~ 3 't' t a ~ b Membershi dues 1 b ~ r ~ ~ ~ t c Fundraising events........... 1 c .'~~"~~~a~II`"' ~ ~ ,4~~~~~ LL ~q d Related organizations 1 d a ' 4.~+t1'~ r~,~~ ~ J w _~1-.rt rrX`+' S«' _ ~1 Is R~ 1~- c~ ~`b~~ ci e Government rants contributions 1 e ~s`~ r ~ ~ ~ ~ u, f All other contributions, gifts, grants, antl l~; ~ ~ , ~ r ~ m ~ similar amounts not included above... 1 f 540, 752 t ~ ' Ih ~ o g Noncash contribns included in Ins la-lf:.. $ 46, 869. i ~ ~ ~ °a h Total. Add lines la-lf.. ~ 540, 752. _ ~~'~~~~,~~_~~`_`'~~,~h:, ~ Business Code ~ ~~'~,G x~~ ~ ~ ~ - + ~.!-mw. 2a Patient Servi_ce__R_ev_e_n_ue_ 5, 383, 005. 5, 383, 005. b ProcLram Fees 2, 330. 2, 330. W - U_ C ~ d ~ e _ a o f All other program service revenue . a g Total. Add lines 2a-2f. ~ 5, 385, 335. ` ~~n~:.~~~~, - 3 Investment income (including dividends, interest and other similar amounts) ~ -340, 755. -340, 755. 4 Income from investment of tax-exempt bond proceeds . 5 Royalties ~ (i) Real (ii) Personal - ~ - - - w, _ 6a Gross Rents......... _ _ b Less: rental expenses ~ ~ x c Rental income or (loss).... g ~ ~ b d Net rental income or (loss D (i) Secunties (ii) Other ~e - S 7 a Gross amount from sales of - assets other than inventory . 1 O O , 0 0 0 .w' ~ ~ f ~r s • _ - ' b Less: cost or other basis ~ 7`b s ~ ~ and sales expenses 3 , 18 9 _ . ~ « ~ 4 c Gain or (loss). 96, 811. M~~ ~ ~ ~ ~f• d Net gain or (loss) ~ 96, 811. 96, 811. r - 's j 7" 9 rruv , ?x „r~s.~ r^rsr t k ~ 8a Gross income from fundraising events t, ~,r ~ . ~ a ~ (not including . $ ^ • ~ ~ W of contributions reported on line lc). ~ r ~ ~i ; ~ See Part IV, line 18 a 65 119 r~§t"~'~ >,.~,~~~~~~~~e~~ ~ r +'fis ~~r~~''d~ ~ W r b Less: direct expenses b 24, 205 ~ .1. ~ ~ ~ . . w-.~.~~~~ ° c Net income or (loss) from fundraising events.......... ~ 40, 914. 40, 914 . 9a Gross income from gaming activities. ~"~~`s~~r'~ , j ~ ~ ~ {ti~.~~r rr,';5'~"~~v~`v ~ See Part IV, line 19.. a cr~t I~ ~A~ 4.~. b Less: direct ex enses. b ~~L nn~,~ ~y ~r _ ~u£. ~ N.1,,~ ;t, ~ ate; p „«.._~~~6y".::~~a~ a _ --r r~?t~^ 3`"y,, <+d.,v 1~1 nt.~i,``~5~„« c Net income or (loss) from gaming activities ~ I - .:,~5titt,L ' i ILA ~.fi"= .x + x}~.,,'y}u~'ry i.:,r,- ui s nct 10a Gross sales of inventory, less returns , ~ ~ ; ' I s~~ 1" ~ ~ ~ ' E ; and allowances a ~ ' I I ~ ~ E,~~ b Less: cost of Dods sold . b _ _ ~ ~a - .r c Net income or (loss) from sales of inventory........... ~ Miscellaneous Revenue Business Code ~ iy i` fr,,,."~ 11a Miscellaneous_Income _ 2,230. 2,230. - b c d All other revenue e Total. Add lines l la-1ld ~ 2, 230. ? ~ -T~,; 12 Total Revenue. Add lines 1 h, 2g, 3, 4, 5, 6d, 7d, 8c, 9c, lOc, and lie ~ 5, 725, 287. 5, 184, 535. 0. 0 BAA TE=AOlU9L Izns~2oos Form 990 (2008) Form 990 (2008) Hope Hos ice, .Inc. 94-2576059 Page 10 fParrA1X~" Statement of Functional Expenses Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A} but are not required to complete columns (B), (C), and (D}. Do not inc/ude amounts reported on lines Total exApenses Program service Management and Fundraising 6b, 76, 86. 96. and 106 of Part V///. ex enses general expenses expenses 1 Grants and other assistance to governments ,~-r~~~.A 'x-~ and organizations in the U.S. See °art IV, ~ ~ . ~ + ~ ~ line 21 . r7 3 .,k 2 Grants and other assistance to individuals in ~ ' sw the U.S. See Part IV, line 22 ~ ~ „ ~ 3 Grants and other assistance to governments, ~ ~?i~ organizations, and individuals outside the ~`ay~'~ ~ti ~ , U.S. See Part IV, lines 15 and 16... a ~ , ~ 4 Benefits paid to or for members ~-~~'~~,~~a~ ~ M.~~~~'~x~~`- 5 Compensation or current officers, directors, trustees, and key employees 382, 495. 336, 596. 26, 775. 19, 124. g Compensation .not included above, to disqualified persons (as defined under section 4958(f)(1) and persons described in section 4958(c)(3)(B) 0 . 0 . 0 . 0 , 7 Other salaries and wages 2, 950, 494. 2, 601, 545. 215, 519. 133, 430. g Pension plan contributions (include section 401(k) and section 403(b) employer contributions) . 9 Other employee benefits 226, 687. 203, 109. 13, 983. 9, 595. 10 Payroll taxes 271, 010. 242, 822. 16, 717. 11, 471. 11 Fees for services (non-employees).......... . a Management . b Legal 2, 717. 1, 294. 1, 197. 226. c Accounting 13 , 925. 12 , 254. 975. 6 9 6 . d Lobbying z . ~ 5 ~ g e Prof fundraising sues. See Part IV, In 17...... f Investment management fees . g Other 241, 480. 115, 001. 106, 409. 20, 070 . 12 Advertising and promotion 64, 873. 51, 340. 462. 13, 071. 13 Office expenses 819, 385. 779, 744. 25, 605. 14, 036. 14 Information technology 15 Royalties 16 Occupancy 143, 862. 124, 795. 10, 632. 8, 435. 17 Travel 81, 387. 80, 480. 397. 510 . 18 Payments of travel or entertainment expenses for any federal, state, or local public officials . 19 Conferences, conventions, and meetings 112 , 92 0 . 4 0 , 9 7 8 . 71, 015. 92 7 . 20 Interest 21 Payments to affiliates . 2Z Depreciation, depletion, and amortization 2 7 , 93 6 . 2 4 , 5 84 . l , 955. 1, 3 97 . 23 Insurance 85, 456. 79, 695. 3, 333. 2, 428 . 24 Other expenses. Itemize expenses not ~ ~ ~ ~ ~ r`i '"~~"'~r , ra ea covered above. (Expenses grouped together ~ _ , ~r ~ : ~,a~ ~ ~ i ~ and labeled miscellaneous may not exceed ~ ~ ~ ' ~ - ~ k 5 /o of total ex enses shown on line 25 ~ r ~ „yT ~ ~,r -+k below. P s ~r~ x a. ~~~33~ ~ ~ ~ „ '~~`~i~~. ,-..~rit~~~ i.A- :.,'r- saF~~_° ~~~T,# §~:r {m _m~~~ t„ c r '+li`i'h''a. ~fi 4,.. a Room & Board Reimbursement 269,681. 269,681. b Bad Debt 60,953. 60,953. ~ c Miscellaneous_Ex~________ 18,003. 15,574. 1,539. 890. d In-Kind Expenses 14,246. 14,246. e Fundraising Expenses _ _ _ _ _ ~ 10, 636. 12 . 10, 624 . f All other expenses 4 , 6 81 . 4 , 6 71 . 6 . 4 . 25 Total functional expenses. Ndd lines 1 through 24f...... ~ 5, 8 0 2, 8 2 7. 5, 0 4 5, 12 8. 4 9 6, 519 . ~ 2 61, 18 0. 26 Joint Costs. Check here ~ ~ if rollowing SOP 98-2. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation........ . BAA Form 990 (2008) T_ AOIIOL 12119/08 Form 990 (2008) Hope Hos ice, Inc. 94-2576059 Page 11 PartiX;_'~~ Balance Sheet (A) (B) Beginning of year End of year 1 Cash -non-interest-bearing 1, 701 . ~ 1 6, 423. 2 Savings and temporary cash investments 2, 225, 634. ~ 2 ~ 909, 775. 3 Pledges and grants receivable, net 2, 502. 3 4, 810. 4 Accounts receivable, net 1, 078, 862. 4 1, 157, 964. 5 Receivables from current and former officers, directors, trustees, key employees, or other related parties. Complete Part II of Schedule L 5 6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) ~ ` and persons described in:section 4958(c)(3)(B). Complete Part II of Schedule L... 6 s 7 Notes and loans receivable, net 7 s E 8 Inventories for sale or use 8 s 9 Prepaid expenses and deferred charges 40, 544. 9 74, 182. 10a Land, buildings, and equipment: cost basis 10a 373 164 4 ~ ~ g~ b Less: accumulated depreciation. Complete Part VI of I ~;T ~ ~j~ Schedule D 10b 143, 402. 83, 830. 10c 229, 762 . 11 Investments -publicly-traded securities 11 12 Investments -other securities. See Part IV, line 11 2, 118, 728. 12 3, 53.8, 572 . 13 Investments -program-related. See Part IV, line 11 13 14 Intangible assets 14 15 Other assets. See Part IV, line 11 329, 127. 15 37, 127 . 16 Total assets. Add lines 1 through 15 (must equal line 34) 5, 880, 9'28. 16 5, 958, 615 . 17 Accounts payable and accrued expenses 256, 448. 17 411, 675. 18 Grants payable 18 19 Deferred revenue 19 20 lax-exempt bond liabilities 20 e 21 Escrow account liability. Complete Part IV of Schedule D 21 c ~ 22 Payables to current and former officers, directors, trustees, key employees, ~ y x",~ 1 highest compensated employees, and disqualified persons. Complete Part II ' T i of Schedule L 22 E s 23 Secured mortgages and notes payable to unrelated third parties 23 24 Unsecured notes and loans payable 24 25 Other liabilities. Complete Part X of Schedule D 25 26 Total liabilities. Add lines 17 throw h 25 256, 448. 26 411, 675 . T Organizations that follow SFAS 117, check here X and complete lines z s~ ' ~ ~ ~ <x 27 through 29 and lines 33 and 34. ~ s 27 Unrestricted net assets . 5, 582, 055. 27 5, 521, 379. T 28 Temporarily restricted net assets 42, 425. 28 25, 561 . s 29 Permanently restricted net assets _ 29 R Organizations that do not follow SFAS 117, check here ? ~ and complete ...i ~.r~" ~a~ I~~~ t~-' "r""~ ~ fines 30 through 34. ~t~i~~ ~t_~ a , p 30 Capital stock or trust principal, or current funds 30 a 31 Paid-in or capital surplus, or land, building, and equipment fund 31 A 32 Retained earnings, endowment, accumulated income, or other funds 32 E 33 Total net assets or fund balances. 5, 624, 480. 33 5, 546, 940. s 34 Total liabilities and net assets/fund balances 5, 880, 928. 34 5, 958, 615. 1Farf;Xlh~~i Financial Statements and Re orEin Yes No 1 Accountin method used to re are the Form 990: ~ Cash X? Accrual ~ Other 9 P P ~:~F: ire; z~sr~ . a,. w,. _ 2a Were the organization's financial statements compiled or reviewed by an independent accountant? 2a X b Were the organization's financial statements audited by an independent accountant? 2b X c If 'Yes' to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? 2c X 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? 3a X b If 'Yes,' did the organization undergo the required audit or audits? 3b~ BAA Form 990 (2D08) T..P.OI l l L 12122/08 OMB No. 1545-0047 SCHEDULE A Public Charit Status and Public Su ort p (Form 990 or 990-EZ) Y PP 2®®p To be completed by all section 501 (c}(3) organizations and section 4947(a){1) ,f,,,. ; nonexempt charitable trusts. ~ 1~;&>r r t~,u~~tFt Department of the Treasury ?~~flpe~ to~PUbIIC^'~~""9G Infernal Revenue Service ~ Attach to Form 990 or Form 990-EZ. ? See se crate instructions. ,y Irispect(on~'>$~~c Name of 'the organization Employer identification number Hope Hospice, Inc. 94-2576059 ~~Part`xl; Reason for Public Charity Status (All organizations must complete this part.) (see instructions) The organization is not a private foundation because it is: (Please check only one organization.) 1 A church, convention of churches or association of churches described in section 170(b}(1}(A)(i). 2 A school described in section 170(b)(1xA}(ii). (Attach Schedule E.) 3 A hospital or cooperative hospital service organization described in section 170(b}(1)(Axiii). (Attach Schedule H.) 4 A medical research organization operated in conjunction with a hospital described in section 170(bx1xA}(iii). Enter the hospital's name, city, and state: 5 ~ An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b}(1}(Axiv). (Complete Part II.) 6 A federal, state, or local government or governmental unit described in section 17D(b}(1}(Axv). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(bXlxAxvi). (Complete Part II.) 8 ? A community trust described in section 170(li}(1}(A}(vi). (Complete Part II.) 9 X? An organization that normally receives: (1) more than 33-1/3 % of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions -subject to certain exceptions, and (2) no more than 33-1l3 % of its support from gross investment income and unrelated business taxable Income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a}(2). (Complete Part III.) 10 8 An organization organized and operated exclusively to test for public safety. See section 509(a}(4). (see instructions) ll An organization organized and operated exclusively for the benefit of, to perform the functions of, or carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a}(3). Check the box that describes the type of supporting organization and complete lines lie through l lh. a Type I b Type I I c ~ Type III -Functionally integrated d ~ Type III- Other e ~ By checking this box, t certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a) (2). f If the organization received a written determination from the IRS that is a Type I, Type I I or Type III supporting organization, check this box g Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons? Yes No (i) a person who directly or indirectly controls, either alone or together with persons described in (ii) and (iii) below, the governing body of the supported organization? 11 g (i) (ii) a family member of a person described in (i) above? 11 g (ii) (iii) a 35% controlled entity of a person described in (i) or (ii) above? 11 g (iii) h Provide the following information about the organizations the organization su orts. Name of Supported (i) .IN (ii) Type of organization (iv) Is the (v) Did you notify (vi) Is the (vii) Amount of Support Grganizaiion (described on lines 1-9 organization in col. the organization in organization in col. above or IP.C section (i) listed in your col. of (i) ora_anized in the (see instructions)) governing your support? U.S.? document? Yes No Yes No Yes No Total _ r ~ ~ ; ar__~ BAA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule A (Form 990 or 990-EZ) 2008 r~_AO4o1 i_ 12n ~(os Schedule A (Form 990 or 990-EZ) 2008 Hole Hos iCe, Inc. 94-2576059 Page 2 :;Fartal`? Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I.) Section A. Public Su ort Calendar year (or fiscal year (a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) Total beginning m) 1 Gifts, grants, contributions and membership tees received. Do not include 'unusual grants.'.. . 2 Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf . 3 The value of services or facilities furnished to the organization by a governmental unit without charge. Do not include the value of services or facilities generally furnished to , the public without charge . 4 Total. Add lines 1-3........... 5 The ortion of total ~ ~ ~ ~ i y ~ ~aa'" contributions by each person ~ ~ - s ' ` (other than a governmental a _ unit or publicly supported _ ~ s ~ k ~ r organization) included on line 1 ~ ~ ?il - ~ t ~ 3`~t` that exceeds 2% of the amount _ ~ _ ~ _ ~ shown on line 11, column (f) ~ ,-R r 4, 6 Public support. Subtract line 5 ~ y, G ~ i from line 4 . _ ~ 'R~;~~~`.~.a.~~ ..y, = ~ Section B. Total Su ort Calendar year (or fiscal year (a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) Total beginning m) 7 Amounts from line 4.......... . 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and Income form similar sources . 9 Net income form unrelated business activities, whether or not the business is regularly carried on . 10 Other income. Do not include gain or loss form the sale of capital assets (Explain in Partly.) 11 Total support. Add lines 7 shy, ks ~~,T ` ' ~ ~ ~ r through 10 ~~~-~~~A ~ ,~,n.... .,v , ~ ~ z 12 Gross receipts from related activities, etc. (see instructions) 12 13 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) n organization, check this box and stop here ~ I I Section C. Com utation of Public Su ort Percents e 14 Public support percentage for 2008 (line 6, column (f) divided by line 11, column (f) 14 15 Public support percentage for 2007 Schedule A, Part IV-P., line 26f 15 16a 33-1 f3 support test - 2008. If the organization did not check the box on line 1 ,and the line 14 is 3-1/3 /o or more, check th ~ and stop here. The orgarnzation qualifies as a publicly supported organization . . , is box b 33-113 support test - 2D07. If the organization did not check a box on line 13, or 16a, and line 15 is 33-1/3% or more, check this box and stop here. The organization qualifies as a publicly supported organization ~ 17a 10%-facts-and-circumstances test - 20D8. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the 'facts-and-circumstances' test, check this box and stop here. Explain in Part IV how the organization meets the 'facts-and-circumstances' lest. The organization qualifies as a publicly supported organization......... ~ b 10%-facts-and-circumstances test - 2007. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the 'facts-and-circumstances' test, check this box and stop here. Explain in Part IV how the organization meets the 'facts-and-circumstances' test. The organization qualifies as a publicly supported organization ~ 18 Private foundation. If the organization did not check a box on line, 13, 16a, 16b, 17a, or 17b, check this box and see instructions ~ BAA Schedule A (Form 990 or 990-EZ) 2008 T__AOe02L 12/17/03 Schedule A (Form 990 or 990-EZ) 2008 HO e Hospice, Inc. 94-2576059 Page 3 '~Part1111=1`~' Support Schedule for Organizations Described in Section 5Q9(a)(2) (Complete only if you checked the box on line 9 of Part I.) Section A. Public Su ort Calendar year (or fiscal yr beyinning in)? (a) 2004 (b} 2005 (c) 2006 (d) 2007 (e) 2008 (f) Total 1 Gifts, grants, contributions and membership fees received. Do not include unusual grants.' 446, 678. 500, 314. 973, 889. 958, 477. 540, 752. 3, 420,110 . 2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in a activity that is related to the organization's tax-exempt purpose 2, 546, 896. 3, 438, 020. 3, 866, 179. 4, 882, 899. 5, 385, 335. 20,119, 329. 3 Gross receipts from activities that are not an unrelated trade or business under section 513 0 . 4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 0 . 5 The value of services or facilities furnished by a governmental unit to the organization without charge.... 0 6 Total. Add lines 1-5........... 2, 993, 574. 3, 938, 334. 4, 840, 068. 5, 84.1, 376. 5, 926, 087. 23, 539, 439. 7a Amounts included on lines 1, 2, 3 received from disqualified persons 0. 0. D. 0. 0. D. b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of 1 % of the total of lines 9, lOc, 11, and 12 for the year or $5,000... 140, 217. 69, 495. 0. 0. 0 . 209, 712 . c Add lines 7a and 7b........... 140, 217. 69, 495. 0: 0 . 0 . 209, 712 . 8 Public support (Subtract line 7c from line 6.) . j ~`~z~_ ~ _ _ 23, 329, 727 . Section B. Total Su ort Calendar year (or fiscal yr beginning in) ? (a) 2004 (b) 2005 (c) 2006 (d) 2007 (e) 2008 (f) Total 9 Amounts from line 6........... 2, 993, 574..3, 938, 334. 4, 840, 068. 5, 841, 376. 5, 926, 087. 23, 539, 439. 10a Gross income from interest, dividehds, payments received on securities loans, rents, royalties and income form similar sources gg, 300. 128, 494. 307, 325. 125, 205. 108, 450. 767, 774 . b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975... 0 , c Add lines l0a and lOb......... 98, 300. 128, 494. 307, 325. 125, 205. 108, 450. 767, 774. 11 Net income from unrelated business activities not included inline lOb, whether or not the business is regularly carried on 0 , 12 Other income. Do not include gain or loss from the sale of capital assets (Ex lain in Part Iv.). See ~ar.t .IV 1, 193. 5, 158. 9, 661. 1, 211. 2, 230. 19, 453. 13 Total support. (add Ins 9, lOc, 11, and 12.) _ ~ s ~ 24, 326, 666 . 14 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) n oraanization, check this box and stop here ~ I l Section C. Com utation of Public Su ort Percenta e 15 Public support percentage for 2008 (line 8, column (f) divided by line 13, column (f)) . 15 95.9 16 Public support percentage from 2007 Schedule A, Part IV-,4, line 27g 16 94 .0 Section D. Com utation of Investment Income Percenta e 17 Investment income percentage for 2008 (line l Oc, column (f) divided by line 13, column (f)) 17 3 . 2 18 Investment income percentage from 2007 Schedule A, Part IV-A, line 27h 18 3 . 1 19a 33-1!3 support tests - 2008. If the organization did not check the box on line 14, and line 15 is more than 33-113%, and line 17 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ~ X? b 33-113 support tests - 2007. If the organization did not check a box on line 14 or 19a, and line 16 is more than 33-1 /3%, and line 18 is not more than 33-1/3%, check this box and stop here. The organization qualifies as a publicly supported organization............ ~ 20 Private foundation. ff the organization did not check a box on Ilne 14, 19a, or 19b, check this box and see instructions ? BAA TE-A0403L ouz9~o5 Schedule A (Form 990 or 990-EZ) 2008 Schedule A (Form 990 or 990-EZ) 2008 Hope Hos iCe, Inc. 94-2576059 Page 4 _P.arfaU<~"~ Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; .Part II, line 17a or 17b; or Part III, line 12. Provide any other additional information. (see instructions) BQQ TP,OcD4L ioio~ios Schedule A (Form 990 or 990-EZ) 2008 2005 Schedule A, Part IV -Supplemental Information Page 5 Client HOPE Hope Hospice, Inc. 94-2576059 3/05/ 10 11:25AM Part III, Line 12 -Other Income Nature and Source 2008 2007 2006 2005 2004 Other Income 2,230. 1,211. 9,661. 5,158. 1,193. Total $ 2,230. $ 1,211. $ 9,661. $ 5,158. $ 1,193. Schedule B oMe Nb. lses-ooa7 (Form 990, 990-EZ, or 990-PF) Schedule of Contributors Department of the Treasury ' Atta` h to Form 990, 990-EZ and 990-PF See separate instructions. Internal Revenue Service Name of the organization Employer identification number Hope Hos ice, Inc. 94-2576059 Organization type (check one): Filers of: Section: Form 990 or 990-EZ X 5D1(c)( 3 ) (enter number) organization 4947(a)(1) nonexempt charitable trust not treated as a private foundation 527 political organization Form 990•PF 5D1(c)(3) exempt private foundation 4947(a)(1) nonexempt charitable trust treated as a private foundation 501(c)(3) taxable private foundation Check if your organization is covered by the General Rule or a Special Rule. (Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.) General Rule - For organizations filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in .money or property) from any one contributor. (Complete Parts I and II.) Special Rules - XDFor asection 501(c)(3) organization filing Form 990, or Form 990-EZ, that met the 33-1/3% support test of the regulations under sections 509(a)(1)/170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the greater of (1) $5,000 or (2) 2% of the amount on Form 990, Part VIII, line lh or 2% of the amount on Form 990-E line 1. Complete Parts I and II. For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor, during the year, aggregate contributions or bequests of more than $1,000 for use exclusively for religious, charitable, scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and III. For a section 501(c)(7), (8), or (10) organization filing Form 990, or Form 990-EZ, that received from any one contributor, during the year, some contributions for use exclusively for religious, charitable, etc, purposes, but these contributions did not aggregate to more than $1,000. (If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc, purpose. Do not complete any of the Parts unless the General Rule applies to this organization because it received nonexciusively religious, charitable, etc, contributions of $5,000 or more during the year.) ~ $ Caution: Organizations that are not covered by the General Rule and/or the Special Rules do not file Schedule B (Form 990, 990-EZ, or 990-PF) but they must answer 'No' on Part IV, line 2 of their Form 990, or check the box in the heading of their Form 990-EZ, or on line 2 of their Form 990-PF, to certify that they do not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF). BAA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions Schedule B (Form 990, 990-EZ, or 990-PF) (2008) for Form 990. These instructions will be issued separately. T.~A0701L 12/18!08 Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page 1 of 1 of Part Name of organization Employer identification number . Hope Hospice, Inc. 94-2576059 P;arf~li Contributors (see instructions.) (a) (b) (c) (d) Number Name, address, and ZIP + 4 Aggregate Type of contribution contributions 1 Tri-Valley_Communit~ Foundation _ _ _ _ _ _ _ _ _ _ _ _ _ _ Person X Payroll 5674 Stoneridge Drive,_Ste_112___ $ 19,245. Noncash (Complete Part II if there Pleasanton, CA 9458 8 _ _ _ _ _ _ _ - _ - _ is a noncash contribution.) (a) (b) (c) (d) Number Name, address, and ZIP + 4 Aggregate Type of contribution contributions 2 Janet Eddleman _ _ Person X Payroll 2155 Westbrook Lane $ 13, 000. Noncash (Complete Part II if there Livermore, CA 94550 _ _ _ _ _ _ is a noncash contribution.) {a) (b) (c) {d) Number Name, address, and ZIP + 4 Aggregate Type of contribution contributions 3 Mildred Peters Estate _ _ _ _ _ _ Person X Payroll 2109 Fourth Street _ _ _ _ _ _ _ _ _ _155, 348_ Noncash (Complete Part II if there Livermore, CA 94550 is a noncash contribution.) (a) (b) (c) (d) Number Name, address, and ZIP + 4 Aggregate Type of contribution contributions 4 Lawrence Livermore National Lab _ _ Person X. - Payroll P.O.Box 808 17,745_ Noncash (Complete Part 11 ifi there Livermore, CA 94551-0808 _ _ is a noncash contribution.) (a) (b) (c) (d) Number Name, address, and ZIP + A Aggregate Type of contribution contributions 5 Winston Strawn,_LLP_ _ _ _ _ _ _ _ - Person Payroll 101 California Street, #3900 _ 15,528_ Noncash X (Complete Part II if there San Francis Co, _CA 94111 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ is a noncash contribution.) (a) (b) (c) (d) Number Name, address, and ZIP + 4 Aggregate Type of contribution contributions Person Payroll Noncash (Complete Part II if there _ _ is a noncash contribution.) BAA rr~o7o2~ osrosros Schedule B (Form 990, 99D-EZ, or 990-PF) (2D08) Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page 1 of 1 of Part II Name of organization Employer identification number Hope Hospice, Inc. 94-2576059 ~Part~[1~~~, NOncash Property (see instructions.) (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) Le al services rovided 5 $ 15,528. 6/30/09 (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see tnstructions) (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) (a) (b) (c) (d) No. from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) (a) (b) (c) (d) No: from Description of noncash property given FMV (or estimate) Date received Part I (see instructions) BAA Schedule B (Form 990, 990-EZ, or 990-PF) (2008) T=~A0703L 08!05/03 Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Page 1 of 1 of Part III Name of organizaiion Employer identification number Ho e Hos ice, Inca 94-2576059 Part~lll; Exc/usive/y religious, charitable, etc, individual contributions to section 501(c)(7), (8), or (10) organizations aggregating more than $1,000 for the year.(complete cols (a) through (e) and the following line entry.) For organizations completing Part III, enter total of exclusively religious, charitable, etc, contributions of 51,OOD or less for the year. (Enter this information once -see instructions.)............ ~ $ N/A (a) (b) (c) (d) No, from Purpose of gift Use of gift Description of how gift is held Part I N/A (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) (b} (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) (b) (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee (a) (b). (c) (d) No. from Purpose of gift Use of gift Description of how gift is held Part I (e) Transfer of gift Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee BAA Schedule B (Form 990, 990-EZ, or 990-PF) (2008) Tc~A0704L OelO1/03 SCHEDULED oMe No. lees.ooa~ (Form 990) Supplemental Financial Statements 2®®~ Attach to Form 99D. To be completed by organizations that ~~~x+Open to Pubhc~z ~i Deparimeni of the Treasury Internal Revenue Service answered 'Yes.' to Form 990, Part IV, lines 6, 7, 8, 9, 1 D, 11, or 12. ,Inspectton~'~~, Name of the organization Employer Identification number Hope Hospice, Inc. 94-2576059 ~Pfart=;I~~~~Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts Complete if the organization answered 'Yes' to Form 990, Part IV, line 6. (a) Donor advised funds (b) Funds and other accounts 1 Total number at end of year . 2 Aggregate contributions to (during year).... . 3 Aggregate grants from (during year) . 4 Aggregate value at end of year . 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? Yes ~ No 6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be used only for charitable purposes and not for the benefit of the donor or donor advisor or other n impermissible private benefit?? . Yes I I No Part"III Conservation Easements Complete if the organization answered 'Yes' to Form 990, Part IV, line 7. 1 Purpose(s) of conservation easements held by the organization (check all that apply). Preservation of land for public use (e.g., recreation or pleasure) BPreservation of an historically important land area Protection of natural habitat Preservation of certified historic structure Preservation of open space 2 Complete lines 2a-2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax ear, _ ~ Held at the End of the Year a Total number of conservation easements 2a b Total acreage restricted by conservation easements 2b c Number of conservation easements on a certified historic structure included in (a) 2c d Number of conservation easements included in (c) acquired after 8/17/06 2d 3 Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the taxable year ? 4 Number of states where property subject to conservation easement is located ? 5 Does the organization have a written policy regarding the periodic monitoring, inspection, violations, and enforcement of the conservation easement it holds? ~ Yes ~ No b Staff or volunteer hours devoted to monitoring, inspecting, and enforcing easements during the year ? 7 Amount of expenses incurred in monitoring, inspecting, and enforcing easements during the year ? $ 8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and 170(h)(4)(BXii)? ~ Yes ~ No 9 In Part XIV, describe how the organizatipn reports conservation easements in its revenue and expense statement, and balance sheet, and include, if applicable, the text of the footnote to the organization's financial statements that describes the organization's accounting for conservation easements. ~P:art`!I:Ih~ Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets Complete if the organization answered 'Yes' to Form 990, Part IV, line 8. 1 a If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIV, the text of the footnote to its financial statements that describes these items. b If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items: (i) Revenues included in Form 990, Part VIII, line 1 . . . ? $ (ii) Assets included in Form 990, Part X ? $ 2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the following amounts required to be reported under SFAS 116 relating to these items: a Revenues included in Form 990, Part VIII, line l . ? $ b P,ssetsincluded in Form 990, Part X ? $ BAA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule D (Form 990) 2008 T==F3301 L 12/23103 Schedule D (Form 990) 2008 Ho e Hos ice, Inc. 94-2576059 Page 2 ~Pa~t~l.~a Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) 3 Using the organization's accession and other records, checVc any of the following that are a significant use of its collection items (check all that apply): a Public exhibition d n Loan or exchange programs b Scholarly research e iL-JI Other c Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIV. 5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection? Yes No LLPa`rf-;IV_~ Trust, Escrow and Custodial Arrangements Complete if organization answered `Yes' to Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21. 1 a Is the organization an agent, trustee, custodian, or other intermediary for contributions or other assets not included on Form 990, Part X? ~ Yes ~ No b If 'Yes,' explain the arrangement in Part X!V and complete the following table: Amount c Beginning balance 1c d Additions during the year ld e Distributions during the year . 1e f Ending balance 1f 2a Did the organization include an amount on Form 990, Part X, line 21? ~ Yes ~ No b If 'Yes,' explain the arrangement in Part XIV. ~Pa,:i~V Endowment Funds Com lete if or anization answered 'Yes' to Form 990, Part IV, line 10. (a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back x ~ - a- 1 aBeginning of year balance 4, 100, 000 . - _ '~~T ~ b Contributions _ f~~"~'g" ~ i6'LH~ c Investment earnings or losses.. _ ~ 3" y f , - - - d Grants or scholarships......... ~ . ~ ± . e Other expenditures for facilities - K~~~~' and programs 339, 102 „ .F f Administrative expenses....... ~ ' ~ ~ -~1p"~~ gEnd of year balance.......... 3, 760, 898. fir'""'~ F ~ - i 2 Provide the estimated percentage of the year end balance held as: a Board designated or quasi-endowment ? 100.00 'o b Permanent endowment c Term endowment 3a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: Yes No (i) unrelated organizations 3a(i) X (ii) related.organizations 3a(ii) X b If 'Yes' to 3a(ii), are the related organizations listed as required on Schedule R? 3b 4 Describe in Part XIV the intended uses of the organization's endowment funds, See Pdrt XIV ~Par'ttV_hs Investments-Land, Buildin s, and E ui ment. See Form 990, Part X, line 10. Description of investment (a} Cost or other basis (b) Cost or other (c) Depreciation (d) Book Value (investment) basis (other) 1a Land b Buildings - - - cLeasehold improvements . d Equipment 349, 707 , 126, 099. 223, 608 . e Other 23, 457. 17, 303. 6, 154 . Total. Add lines la-le (Column (d) should equal Form 990, Part Y, column (B), line ]o(c).)...... ? 229, 762 , BAA Schedule D (Form 990) 2008 T ~ EA3302'. 12!23/08 Schedule D (Form 990)2008 HO e HOS ice, Inc. 94-2576059 Page 3 ~ParfUllt`~ Investments-Other Securities See Form 990, Part X, line 12. (a) Description of security or category (b) Book value (c) Method of valuation (including name of security Cost or end-of- ear market value Financial derivatives and other financial products......... . Closely-held equity interests . other Domestic Equities_ _ _ _ _ _ _ _ _ _ _ 671, 956. End of Year Market Value Inter_na_tion_al_E_c~uities _ _ _ _ _ _ _ _ _ _ _ 284, 48 9 . End of Year Market Value Fixed_Income _ _ 662,525. End of Year Market Value Certi_fi_c_a_te_s_ of Deposit _ _ _ _ _ _ _ _ _ _ 1, 917, 354. End of Year Market Value Other 2,248. End of Year Market Value Total. (Column (b) should equal Form 990 Part K, col. (8) line 1Z) ~ ~ 3 , 538 , 5 7 2 . ~-n M ' a .k . ~ ~Part~Vl'Ila Investments-Pro ram Related See Form 990, Part X, line 13 N/A (a) Description of investment type (b) Book value (c) Method of valuation Cost or end-of- ear market value Total. Column (b (should equal Form 990, Part X. Cot. (8) line 13J ~ F". r`_ ~,~~r"~t~:rr9 ~'"~'L~k~. ~Part~l'~,~„' Other Assets (See Form 990, Part X, line 15) N/A (a) Description (b) Book value Total. Column (b) Total (should equal Form 990, Part X; col. (8), line 15) aPart~X!;~~; Other Liabilities (See Form 990, Part X, line 25) b Amount (a) Description of Liability ~a ~ ~ r~{~`~ Federal Income Taxes ~ , ' ;e ; R ) . 5 ~ ~ 1 S t } F rfii t y~f1 s~~ ns- a 'p~e'~`F,j-t k 'ts"s ~`n' F" 'u ,t 4 W '~LL ~-a~G~.ti. sir' ~tY t ywn~~~y~'xtC °.a~ rya .^"i: ce"~ ' ~ ~r~ci ~ ~ ~ xfp~a~ d+2~.~,~+,..,~~ d' 9 t ~ ~ iy~.. 3 Y~ a fh ~`v-. Total. Column (b) Total (should equal Form 990, Part Y,, col. (8) Iine25) ~ ~.`t;"{-->;~ ;'P~~,.' s ~ In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48. BAA r~~ssosL io~zsios Schedule D (Form 990) 2008 Schedule D (Form 990) 2008 HO e HOS iCe, Inc. 94-2576059 Page 4 ,~P~ar#~+)CI~ Reconciliation of Chan a in Net Assets from Form 990 to Financial Statements 1 Total revenue (Form 990, Part Vlll,column (A), line 12) 5, 725, 287 . 2 Total expenses (Form 990, Part IX, column (A), line 25) 5, 802, 827 . 3 Excess or (deficit) for the year. Subtract line 2 from line l -77, 540 . 4 Net unrealized gains (losses) on investments . 5 Donated services and use of facilities 6 Investment expenses . 7 Prior period adjustments . 8 Other (Describe in Part XIV) 9 Total adjustments (net). Add lines 4-8 . 1d Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 -77, 540 . ~Part~X,ll~ Reconciliation of Revenue er Audited Financial Statements With Revenue er Return 1 Total revenue, gains, and other support per audited financial statements 1 5, 749, 492 . 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: a Net unrealized gains on investments 2a b Donated services and use of facilities 2b cRecoveries of prior year grants 2c i.°•> d Other (Describe in Part XIV)....Se.e. Part..XIV 2d 24, 205. Y.:. e Add lines 2a through 2d 2e 24, 205 . 3 Subtract line 2e from line 1 3 5, 725, 287 . 4 Amounts included on Form 990, Part VIII, line 12, but not on line 1: a Investments expenses not included on Form 990, Part VIII, line 7b 4a r"~ ` y;ix . b Other (Describe in Part XIV) 4b ~ c Addlines 4a and 4b 4c 5 Total revenue. Add lines 3 and 4c. (this should equal Form 990, Part 1, line 12.) 5 5, 725, 287 . ~~Pa'rtXlll Reconciliation of Ex enses er Audited Financial Statements With Ex enses er Return 1 Total expenses and losses per audited financial statements 1 5, 827, 032 . 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: r~.. a Donated services and use of facilities 2a ti . b Prior year adjustments 2b c Losses reported on Form 990, Part IX, line 25 2c .,~.s d Other (Describe in Part XIV)....See. Pact..XIV 2d 24, 205. eAdd lines 2a through 2d 2e 24, 205 . 3 Subtract line 2e from line 1 3 5, 802, 827 . 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investments expenses not included on Form 990, Part VIII, line 7b 4a t~. b Other (Describe in Part XIV) 4b c Addlines 4a and 4b 4c 5 Total expenses. Add lines 3 and 4c (This should equal Form 990, Part I, line 18.) 5 5, 802, 827 . PF~rtYXI~V,.Su lementallnformation Complete this part to provide the descriptions required for Part I I, lines 3, 5, and 9; Part III, lines .1 a and 4; Part IV, lines 1 b and 2b; Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Part_V=Line_4_=_Intended_Uses of_Endowment_~und:__________________ The_intended_uses of_ the _orc~anizatic~n' s en 1owm~nt f.~n 1~_ax_e ~Qr_~Qmp~tt~r~__ market~inc~iz.P~rade~~nd_hui.l r3; ng~eagital_im~rQ~zements..-------------------- p~rt_XL-_Line_8r_P~t_ XII-T i nP 2L17_a11C1~3.r'f-XZLL-~i~Q_2d~----------------- Adjustment for _direct_ex~enses_ fQr_fundr~i~inc~ ~v~~t~_>~~~~esL4~_EQ~m_994___ l~~t_ahQw~ gr4sa_izL~..in~n~ia.L~~~.tements_.-------y------------------------ BAA T~~ssov~ tz/zs/o& Schedule D (Form 990) 2008 Schedule D (Form 990) 2008 Paoe 5 ~Pa'rf.Xl1'/~t:~ Supplemental Information (continued) - BAA r__,a?sos! o~iz-:;os Schedule D (Form 990j 2008 2008 Schedule D, Part XIV -Supplemental Information Page 6 Client HOPE Hope Hospice, Inc. 94-2576059 3/17/10 12:15PM Schedule D, Part XII, Line 2d Other Revenue Included In FIS But Not Included On Form 990 Net Fundraising Expenses $ 24,205. Total $ 24,205. Schedule D, Part XIII, Line 2d Other Expenses And Losses Per Audited FIS Net Fundraising Expenses $ 24, 205. Total $ 24;205. 2008 Federal Worksheets Page 1 Client HOPE Hope Hospice, Inc. 94-2576059 3/17/ 10 12:OOPM Schedule D, Part V Endownment Funds Current Prior Two Yrs. Three Yrs. Four Yrs. Year Year Back Back Back Beginning of year balance 4, 100, 000. 0 . 0 . 0 . 0. Contributions 4, 100, 000 . Investment earnings (losses) Grants or scholarships Expend. for facilities & progs 33 9,102. Administrative expenses End of year balance 3, 760, 898. 4,100, 000. 0 . 0 . 0 . OMB Na. 1545-0047 sCHE~u~E G Supplemental Information Regarding (Form 990 or 990-EZ} Fundraising or Gaming Activltles 200 Must be completed by organizations that answer 'Yes' to Form 990, Pact IV, fines 17, 18, " O r' n to~Pub( c~'- Depariment of the Treasury ~ ~p ~ +'~u; Internal Revenue Service or 19, and by organizations that enter more than $15,000 on Form 990-EZ, line 6a. ,w~lii'spectron ~-^~~;4,~ Name of the organization Employer identification number Ho e Hos ice, Inc. 94-2576059 EP=art~1?, Fundraising Activities. Complete if the organization answered 'Yes' to Form 990, Part N, line 17. 1 Indicate whether the organization raised funds through any of the following activities. Check all that apply. Mail solicitations Solicitation of non-government grants Email solicitations Solicitation of government grants Phone solicitations Special fundraising events In-person solicitations 2a Did the organization have written or oral agreement with any individual (including officers, directors, trustees or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services? Yes ~No b If 'Yes,' list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is to be compensated at least $5,000 by the organization. Form 990EZ filers are not required to complete this table. (v) Amount paid to (i) Name of individual (ii) Activity (iii) Did fundraiser (iv) Gross receipts (or retained by) (vi) Amount paid to or entity (fundraiser) Have custody or control from activity fundraiser listed in (or retained by) of contributions? col.(i) organization Yes No Total ~ 0. 3 List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing. BAA For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990. Schedule G (Form 990 or 990-EZ) 2008 T==P3701L 121181DS Schedule G (Form 990 or 99D-EZ) 2008 Hope HOSpiCe, Inc. 94-2576059 Page 2 P~art~ll`F Fundraising Events. Complete if the organization answered 'Yes' to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000. (a) Event #1 (b) Event #2 (c) Other Events (d) Total Events Ship of Hope G .Crow Canyon Co 2 (Add col. (a) through ' event t e event t e CO. (C)) ( yp) ( yp) (total number) R E V E 1 Gross receipts 50, 925. 8, 729. 5, 465. 65, 119. N U E 2 Less: Charitable contributions......... . 3 Gross revenue (line 1 minus line 2)..... 50; 925. 8, 729. 5, 465. 65, 119. 4 Cash prizes D I R 5 Non-cash prizes E C T 6 Rent/facility costs . E X E 7 Other direct expenses 24, 205. 24 205. N ' S s 8 Direct expense summary. Add lines 4- through 7 in column (d) ~ 24, 205 . 9 Net income summary. Combine lines 3 and 8 in column (d) ~ 40, 914 . ~Par,'•k~fll~ Gaming. Complete if the organization answered 'Yes' to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a. R (a) Bingo (b) Pull tabs/Instant (c) Other gaming (d) Total gaming E bingo/progressive (Add col. (a) through ~ bingo col. (c)) E N U E 1 Gross revenue 2 Cash prizes E D X ' ~ r 3 Non-cash prizes R E E N C 5 r E 4 Rent/facility costs . s 5 Other direct expenses Yes $ Yes o Yes o 6 Volunteer labor No No No 7 Direct expense summary, Add lines 2 through 5 in column (d) ~ 8 Net gaming income summary. Combine lines 1 and 7 in column (d) ~ YES NO 9 Enter the state(s) in which the organization operates gaming activities: a Is the organization licensed to operate gaming activities in each of these states? 9a b If 'No,' Explain: 'r~,_ 4 1Da Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? l0a b If 'Yes, Explain: 11 Does the organization operate gaming activities with nonmembers? 11 12 Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity formed to °=`--!W-~~''=~''"=-' administer charitable gaming? 12 BAA T==P.3702L oan~ios Schedule G (Form 990 or 990-EZ) 2008 Schedule G (Form 990 or 990-EZ) 2008 Hope HOSpiCe, Inc. 94-2576059 Page 3 YES NO 13 Indicate the percentage of gaming activity operated in: ° '-Y' ~ t s a The organization's facility....... 13a o t, t''„; b An outside facility.. 13b o 14 Provide the name and address of the person who prepares the organization's gaming/special events books and records >~t`~ ,d; rM t yr 4x~ w Name: ' ~'t` ~ t ~ ,~7~,~~ spy Mtn Address: ' Y3;~hr= " ` 15a Does the organization have a contact with a third party from whom the organization receives gaming revenue?.......... 15a b If 'Yes,' enter the amount of gaming revenue received by the organization $ and the amount 9 e of gaming revenue retained by the third party $ c If 'Yes,' enter name and address: z~~, itY~~~.' Name: ' r r ' r,,. - Address: ? ~ ~~'a ----------------------------------------------------st-~ a:~ :a N~~~ 16 Gaming manager information a~ - . „t _ Name: ' - ~ c..ll. - - ~ F Lf Gaming manager compensation ~ $ ~ - Description of services provided: ? ~ m~ Director/officer Employee Independent contractor ; ~ . i a~. F. 17 Mandatory distributions tl " 5, { a Is the organization required under state law to make charitable distributions from the gaming proceeds to retain the ; state gaming license? . 17a' . b Enter the amount of distributions required under state law distributed to other exempt organizations or spent in the r , a, r'~` " i'=~ i{ - organization's own exempt activities during the tax year: $ ~ BAA TEEA3703L o7nsros Schedule G (Form 990 or 990-EZ) 2008 OMB No. 15450047 SCHEDULE L Transactions with Interested Persons (Form 990 or 990-EZ) 2008 Attach to Form 990 or Form 990-EZ. To be completed by organizations that answered ~ ,,,-,,,~,y,~ 'Yes' on Form 990, Part IV, hne 25a, 25b, 26, 27, 28a, 28b, or 28c, i',i,.Openito Public '~f"! Department of the Treasury or Form 990-EZ, Part V, line 38a or 40b. k'"i~~.lnspectfonT' Internal Revenue Service =.r,;;,,~+~~ _ Name of the organization Employer identification number ~ Hoe Hospice, Inc. 94-2576059 ~Parfnl Excess Benefit Transactions (section 501(c)(3) and section 501(c)(4) organizations only). To be completed by organizations that answered 'Yes' on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b. ~ (a) Name of disqualified person (b) Description of transaction (c) Corrected? Yes No 2 Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958 ~ $ 3 Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ~ $ ¢Partl!I~,~ Laans to and/or From Interested Persons. To be completed by organizations that answered 'Yes' on Form 990, Part IV, line 26 or Form 990-EZ, Part V, line 38a. (a) Name of interested person and purpose (h) Loan to or from (c) Original (d) Balance due (e) In default? Approved (g) Written the organization? prinapal amount by board or agreement? committee? To From Yes No Yes No Yes No Total . ~ $ _ ~ ~I,'. _ ~~s ~Part~;l'I,. Grants or Assistance Benefitting Interested Persons. To be completed by organizations that answered 'Yes' on Form 990, Part IV, line 27. (a) Name of interested person (h) Relationship between interested person and (c) Amount of grant or type of assistance the organization ~Pa_rt~~IV;x`: Business Transactions Involving Interested Persons. To be completed by organizations that answered 'Yes' on Form 990, Part IV, line 28a, 28b, or 28c. (a) Name of interested person (b) Relationship between (c) Amount of (d) Description of iranszction (e) Sharing of interested person and the transaction S organization's organization revenues? Yes No Charles Crohare VP for Tri-Val 126,372. See Schedule 0 X Mar ie Perry VP Herita e Ba 865,876. See Schedule 0 X BAA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule L (Form 990 or 990-EZ) 2008 r_=A~sotL tvnros SCHEDULE M Non-Cash Contributions OMB No. 1545-0047 (Form 990) ~®®p To be completed by organizations that answered 'Yes' OO on Form 990, Part IV, lines 29 or 30. ~ J~.u w~l Department a the Treasury + 30pen to=Putilfc~"~a`r*,~` Internal Revenue Service ? Attach to Form 990. ans ectwrrw ~x,,,~ P<r-.a. „:mot Name of the organization Employer identification number Hoe Hospice, Inc. 94-2576059 Parf~:I}x~ T es of Pro ert (a) (b) (c) (d) Check if Number of Revenues reported Method of determining applicable Contributions on Form 99D, revenues Part VIII, line lg 1 Art-Worl<s of art . 2 Art-Historical treasures . 3 Art-Fractional interests . 4 Books and publications ; ~ s ~ ~ x 5 Clothing and household goods 6 Cars and other vehicles 7 Boats and planes . 8 Intellectual property 9 Securities-Publicly traded . 10 Securities-Closely held stock . 11 Securities-Partnership, LLC, or trust interests . 12 Securities-Miscellaneous 13 Qualified conservation contribution (historic structures)..... . 14 Qualified conservation contribution (other)...... . 15 Real estate-Residential . 16 Real estate-Commercial . 17 Realestate-Other 18 Collectibles 19 Food inventory 20 Drugs and medical supplies . 21 Taxidermy 22 Historical artifacts . . 23 Scientific specimens . 24 Archeological artifacts 25 Other ? (Supplies 1 14,246. 26 other ? (See Schedule 0 27 Other ? ( 28 Other ? ( 29 Number of Forms 8283 received by the organization during the tax year for contributions for which the organization completed Form 8283, Part IV, Donee Acknowledgement 29 Yes No »v.~ -y;, 30a During the year, did the organization receive by contribution any property reported in Part I, lines 1-28 that it must 'k G - hold for at least three years from the date of the initial contribution, and which is not required to be used for exempt _ t ~ ' • - 1 purposes for the entire holding period? 30a X b If 'Yes,' describe the arrangement in Part II. ~ .G3: 31 Does the organization have a gift acceptance policy that requires the review of any non-standard contributions? 31 X 32a Does the organization hire or use third parties or related organizations to solicit, process, or sell rtoncash contributions? 32a X b If 'Yes,' describe in Part I I. ;rte`°}` Ti ~ 33 If the organization did not report revenues in column (c) for a type of property for which column (a) is checked, _ ri ` describe m Part II. ' BAA For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule M (Form 990) 2008 TE=A4601 ! i 2n Bros Schedule M (Form 990) 2008 HOpe HOS iCe, Inc. 94-2576059 Page 2 ":P;art~~IJ~= Supplemental Information. Complete this part to provide the information required by Part I, lines 30b, 32b, and 33. Also complete this part for any additional information. BAA T==Ac602L o~nc~os Sch=dule M (Form 990) 2008 i. • OMB No. 1545-0047 SCHEDULE 0 Supplemental Information to Form 990 (Form 990) ~ 0 ® Q Attach to Form 990. To be completed by organizations to provide ~ ~,-r=,~ additional information for responses to speclffc questions for the Open to Publ(c'~a~s~; Department of the Treasury Form 990 or to rovide an additional information. ~ 1'ns ect(on r ~b Internal Revenue Service P Y ~ v~.~,.~ p,~~;_3~,_~d~.. Name of the organization Employer identification number Hope Hospice Inc 94-2576059 Schedule_M~ Line 26- Non Cash Contrib________________________________________ _ _ Total Non Cash_Contributions is _$46,869_ _ The make_u~ of this amount is as_follows_ _ Legal Fees____$15,528_ Advertising____17,095_______________ Supplies ______14,246_____________ _ _ Schedule M_does not require to_list donated services or use of_space,_ and therefore _ - _ _ we_are_showing_the_details_here _ Schedule L -Interested Persons _ _ Charles Crohare_served_as Treasurer of_the_Board of Directors for Hope_Hospice_ _ _ _ _ durin~_the_fiscal year ended June 30,_2009__ He _i s_the_Vice_President:Relationshi~___ _ _ Manager for Tri=Valle~_Bank _ _ Monies on deposit as_of June_30,_2009 were $101,294 in ___a Certificate of Deposit and $25, 078 in a Money Market_account__________________ _ _ Margie_Perr~ served as_the_Vice President of the Board_of Directors _f or Hope Hospice _ _ durin~_the_fiscal year ended June 30, 2009. She is the Vice-President/Branch _ _ Manager _f or Heritage Bank of Commerce._ Monies_on d~osit as of June 30, 2009 were _ _ _$174,698 in a checking_account_and_$691,178 in_a Mone~_Market account._ Form 990, Part VI, Line 10 -Form 990 Review Process The Form 990 will be presented to a committee of the Board of Directors established for that purpose. That committee will take the Form 990 to the Board of Directors for recommendation and approval for filing. Form 990, Part VI, Line 12c -Explanation of Monitoring and Enforcement of Conflicts The Board of Directors and key management staff will fill out the "Conflict of Interest Disclosure Statement." These statements will be reviewed by the chair of the Board of Directors who .will determine appropriate action if a conflict of interest is identified. BAA For Privacy Act and paperwork Reduction Act Notice, see the instructions for Form 990. T==Ae907 L 72/19/08 Schedule O (Form 990) 2008 Schedule 0 (Form 990) 2008 Page 2 Name of the organization Employer identification number Hope Hospice, Inc. 94-2576059 _ _ Form 990, Part VI, Line 15b _Compensation Review & Approval Process for Officers & Key Em~lo~ees_ _ _ _ _ _ _ The finance committee reviews comparability data (wage surveys and contacts other hospices) and makes a recommendation to the Board of Directors. Form 990, Part VI, Line 19 - Other Organization Documents Publicly Available The exempt organization's governing documents, policies, and financial statements are made available to the public upon request. BAA Schedule 0 (Form 990) 2008 TA4902L 12/11!2008