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HomeMy WebLinkAboutCOM 0667.032 1998-2000 trier • . ✓Gom 0 661 V5 0 i , - /Sh rkur vr-5 ol'r`� o ;1 . 9r M1 • Stephen K. Yamashiro , : ,\ �� /,. .' Harr A. Takahashi t .; Director `., s - .+.• S. K. Schulte -- R ".`w or, �' -- EC ' 1 Deputy � � ,,AN 3 1 zoo'? County of 3aivaii DEPARTMENT OF FINANCE 25 Aupuni Street, Room 118 • Hilo, Hawaii 96720 -4252 (808) 961-8234 • Fax (808) 961 -8248 HAWAII COUNTY NONPROFIT GRANTS (FY 2000 -01) HUMAN SERVICES NONPROFIT GRANTS REVIEW COMMITTEE (HSNPGRC) FISCAL YEAR ENDING:Iune 30, 2001 DATE OF APPLICATION: GRANT APPLICATION FOR: N ©s pi C eS a e r era tie M ek , 1 ?to 7 it/vi (Program Title) Legal Name of Organization: / 0 S p 1 G 'e.. iti 071 A la / _ • Mailing Address: Pia. V 02 !i f 7 GI ALA a.vn , / � / L 9674<c Facility/Site Address: (, 7 5e,-/I/ex O 91 RA (ate, t /} .kat (lid - 5e - /I- , l�r rl 9(7'/C7 Director /Site Manager: n/ om J/e � ` C &4t4U hit.Phone: cgd 3 3 (7 3311 – 0 Organization President: 9, _1 k t c1 Phone: C °0 3 ` - 9'6 3 ?– Contact Person (Grant Writer) 8,1 I C'e S I.. L,, 'VW c ' , -.. Y. h Phone: (ne., : - -GLI33V Amount of request for County funds: $ ( a1 OQO • 0:3 Total annual budget of organization: $ Has the applicant applied for any other funds from the County of Hawaii this fiscal year? 0 Yes Source /Department: (S/ No Agency /Program(s): 0 Social Services 0 Youth Programs ( Elderly Programs . Check Category (ies) 0 Culture and Arts CS Education CS Other Comm. No...L.6 '7l 9 . File No. ADM Briefly, define the program for which funding is being requested: Ref. To: ke Th A /Gee BePeAUe.m tit lei ai3A- Ref. Date FEB 2 R 'nun J,j/s ,ottuts." ,td des /fitted t ?CC iloct tie occwr at e.e- G6 m lled/ed-- -b r• eaue o r '`U r_ , • • . , . .c.em z 1• . Thu / s Aid a t2 a a,e-d p ra 7 r a i 'R w )1..; . ki QUALIFYING STANDARDS FOR APPLICANTS An applicant must meet all of the following standards: Be chartered or otherwise authorized to do business in the State for charitable purposes and exempted from the Federal income tax by the Internal revenue Service. 0 Have a governing board whose members serve without compensation and have no conflict of interest between their regular occupations and the services provided. 05 Have bylaws or policies which describe the manner in which business is conducted, including management, audit, fiscal policies and procedures, policies on nepotism, and policies on management of potential conflict of interest. 0 Have at least one year's experience with the service or activity for which the appropriation is sought or can otherwise demonstrate to the satisfaction of the County sufficient expertise to successfully carry out the service or activity. Be licensed and accredited in accordance with applicable requirements of Federal, State and County laws. II. • GRANT CONDITIONS The applicant agrees to comply with the following terms & conditions prior to receiving a grant award. A. Comply with applicable Federal and State laws prohibiting discrimination against any person on the basis of race, color, national origin, religion, creed, sex, age, or handicap. B. Agree not to use any public funds for purposes of entertainment or perquisites. C. Comply with such other requirements as the Director of Finance may prescribe to ensure adherence by the nonprofit organization with Federal, State, and County laws, and established standards for fiscal and program management. D. Allow the Director of Finance, the committees of the council and their staffs, and the Legislative Auditor access to records, reports, files, and other related documents in order that the program, management, and fiscal practices of the nonprofit organization may be monitored and evaluated to assure the proper and effective expenditure of public funds. III. RECORDS AND REPORTS • ' A. The applicant shall follow generally accepted accounting procedures and practices and shall maintain books, records, documents, and other evidence, which sufficiently and properly account for the expenditure of County funds. The books, records and documents shall be subject at all reasonable times to inspection, reviews, or audits by the County expending agency, the Director of Finance, and the Legislative Auditor, or by their representatives. B. The County expending agency, Director of Finance, or County Council may request periodic written reports on the use of County funds. • C. The nonprofit organization shall submit a final written report to the Legislative Auditor within sixty (60) days after June 30 of the fiscal year. The report shall include an explanation of the public benefits derived from the awarding of the grant and a listing of other funding sources and amounts obtained during the award period. 2 • • IV. QUARTERLY ALLOCATION Under no circumstances shall grant funds be disbursed in a lump sum payment. Grant funds will be disbursed to Grantees only through a quarterly allocation process. The disbursement of grant funds can be formulated on an equal quarterly apportionment basis. V. GRIEVANCE PROCEDURE The applicant will adopt and maintain a grievance procedure to assure proper accounting for any concems and complaints about its programs or services that may arise from its members, employees, clients or from other members of the public. VI. DISCLOSURE OF INFORMATION All information, data, or any other material provided to the County by virtue of this application shall be subject to the Uniform Information Practices Act (UIPA), ch. 92F, Hawaii Revised Statutes. All such material is deemed government record and shall be open to the public and may be provided to other public and/or private funding sources. VII. CONTINUED ELIGIBILITY Any applicant or recipient who withholds or omits any material facts or deliberately misrepresents such facts to the County of Hawaii shall: I) Immediately be disqualified from consideration for Nonprofit Grant funding; OR 2) be in violation of the terms of the Grant Agreement of County funds in which case a grant agreement can be terminated by the County and the recipient or provider may be liable to reimburse all or a portion of any funds received therein. VIII. ACKNOWLEDGMENT / r` b s�t( 0 koYn (Legal Name of Organization) • hereby agrees to administer the 7 Iospi G e PA- ©1 Na�v. (Program Title) J in accordance with the regulations, policies and procedures prescribed by the Hawaii County Finance Department. Distribution of grant funds is limited to grantees, which are in compliance with County regulations, policies and procedures. The County reserves the right to withhold grant distributions at any time the grantee is not in compliance. It is the policy of the County of Hawaii and for those who do business with the County to provide equal employment opportunities to all persons regardless of race, physical disabilities, color, religion, sex, age, or national origin as mandated by the Federal Civil Rights Acts, as amended, and any other federal or state laws relating to equal employment opportunities. IX. AMENDMENTS TO THE APPLICATION/EVALUATION The applicant assures that it will submit to the HSNPGRC for prior review and approval, a written request and justification for any changes, additions, or deletions to any portion(s) of the grant application or a duly executed Grant Agreement of County Funds. The applicant will cooperate and assist in any effort undertaken by the HSNPGRC to evaluate, inspect or otherwise monitor the effectiveness, feasibility, and/or cost efficiency of any and all practices, policies and procedures or activities pursuant to this application or any grant designation or allocation received as a result of this application. 3 • • • X. AUTHORITY AND CAPACITY OF APPLICANT The applicant certifies that it has the authority and capacity to develop and submit this application, and to fully administer the program(s) pursuant to this application. UNSIGNED PROPOSALS WILL NOT BE ACCEPTED! odattt ./ Signature of Presiden Da e S ign re of Executive Director/Manager D to • • 4 • • • Program Service Description A. Overview 1) Description of Program: The Bereavement Program is designed to prevent the occurrence of complicated bereavement or "unhealed grief" in the bereaved in the community. This is a section of the overall Hospice program for End of Life Care for lioth the dying and their families, including not just Hospice patients but also all people in the community. • 2) The significant service that is provided is an organized program made available to tpe public, run by a qualified Masters in Social Work Counselor with training in grief counseling. This program includes contact with the families of the dying before and after the patient has died This is one on one counseling, a grief support group, periodic fnailouts and telephone call follow -up as well as a lending library with information books and tapes on understanding grief. 3) The specific outcome to be achieved is to prevent the occurrence of "complicated bereavement ", or `unhealed grief' in the bereaved in our community. 4)This program empowers clients to facilitate the task of healing their grief by several different sections. Review of bereavement literature shows that it is normal for grief to heal; that the grieving process following a significant loss is painfully intense and lasts for a long time, but that grief does heal if the bereaved person is able to accomplish the 5 stages or "tacks" of healing: The five tacks of healing grief are: (1) Gradually accept the painful truth that the loss has occurred • (2) Acknowledge, experience, and express the painful feelings until • healing occurs. (3) Begin putting one's life back together. (4) Put the loss into a wider context of meaning. (5) Reach out to others who have suffered losses 'Complicated bereavement- grief that does not heal - happens when these healing tasks are not accomplished. 2 The most significant task, which makes up most of the grieving process is the second one: acknowledging, experiencing, and expressing the feelings of grief over and over, until healing occurs. Accomplishing this task is also where most problems in bereavement occur, mostly because: 1) The bereaved does not know how to grieve, has come to believe that recurring, intense feelings of grief are abnormal and should not be allowed. 2) The bereaved is discouraged from expressing his/her feelings and does not have the opportunity to express these feelings. It follows that if the bereaved can learn to • acknowledge and experience feelings of grief, and are given the opportunity to express these feelings, normal healing will likely occur, and complicated bereavement avoided. B. Problem! Need 1) This program is designed to support the families of Hospice patients who are grieving in order to facilitate the stages of healing and prevent complicated bereavement. 2) This program supports North and South Kona with a current population of about 30,000 people and a death rate of about 140 per year. Clinebell, Howard and Martha Hickman. Growing Through Grief: Personal Healing.. • UMCom Productions: 810 12 Ave. S., Nashville, TN 37203 2 Clinebell, Howard and Martha Hickman Growing Through Grief: Personal Healing. UMCom Productions:. 810 12 Ave. S., Nashville, TN 37203 - • • 31 Our agency serves North and South Kona and we are open five days a week, with on -call Registered Nurse services provided 7 days a week, 24 hours a day. C. Collaboration/ Coordination 1) We collaborate and coordinate our services with all professional and service organizations in this area. We belong to the Hospital Discharge Planning group that meets weekly at Kona Hospital, as well as the Case Management Project run by the Public Health Department. This allows us to offer our services to any member of the community. At this time there are no other daytime support services offered for this community need, and we believe our program does not overlap any other programs, and therefore remains cost - effect, achieving maximum program efficiency. 2) There is no known duplication of this type of support service for our designated target group. D. Goals and Objectives: • - ' I )The major goals of this program is to allow the bereaved the knowledge and opportunities needed to acknowledge, experience; express and share their feelings of grief so that they may heal their grief. 2) Specific actions steps that are planned are a) a support grief that meets once a week, facilitated by our Bereavement counselor, b) home visits and telephone calls to the bereaved to support the bereaved by allowing them to talk and express their feelings about the loss, c) mailouts, inservices, Letters, books and tapes available during office hours to educate the bereaved in the stages of grieving. 3) Our services begin for Hospice patients before they die, and continue afterwards for a year for the family. 4) The clients will achieve Intermediate Outcomes by participating in our programs. communicating with the Bereavement counselor, attending the grief support group. The long term Ultimate Outcome will be demonstrated by the absence of complicated grieving, shown by interviews with the client and the absence of reports from the community and professionals on complicated grieving. E. Service Deliver 1) These programs are provided by telephone, or home visits or meetings and group support given in the Hospice office. Records will be made frequently, monthly with a review of the Bereavement Assessment and Plan of Care. . F. Evaluation Hospice will review the bereaved records quarterly to accrcc if complicated grieving is occurring. At that . time professional staff will intervene appropriately. Criteria for complicated bereavement includes: - r • - expressing thoughts of suicide -self- destructive or extremely risky behaviors - inability or unwillingness to talk about the loss -not expressing feelings about the loss - excessive drinking; abuse of drugs depression or anxiety needing medical/therapeutic intervention ('as opposed to sadness, emotional pain) . - isolation: refusing to be with others, refusing to go out -sleep that is so poor that hegtth is compromised -very significant weight loss and /or weakness due to not eating - turning away from one's spiritual foundation or belief system without searching for new . meaning or a new foundation _ - refusal or inability to participate in any activities that have been meaningful - indication bf server emotional disturbance or cognitive impairment. • • Hospice professional staff conducting reviews are Licensed Social Workers, Registered Nurses, Licensed Counselors, Licensed Counselors, Licensed Psychologists, and Medical Doctors. • G. Program Fees: - 1) Hospice does not charge a membership fee for this service, nor do we propose charging. H. Viability 1)This program, though unfunded, is mandated by Medicare HCFA. 2)We are funded by donations, fundraising and grantwriting for this program. 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Schutte % ` y f OF H r r Deputy Countp of 3atuaii DEPARTMENT OF FINANCE 25 Aupuni Street, Room 119 • Hilo, Hawaii 96720 -4252 • (808) 961-8234 • Fax (808) 961 -8248 HAWAII COUNTY NONPROFIT GRANTS (FY 2000 -01) FINANCIAL QUESTIONNAIRE Please include as an attachment an explanation for all "NO" answers to questions #1 thru 11 below: Yes No VO 0 1. Has the agency operated continuously for the past three (3) years? (5 CS 2. Has the agency operated with a positive cash flow for the past (3) years? 3. Does your Board of Directors approve a detailed cash flow budget before the beginning of each fiscal year? (3 0 4. Do your Board meeting minutes show that:,quarterly financial statements are approved? ' 0 5. Is your equity balance at least 20% of your Total Liability balance? (! (5 6. Is your Total Current Asset balance. larger than your Total Current Liability balance? if 0 7. Are bank reconciliations and accounting performed by someone other than the check signatory? l✓J / 0 8. Are you. fully insured for the agency's velticle(s) and building(s)? Cd 0 9. Is your Workers' Compensation at least 234 of payroll? • V 0 10. Are you current (not delinquent) on all payroll and payroll tax payments? 11. Is the agency free of any pending litigation, liens or judgments? 0 12. Within the past 12 months, has the agency applied for vendor or bank credit and was denied credit? If yes, please explain. ,4s the grant applicant, 1 cert fy that the agency has satisfactorily responded to each of the above questions and explained as needed. I hereby cert that this information is true and correct to the best of my knowledge. Agency: cert. i(0, &— LflIt Phone: - 3(4 U 3 3q � " Prepared by: NY t i , La AP • Print Name/Title I ;cure Date Certified by: VI lQ4A Baku wto.AY1 ,/ / ,• , v Print Name of Executive Director t natur D to 1ffY F • • • • Hospice of Kona, Inc. (a non - profit organization) Financial Statements December 31, 1996 & 1995 • Ann Fukuhara Certified Public Accountant • • • Hospice of Kona, Inc. Table of Contents Independent Auditor's Report 1 Financial Statements Statements of Financial Position 2 Statement of Activities 3 Statement of Functional Expenses 4 Statement of Cash Flows 5 Notes to Financial Statements 6 - 10 Management Letter 11 - 12 - Ann N. Fukuhara, CPA 714 Kanoelehua Avenue P.O. Box 6691 Hilo, Hawaii 96720 (808) 961 -5532 Fax (808) 934 -8589 Finail: anf @gte.net Independent Auditor's Report To the Board of Directors Hospice of Kona, Inc. Kona, Hawaii I have audited the accompanying statement of financial position of the Hospice of Kona, Inc. (a non - profit organization) as of December 31, 1996 & 1995 and the related statements of' activities, functional expenses and cash flows for the year then ended. These financial statements are the responsibility of the Organization's management. My responsibility is to express an opinion on these financials based on my audit. Except as discussed in the following paragraph, I conducted my audit in accordance with generally accepted auditing standards. Those standards require that I 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. I believe that my audit provides a reasonable basis for my opinion. As discussed in note 8, no accounting controls are exercised over the thrift shop. Accordingly, it was not practicable for me to extend my audit of sales and inventory beyond the amounts recorded. In my opinion, except for the effects of such adjustments, if any, as might have been determine necessary had the sales and inventory referred in the preceding paragraph been susceptible to satisfactory audit tests, the financial statements referred to above present fairly, in all material respects, the financial position of the Hospice of Kona, Inc. as of December 31, 1996, and the changes in its net assets and its cash flows for the year then ended in conformity with generally accepted accounting principles. nn Ann Fukuhara, CPA Hilo, Hawaii November 25, 1997 1 • Hospice of Kona, Inc. • Statements of Financial Position. As of December 31, 1996 1995 ASSETS 1996 1995 Current Assets: - Cash and cash equivalents $ 108,898 $ 46,046 Accounts receivable net, note 3 41,238 124,013 Unrestricted unconditional promise to give 0 95,000 Prepaid expenses 3,277 4,194 Temporarily restricted pledge - Weinberg Foudnation, note 4 100,000 100,000 Total current assets 253,413 369,253 Property and equipment, 780,493 820,482 net of accumulated depreciation of $102,091 and 55,552 respectively, note 5 Land 150,000 150,000 Total assets $ 1,183,906 $1,339,735 LIABILITIES AND NET ASSETS Current liabilities Accounts payable $ 33,244 $ 50,059 Accrued expenses 14,506 9,617 Capital lease 0 5,102 Current portion of housing obligation 7,200' 6,046 Total current liabilities 54,950 70,824 Housing obligation,note 6 26,054 34,408 Total liabilities 81,004 105,232 Net Assets: Unrestricted, noted 1,002,902 1,122,003 Temporarily restricted, note I 100,000 112,500 Total net assets 1,102,902 1,234,503 Total liabilities and net assets $1,183,906 $ 1,339,735 • The accompanying notes are an integral part of these financial statements. 2 ' • Hospice of Kona, Inc. • Statement of Activities For the Year Ended December 31, 1996 (with comparative totals for 1995) Temporarily , 1996 1995 Unrestricted Restricted Total Total REVENUES, GAINS AND OTHER SUPPORT Revenues and support Patient revenues $ 393,417 $ 393,417 $ 663,048 Grants and contributions - 147,718 147,718 ✓ 338,779 Thrift Store, note 8 47,016 47,016 ✓ Interest 3,550 3,550 4,062 Special events 26,985 26,985 1 ,/ 2,405 Other 8,227 8,227 ✓ 8,079 Total revenues and gains 626,913 - 626,913 1,016,373 Net assets released from restrictions Restrictions satisfied by payments - 200,000 Total net asset released from restrictions - - - 200,000 Total revenues and other support - 626,913 - 626,913 1,216,373 EXPENSES Patient care, bereavement support 595,195 595,195 630,825 General and administrative 159,505 159,505 160,625 Fundraising 3,814 3,814 4,443 758,514 - 758,514 795,893 Change in net assets (131,601) - (131,601) 420,480 Net assets, beginning of year 1,122,003 112,500 _ 1,234,503 814,023 Transfers 12,500 (12,500) Net assets, end of year $ 1,002,902 $ 100,000 $ 1,102,902 $ 1,234,503 The accompanying notes are an integral part of these financial statements. 3 • Hospice of Kona, Inc. • Statement of Functional Expenses For the Year Ended December 31, 1996 (with comparative totals for 1995) / Patient Care General & Bereavement and 1996 1995 Programs 'Administrative Fundraising Total - Total Salaries $ 272,057 $ 68,014 $ 340,071 $ 417,269 Other employee benefits 21,011 5,254 26,265 23,008 Payroll taxes 28,998 7,249 36,247 39,755 Total salaries and related expenses 322,066 80,517 - 402,583 480,032 Patient and medical supplies 96,224 96,224 117,470 ' Occupancy =37,246 9,312 46,558 43,048 Staff mileage 14,624 14,624 13,412 Utilities - 11,431 2,858 14,289 14,362 Office 11,207 2,802 14,009 10,622 Professional services and consultants 18,469 27,704 46,173 16,052 Insurance 12,612 3,153 15,765 38,860 Travel 1,532 383 1,915 1,971 Conventions and meetings - - 3,510 Printing 2,309 , 9,237 11,546 5,711 Supplies and publications 850 567 1,417 5,156 Postage 827 1,241 2,068 1,887 Advertising & promotion 819 3,275 4,094 . 2,438 Interest - - 658 Dues, licenses, and fees 2,214 2,214 1,590 4 Education & training 1,749 437 2,186 4,240 Repairs and maintenance ' 15,094 3,774 18,868 5,368 Property taxes and other taxes 2,176 544 2,720 Other expenses 8,729 2,179 3,814 14,722 2,951 Total expenses before depreciation 557,964 150,197 3,814 711,975 769,338 Depreciation 37,231 9,308 46,539 26,555 Total Expenses $ 595,195 $ 159,505 $ 3,814 $ 758,514 $ 795,893 The accompanying notes are an integral part of these financial statements. 4 • Hospice of Kona, Inc. • Statement of Cash Flows For the Year Ended Decembr 31; 1996 (with comparative totals for 1995) 1996 1995 Cash Flows From Operating Activities: Change in net assets $ (131,601) $ 420,480 Adjustments to reconcile change in net assets to net cash provided by operating activities: Depreciation 46,539 26,555 Noncash contributions (2,000) (Increase) decrease in patient accounts receivable 82,775 (8,643) (Increase) decrease in other receivables 95,000 (195,000) (Increase) decrease in prepaid expenses 917 13,355 Decrease in deposits 2,869 Increase (decrease) in accounts payable (16,815) 5,466 Increase (decrease) in accrued liabilities 4,889 (9,829) Net cash provided by operating activities 81,704 253,253 Cash Flows From Investing Activities: Purchase of equipment (6,550) (297,434) Net cash used by investing activities (6,550) (297,434) Cash Flows From Financing Activities: Proceeds (repayment) from note payable - (88,752) Payments made to housing obligation (7,200) (6,046) Repayment of capital leases (5,102) (2,467) Net cash provided by financing activities (12,302) (97,265) Net decrease in cash and cash equivalents 62,852 (141,446) Cash and cash equivalents - beginning of year 46,046 187,492 Cash and cash equivalents - end of year $ 108,898 $ 46,046 The accompanying notes are an integral part of these financial statements. 5 Hospice of Kona, Inc. • • • Notes to Financial Statements December 31, 1996 1. Organization Hospice of Kona, Inc. is a non -profit organization incorporated on August 25, 1985 pursuant to the laws of the State of Hawaii to provide support, skilled services, and education for terminally ill persons and their families. The Organization is supported primarily through fees for patient services, contributions from individuals and businesses, and grants from various foundations and other entities. Approximately 63% of the Organization's revenues for the year ended December 31, 1996, came from third party insurers of its patients. 2. Summary of Significant Accounting Policies Basis of accounting - The financial statements of Hospice of Kona, Inc. has been prepared on the accrual basis of accounting. Donated property and equipment - Donations of property and equipment are recorded as support at their estimated fair value at the date of donation. Assets donated with explicit restrictions regarding their use and contributions of cash that must be used to acquire property and equipment are reported as restricted support. ' Donated services - Hospice of Kona receives a substantial amount of services donated by citizens interested in the Organization's programs. No amounts have been reflected in the financial statements for donated services. Expense allocation - The costs of providing various programs and other activities have been summarized on a functional basis in the Statement of Activities and in the Statement of Functional Expenses. Accordingly, certain costs have been allocated among the programs and supporting services benefited. Income tax status - .Hospice of Kona, Inc. is exempt from federal income tax under Section 501(c)(3) of die Internal Revenue Code. Property and equipment - Property and equipment are stated at cost or, if donated, at the fair value at the date of donation.- Depreciation is computed primarily on the straight line basis. Accounting estimates - The preparation of financial statements in conformity with generally accounting principles requires management to make estimates and assumptions that affect certain reported amounts and disclosures. Accordingly, actual results could differ from those estimates. 6 • Hospice of Kona, Inc. • • Notes to Financial Statements, continued 2. Summary of Significant Accounting Policies - continued Restricted and unrestricted revenue and support - Contributions received are recorded as unrestricted, temporarily restricted, or permanently restricted support, depending on the existence and/or nature of any donor restrictions. Support that is restricted by the donor is reported as an increase in unrestricted net assets if the restriction expires in the reporting period in which the support is recognized. All other donor - restricted support is reported as an increase in temporarily or permanently restricted assets, depending on the nature of the restriction. When a restriction expires, (that is when a stipulated time restriction ends or purpose restriction is accomplished), temporarily restricted net assets are reclassified to unrestricted net assets and reported in the Statement of Activities as net assets released from restrictions. 3. Accounts Receivable Accounts receivable as of December 31, 1996 & 1995 consists of third party insurers as follows: 1996 1995 Accounts receivable $47,848 $136,513 Allowance for doubtful accounts (6,610) (12,500) Net receivables $41.238 $124,013 4. Temporarily restricted pledges — Weinberg Foundation Hospice of Kona, Inc. was awarded two grants from the Harry and Jeanette Weinberg foundation amounting to a total of $300,000. The Foundation agreed to pledge $200,000 for the Hospice of Kona's improvement project of the residential facility. The agreement stipulates that Hospice of Kona commence construction of the project by June 30, 1995 and complete the project by 7 • Hospice of Kona, Inc. • Notes to Financial Statements, continued 4. Temporarily restricted pledges - Weinberg Foundation - continued December 31, 1995. Hospice of Kona completed the construction of the project during August 1995. The Foundation also granted Hospice of Kona an endowment fund for the sum of $100,000. Under the terms of the agreement, the endowment funds are to be deposited in a federally insured bank or financial institution that provides the highest treasury rates over a one to five year period and such savings deposit shall be subject to approval from the Foundation. Further, all income received from the endowment fund must be used for - the specific purpose such as repair and maintenance to the residential care facility and for major equipment purchases. In the subsequent period, the agreement was amended. Hospice of Kona will not operate a residential care facility but a "Hospice Care House" for which the organization will allow to house the corporation's administration and to provide counseling, training, and education. The Weinberg foundation has agreed to the new amendment to the Endowment Fund.. 5. , Property and Equipment As of December 31, 1996 & 1995 property and equipment consisted of the following: 1996 1995 Hospice Care House $800,355 $800,355 Vehicles 33,356 33,356 Equipment 48,873 42,323 882,584 876,014 Less accumulated depreciation 102,091 55,552 Land 150,000 150,000 • $930.493 $970.482 8 • • 1 Hospice of Kona, Inc. Notes to Financial Statements, continued 6. Housing Obligation Hospice of Kona received residential real property located in Kailua -Kona during 1994. Under the terms of the contribution, Hospice of Kona assumed a mortgage in the amount of $25,000 which has been repaid in 1995 and agreed to pay the housing costs of the donor of the property for the remainder of the donor's life. Payments made on the donor's housing costs for the year ended.. amounted to $7,200. The housing obligation as of December 31, 1996 and 1995 are as follows: 1996 1995 Housing obligation — current portion $7,200 $6,046 Long term portion 26,054 34,408 Total Liability $33,254 $40.454 7. Leases a. Lease of van - Hospice of Kona received a van as a donation during 1993 with a fair value of $31,356. Hospice of Kona entered into an agreement May 1993 which expires in April 1998 to lease the van to another not for profit organization. Under the terms of the lease, lessee will pay a monthly rent ,of $100 along with license, operating costs and insurance. The lease also allows the use of the van by Hospice of Kona without charge, with prior notice given to lessee. Rent received by Hospice of Kona amounted to $1,200 for 1996 and 1995. b. Lease of office space - On July 15, 1996, Hospice of Kona entered into a noncancelable operating lease for office space located at 74 -5599 Alapa Street. The - lease expires on July 15, 1999 with a minimum rent of $5,711 for July 16, 1996 through July 15, 1997, $7,229 for July 16, 1997 through July 15, 1998 and $8,434 for July 16, 1998 through July 15, 1999. The lease also requires payments for common area expenses, insurance, and general excise taxes. 9 •' • Ann N. Fukuhara, CPA TAXPAYER: Hospice of Kona, Inc. INSTRUCTIONS FOR FILING Form 990 . Return of Organization Exempt from Income Tax • FOR THE YEAR ENDED December 31, 1998 To be signed Officer and dated by Amount of Tax None Mail tax return Internal Revenue Service to Ogden, UT 84201 -0027 Certified mail recommended, with return receipt. For metered mail, meter date is not evidence of timely f ding. Return must be mailed on or ASAP - November 15, 1999 bet we Spt eial Instructions Note: The return will be amended after the audit Firm 990 Real of Organization Exempt From •.me Tax OMB No. 1545-0047 Under section 501(e) of the Internal Revenue Code (except black lung benefit 1998 • • trust or private foundation) or section 4947(aX1) nonexempt charitable trust This Form is Department or the Treasury Open to Public • Internal Revenue Service Note; The organization may have to use a copy of this rettmh to satisfy state reporting requirements. Inspection A For the 1998 calendar year, OR tax year period beginning . 1998, and endin , 19 B Check if: Please C Name of organization, number and street, city, town, state, and ZJP code D Employer identification number as: °r label or ospice of Kona, Inc. 99- 0246297 Initial return pty� E Telephone number Flnalreturn see .0. Box 217 808 - 334 -0334 5 edie F Check► if exemption application Amended return InsetruG- (required also for bons. is endin stale reporting) , ailua -Kona, HI 96745 1 P 9 G Type of organization — 14 Exempt under section 501(cX 3 ) • (insert number) OR • L.1 section 4947(a)(1) nonexempt charitable trust Nate: Section 501(c)(3) exempt organizations and 4947(a)(1) nonexem t charitable trusts MUST attach a completed Schedule A (Forn990), H(a) Is this a group realm filed for affiliates? UYes N No I If either box in H is checked "Yes," enter four -digit group exemption no. (GEN)► (b) If "Yes," enter number of affiliates for which return is filed: • J Accounting method: 0 Cash M Accrual • (c) • this a separate return filed by an organization covered by a group ruling? Yes N n Other (specify)• It Check here • U if the organization's gross receipts are normally not more than $25,000. The organization need not file a return with the IRS; but if it received a Form 990 Package in the mail, it should file a return without financial data: Some states require a complete return. _ Note: Form 990-EZ may be used by organizations with gross receipts Less than $100,000 and total assets less than $250.000 at end of year. alittil Revenue, Expenses, and Changes in Net Assets or Fund Balances (See Specific Instructions on page 13.) . 1 Contributions, gifts, grants, and similar amounts received: ''`a a Cirect public support la I 45,488..-, b Indirect public support 1b 582 c Government contributions (grants) 1 c ' d Total (add lines la through lc) (attach schedule of contributors) (cash $ noncash $ . ) 1d 46,070. 2 Program service revenue including government fees and contracts (from Part VII, line 93) 2 233,661. 3 Membership dues and asses avnents 3 4 Interest on savings and temporary cash investments 4 41. 5 Dividends and interest from securities 5 . 6a Gross rents - 6a b Less: rental expenses 6b • C Net rental Income or (loss) (subtract line 6b from line 6a) 6c 7 Other investment income (describe • ) 7 Revenue 8a Gross amount from sale of assets other (A) Securities (8) Other , than inventory 8a 7,172 ., 3-0 : ,.,... b Less cost/other basis & sales expenses. 8b - . C Gain or (loss) (attach schedule) • 8c 7,172'. d Net gat or (loss) (combine line 8c, columns (A) and (B)) 8d 7,172. 9 Speer events and activities (attach schedule) : a Gross revenue (not including $ of " contributions reported on line la) 9a 626. ; b Less direct expenses other than fundraising expenses 9b 293. • a . `; C Net income or (loss) from special events (subtract line 9b from line 9a) 9c 333. 1 Oa Gross sales of Inventory, less returns and allowances..... . 10a 1 98,977.0 b . Less: cost of goods sold .. 10b ' s"^t. c Gross profit or (loss) from sales of inventory (attach schecc.:) (subtract line 10b from line 10a).. 10c 98,977. 11 Other revenue (from Part VII, line -103) 11 1,170. 12 Total revenue (add lines 1d, 2, 3. 4, 5, 6c, 7, 8d, 9c, 10c, and 11) 12 387,424. 13 Program services (from line 44, column (8)) 13 354,750. 14 Management and general (from line 44, column (C)) 14 28,735. Expenses 15 Fundraising (from line 44 column (0)) _ 15 16 Payments to affiliates (attach schedule) 16 • 17 Total expenses (add lines 16 and 44, column (A)) 17 383,485. 18 Excess or (deficit) for the year (subtract line 17 from line 12) 18 - 3,939. Net 19 Net assets or fund balances at beginning of year (from line 73, column (A)) 19 995,304. Assets 20 Other changes in net assets or fund balances (attach explanation) 20 21 Net assets or fund balances at end of year (combine lines 18, 19, and 20) 21 999,243. For Paperwork Reduction Act Notice, see page 1 of the separate instructions. CAA 8 99012 NTF 18758 GLD 4224 Form 990 (1998) Copyright Forms Software Only, 1998 Nalco • Form GI JO „ ppaaviat:tun Tor txtension or Time To File • • , (Rev. June 1998) Cera Excise, Income, Information,. Other Returns OMB No. 1545 -6%8 Debarment of the Treasury Internal Reveu• Sarvlce • " Ow File a separate application for each return. . Name Please type or Hospice -of Kona apioydentiticatlnaber print. File the •` Inc Inc• - 99 ;0246297 original and one Number, street, and room or stale no. (or P.O. box no. if mall is not delivered to street address) copy by the due date for filing P. 0. Box 217 your return. See • instructions on City, town or post office, state, and ZIP code. For a foreign address, see instructions. bad`. Kailua -Kona, HI 96745 Note: Corporate income tax return filers must use Form 7004 to request an extension of time to file. Partnerships, Rana, and ' trusts must use Perm 8736 to request an extension of time to file Form 1065, 1066, or 1041. 1 I request an extension of time until November1S 1999 .�to file (check only one): ❑ Form 708 -GS(D) ❑ Form 990-T (sec. 401(a) or 408(a) trust) Cr Form 1120 -ND (sec. 4951 taxes) ; J ! crma812 ❑ Fomt 706 -GS(T) ❑ Form 990-T (trust other than above) ❑ Form 3520 -A ❑ Fomn8613 ® Form 990 or 990 -EZ ❑ Form 1041 (estate) (see instructions) ❑ Form 4720 ❑ Form8725 ❑ Form 990 -BL ❑ Form 1041 -A ❑ Form 5227 • ❑ Forin8804 ❑ Form 990 -PF ❑ Form 1042 • ❑ Form 6089 ' ❑ Fohn'31 If the organization does not have an office or place of business In the United States, check.this box ► ❑ 2a For calendar year 19 9 8 , or other tax year beginning and ending b If thls tax year Is for less than 12 months, check r.ason: ❑ Initial return ❑ Final retum ❑ Change In accounting petbd 3 Has an extension of time to file been previously !,.: ;ntec `or this tax year? Yes kNo 4 State In detail why you need the extension Ho of Kona is in the process of/ compipting_anaudit_pf their financial statements, An extension off time is required to file a complete -- _ and accurate - return. _ 5a ' If this form is Von 706 GS(D), 706 GS(T), 990 -BL, 990-PF, 990 -T, 1041 (estate), 1042, 1120 -ND, 4720, 6069, 8612, 8613, 8725, 8804, or 8831, enter the tentative tax, less any nonrefundable credits. See Instructions. $ -0- b If thls form Is for Form 990 - PF, 990 - T, 1041 (estate), 1042, or 8804, enter any refundable credits and estimated tax payments made. Include any prior year overpayment allowed as a credit $ - 0 - c Balance due. Subtract line 5b from line 5a. Include your payment with this form, or deposit with FTD coupon if required. See Instructions $ - 0 - Signature and Verification Under penalties of perjury, I declare that I have examined this form, Including accompanying schedules and statements, and to the best of my knowledge aahbellei, It Is true, correct, and complete; and J that 1 am authorized to prepare this loan. • Signature II 6 AIM*" ✓' Tine ► C PA Date r 0 7 / 2 7 /99 FILE ORIGINAL AND ONE COPY. The IRS will show below whether or not your application is approved and will retum the crpy. • Notioee-to Applicant —To Be Completed by the IRS ( ErWe HAVE approved your application. Please attach this form to your return.. ❑ We HAVE NOT approved your application. However, we have granted a 10 - day grace period from the later of the date shown below or the due date of your return (including any prior extensions). This grace period is considered to be a wild extension of time for elections otherwise required to b made on a timely return. Please attach thls form to your retun. ❑ W e H A V E NOT approved your application. After cc - :g the reasons stated In Item 4, we cannot grant your request for an extension of time to file. We are not granting thr L ay grace period. ❑. We cannot consider your application because it was pled after the due date of the return for which an extension was requested. ❑ Other... __ . _ . • . By. . • Director Dale If you want a copy of this form to be returned to an address other than that shown above, please enter the address to which the copy should be snit. Name Meese Ann Fukuhara, CPA Type Numb.,, street, and room or stab ne. (01` P.O. box no. if metl is not delivered to street address) or P. 0. Box 6691 Print City, town or post office, state, and ZIP code. For a foreign address, see inatrucllona. Hilo, HI 96721 For Paperwork Reduction Act Notice, see back of form. Cat. No. 11976B Form 2758 (Rev 6-98) 377 • - Farm' 2758 �Iication for Extension of Tim ile • (Rev. June 1998) Certain�ccise, Income, Information, and ter Returns OMB No. 1545-0148 Department m the Treasury Internal Revenue Service P File a separate application fa each return. Please type or Name Employer ID number print. File the Hospice' of Kona, Inc. 99- 0246297 original and one Number, street, and room or suite no. (or P.O. box no. if mail is not delivered to street address) • copy by the due P.O. Box 217 date date for c•:rg your return. See instructions on City, town or post office, state, and ZIP code. For a foreign address, see instructions. . 3 page 2. Kailua -Kona, HI 96745 Note: Corporate income tax return filers must use Form 7004 to request an extension of time to file. Partnerships, REMICs, and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041: al 1 1 . • . ,ast an extension of time until Auqu s t 16, 1999 , to se (check only one): • Ci Fu;n 706 -GS(D) Form 990 -T (sec. 401(a) or 408(a) trust) Form 1120 -ND (sec. 4951 taxes) Form 8612 !� °C. Form 706 -GSM Form 990-T (trust other than above) Form 3520 -A Form 8613 O w Farm 990 or 990-EZ Fam 1041 (estate) (see instructions) Form 4720 Form 8725 Z F;.: I - r m 990-BL Form 1041 -A Form 5227 Form 8804 � ul Form 990-PF Form 1042 Form 6069 . Form 8831 -• ;- If Ore organization does not have an office or place of business in the United States, check this box ► 0 2a For calendar year 19 98 , or other tax year beginning and ending b If this tax year is for less than 12 months, check reason' 0 Initial return U Final return 0 Change in accounting period 3 Has an extension of time to file been previously granted for this tax year? 0 Yes 0 No 4 State in detail why you need the extension Hospice of Kona is in the process of completing an audit of their financial statements. An extension of time is require( I to 91 173 a _complete and accurate return. i 5a-i( this forrrj tgf(a(prm 708- GS(D), 706- GS(T), 990 -BL, 990 -PF, 990 -T, 1041 (estate), 1042, 1120 -ND, 4720, 6069, I J. ,- 8612, - 8613;8 1 8831, enter the tentative tax. less any ,, onrefundable credits. See instructions $ 0 . ; 4 4 form is ji-. F�pr, F, 990-7, 1041 (estate), 1042, or 8€1 a, enter any refundable credits and estimated h 1 teepajymentaii+eae, f ' e any prior year overpayment allowed as a credit $ 0 . '-- 68alancedae.Su 5b from line 5a. Include your payment with this form, a deposit with FTD coupon it ),_. t regoire4 - SFhe inshucti $ 0. Signature and Verification Under penalties of perjury, I declare that 1 have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, It is true, correct and complete; and that I am authorized to prepare this form. Signature ► &L44..1 Title ► CPA Date ► 0 5 / 12 / 9 9 FILE ORIGU IAL AND ONE COPY. The IRS will show below whether or not your application is approved and will return the copy. pace to . , ppiicant - To Be Completed by the IRS We HAVE approved your application. Please attach this form to your return. ! I HAVE NOT approved your applicetbn. However, we have granted a 10-day grace period from the later of the date shown below or the due date of your return (including any prior extensions). This grace period is considered to be a valid extension of time for elections otherwise required to be made on a timely return. Please attach this form to your return. 0 We HAVE NOT approved your appial on. After considering the reasons stated in item 4, we cannot grant your request for an extension of time to file. We ere not granting the 10-day grace period. 0 We cannot consider yotr application because it was filed after the due date of the return for which an extension was requested. • 0 Other: • • By: Director . Date If you want a copy of this form to be retuned to an address other than that shown above, please enter address to which the copy should be sent. • Name Ann Fukuhara, CPA Please Number, street, and room or suite no. (or P.O. box no. if mail is not delivered to street address) . or P.O. Box 6691 Prim City, town or post office, state, and ZIP code. For a foreign address, see instructions. Hilo, HI 96721 For Paperwork Reduction Act Notice, see page 2 of form. Form 2758 (Rev. 6 -98) CM 8 27581 NTF 15755 OLD 3258 Copyright Forms Software Only, 1998 Nelco • rermeso 1998) Hospice of Kona, Inc. 99- 0246297 Page Mang Statement of All tlons must complete column (A). Columns (et (C). and (D) •tiredfor section 501 (cX3)and(4)organiationsand Functional Expenses sec �7(ax1)noneaempl charitable trusts but optional for other�pecific Instructions on page 17.) Do not include amounts reported on line `�.E + :,.,; (B) Program (C) Management • y (A) Total 6b, 8b, 9b, 10b, or 16 of Part I. ; �3�. services and general (D) Fundraising 22 Grants and allocations (attach schedule) • : ^ . ` Y`a "' >Q (Caen$ cash$ ) 22 `'• 23 Specific assistance to individuals (attach sch.). 23 ',,4417 ' + }ti , < 24 Benefits paid to or for members Nilsen sch.) . 24 a ` , : .,, bit, ,� " ?t 25 Compensation of officers, directors, etc .... 25 26 . Other salaries and wages 26 216,276. 194,648. 21,628. 27 Pension p'an contributions 27 28 Other emcloyeebenefits 28 7, 71.5., 6,944 . 772. 29 Payroll taxes 29 25,578. 23,020. 2,558. 30 Professional fundraising fees 30 • 31 Accounting fees 31 3,777 . 3,777 . 32 Legal fees 32 400 . 4 0 0. 33 Supplies 33 34 Telephone 34 9,176. 9,176. 35 Postage and shipping 35 323. 3 2 3. 36 Occupancy 36 46,025. 46,025. ' 37 Equipment rental and maintenance 37 38 Printing and publications 38 284. 2 8 4. 39 Travel 39 40 Conferences, conventions, and meetings 41 Interest 41 770. 7 7 0. 42 Depreclati n, depletion, e tc . (attach schedule) 42 43 Other expenses (itemize): a 43a b 43b c 43c d 43d e See Sch. Attached 43e 73,160. 73,160. 44 Total functional expenses (age lines 22 through 43)Offlan locations completing columns (B)4D), carry these totals to lines 13.15.. 44 383,485. 3 5 4, 7 5 0. 28,735. Reporting of Joint Costa. — Did you report in column (B) (Program services) any joint costs from a combined educational campaign and fundraising solicitation? 11 0 Yes 0 Nr If 'Yes,• enter (1) the aggregate amount of these joint costs ... $ ; (It) amt. allocated to Prog. services .. $ , • (III) the amount allocated to Management and general $ ; and (iv) amt. allocated to Fundraising $ ITPX1011 Statement of P dram Service Accomplishments (See Specific Instructions on page 20.) What Is the organization's primary exempt purpose? lo See statement Program Service organizations must describe their exempt purpose achievements in a clear and concise manner. State the number of clients Expenses All 5O1 or9 P P (Required for served, publications issued, etc. Discuss achievements that are not measurable. (Section 501(c)(3) and (4) organizations and and (4) pros., and 4947(all l 4947(ax1) nonexempt charitable trusts must also enter the amount of grants and allocations to others.) trusts; but optional for athers.l a Direct patient care services to 46 terminally ill patients and bereavement care support services to 48 family members of patient: involving individual group contact. (Grants and allocations $ ) 354,750. b . (Grants and allocations $ ) C (Grants and allocations $ ) • d • (Grants and allocations $ ) e Outer program services (attach schedule) (Grants and allocations $ ) f Total of Program Service Expenses (should equal line 44, column (8), Program services) 1 3541750. CAA 8 99012 err 18759 GLD 4224 . Copyright Forms Soewre Only , 1998 Nelco Ponn99o(1999). Hospice of.aa, Inc. 99- 0246297 • . Page . [paitilti Balance Sheets (See ific Instructions on page 20.) • Note: Where required, attached schedules and amounts within the description (A) OR column should be for end-of -year amounts only. Beginning of year End of year 45 Cash — non-interest-bearing 45 46 Savings and temporary cash investments 24,761. 46 13,065. M. 47a Accounts receivable 47a 27, 630 . b Less allowance for doubtful accounts 47b 6,610. 8 , 422. 47c 21, 020. :iraii Si ; -' — XrrI:,: : °;ap' ni. ;:s 48a Pledges receivable 48a A _ b Les& allowance for doubtful accounts 481 48c 49 Greats receivable 100,000. 49 100_000. 50 Receivables from officers, directors, trustees, and key employees (attach schedule) 50 51a Other notes and loans receivable (attach • schedule) 513 1, 075. •4 b Less allowance for doubtful accounts 511) _ 51c 1,075. Assets 52 Inventories for sale or use • ' 52 :3 Prepaid expenses and deferred charges 3,277. 53 18,910. 14 Investments — securities (attach schedule) 54 65a investments — land, buildings, end 'It equipment basis 55a . b Less accumulated depreciation (attach schedule) 551) 55c Ives:anents — other (attach schedule) 56 �'i ,. ..and. buildings, and equipment basis '57a1 1, 0 32 , 5 8 4 . b Less: accumulated depreciation (attach schedule) 57b 102, 091. 930, 493. 576 930, 493. 58 char • Deposits ) 58 Other daaerlba '9 Total assets (add lines 45 through 58) (must equal line 74) 1, 066, 953. 59 1, 084, 563. • .0 Accounts payable and accrued expenses 38, 395 . 60 52, 066. 6 1 Grants payable 61 62 Deferred revenue • 62 63 Loans from officers, directors, trustees, and key employees (attach el liabilities schedule) 63 Tax- ecempt bond liabilities (attach schedule) - 64a Mortgages and other notes payable (attach schedule) 64b b' Other '. See Schedule ) 33,254. 65 33,254. ',ab1114ees (dex 6c Total liabilities (add lines 60 though 65) 71 , 6 4 9 . 66 85,320. Organization that follow SFAS 117,eheck here ..• N and complete lines 67 '10: thrn :: -: ea and Wes 73 and 7i -„ 67 unres::ricted 995, 304. 67 999,243. 68 Temporarily restricted 68 1 69 Permanently restricted 69 1 - Net Organizations that do not follow SFlL4 117, check here... • 0 and complete f Assets lines 70 through 74. . a.r.`- or Fund 70 Capital stock, trust principal, aat/rent funds . 70 Balances 71 Paid -innr capital surplus, or led, building, and equipment fund 71 72 Retained earnings, endowment,. accumulated Income, or other funds 72 . 73 To net assets or fund balances (add lines 67 through 69 OR lines 70 ` * ^`" through 72; column (A) mustequal line 19 and column (B) must equal it:: :.: line2l) 995, 304. 73 . 999, 243. 1 74 Total liabilities and net assess/ fund balances (add lines 66 and 73) 1, 066, 953. 74 1, 084,563. Form 990 is evadable for public inspection and, for some people, serves as the primary or sole source of information about a particular organization. How the public perceives an aganization in such cases may be determined by the information presented on its return. Therefore, please make sure the return is complete ardlaccurate and fully describes, in Part 111, the organization's programs and accomplishments. CM . 8 99034 NTF 18760 GLD4225 Copyright Forms Software Only, 1998 Nelco , Form990(1998) Hospice of a, Inc. 99- 0246297 Page Alliiiiier Reconciliation o enue per Audited A SSIII Re iliation of Expenses per Audited Financial Statemen with Revenue per Financial Statements with Expenses per Return (See Specific Instructions, page 22.) Retum a Total revenue, gains, and other support ,..a ra; -` ' "5; a Total expenses and losses per audited - t , f ;"e per audited financial statements • a ni financial statements • a II / A tzilso. m: b Amounts included on line a but not on T : . : b Amounts included on line a but not :' line 12, Form 990: - A on line 17, Form 990: l I ( 1 ) Net unrealized gains r (1 ) Donated services 1 t`.. on investments .. § ' 511:44 , 7 & use of facilities.. $ ; * xx " r . (2) Donated services S' e a (2) Prior year adjust- � • & use of facilities . §`� - q °+ , menu reported on l`,. (3) Recoveries of prior a ` li ne 20, Form 990. $ s. - ,` year grants $ * j = * 9/, (3) Losses reported on 0 d ` ':: k x .air (4) Other (specify): ,„ , ' line 20, Form 990. § . ; t ° t ` , (4) Other (specify) .1.-M --- $ 1,a a 'f ' " , 1 ; r. c:aounts on lines 1 through 4 • b $ t F Add amounts on lines (1) through (4)...► b C _ale a minus line b • e C Une a minus line b - • c d Amounts included on line 12. .. . v-. . ' . 4 . ' d Amounts included on line 17,,.s ,�,,, Form 990 but not on line a: Form 990 but not on line a: g a (1) investment expenses (1) Investment expenses . +i"S f s not included on ` not included on % ;) �% y 4 line 6b, Form 990 $ •. • line 6b, Form 990.5 : N (2)Oti1er (specify): . ` a . (2) Other (specify): ,: - l t w r % r .. w 5 , . $ . ?. $ =if fir Add amounts on lines (1) and (2) • Add amounts on lines (1) and (2) • d e Total revenue per line 12, Form 990 a Total expenses per line 17, Form 990 (line c plus line d) • e (line c plus line d) • e Ott,* List of Officers, Directors, Trustees, and Key Employees (Ust each one even if not compensated; see Specific Instructions on page 22.) (13) Titie and average (C) Compensation (D) Contributions to (E) Expense (A) Name and address hours per week (if not paid, employee benefit plans account and other . devoted to position enter -0 -.) & deferred comp. allowances See attached schedule 75 Did any officer, director, trustee, or key employee receive aggregate compensation of more than $100,000 from your organization and all related organizations, of which more than $10,000 was provided by the related organizations?.... • 9 Yes ® No If "Yes." attach schedule — see Specific Instructions on page 22. CAA 8 99034 NTF 18761 GLD 4225 Copynpet Forms Software Only, 1998 Nelco Form 990 1898 Hospice of . - •a Inc. 99- 0246297 Pa. - a: t'" ' Other Information ( •ecific instructions on page 23.) Yes No 76 Did organization engage in any active • not previously reported to IRS? If "Yes," attach de . .. description of each activity 1 76 X ' 77 Were any changes made in the organizing or governing documents but not reported to the IRS? MIN X 11 "Yes," attach a conformed copy of the changes. .. FM ler 78a Old the organization have unrelated business gross income of $1,000 or more during the year covered by this return? 78a X b If "Yes." has it filed a tax return on Form 990-T for this year? N /A 78b, 79 Was there a liquidation, dissolution, termination, or substantial contraction during the year? 0 "Yes," attach a statement 79 X 80a Is the organization related (other than by association with a statewide or nationwide organization) through common -.. ^„ membership, governing bodies, trustees, officers, etc., to any other exempt or nonexempt organization? 80a= X b If "Yes,' enter the name of the organization • N/A - _` and check whether it is 0 exempt OR 0 nonexempt. Niir &i : 810 Enter the amount of political expenditures, disc[ or indirect, as described in the instructions for line 81 181a1 N /A ' " b Did the organization file Form 1120 -POL for this year? N / A 81b 82a Did the organization receive donated services or the use of materials, equipment, or facilities at no charge or at ®© substantially less than fair rental value? b If "Yes," you may indicate the value of these items here. IM not include this amount ' (44 as revenue in Part 1 or as an expense in Part 11. (See instructions for reporting in y „ Partlll.) - 82b N /A 83a Did the organization comply with the public inspection requirements for returns and exemption applications? 83a b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? 84a Did the organization solicit any contributions or gifts that were not tax deductible? Ell X b If "Yes,' did the organization include with every solicitation an express statement that such contributions or gifts were not , ` ^" tax deductible? N/A 85 5o1(cX4), (5), or (6) organizations. — a Were substantially all dues nondeductible by members? N/A 85a. b Did the organization make only in -house lobbying expenditures of $2,000 or less? N/A 85b If ^' :;s answered to either 85a or 85b, do riot complete 85c through 851 below unless the organization received a .., waiver proxy tax owed for the prior year. 3 C Dues, assessments, and similar amounts from members 85c N A .- ' . d Sedbn 162(e) lobbying and political expenditures 85d .1111 , i. 9 Aggegate nondeductible amount of section 6033(ex1)(A) dues notices 85e N /A f Taxable amount of lobbying and political expenditures (line 85d less 85e) 85f N / A , . . 9 Doan the organization elect to pay the section 6033(e) tax en the amount in 85f? N/ A ®: h If xtion 6f 3S(ex1)(A) dues notices were sent, does the r: - .nizatlon agree to add the amount in 85f to its reasonable • e> late of dues allocable to nondeductible lobbying and tc.:!ical expenditures for the following tax year? . N/A 86 5: c)7) organizations. — Enter: a Initiation fees and capital contributions included on A i" 4,5 fir 86a N A zs t 'l'' b G. ..e, Iceipts, included on line 12, for public use of club facilities 86b1 N A sue;, '*. 87 5C 1(cX12) organizations. — Enter: . a Glass income from members or shareholders �� -.. r . b Gross income from other sources. (Do not net amounts due or paid to other sources - '- - against amounts due or received from them.) 87b N/ A V. ; ' 88 N any time during the year, did the organization own a 50% or greater interest in a taxable corporation or partnership? If"Yes," complete Part IX X 89a 501(c)(3) organizations. — Enter: Amount of tax imposed on the organization during the year under:, ,1:„ sedon 4911 • 0 . ; section 4912 • 0 . ; section 4955 • . 0 Pa" ' r b 501(cX3) and 501(c)(4) organizations. — Did the organization engage in any section 4958 excess benefit transaction dying the year? If "Yes," attach a statement explaining each transaction 89b X c Enter: Amount of tax Imposed on the organization managers or disqualified persons during the year under sedlons 4912, 4955, and 4958 • 0 . d Enter: Amount'of tax on line 89c, above, reimbursed by the organization • 0 90a LM the states with which a copy of this return is filed • N/A - b Number of employees employed in the pay period that includes March 12, 1998 (See instructions) 90b1 91 The books ere in care of• Hospice of Kona, Inc. Telephone no.►( 334 -0334 Located at • Kai lua. Kona, Hawaii zIP +4► 96745 92 Se -:!ion 49147(ax1) nonexempt charitable trusts filing Form 990 in lieu of Form 1041 -- Check here • U ar°: inter the amount of tax - exempt Interest received or accrued during the tax year ► 1 1 CAA d 99056 NTF 18762 GLD 2877 Copyright Farms Software Only. 1998 NWIC° • Form 990 (1998) Hospice of ona, Inc. 99- 0246297 Pace apart VIt Analysis of Incom ducing Activities (See Specific Instructio age 27.) Ern; gross amounts unless otherwise _ Unrelated business income Exclude ction 512, 513, or 514 (E) • indicated. Bust ass ( (C) (D) Related or exempt 93 Program service revenue: code Amount Exclusion code Amount function income Patient services - 233,661. d _ e f Medicare / Medicaidpaymaob n � gFees and c ontracts from govt. agencies . . 94 = ^,gip dues and esaeepnenle 35 navings and temporary cash 14 41. 96 C:.,:enua and interest from securities.... .. .� .:.,r ;, l , r 97 Net rental income or (loss) from real estate: � "�'..., , �. W r .; -iKa g,i , � � p �;.^,e. 5 �� a ,, ,, �, s z Fu „. _t adebt- financed property �p bnot debt - financed property gg Net rental income of (loss) from personal noperty 99 :ther investment income l 100 Gain or (lose from sales of assets other 7, 172. man inventory 101 Net income or(los$tfrom special events.. . 333• 102 Gross off - •t !noss) from safesof inventory . 98, 977. 103 Other , r.ue: a b c d eE : :ch. Attached 1,170. 104 , rod columns (B).(o), and (E))... ;` 0 41. 341, 313. 105 Total (aud line 104, columns (B), (D), and (E)) ► 341, 3 5 4 Note: (Line 105 plus line 1d, Part I, should equal the amount on line 12, Part I.) (IutVt Relationship of Activities to the Accomplishment of Exempt Purposes (See Specific Instructions on pg. 28) Line No. Explain how each activity for which income is reported column (E) of Part VII contributed importantly to the accomplishment of the organization's exempt purposes (other than by providin ;.Inds for such purposes). 93 Approximately 48 terminally ill patients as well as their families were provided with skilled services, support and ducation. 101 - spice sponsored various fundraising events in order to serve ;:_ogram patients. 56 terminally ill patients as well is their families benefited from skilled services. 10: Hospice operates a thrift shop. Proceeds from the thrift shop are used to serve terminally ill patients. 101 All other income are used for program expenses. 56 terminally ill patients benefited from revenues. 100 Proceeds from sales of assets are used to serve the terminally ill iX Irrc? rmation Regardlrgjaxabie Subsidiaries (Complete this Part if "Yes" box line 88 is checked.) ga of Name, address, and employer identi(saGhn Percents ownership Nature of Total End-of-year ^,um. er of corporation or partnership interest business activities income assets N/A Please Un,er oema lties Gtperory, I e l have xami isetur,ng accoi schdu antamns, and to t of my led5 and � uelner , nais amt, o rrec t, and tea ef7e7 tG prepa than includi of icer)isbase on ng all in tian d s 01 w h prep h asanyk now e .(See General Matsu I n U. on paps S) e Sign ' �c . � (� - ]t.Gi r _ , j I u /i rf`Irj k Eiteniu• ScAerwasn a �. Here Signature of officer D e Type or print name and title. Preparers J Date Check if self- Preparer's SSN Paid signature 11/11/99 played ► Preparer'r' =irm's name (or yours Ann Fukuhara, CPA LEIN ■ 94- 3269888 Use 00 : i self- employed) ' 724: Kanoelehua Avenue LP +40 96720 and address Hilo, HI CAA 8 99056 NIF 18783 G1.2.28177 Copynghl Forms Software Only. 1998 Nalco , SCNFDULE A 0 nization Exempt Under Section (c)(3) OMB No. 1545-0047 (Form 990) ept Private Foundation) and Section 501(e), 01(k), 1(n), or Section 4947(a)(1) Nonexempt Chari rust 1998 • • Supplementary Information Department of the Treasury/ See separate instructions. Interim Revenue Service • Must be completed by the above organizations and attached to their Form 990 or 990 -EZ. Name of the organization - Employer identification number Hospice of Kona, Inc. • 99- 0246297 Keirkthl Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (See itstructons on page 1. List each one. If there are none, enter "None. ") (d) Contributions to (e) Expense ( c ) (a) Name and address of each employee paid more (b) Title and average hours Compensation empl. benefit plans a account and than $50000 per week devoted to position Celeriac compensation other allowances None • • Trial number of other employees paid over , : ompensation of the Five Highest Paid Independent Contractors for Professional Services (See :instructions on page 1. List each one (whether inarviduals or firms). If there are none, enter "None.") (. - independent contractor paid more than $50,000 (b) Type of service (c) Compensation . Izme and ad dress of each p N .. No • Total number of others receiving over $50,000 for professional services ► - .,:r ,. , . • -f Fo' Paperwork Reduction Act Notice, sae page 1 of the instructions for Form 990 and Form 990 -EZ Schedule A (Form 990) 1998 • cAA 8 990At2 NTF 18497 an 3274 Copyright Forms Software Only. 1998 Nelco ---/ Hospice of Kona, Inc 99- 0246297 ' Sche'dule A (Form 990) 1998 • Page 2 Fart1111M Statements About Activities Yes No 1 During the year, has the organization attempted to influence national, state, or local legislation, including any attempt to influence public opinion on a legislative matter or referendum? 1 X If "Yes," enter total expenses paid or incurred in connection with the lobbying activities ► $ t c w 1.r :.5'; Organizations that made an election under section 501(h) by filing Form 5768 must complete Part VI -A. Other e ., 1; organizations checking "Yes," must complete Part VI-B AND attach a statement giving a detailed description of the , ` Zak. % - , lobbying activities. r ..'`` 4 2 During the year, has the organization, either directly or indirectly, engaged in any of the following acts with any of its + ' .. ` trustees, directors, officers, creators, key employees, or members of their families, or with any taxable organization with ,:, which any such person is affiliated as an officer, director, trustee, majority owner, or principal beneficiary: ?;"k;; ¢ Sd a Sale, exchange, or leasing of property? 2a X b Lenuing of money or other extension of credit? 2b X c Furnishing of goods, services, or facilities? 2c X d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)? 2d X e Transfer of any part of its income or assets? 2e X If the answer to any question is "Yes," attach a detailed statement explaining the transactions. 3 Does the organization make grants for scholarships, fellowships, student loans, etc.? 3 X 4a Do you have a section 403(b) annuity plan for your employees? 4a b Attach a statement to explain how the organization determines that individuals or organizations receiving grants or loans i from it in furtherance of its charitable programs qualify to receive payments. (See instructions on page 2.) r ; FC.TiV Reason for Non - Private Foundation Status (See instructions on pages 2 through 4.) The organization is not a private foundation because it is: (Please check only ONE applicable box.) 5 .r. rch, convention of churches, or association of churches. Section 170(b)(1)(A)(i). 6 lot. Section 170(bX1)(A)61). (Also complete Part V, page 4.) 7 Dital or a cooperative hospital service organization. Section 170(b)(1)(A)(ii). 8 j A FL ;eral, state, or local government or governmental unit. Section 170(b)(1)(AXv). 9 0 A medical research organization operated in conjunction with a hospital. Section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state ► 10 9 An organization operated for the benefit of a college or university owned or operated by a governmental unit. Section 170(b)(1)(A)(iv). (Also complete the Support Schedule in Part IV-A.) 118 0 An ganization that normally receives a substantial part of its support from a governmental unit or from the general public. Sr-_ m 170(b)(1XA)(vi). (Also complete the Support Schedu:.: n Part IV-A.) 11b / munity trust. Section 170(b)(1XA)(vi). (Also complete th Support Schedule in Part IV-A.) 12 P. ionization that normally receives: (1) more than 33 1137. of its support from contributions, membership fees, and gross recen is from activities related to its charitable, etc., functions — subject to certain exceptions, and (2) no more than 33 113% 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(aX2). (Also complete ' Support Schedule in Part IV -A.) 13 9 An organization that is not controlled by any disqualified persons (othe . an foundation managers) and supports organizations described in: (1) lines 5 through 12 above; or (2) section 501(c)(4), (5), or (6), if they meet the test of section 509(aX2). (See section 509(a)(3).) Provide the foilowing.information about the supported organizations. (See instructions on page 4.) (a) Name(s) of supported organization(s) (b) Line number from above N/A • 14 t I An organization organized and operated to test for public safety. Section 509(a)(4). (See instructions on page 4.1 CAA 8 990Al2 NTF 18488 GLD 3274 Copyright Forms Soft ware Only, 1998 Nalco _ Hospice of Kona, Inc. 99- 0246297 • + Schedule A (Form 990) 1998 Page 3 Flit IV -kJ Support Schedul mplete only if you checked a box on line 10, 11, Use cash method of accounting. . Note: You may use.the worksheet in the instructions for converting from the accrual to the cash method of accounting. Calendar year (or fiscal year beginning 'OP' (a) 1997 (b) 1996 (c) 1995 (d) 1994 (e) Total 15 Gifts. grants, and contributions • . received. (Do not include unusual grants. Beeline 28) 39, 599. 147, 718. 538, 779. 207, 383. 933, 479. 16 Membership fees received 17 Goss receipts from admissions. merchandise sold or services performed. or furnishing of facilities in any activity that is not a business unrelated to the organization's charitable, 235, 810. 476, 192. 731, 603. 703, 421. 2,147,026.. 18 Gross income from interest. dividends. amounts received from pPoymenls °uritie° oans - l royal on 512 (a)t rents. royalties. and unrelated business - - taxable income (less section 511 lazes) from businesaes acquired by June 30, 15 330. 3,550. 4,062. 2,113. 10,055. 19 Net income from unrelated business activities not Included in line 18 20 Tax revenues levied for the organization's benefit and either paid to it or expended on its - - behalf - 21 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 22 Other income. Attach a schedule • Do not Include gain orlloss) from 1 199. 8 227. 22 426. sale of capital assets , r , 23 Total of lines 15 through 22 289, 938. 635, 687. 1, 274, 444. 912, 917. 3, 112, 986. 24 Line 23 minus line 17 54,128. 159, 495. 542, 841. 209, 496 965 960. 25 Enter l %of line 23 2,899. 6,357. 12,744. 9, 129.' = % ; V, 4 26 Organizations described on lines 10 or 11: a Enter 2% of amount In column (e), line 24 • 26a 19 319. b Attach a list (which is not open to public inspection) showing the name of and amount contributed by each t ' ...„s? it. % s person (other than a governmental unit or publicly supported organization) whose total gifts for 1994 ,, ,, , ,, ?a "" • through 1997 exceeded the amount shown in line 26a. Enter the sum of all these excess amounts • 26b [�, C Total support for section 509(aX1) test Enter line 24, column (e) _ • 26c 965,960. d Add: Amounts from column (e) for lines: 18 10,055. 19 ; ` t ; *. 22 22,426. 26b .. ■ 26d 32,481. e Public support (line 26c minus line 26d total) • 26e 933,479. f Public support percentage (line 26e (numerator) divided by line 26c (denominator)) • 26f 96.64% 27 Organizations described an fine 12: a For amounts included in lines 15, 16, and 17 that were received from a "disqualified person,' attach a list to show the name of, and total amounts received in each year from, each disqualified person." Enter the sum of such amounts for each year: (1997) 0 . (1996) 0 . (1995) 0 . (1994) 0 . b For any amount Included in line 17 that was received from a nondisqualified person, attach a list to show the name of, and amount received for each year, that was more than the larger of (1) the amount on line 25 for the year or (2) $5,000. (Include in the list organizations described in lines 5 through 11, as veil as individuals.) After computing the difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excess amounts) for each year: (1997) 0 . (1996) 0 . (1995) 0 . (1994) 0, • C Add: Amounts from column (e) for lines: 15 0 . 16 0 . 17 0 . 20 0 . 21 0 . .. ■ 27c 0 . d Add: Line 27a total 0 . and line 27b total 0 . .. • 27d 0 . ' e Public support (line 27c total minus fine 27d total) • 27e _ 0 . f Total support ' * k '- tz's " } ` :� i'`, pport for section 509(aX2) test Enter amount on line 23, col. (e) ■ 2 1 a t u t ; ; A ,. ;I g Public support percentage (line 27e (numerator) divided by line 27f (denominator)) • , 27g ^/e • h Investment Income percentage (line 18, column (e) (numerator) divided by line 27f (denominator)) 27h 28 Unusual Grants: For an organization described in line 10, 11, or 12 that received any unusual grants during 1994 through 1997, attach a list (which is not open to public inspection) for each year showing the name of the contributor, the date and amount of the grant, and a brief description of the nature of the grant. Do not include these grants in line 15. (See instructions on page 4.) CAA 8 990A34 NTF 18489 GLD 3275 . • Copyright Forms Software Only, 1998 Nalco . Hospice or Kona, Inc. 99 - UZ4bZ9I . ' Schedule A Form 990 1998 Paz 4 ' P. h v; Private School Qulunaire (See instructions on page 4.) (To be completed 0 by schools that checked the box on e 6 in Part IV) N/A Yea No 29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, other governing instrument, or in a resolution of its governing body? 29 30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its brochures, ' " r catalogues. and other written communications with the public dealing with student admissions, programs, and ' , scholarships? 30 31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during the c s a period of solicitation for students, or during the registration period if it has no solicitation program, in a way that makes w ` -. the policy known to all parts of the general community it serves? 31 If "Yes," please describe; if "Norplease explain. (If you need more space, attach a separate statement) ElqkqiiV,' W ryk 4 t f .,�Ar,ZWW 32 Does the organization maintain the following: ,,� ,: c a Records Indicating the racial composition of the student body, faculty, and administrative staff? - 32a b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory basis? 32b c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing with student admissions, programs, and scholarships? 32c d Copies of all material used by the organization or on its behalf to solicit contributions? 32d i u If you answered "No" to any of the above, please explain. (If you need more space, attach a separate statement) g; y . '3 Y ". micittiot 33 Does the organization discriminate by race in any way with respect to; a& x a Students' rights or privileges? . - b Admissions policies? C Employment of faculty a administrative staff? d Scholarships or other financial assistance? e Educational policies? f Use of facilities? g Athletic programs? . h Other extracurricular activities? If you answered "Yes' to any of the above, please explain. (If you need more space, attach a separate statement.) i r x ,n 9 'Site • 34a Does the organization receive any financial aid or assistance from a governmental agency? b Has the organization's right to such aid ever been revoked or suspended? M■ If you answered "Yes" to either 34a or b; please explain using an attached statement. ° ma- . al. 35 Does the organization certify that it has complied with the applicable requirements of sections 4.01 through 4.05 of Rev. Proc. 75 -50, 1975 -2 C.B. 587, covering racial nondiscrimination? If "No," attach an explanation 35 CAA 8 990A34 Nrr 18490 GLD 3275 Copyright Forms Software Only. 1998 Nalco Hospice of Kona, Inc.,' 99- 0246297 e Sch€ dule A (Form 990) 1998 Page 5 P9rt.V1=A$ Lobbying Expeeres by Electing Public Charities (See tions page 6.) NSA (To be completed ONLY by an eligible organization that filed Form 5768) Check here • a _ if the organization belongs to an affiliated group. Check here ► checked "a" apply. . b if you chked "" above and "limited control" provisions appl (a) (b) Limits on Lobbying Expenditures N/A Affiliated group To be completed totals for ALL electing (The term "expenditures" means amounts paid or incurred.) organization 36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 36 37 Total lobbying expenditures to influence a legislative body (direct lobbying) 37 1 38 Total lobbying expenditures (add lines 38 and 37) _ 38 39 Other exempt purpose expenditures 39 40 Total exempt purpose expenditures (add lines 38 and 39) 40 41 Lobbying nontaxable amount Enter the amount from the following table — 44:F4* '' n ; If the amount on line 40 is - The lobbying nontaxable amount is - r , , P ,: �s _ •` d Not over $500,000 20% of the amount on line 40 r _" '' t � ` ` a ", 4,e + Over $500,000 but not over $1,000,000... 5700,000 plus 15% of the excess over f500.000' .h +{ k `r"'t` Over $1,000,000 but not Over $1,500,000 . 3175.000 plus t0% of the excess over 51.000000 P 41 Over Si , 500,000 but not over $17,000,000 5225,000 plus 5% of the excess over 51 ,500,000 , . ;.,x€- „� �" " x3; Over 517,000,000 $1,000,000 _ - : fir , "' - kx '"' 42 Grassroots nontaxable amount (enter 25% of line 41) 42 43 Subtract line 42 from line 36. Enter -0- if line 42 is more than line 36 43 44 Subtract line 41 from line 38. Enter -0- if line 41 is more than line 38 44 1 `s Z Caution: If there is an amount on either line 43 or line 44, you must file Form 4720. 7 „ k..N 24, ..�''. _4 -s ., E4 , , ''ice' _ 4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instruc for lines 45 ttrough 50) on page 7.) Lob Expenditures During 4 -Year Averaging Period Calendar year (or fiscal (a) ( b) (c) (d) (e) - yearbeginningin) • 1998 1997 1996 1995 Total 45 Lobbying • nontaxable amount . N A 0 . 0 . 46 Lobbyin ceiling "" +:z.r. t . V_,.,.. ,, .,,„„ ' "" :"" Ift amount (150% f ' - . ` fE r - - � 17 £ e3 i r a .c.' of line 45(en , ,�„ , :, : ..:5 r x * ,' 5 u 4 r, s . _ .. 0 . 47 Total lobbying expenditures 48 Grassroots nontaxable amount 49 Grassroots ceiling ' a : -` , ,o f - a ., -`c ,q. ngs. t rI :.'":,,,,,,;.•;•'•: a; of line 4 (( )) ,e..., . .. . ti` x kci a"z i �gaas.l z+ezas --,,.. ; ,. .r � .rn. 4 50 Grassroots lobbying expenditures Peal/fad Lobbying Activity by Nonelecting Public Charities (For reporting only by organizations that did not complete Part VI -A) (See instructions on pa a 8.) During the year, did the organization attempt to influence national, state or local legislation, including any Yes No Amount attempt to influence public opinion on a legislative matter or referendum, through the use of: a Volunteers X a.., �"�P b Paid staff or management (Include compensation in expenses reported on lines c through h.) X .,� +$�E'_' C Media advertisements - X d Mailings to members, legislators, or ftre pudic X 8 Publications, or published or broadcast statements X f Grants to other organizations for lobbryMg purposes X g Direct contact with legislators, their sta(s, government officials, or a legislative body X h Rallies, demonstrations, seminars, conventions, speeches, lectures, or any other means X 1 Total lobbying expenditures (add finest trough h) - - r, ;'% If "Yes" to any of the above, also Media statement giving a detailed description of the lobbying activities. CAA 8 990A56 NTF 19491 GLEE 3276 . Copyright Forms Software Only, 1998 Nelco - .Hospice of Kona, Inc. yy- uzibzyf Schedule A Form 990 1998. Pa9a f a [artVtt Information Reg g Transfers To and Transactions ant�tionships With Noncharitable Exempt Organize ns 51 Did the reporting organization directly or indirectly engage in any of the following with any other organization described in section 501(s) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations? a Transfers from the reporting organization to a noncharitable exempt organization of: Yes No (I) Cash 51a(i) X pp Other assets a(ii) X b Other transactions: • (I) Sates of assets to a noncharitable exempt organization b(i) X (ii) Purchases of assets from a noncharitable exempt organization b(ii) X (Ili) Rental of facilities or equipment b(iii) X (iv) Reimbursement arrangements b(iv) !i X . (v) Loans or loan guarantees - - b(v) X (vi) Performance of services or membership or fundraising solicitations b(vi) X c Sharing of facilities, equipment, mailing lists, other assets, or paid employees C X d If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fair market value of tta goods, other assets, or services given by Ute reporting organization. If the organization received less than fair market value in any transaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received: (a) (b) (c) -(d) Line no. Amount involved Name of noncharitable exempt organization Description of transfers, transactions, & sharing arrangements N/A 52a Is the organization directly or indirectly affiliated with, or related to, one or more tax -exempt organizations described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? ► 9 Yes 9 No b If "Yes," complete the following schedule: • (a) (b) (c) • Name of organization Type of organization Description of relationship N/A • • • • • CAA 8 990A56 NTF1 C,LD3276 • Copyright Forma Software Only, 1998 Nalco NAME:Hospice of Kona, Inc. ID NO:99- 0246297 • SUPPORTING SCHEDULE./ 1998 Form 990 Part I - Statement of Revenue, Expenses, and Changes in Net Assets Line 10c - Gross Profit on Sales of Inventory Gross Sales less returns Cost of Gross Description & allowances Goods Sold Profit Sales of donated items 98,977. 98,977. Totals 98,977. 98,977.. • • NAME:Hospice of Kona, Inc. ID NO:99- 0246297 • • SUPPORTING SCHEDULE • 1998 Form 990 Part II - Statement of Functional Expenses Line 43 - Other Expenses (B) Program (C) Mgmt. (D) Fund - Description (A) Total Services & General raising Professional services 1,246. 1,246. Office expenses 3,248. 3,248. Auto expenses 1,722. - 1,722. Insurance 7,596. 7,596. Patient medical expenses 35,127. 35,127. Miscellaneous expenses 1,364. 1,364. Repairs 15. 15. Bad debt expense 7,458. 7,458. Taxes - general excise 3,643. 3,643. Dues 425. 425. Program expenses 364. 364. Mileage 5,031. 5,031. Advertising 523., 523.. Bank service charges 562. 562. Equipment lease /rentals 2,536. 2,536. Staff training 57. 57. Payroll processing fees 2,243. 2,243. Totals 73,160. 73,160. • Hospice of Kona, Inc. ID No. 99-0246297 PART III: Statement of Program Service Accomplishments Exempt purpose of Hospice of Kona: Hospice of Kona, Inc. is a non -profit organization incorporated on August 25, 1985 pursuant to the laws of the State of Hawaii to provide support, skilled services, and education for terminally ill persons and their families. The Organization is supported primarily through fees for patient services, contributions from individuals and businesses, and grants from various foundations and other entities. NAME:Hospice of Kona, Inc. ID NO:99- 0246297 • SUPPORTING SCHEDULE • 1998 Form 990 Part IV, Balance Sheets - Line 51 Other Notes and Loans Receivable Original Balance Date of Maturity Description Amount Due Note Date Due from FHB - 1,075. 1,075. Totals 1,075. 1,075. 1998 Form 990 Part IV, Balance Sheets - Line 57 Land, Buildings, and Equipment Cost/ Accumulated Book Description Basis Deprec. Value Property & Equipment 882,584. 102,091. 780,493. Land 150,000. 150,000. Totals 1,032,584. 102,091. 930,493. 1998 Form 990 Part IV, Balance Sheets- Line 65 Other Liabilities Description • Amount Housing obligation 33,254. Total 33,254. • NAME:Hospice of Kona, 46 • ID NO:99- 0246297 • SUPPORTING SCHEDULE 1998 Form 990 Part V - List of Officers, Directors, and Trustees (D)Contri- (E) Expense (B)Title and (C)Compen- butions to account and average hours sation (if employee other (Al Name and Address per week not paid) ben. plans allowances Jerry Magoon President 0. 0. 0. P.O. Box 2579 .5 hrs /wk Kailua -Kona, HI Elizabeth Swan Vice President 0: 0." 0. P.O. Box 5594 .5 hrs /wk Kailua -Kona, HI Helen "ercier Secretary 0. P.i 4058 .5 hrs /wk 0. 0. Ka_ ona,•HI Ka: aroma Treasurer 0. 0. 0. P• 217 .50 hrs /wk Ka: .na, HI Re Shomaoka Board Member 0. 0 0. P•' 217 .5 hrs /wk Kali %na, HI- Meila `cComber Board Member 0. 0. 0. P.O. Bv.. 217 Kailua -Kona, HI • • . NAME:Hospice of Kona, nc. ID NO:99- 0246297 • SUPPORTING SCHEDUL • 1998 Form 990 Part VII Analysis of Income - Producing Activities Line 103 - Other Revenue Unrelated Excluded by sec. Business Income 512, 513, or 514 (e) Related (a) (c) or exempt Bus. (b) Excl. (d) function Description code Amount code Amount income Miscellaenous income 1,170. Totals 1,170. • • • • • • ::. Internal Revenue Service EP/E0 Disclosure Desk P.O. Box 2350 Angeles, CA 90053 • Persbn,to L. 3arragan (A to K) F. Miraflor (L to Z) HOSPICE- OF KONA INC Telephone Number: (213)894 -4232 P.C. 30X 1444 Refer Reply to: KAILUA KONA, HI 9C745 91 -541 Date: 8 9 • • • • RE: 99- 0246297 • HOSPICE OF KONA INC • • Gentlemen: This is in response to your request for a determination. letter of the above -named organization.' • • A review o.! our records indicates that the above -named organization was recognized to be exempt from Federal income tax in JUNE, 1986, as an organization described in Internal Revenue Code section 501(0)(3). It is further • :lassi_`ied as an organization that is not a private foundation as defined in section 509(a) of the code, because it is an organization described in .section 170(b)(1)(A)(vi). This letter is to verify your exempt status and the fact that the determination letter issued in JUNE, 1936 continues to be in effect. If you ars in need of further assistance, please feel free to contact me at the above address. We appreciate your cooperation in this regard. • Sincerely, • Disclosure Assistant • • _ :IS CERTIFICATE IS ISSUED AS A MATTER y Ra1ATION COMPANIES AFFOI. COVERAGE r _ ;LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE - COMPANY A: Legion La ura:at Comps )LDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR COMPANY 8: . - . _ .TER THE COVERAGE A FFORDED DV THE POLICIES BE Low. '.ODUCEK • INSURE • . AO Insurance Agency, Inc. Hospice of Kona - - 0. Box 988 74-5094 Palani Rd Helena, CA 94574 Kaihra -Kona, HI 96745 - overages IS IS TO CERTIFY TIM] THE POLICIES OF INSURANCE LISTED BELOW HAVE BtEN ISSUED 10 THE INSURED NAMED ABOVE FOR AE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OCUM ENT WTR 1 RESPECT TO WHICH THIS CERTIFICATE MAY eE ISSULTJ OR MAY PERTAIN, THE INSURANCE AFFORDED 8Y THE .!LICIT• S DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN ;AY HAVE BEEN REDUCED DY MID CLAIMS. constrain W'IRA71ON IJIQI3 1 JC R TYFR OF INSURANCE MIY I RAT! DAT! A GENERAL LIABILITY P1.5-0oulu 1v0199 I2N1mo BIt rnc0)450EO X COMP. FORMCIIim Mode swag GRITS INCIDENT 11,000,000 PREMisES,aFERATIONS DI A PDCONa1 ao CON1RACTVAL•u04TlW SBIGLBID8rS AGO 55.000.000. B. F. PPOrEATYDAMAGE . POs0HALRU AGG 11,000.000. • A AUTO LIABILITY 175-00011! 12/01799 12/0U00 Mt EDCOMBD'RD . SQICRB LOUT OLC M I J,UOQ. . X HIRED AUTOS X NON OWNED AUTOS - EXCESS LIABILITY • ' S UMBRELLA oTHFR 'FORM AGGREGATE S . • p'1NRRINAN A OTHER . X MEDICAL PROP. ?45-100111 17101199 12101100 El& EU COMBINED LIABILITY • CLAIMS MADE SINIXEWUT INCIDENT 51.000.00. 111 i PO COMBINED • • SINGLE LOUT AGG 11000.000. . Wa/RUPIION OF OrlRATIDNS . IIOSPICE/ HOME I IEALTII IF CERTIFICATE MAMMA Hospice of Kona PO Sox 217 • . Kailua -Kona. HI 96745 CANCELLATION S11auLU ANY OF THE ABOVE DESCRIBED INUCIES BE CA NCELLED BEFORE THE EXPIRATION DATE 7 77: THE ISSUING COMPANY. WILLENDEAVOR TO MAT ?Boars WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAME^ A IVNE, UIYJ' FAILURE TO MAIL gUCH NOTICE SHALL IMPOSE NO OBLIGATION ORLIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENT, OR REPRESENTATIVES. . . AUU. RI THHOZED REMISES-1St-Mr: ' ." C .I 0 ✓LTA�. • • - • . - _ LEGION INSURANCE COMPANY One Logan Square . Philadelphia, PA 19103 • NATIONAL HOSPICE ORGANIZATION NOT FOR PROFIT ORGANIZATION DIRECTORS & OFFICERS LIABILITY POLICY DECLARATIONS • Policy Number: D02 - 0774170 THIS IS A CLAIMS MADE POLICY Unless an extended reporting period applies, the coverage of this policy is limited to those "Claims" . which arise from "Wrongful Acts" happening after the retroactive date, it any, stated In the declarations. Coverage is also limited to "Claims" first made against the "Insured" during the "Policy Period ". In addition, "Defense Costs" are subject to the self- insured retention, and will reduce the limits of liability available to pay settlements and judgments. Please review the policy carefully and discuss the coverage with your insurance advisor. Item 1. Organization: Hospice of Kona 74 -5094 Palani Rd Kailua -Kona, HI 96740 Item 2. Limits of Liability: Each Loss $1,000,000. Each Policy Year $1,000,000. • Note that the limits of liability and deductible are reduced or exhausted by Defense Costs. Item 3. Policy Period: From 12:01 a.m. on: 12/1/1999 to 12:01 a.m. on: 12/1/2000 Local time at Organization's address. Item 4. Deductible Amount: (A) Non- Indemnifiable Loss NONE (8) Indemnifiable Loss 51,000. Item 5. Extended Reporting Period: (A) Additional Premium: 100% of Expiring (B) Additional Period: 12 Months Item 6. Retroactive Date: N/A Item 7. Termination of Prior Policies: NONE Item 8. Premium: 708 By: a_ 410121 (2-98) 1 �. i i• • • IN THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS • STATE OF HAWAII In the Matter of the Petition ) ) of • ) ) • HOSPICE OF KONA, INC., ) • For a Charter of Incorporation) ) f i '.. I � (( y 2 61.; x,. • `` ,I LJ ..'., iti 6..._. U ."!_ L . .I PETITION FOR CHARTER and CHARTER OF INCORPORATION • • • CADES SCHUTTE FLEMING & WRIGHT • MICHAEL P. PORTER 1000 Bishop Street Honolulu, Hawaii 96813 • ( IN THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS STATE OF HAWAII In the Matter of the Petition ) ) of ) ) • HOSPICE OF KONA, INC., ) ) • For a Charter of Incorporation) ) PETITION FOR CHARTER OF INCORPORATION • The undersigned, a majority of whom are residents of the State of Hawaii, hereby petition for a charter of incorporation pursuant to Section 416 -19, Hawaii Revised Statutes, as amended, and Section 416 -20, Hawaii Revised Statutes, as amended, for themselves and their associates as a nonprofit corporation under the name of HOSPICE OF KONA, INC., and in connection herewith do hereby incorporate by reference the accompanying proposed charter of incorporation setting forth various matters required under Section 416 -20, Hawaii Revised Statutes, as amended. DATED: Honolulu, Hawaii, August 1985. r ; MICHA P. PORTER • JANE LaPLANTE r 1 411 k RICHARD A. HICKS • . . a • • STATE OF HAWAII ) ) SS: CITY AND COUNTY OF HONOLULU ) MICHAEL P. PORTER, JANET LaPLANTE, and RICHARD A. HICKS, being first duly sworn, on oath depose and say: That MICHAEL P. PORTER, JANET LaPLANTE, and RICHARD A. HICKS are the petitioners named in and who signed the foregoing Petition for Charter; that MICHAEL P. PORTER, JANET LaPLANTE, and RICHARD A. HICKS have read said Peti- tion, know the contents thereof, and that the saute is true to the best of their knowledge and belief. SAl Z 7 c MICHAEL P. PORTER JAN 'aPLANTE I ' r RICHARD A. HICKS Subscribed and 9worn to before me this)3 4 day of lAjlf,.rl.4 , 1985. ' (5 ) (Lh& k (I C).4A. Notary Public, State of E{awai My commission expires: /1' • „ i • • • • • • • • IN THE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS STATE OF HAWAII In the Matter of the Petition ) of ) HOSPICE OF KONA, INC., For a Charter of Incorporation) ) CHARTER OF INCORPORATION WHEREAS, M[CHAEL P. PORTER, JANET LaPLANTE, and RICHARD A. HICKS have made application to the Director of the Department of Commerce and Consumer Affairs of the State of Hawaii to grant to them and their associates a charter of incorporation as a nonprofit corporation under the name HOSPICE OF KONA, INC., for the purposes and with the powers hereinafter stated, I, the Director of the .Department of Commerce and Consumer Affairs, State of Hawaii, in the exercise and - execution of all power and authority conferred on me, hereby constitute HOSPICE OF KONA, INC. and their associates a nonprofit corporation under the laws .of the State of Hawaii. ARTICLE I Corporate Name • Section 1.1 The name of the Corporation shall be HOSPICE OF KONA, INC.. ARTICLE [I Location of the _Corporation Section 2.1 The location of the Corporation shall be Kailua -Kona, Hawaii and the address of its initial office shall be 78 -261 Manukai Street, #201, Kailua -Kona, Hawaii 96740. • ARTICLE III Corporate Purposes • Section 3.1 Purposes. The Corporation is orga- nized exclusively for the following purposes: (i) To provide support and care for persons in the last phases of incurable disease so they can live their remaining time as fully and comfortably as possible; (ii) To provide an ongoing educational program for professionals and the general public on the methods of providing care for the terminally ill and their families; 4 • • • (iii) To institute a program of home care to be provided by a medically supervised interdisciplinary team of professional and lay volunteers trained to care for dying patients and their families during the last phases of terminal illness, and to provide a program of support for the survivors; and (iv) to operate exclusively for charitable, liter- . ary, educational and scientific purposes, within the meaning of Section 501(c)(3) of the Internal Revenue Code, including for such purposes, the making of distributions to organizations that qualify as tax- exempt organizations under Section 501(c)(3) of the Internal Revenue Code of 1954 (or any future corresponding provisions). Section 3.2 Restrictions. No part of the-assets or earnings of the Corporation shall inure to the beueEit of any member of the Corporation or individual. The Corpora- tion shall not participate in or intervene (including the publication or distribution of statements) in any political campaign on behalf of any candidate for public office. Notwithstanding any other provision of this Charter, the Corporation shall not carry on any activities not permitted to be carried on: (i) By a - corporation exempt from Federal Income Tax under Section 501(c) (3) of the Internal Revenue Code of 1954 (or the corresponding provision of any future United States Internal Revenue Law); or (ii) By a corporation, contribu- tions to which are deductible under Sec - tion 170(c) (2) of the Internal Revenue Code of 1954 (or the corresponding provi- sion of any future United States Internal Revenue Law). ARTICLE IV • Corporate Powers Section 4.1 The Corporation shall have and possess all the powers permitted to nonprofit corporations under the laws of the State of Hawaii. ARTICLE V Corporate Life Section 5.1 The duration of this Corporation shall be perpetual. ARTICLE VI Directors and Officers Section 6.1 Board of Directors. There shall be a board of directors consisting of not fewer than three (3) 2 • 9 • • persons. The Board of Directors shall have and may exercise all the powers of the Corporation except as otherwise provided by law, this Charter or the Bylaws. Section 6.2 Officers. The officers of the Corpo- ration shall be a president, one or more vice presidents, a secretary and a treasurer. The Corporation may have such additional officers as shall be determined in accordance with the Bylaws. The officers :shall have the powers, per- form the duties and be appointed in the manner set forth in the Bylaws. Any person may hold two or more offices of the Corporation unless such practice is prohibited by the Bylaws. Section 6.3 Initial Officers. The following persons shall be the initial officers and directors of the Corporation and shall hold office for the first year or until their successors are duly elected pursuant to the Bylaws: Marcia Lockwood, President and 78 -261 Manukai St. #201 Director Kailua -Kona, HI 96740 Cynthia Salley, Vice President Box 500 and Director Honaunau, HI 96726 Judy Rietow, Vice President and 76 -6322 Mahuahua P1. Director Kailua -Kona, HI 96740 Sandol Stoddard, Secretary and 78 -6646 Mamalahoa Hwy. Director Holualoa, HI 96725 Pat Taylor, Treasurer and 75 -6016 Alii Dr. #221 Director Kailua-Kona, HI 96740 ARTICLE VII LIABILITY AND INDEMNIFICATION OF OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS Section 7.1 No Liability to Corporation. No director, officer, employee or other agent of the Corpora- tion and no person serving at the request of the Corporation as a director, officer, etnployee or other agent of another corporation, partnership, joint venture, trust or other enterprise and no heir, or personal representative of any such person shall be liable to the Corporation for any loss or damage suffered 'by it on account of an action or omission by such person as a director, officer; employee or other agent if he acted in good faith and in a manner reasonably believed to be in or not opposed to the best interests of this Corporation, unless with respect to an action or suit by or in the right of the Corporation to procure a judgment in its favor such person shall have been adjudged to be liable for negligence or misconduct in the performance of his duty to this Corporation. Section 7.2 Indemnity. (1) The Corporation shall indemnify any person who was or is a party or is threatened to be trade a party to any threatened, pending or completed action, suit or proceeding, whether civil, criminal, admin- istrative or investigative (other than an action by or in 3 " 11 4 • • the right of the Corporation) by reason of the fact that he is or was a director, officer, employee or other agent of the Corporation or is or was serving at the request of the Corporation as a director, officer, employee or other agent of another corporation, partnership, joint venture, trust or other enterprise, against expenses (including attorneys' fees), judgments, fines and amounts paid in settlement actually and reasonably incurred by him in connection with such action, suit' or proceeding: if he acted in good faith and in a manner he reasonably believed. to be in or not opposed to the best interests of the Corporation, or, with respect to any criminal action or proceeding, had no reason- able cause to believe his conduct was .unlawful. The termi- nation of any action, suit or proceeding by judgment, order, settlement, conviction, or upon a plea of nolo contendere or its equivalent, shall not, of itself, create a presumption that the person did not act in good faith and in a manner Which he reasonably believed to be in or not opposed to the best interests of this Corporation or, with respect to any criminal action or proceeding, had .reasonable cause to believe that his conduct was unlawful. (2) The Corporation shall indemnify each person who was or is a party or is threatened to be made a party to any threatened, pending or completed action or suit by or in the right of the Corporation to procure a judgment in its favor by reason of the fact that such person is or was a director, officer, employee or agent of the Corporation or is or was serving at the request of the Corporation as a director, officer, employee or agent of another corporation, partnership, joint venture, trust or other entity, against: expenses (including attorneys' fees) actually and reasonably incurred by him in connection with the defense or settlement of such action or suit if he acted in good faith and in a manner he reasonably believed to be in or not opposed to Ehe best interests of this Corporation, except that no indemni- fication shall be made in respect of any claim, issue or matter as to which such person shall have been adjudged to be liable for negligence or misconduct in the performance of his duty to this Corporation unless and only to the extent that the court in which such action or suit was brought shall determine upon application that, despite the adjudica- tion of liability but in view of all the circumstances•of the case, such person is fairly and reasonably entitled to indemnity for such expenses which such court shall deem proper. (3) To the extent that a director, officer, employee or other agent of the Corporation or of any divi- sion of the Corporation, or .a person serving at the request of the Corporation as a director, officer, employee or agent of another corporation, partnership, joint venture, trust or other entity, has been successful on the merits or otherwise in defense of any action, suit or proceeding referred to in paragraphs (1) and (2) of this section, of In defense of any claim, issue or matter therein, he shall be indemnified against expenses (including attorneys' fees) actually and reasonably incurred by him in connection therewith. (4) Any indemnification under paragraphs (1) and (2) of this section (unless ordered by a court) shall be made by the Corporation only if authorized in the specific • 4 t • R` • • • • case upon a determination that indemnification of the direc- tur',, officer, employee or agent is proper in the circum- stances because he has met the applicable standard of con- . ' duct set forth in paragraphs (1) and (2). Such determina- tion may be made: (i) by the Board of Directors by a majority vote of a quorum consisting of directors who were .riot parties to such action,, suit or proceedings; (ii) if such a quorum is not obtainable, or, even it obtainable and a quorum of disinterested direc- tors so directs, by independent legal counsel in a written opinion to the Corporation; (iii) if a quorum of disinterested directors su directs, by a majority vote of the members; or (iv) by the court in which such proceeding is or was pending upon application made by the Corpora- tion or the agent or • the attorney or other person rendering services in connection with the defense, • whether or not such application by the agent, attorney or other person is opposed' by the Corpora- . Lion. • • (5) Expenses incurred in defending a civil or criminal action, suit or proceeding may be paid by the Cor- poration in advance of the final disposition of such action, suit or proceeding as authorized by the Board of Directors in a particular case upon receipt of an undertaking by or on behalf of the director, officer, employee or agent t� repay such amount unless it shall ultimately be determined that he , • • is entitled to be indemnified by the Corporation as autho -- rized in this article. • (6) The indemnification provided by this article shall not be deemed exclusive of any other rights to which those indemnified may be entitled and shall continue as to a person who has ceased to be a director, officer, employee or • agent and shall inure to the benefit of the heirs and per- sonal representatives of any such person. (7) The Corporation, shall have the power to pur- chase and maintain insurance on behalf of any person who is or was a director, officer, employee or other agent of the Corporation or is or was serving at the request of the' Corporation as a director, officer, employee or other agent • of another corporation, partnership, joint venture, trust or other enterprise; against any Liability asserted against him and incurred by him in any such capacity or arising out of his status as such, whether o.r not the Corporation would , have the power to indemnify him against such liability under - the provisions of this Article. ARTICLE VIII Membership Section 8.t Membership in the Corporation may be held by all: who ha-va: t.he- qualification& o•& rnuae►be,rsdrip • 5 . • • specified in the Bylaws. Members of the Corporation shall • be admitted or expelled in the manner provided by the Bylaws. ARTICLE IX Non - Profit • Section 9.1 The orporation is not organized for profit and it will not issue any stock, and no part of its assets, income, or earnings shall be distributed to its members, directors, or officers, except for services actually rendered to the Corporation, except that the Corpo- ration shall be empowered to make payments and distributions in furtherance of the exempt purposes for which it was formed. This corporation is organized exclusively for purposes within the meaning of section 501(c)(3) of the Internal Revenue Code of 1954. The corporation shall not participate or intervene in any political campaign On behalf of any candidate for public office. • Notwithstanding any other provision of these articles, the corporation shall not .carry on any other acti- vities not permitted to be carried on (a) by a corporation exernpt from Federal income tax under section 501(c)(3) of the Internal Revenue Code of 1954 (or the corresponding pro- vision of any future United States Internal Revenue Law) or (b) by a corporation contributions to which are deductible under section 170(c)(2) of the Internal Revenue Code of 1954 (or the corresponding provision of any future United States Internal Revenue Law). ARTICLE X ' Corporate Liability Section 10.1 The property of the Corporation shall alone be liable in law for the payment of the debts and liabilities of the Corporation. ARTICLE XI Corporate Dissolution Section 11.1 If the Corporation shall cease to exist or shall be dissolved, all property and assets of the Corporation of every kind, after payment of its just debts, shall be distributed only to one or more public agencies, organizations, corporations, trusts or foundations having like purposes and organized and operated exclusively for charitable, scienti.tic, e or literal? purjioreee, no part of whose assets, income or e may be used for dividends or otherwise withdrawn or distributed to or inure to the benefit of any private shareholder or individual and the activities of which do not include participation or intervention in any political campaign on behalf of any 6 • . • • • candidate for public office. In no event shall any dis- 'tribution be made to any organization unless it qualifies as • a. tax- exempt organization under Section 501(c)(3) of the Internal Revenue Code of 1954 (or any future corresponding provision) with purposes similar or related to those of the Corporation. ARTICLE XII Bylaws Section 12.1 Adoption. The Bylaws shall be adopted by the signers of the petition for this Charter of Incorporation. Section 12.2 Amendment. The power to alter, amend or repeal .the Bylaws or adopt new bylaws shall be vested in the Board of Directors subject to repeal or change by action of the members. ARTICLE XIII Charter of Incorporation Section 13.1 This Charter shall be subject to amendment from time to time in the manner set forth by law, and the Corporation shall be subject to all general laws now in force or hereafter enacted with regard to corporations of this mature. GIVEN under my hand and seal of the Department of Conunerce and Consumer Affairs, 1yj�kk\\((hi Z:! "'d. o ? , f r• :� __ 1985. ` Dire h '`:1 tment of Commerce and Consumer Affairs State of Hawaii Y 'C _ Russell H. YaMashita Corporation and Securities Administrator • 7 • . . • �.k BYLAWS HOSPICE OF KONA • ARTICLE I • ACTIVITIES The activities of this Corporation shall be those necessary and appropriate' to accomplish the purposes of the Corporation as stated in the Charter .of Incorporation. ARTICLE [1 OFFICES • Section 2.1 Pri Office. The principal office of the Corporation shall be at such place in the _ State of Hawaii as the Board of Directors shall from time to time determine. The mailing address of the initial princi- pal office of the Corporation is 78 -261 Manukai Street #201, Kailua -Kona, Hawaii 96740. • Section 2.2 Other Offices. The Corporation may have such other offices within the. State of Hawaii as the board of Directors may designate. ARTICLE I I L: • MEMBERS Section 3.1 General. The members of the Corpora- tion shall consist of all members of the Board of Directors and all persons elected to membership in accordance with these Bylaws. Membership in the Corporation shall be evi- • denced by the membership roll of the Corporation. Section 3.2 Admissio__n so f Members. The power to admit and expel members shall be vested solely in the Board of Directors. The Board of Directors shall from time to time prescribe the qualifications and requirements for membership and shall have the power to create classes o6 membership conferring such rights and privileges and imposing such obligations as may from time to time be determined' by the Board of Directors. ARTICLE IV • MEETING OF MEMBERS Section 4.1• Anntial Meeting. The annual meeting of the members snail be. held each year at .such time And place as. the •I!'oard of Directors determines' for the purposes of electing directors and transacting, such other business - as. . may come before Ute meeting. The members may di.spense.with the annual meeting by unanimous written consent. • • III • Section •I.2 Speci.el Meetings. Special meetings of this members for any purpose or purposes may be held at any I. into upon iho call of the President:, ut the call of any two directors, or' upon the written '"quest of one - fourth • (1/4) of the membcru entitled to vote thereat.' Section 4.3 Place of. Meeting. The Board of Ditec- tors may designate any place as the place of meeting for any annual meeting or any special meeting of the members. If no • designation is made, the place of meeting shall be the prin- cipal office of the Corporation. • Section 4.4 Notice of Meetings. Notice of all Meetings, annual or special, stating fire place, day and hour of the meeting and whether Lt is annual or special, and in case of a special meeting stating the purpose or purposes thereof, shall be given personally or by mail. If by mail, such notice shall be postage prepaid to each metilber at his address as it appears on the membership roll of the corpora- tion at least ten (10) days before the meeting. action 4.5 Adjourned Meetings and Notice Thereof. Any meeting of the members, :Annual or special, whether or not a quorum is present, may be adjourned from time to time by the vote of a majority of the members present, but in the . absence of a quorum no other business may be transacted at ' ' any such meeting. When any members' meeting, either annual or special, is adjourned for thirty (10) days or more, notice of the adjourned meeting shall be given as in the case of an original meeting. Otherwise it shall not be necessary Lo give any notice of an adjourned meeting other than by announcement at the meeting at which such adjournment is taken. Section 4.6 Voting. At all meetings of members, every member entitled to vete shall have the right to vote . , in person or by written proxy. , Section 4.7 quorum: A majority of the members entitled to vote shall be necessary to constitute a quorum for the transaction of business. • ARTICLE V BOARD OF DIRECTORS Section 5.1 Number and Qualification of Directors. The authorized number of directors of the Corporation during each year shall be such number, not fewer than three (3), as may be fixed by the Board of Directors; provided that such number shall always be a whole multiple of three. • Section .5.2 Election. Except for the initial . directors; one -third directors shall be elected at teach ' annual meeting of .the members of the Corporation AZIr at any special meeting of members held for that purpose.' 2 . 3 • • °> h¢ S nun 5. i 'l?•rm of UEtiice. All di roctots shall , ld +ild oft 1c9 until their tespecl ive successuts are elected. Section 5.4 Permanent __Vac'iueies.' Permanent vacancies, on the Board - of Dirctors caused by death, tesignat.i.on, unreasonable absences, removal or other cause . may be filled by .a majority of the remaining directors, though. less than a quorum, or by a sole remaining director. Each director so elected shall hold office until his successor is elected Al. the next annual or a special meeting of the members. Unreasonable absences shall mean absence from three consecutive regular meetings of the Board of Directors unless the absent director is off of the Island, ill 'or otherwise satisfies the Board of Directors that the absences were reasonable. The ,decision of the Board of Directors shall be conclusive as to all persons and the Corporation. Section 5.5 Temporary__ Vacancies; Temporary Directors. Iu the case of a temporary vacancy due to the absence of any director or the sickness or disability of any director, the remaining directors, or director, may appoint some person as a substitute director who shall be a director • during such absence or disability and until such absent 61 rector returns to duty. The determination by the remain- ` ing directors, as shown by the•minutes, of the fact of such absence or disability and the duration thereof shall he conclusive as to all persons and the Corporation. Section 5.6 Reduction. No reduction, of the autho- rized number of directors shall have the effect of removing any director prior to the expiration of the tern of office. ARTICLE VI MEETINGS OF THE 'BOARD OF DIRECTORS . Section 6.l Regular Meetings. A regular meeting of the Board of Directors shall be held immediately after, and at the same place as, the annual meeting of members. Nu notice other than this bylaw needs be given. 'Tie Board of Directors may provide, by resolution, the time and place for the holding of additional regular meetings. No notice other than such resolution need be given. Section 6.2 Special.• Meetings. Special meetings of the Board of Directors May be called by or at the request of the President or any two directors. The person or persons authorized to call_ special meetings of the Board of Direc- tors may fix any place: within the State of Hawaii as the place for holding any special meeting of the Board of Direc- tors called by theta. • Section 6.3 Notice. The Secretary shall give notice of each meeting of the Board of Directors in writing by mailina,.khe same not less than three (3) days before the meeting or by giving notice personally, by telephone or by. • . telegraph not less titan one (1) day before the meeting; or as otherwise prescribed by the Board. The failure by_ Secretary to give such notice or by any director to receive • 3 • • • • • • • a • • •;ucil luti.:e :;ha1 nut invalidate th1! Lrroccedinrls of an (I•I,r at which a quorum of tllo ,ILrectnrs 1:3 present. Sfr t:i::o .: ^e1 not Im•giv��l to any dileraot who shall, c!ithec . I � ' r noel aftr Cllr: meeting, sulllliit - a signed waiver at notice or attend such mef:l:inq willemit protecting, prior, to or at its commencement, the lack of nct:•'e to him. Except as otherwise provided by law, the Charter of Incorporation or by, these Bylaws: a notice oi waiver of notice need not state the purposes of such meeting. . - Section 6.4 fleet-ilm_ind..AdjournMer>_l. The majority ion of the directors shall c.onstt t .u of q o No to I1 Laken, other than the apt temporaly vacancies, shall•bind the•Corporatlou unless it shall receive the concurring vote of a majority of the quorum of all the directors. In the absence of a quorum, the presiding officer or a majority of the directors present may adjourn the meeting from time to time without further notice until a quorum is present. Section 6.5 Presumption of.__Assent. A director of the Corporation who is present at a meeting of the Board of Directors be presumed to have rt corporate at is taken assented to theactio shall taken - l the dissent or refusal to vote is entered in the minutes of the meeting or unless the director either files a written dissent to such action-with the person acting as the Secretary of the meeting before the adjour thereof or forward such dissent by certified mail to the Secretary of the Corporation immediately after the adjournment of the meeting. Such right to dissent shall not apply to a direc- tor who voted in favor of such action. ARTICLE VII • POWERS AND DUTIES OF TIIE BOARD OF DIRECTORS Section-7.1 Powers. The corporate powers of this Corporation shall be vested in the Board of Directors to the fullest extent permitted by the laws of the State of Hawaii. The Board of Directors shall have general- charge of the affairs, funds and property of the Corporation, and shall have full power, and it shall be t heir duty, to enforce the Bylaws. The Board of Directors shall have the power to expel any member of the Corporation or remove. any .director of. the Corporation from office without cause. Section 7.2 Dutie It shall be the duty of the directors to cdnduct, manage and control the affairs' and business of the. Corporation ..and to promulgate and enforce rules and regulations .therefor not. inconsistent with law, the Charter of Incorporation or the Bylaws of the Corpora- tion. ARTICLE VIII • 'OFFICERS ' Section B.l Number. The officers of the Corpora . l ion shall be the president, one or more vice presidents, • • 4. . • • S'' 'el try. the '1')easurer anti, in the discretion of the I.!;•:at'd of Dlivetur , a Chairman of the Hoard and such other: rrtfiu - errl as the Heard of Direcl.-,r•; .;It 11 from tu to ti.mre olett with such dug i e>; as tram Itr to time !Way be. pre - s'•r i5ad by the ennui f Iri t g:I.ev ; or the IJv'uwa; rrovidod that the Curhoration all have nut fewer th-•n tiro persons as officers. Sec;:ioe .2 'Elect] and Perm of_ (If() e. All officer- shall ' e ted b• ti:e !Maid of. Directors and shall serve until their succe ;sor:, are elected. One person may hold more than one office. All officers shall be sub- ject lo removal at any time without cause by the Board of Directors. The Board of Directors may, An its discretion elect acting or temporary officers" and may elect officers to fill vacancies occurring for any reason whatsoever, and may Limit or enlarge the duties and powers of any officer elected by it. Officers need not be directors of the Corpo- ration. • Section 8.3 President. The President (in the absence of the Chairman of the Board, if elected) shall preside at all meetings of the members and the Board of Directors. The President shall he the chief executive officer of the Corporation and.s.hall have general charge and supervision of the Corporation. The President shall perform such other duties as are incident to the office or are required by the Board of Directors.' Section 8.4 Vice Presidents. In the absence or disability or refusal Co act by lli.e President, the Vice President or. vice preside :nts shall, in the order designated by the President or the Board of Directors, performs all of • the duties of the ('resident, and when so acting shall have all the powers of and•be subject to the restrictions upon the President. The Vice President or vice presidents' shall have such powers and perform such other duties as from t • ime to time may be prescribed by the President, the Board of Directors ot the Bylaws. • • Section H.5 Treasurer Or Assistant Treasurers The 'Treasurer shall. be :Elie chief financial officer of the :orpnration and exercise general supervision over the' .eceipt, custody and disbursement of Corporate funds. The ,•reasurer shall perform all other duties assigned by the President or the Board of 'Directors. The Assistant 'Trea- surer or assistant treasurers, if elected, shall, in the order designated by't'he President or the Board of Directors, perform all the duties and exercise all the powers of the Treasurer during the absence or disability of the Treasurer, or whenever the office is vacant and shall perform .all the duties assigned by the President or the Board of Directors. • • Section 0.6 Secretary and Assistant .Secretaries. The Secretary,shal.l keep the minutes of all meetings of 'the members and Board ofs irectors. The Secretary shall keep or cause to be kept a register shpwing.the names of the mein- hers, directors and officers with their addresses. The Secretary shall give notice in conformity with the Bylaws of all• meetings of the members and the Board of Directors. • Tjte. 5 • • • • • • Secretary shall also perform all other duties assigned by Lhe President or the Board of Directors. The Assistant Sqt retary or assistant secretaries, if elected, shall, in .01b. order designated by the President or Board of Directors, perform all the duties and exercise all the ;rowers of the Secretary during the absence or disability of the Secretary or whenever the office is vacant, and shall perform all the , duties assigned by the President or the Board of Directors. • Section 0.7 Chairman _of_ the Board. The Chairman of the Board, iE appointed, shall preside at all meetings of the Board of Directors and the members and shall perform such other duties as may be required by the Board of Direc- tors. ARTICLE IX DISBURSEMENTS AND CON'T'RIBUTIONS Section 9.1 Disbursements. Disbursements of the funds of the Corporation for the purposes for which it is organized shall be made by the Board of Directors in its discretion. Section 9.2 Limitations on Disbursements. The Board of Directors shall not make any disbursements or con - tributions of the funds or assets of the Corporation to or for the benefit, directly or indirectly, of any member, director or officer of. the Corporation, except for reason- able payments for services actually -rendered to the Corpora- tion by such member, director or offlceras an employee of the Corporation. ARTICLE X MISCELLANEOUS Section 10.1 Inspection_ of Corporate Records. The . • books of account and minutes of proceedings of the members and directors shall be open to inspection upon the written • • demand of any member entitled to vote, at any reasonable time, and for a purpose reasonably related to his interests • as a member, and shall be exhibited at any time when' required by the demand of a majority of the members. Such inspection may be made in person or by an agent or attorney, and shall include the right to make copies. Demand for inspection may he made in writing upon the President, Secretary or assistant secretary of the Corporation. Section 10.2 Handling of funds. All checks, drafts, or other orders for.'payrnent of money, notes or other evidences of indebtedness issued in the name of or payable to the Corporation shall be signed or endorsed by such person or persons and irr.such manner as, from time to time, • shall be determined by resolution of the Board of Directors. Sectl on 10.3 Execution of Contracts. The Board of Directors inay authorize any officer or officers, agent•or agents, to enter into any contract or execute any instrument , in the name of and on behalf of the Corporation, and - 'such • • 6 • ♦ • • authority may be general or confined to specific instances; and unless so authorized by the Hoard of Directors, no ' off agent or elm loyee shall have any power or authority to bind the Corporation by any contract or engagement,or to pledge i t s credit or to render A t liable for any purpose or to any amount. Section 10.4 Inspect ton of Bylaws. The Corpora- . . 0.on shall keep in its principal orfiee the original or a copy of the Bylaws as amended, certified by the Secretary, which shall be open to inspection by the members at all reasonable tunes during office hours. • ARTICLE XI SEAIr The corporation shall have a seal of such forth as the Board of Directors may from time to time determine. • ARTICLE X11 r AMENDMENTS The Bylaws may be amended or repealed in accordance with the provisions of the Charter of Incorporation. The undersigned, being all of the signers of the Petition for Charter of Incorporation of (HOSPICE OF KONA, INC., hereby adopt the foregoing Bylaws as the Bylaws of the corporation. • DATED: August 23 , 1985. PfriP4 : • . MICIHAEL P. PORTER C JANET LaPLANTE u� RICHARD A. I HICKS - -- • • • • • • • 7 . • • • •