Program services are those activities your organization was created to conduct, plus programs and activities later added, that form the basis of your current federal tax exemption. Program service revenue includes, but is not limited to, revenue from nursing care, assisted living, independent living, adult day care services, home health care, transportation, outpatient services, hospice, meals and other community-based services. Program service revenue would exclude your interest on savings and temporary cash investments, realized and unrealized gains or losses, special events and activities, charitable contributions, and any other services unrelated to LeadingAge’s mission. If your organization does not file Form 990 with the IRS, provide program service revenue from one of the following documents using the IRS definition (see above) for program service revenue:

• The organization’s audited financial statement
• Medicaid Cost Report
• Profit and loss statement

Please report your program service revenue and fiscal year it represents:

Please report an estimate of your program service revenue for the subsequent year: