7340 SW Hunziker | Suite 104 | Tigard, Or 97223 | P 503-684-3788 | F 503-624-0870
MEMBERSHIP DATA FOR FY 15-16
Member Organization_________________________________________Date:___________________________
Person Completing Form:______________________________________Title:___________________________
Phone:__________________________________E-Mail:_____________________________________________
Please check if:
CCRC
Medicare certified
Medicaid certified
Under development/construction
The following information is collected on an annual basis. Please copy this form, enter the following
information for each campus/site, and forward each completed form to Denise We5zel
(dwetzel@leadingageoregon.org, FAX: 503-624-0870, or regular mail) by July 11, 2015. Thank you.
Unit/Bed Calculation:
NonMemory
Care
Endorsed
Memory
Care
Nursing Beds
Assisted Living Units
Residential Care Units
Market Rate Housing Units/
Independent CCRC Units
Subsidized Housing Units
(Section 8, 202, 236)
Total
Community Services:
Type Service
Total
Estimated
Persons
Served
Adult Day
In-Home Care
Home Health
Respite Care
Other:(Specify)_______________
Other :(Specify)______________
Calculation of Assessable Operating Expenses for LeadingAge Oregon Dues:
Assessable Operating Expenses, for LeadingAge Oregon dues purposes, are defined as the total gross
operating expenses of each organization. Certain items are excluded from assessable operating expense
figures in order to be sure that a "cost of doing business" figure is used which is comparable across different
LeadingAge Oregon organizations. Please enter the appropriate information in the table below using figures
from the organization’s most recently compiled annual financial statements.
Total Operating Expenses
Less Deductions:
 Mortgage Principal
 Mortgage Interest
 Mortgage Insurance
 Depreciation
 Property Taxes
Less Total Deductions
Total Assessable Operating Expenses
$
$
$
$
$
$
$
$
Program Service Revenue Definition for LeadingAge Dues:
Program service revenue from aging services would be (but not limited to) revenue from nursing care, assisted
living, independent living units, adult day care, home health care, transportation, outpatient services, meals on
wheels, hospice and community based services. It would exclude interest, investments, realized and unrealized
gains or losses, special events and activities, contributions and any other services unrelated to the mission of
LeadingAge. Please enter the Program Service Revenue and/or Rental Income using figures from the
organization’s most recently filed IRS form 990 (line 9), audited financial statement or annual P&L statement.
Annual Program Service Revenue and/or Rental Income
$
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Payment Options:
Please indicate your preferred method of payment:
Full Payment (encouraged and appreciated)
Quarterly Payments
Monthly Payments
Overview:
A not-for-profit facility/residence or organization that becomes a member of the LeadingAge Oregon also
becomes a member of LeadingAge. The total dues paid by the nonprofit facility or organization are the sum of
LeadingAge Oregon dues and LeadingAge dues. New LeadingAge Oregon members that have not previously
been a member pay 1/3 the full dues their first year, 2/3 their second year and full dues each year thereafter.
Because for-profit LeadingAge Oregon members are not members of LeadingAge, they pay LeadingAge Oregon
dues only. Each campus/site of a parent organization is required to have separate membership status and is
assessed membership dues.
LeadingAge Oregon Dues Structure:
LeadingAge Oregon dues structure is a combination millage and an annual per unit/bed rate. Member dues
are calculated by adding:
 A facility's total number of units/beds times an annual $7.35 per unit/bed and
 A member's annual assessable operating expenses multiplied by a predetermined millage rate of .0008
Startup facilities pay dues on a Bed/Unit Rate only, until financial statements reflect operating expenses
following occupancy. Community service providers that do not have beds or apartments would pay dues on
operating expenses only. Facilities/residences that are "under development" pay a flat fee of $150 per year.
Business Firm Member dues are $375 per year.
LeadingAge Dues Structure:
LeadingAge implemented a new dues structure based on millage in 2005. Dues are calculated based on a
member’s annual program service revenue multiplied by a predetermined millage rate plus a flat rate. Both
the millage rate and flat rate are dependent upon the amount of the member’s annual program revenue. New
LeadingAge members that have not previously been a member pay 1/2 the full dues their first year, and full
dues each year thereafter. Members who join between July 1 and December 31 receive complimentary
membership year 1 and pay full dues in year 2.
If Program Service Revenue is:
Between $0 and $999,999
Between $1,000,000 and $9,999,999
$10,000,000 or more


Millage Rate
0.00040
0.00035
0.00030
Flat Amount
N/A
$50
$550
Minimum dues: $350; Maximum dues: $9,000
Facilities under construction pay a flat fee of $350
For professionals who are not directly affiliated with a provider, LeadingAge has associate member categories.
Associate member dues are as follows:
$ 95
 National/State/Local Organizations $ 620  Individuals
$ 95
 Attorneys:
One - $375
Two - $ 725  Retirees
$1,120
$ 95
 Law Firm
 Trustees/Students
Business Firm Member dues are $890 for firms with 5 or fewer employees, $1,100 for firms with 6 or more
employees and $600 for a one-person shop. If a business firm is also a member of a state association,
LeadingAge discounts their dues by $100.
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