CHURCH HEALTH SERVICES INC: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- CHURCH HEALTH SERVICES INC (EIN 39-1759669)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-11-02
- IRS object ID
- 202213069349301636
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-11-02T11:49:50-05:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 391742997 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | O'CONNOR WELLS & VANDER WERFF LLC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 111 E MAIN STREET | AddressLine1Txt |
| City | WAUPUN | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53963 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 391759669 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHURCH HEALTH SERVICES INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CHUR | BusinessNameControlTxt |
| Phone | 9208871766 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 115 N CENTER STREET | AddressLine1Txt |
| City | BEAVER DAM | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53916 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | THEO O'CONNOR | PersonNm |
| Person Title | EXECUTIVE DIRECTOR | PersonTitleTxt |
| Phone | 9208871766 | PhoneNum |
| Signature | 2022-10-31 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | THEO | PersonFirstNm |
| Person Last | OCONNOR | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | DIANE BANCROFT-DEYOUNG | PreparerPersonNm |
| PTIN | P00195537 | PTIN |
| Phone | 9203249711 | PhoneNum |
| Preparation | 2022-10-31 | PreparationDt |
| Self Employed | Yes (X) | SelfEmployedInd |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | SHIRLEY KITCHEN | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 115 N CENTER STREET | AddressLine1Txt |
| City | BEAVER DAM | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53916 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $1,759,519 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CHURCHCLINIC.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1993 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. | ActivityOrMissionDesc |
| Voting Members Governing Body | 13 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 13 | VotingMembersIndependentCnt |
| Total Employee | 31 | TotalEmployeeCnt |
| Total Volunteers | 20 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $448,987 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,505,881 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $161,079 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $253,403 | CYProgramServiceRevenueAmt |
| PY Investment Income | $226 | PYInvestmentIncomeAmt |
| CY Investment Income | $218 | CYInvestmentIncomeAmt |
| PY Other Revenue | -$3,230 | PYOtherRevenueAmt |
| CY Other Revenue | -$4,404 | CYOtherRevenueAmt |
| PY Total Revenue | $607,062 | PYTotalRevenueAmt |
| CY Total Revenue | $1,755,098 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $137,814 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $488,583 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $601,162 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $88,850 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $134,329 | PYOtherExpensesAmt |
| CY Other Expenses | $151,326 | CYOtherExpensesAmt |
| PY Total Expenses | $622,912 | PYTotalExpensesAmt |
| CY Total Expenses | $890,302 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$15,850 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $864,796 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $756,271 | TotalAssetsBOYAmt |
| Total Assets EOY | $1,483,035 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $183,461 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $20,710 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $572,810 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $1,462,325 | NetAssetsOrFundBalancesEOYAmt |
| Mission | CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $639,413 | ExpenseAmt |
| Grant | $137,814 | GrantAmt |
| Revenue | $253,621 | RevenueAmt |
| Desc | CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. | Desc |
| Total Program Service Expenses | $639,413 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | Yes (1) | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | 0 | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 2 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 31 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Form8899 Filedind | 0 | Form8899Filedind |
| Form1098 C Filed | 0 | Form1098CFiledInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 13 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 13 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | 0 | RegularMonitoringEnfrcInd |
| Whistleblower Policy | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | 0 | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | THEA O'CONNOR | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9208871766 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 115 N CENTER STREET | AddressLine1Txt |
| City | BEAVER DAM | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53916 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (14 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd |
|---|---|---|---|---|---|---|
| THEA O'CONNOR | ||||||
| EXECUTIVE DIRECTOR | 35.00 | Yes (X) | $77,442 | $0 | $5,189 | |
| SHIRLEY KITCHEN | ||||||
| PRESIDENT/BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| STEVE VESSEY | ||||||
| VICE PRESIDENT/BOARD MEMBE | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| TODD HEDBERG | ||||||
| TREASURER/BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| RICK VANT HOFF | ||||||
| SECRETARY/BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | Yes (X) |
| JENNIFER CAMPBELL | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| KAREN COLEY | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| HEIDI WEISS | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| BECKY GLEWEN | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| TOM HEFFRON | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| RICH ZIEMAN | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| CATHY NELSON | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| MARY VOGL-RAUSCHER | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| STEVE WESTRA | ||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $77,442 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $5,189 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
| Cntrct Rcvd Greater Than100 K | 0 | CntrctRcvdGreaterThan100KCnt |
| Fundraising | $21,551 | FundraisingAmt |
| Government Grants | $30,000 | GovernmentGrantsAmt |
| All Other Contributions | $1,454,330 | AllOtherContributionsAmt |
| Total Contributions | $1,505,881 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PROGRAM REVENUES | Desc |
| Business | 624100 | BusinessCd |
| Total Revenue Column | $253,403 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $253,403 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $253,403 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $215 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $215 | RelatedOrExemptFuncIncomeAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $20 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $17 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $3 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $3 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $3 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Fundraising Gross Income | $0 | FundraisingGrossIncomeAmt |
| Contri Rpt Fundraising Event | $21,551 | ContriRptFundraisingEventAmt |
| Fundraising Direct Expenses | $4,404 | FundraisingDirectExpensesAmt |
Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$4,404 | TotalRevenueColumnAmt |
| Exclusion | -$4,404 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,755,098 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $253,621 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | -$4,404 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $137,814 | TotalAmt |
| Program Services | $137,814 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $77,443 | TotalAmt |
| Program Services | $27,105 | ProgramServicesAmt |
| Management And General | $30,977 | ManagementAndGeneralAmt |
| Fundraising | $19,361 | FundraisingAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $444,974 | TotalAmt |
| Program Services | $358,441 | ProgramServicesAmt |
| Management And General | $34,134 | ManagementAndGeneralAmt |
| Fundraising | $52,399 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,578 | TotalAmt |
| Program Services | $6,001 | ProgramServicesAmt |
| Management And General | $1,036 | ManagementAndGeneralAmt |
| Fundraising | $1,541 | FundraisingAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $31,391 | TotalAmt |
| Program Services | $7,122 | ProgramServicesAmt |
| Management And General | $14,003 | ManagementAndGeneralAmt |
| Fundraising | $10,266 | FundraisingAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $38,776 | TotalAmt |
| Program Services | $28,715 | ProgramServicesAmt |
| Management And General | $4,778 | ManagementAndGeneralAmt |
| Fundraising | $5,283 | FundraisingAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $125 | TotalAmt |
| Management And General | $125 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,855 | TotalAmt |
| Management And General | $9,855 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,483 | TotalAmt |
| Program Services | $1,483 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,010 | TotalAmt |
| Program Services | $5,658 | ProgramServicesAmt |
| Management And General | $7,352 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,894 | TotalAmt |
| Program Services | $20,947 | ProgramServicesAmt |
| Management And General | $20,947 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,538 | TotalAmt |
| Program Services | $7,627 | ProgramServicesAmt |
| Management And General | $18,911 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $735 | TotalAmt |
| Management And General | $735 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,971 | TotalAmt |
| Program Services | $1,971 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,011 | TotalAmt |
| Program Services | $20,871 | ProgramServicesAmt |
| Management And General | $7,140 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,462 | TotalAmt |
| Management And General | $7,462 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES/SERVIC | $15,378 | $15,378 | |
| MISCELLANEOUS EXPENSE | $2,558 | $280 | $2,278 |
| PRINTING, PUBLICATIONS, | $2,306 | $2,306 |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $890,302 | TotalAmt |
| Program Services | $639,413 | ProgramServicesAmt |
| Management And General | $162,039 | ManagementAndGeneralAmt |
| Fundraising | $88,850 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $92,515 | BOYAmt |
| EOY | $62,225 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $40,418 | BOYAmt |
| EOY | $15,397 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,200 | BOYAmt |
| EOY | $1,750 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,616 | BOYAmt |
| EOY | $95,200 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $782,930 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $273,662 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $540,180 | BOYAmt |
| EOY | $509,268 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $31,660 | BOYAmt |
| EOY | $34,646 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $36,682 | BOYAmt |
| EOY | $764,549 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $756,271 | BOYAmt |
| EOY | $1,483,035 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,575 | BOYAmt |
| EOY | $20,710 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $164,886 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $183,461 | BOYAmt |
| EOY | $20,710 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $500,862 | BOYAmt |
| EOY | $1,424,910 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $71,948 | BOYAmt |
| EOY | $37,415 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $572,810 | BOYAmt |
| EOY | $1,462,325 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $756,271 | BOYAmt |
| EOY | $1,483,035 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $864,796 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $2,852 | NetUnrlzdGainsLossesInvstAmt |
| Donated Services And Use Fclts | $269,172 | DonatedServicesAndUseFcltsAmt |
| Other Changes In Net Assets | -$247,305 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Organization170 | Yes (X) | PublicOrganization170Ind |
Gifts Grants Contri Rcvd170 GiftsGrantsContriRcvd170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $530,315 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $628,068 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $533,038 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $610,066 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $849,155 | CurrentTaxYearAmt |
| Total | $3,150,642 | TotalAmt |
Total Calendar Year170 TotalCalendarYear170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $530,315 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $628,068 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $533,038 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $610,066 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $849,155 | CurrentTaxYearAmt |
| Total | $3,150,642 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Substantial Contributors Tot | $193,359 | SubstantialContributorsTotAmt |
| Public Support Total170 | $2,957,283 | PublicSupportTotal170Amt |
Gross Investment Income170 GrossInvestmentIncome170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | $435 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | $381 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | $447 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | $273 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $215 | CurrentTaxYearAmt |
| Total | $1,751 | TotalAmt |
Other Income170 OtherIncome170Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | -$16,399 | CurrentTaxYearMinus4YearsAmt |
| Current Tax Year Minus3 Years | -$146 | CurrentTaxYearMinus3YearsAmt |
| Current Tax Year Minus2 Years | -$17 | CurrentTaxYearMinus2YearsAmt |
| Current Tax Year Minus1 Year | -$46 | CurrentTaxYearMinus1YearAmt |
| Current Tax Year | $3 | CurrentTaxYearAmt |
| Total | -$16,605 | TotalAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Support | $3,135,788 | TotalSupportAmt |
| Public Support CY170 | 0.94310 | PublicSupportCY170Pct |
| Public Support PY170 | 0.96310 | PublicSupportPY170Pct |
| Thirty Thr Pct Suprt Tests CY170 | Yes (X) | ThirtyThrPctSuprtTestsCY170Ind |
Form990 Schedule A Part VI Form990ScheduleAPartVIGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: | FormAndLineReferenceDesc |
| Explanation | LOSS ON SALE OF SECURITIES - 2018 AMOUNT: $ -146. 2019 AMOUNT: $ -17. 2020 AMOUNT: $ -46. GAIN ON SALE OF SECURITIES - 2017 AMOUNT: $ 2,242. 2021 AMOUNT: $ 3. LOSS ON DISPOSITION OF ASSET - 2017 AMOUNT: $ -18,641. | ExplanationTxt |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $15,000 | InvestmentCostOrOtherBasisAmt |
| Book Value | $15,000 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $628,569 | InvestmentCostOrOtherBasisAmt |
| Depreciation | $145,519 | DepreciationAmt |
| Book Value | $483,050 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $139,361 | InvestmentCostOrOtherBasisAmt |
| Depreciation | $128,143 | DepreciationAmt |
| Book Value | $11,218 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $509,268 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | BENEFICIAL INTEREST IN FUNDS HELD BY OTHERS | Desc |
| Book Value | $764,549 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $764,549 | TotalBookValueOtherAssetsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $2,053,393 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $2,852 | NetUnrealizedGainsInvstAmt |
| Donated Services And Use Fclts | $269,172 | DonatedServicesAndUseFcltsAmt |
| Other Revenue | $26,271 | OtherRevenueAmt |
| Revenue Not Reported | $298,295 | RevenueNotReportedAmt |
| Revenue Subtotal | $1,755,098 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $1,755,098 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $1,163,878 | TotExpnsEtcAuditedFinclStmtAmt |
| Donated Services Use Fclts | $269,172 | DonatedServicesUseFcltsAmt |
| Other Expenses Included | $4,404 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $273,576 | ExpensesNotReportedAmt |
| Expenses Subtotal | $890,302 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $890,302 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART X, LINE 2: | THE ORGANIZATION IS A NON-PROFIT CORPORATION THAT IS TAX-EXEMPT UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, EXCEPT TO THE EXTENT OF UNRELATED BUSINESS INCOME, IF ANY. THE ORGANIZATION HAD NO UNRELATED BUSINESS INCOME FOR THE YEARS ENDED DECEMBER 31, 2021 AND 2020. MANAGEMENT IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE THE ORGANIZATION'S TAX-EXEMPT STATUS. THE ORGANIZATION IS NOT AWARE OF ANY TAX POSITIONS IT HAS TAKEN THAT ARE SUBJECT TO A SIGNIFICANT DEGREE OF UNCERTAINTY. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | SPECIAL EVENTS EXPENSE (NETTED IN REVENUE ON 990) 4,404. CHANGE IN BENEFICIAL INTEREST IN FUNDS HELD BY OTHERS 21,867. |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | SPECIAL EVENTS EXPENSE (NETTED IN REVENUE ON 990) 4,404. |
Schedule G IRS990ScheduleG
Fundraising Event Information FundraisingEventInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Event1 | EVENING FUNDRAISER | Event1Nm |
| Gross Receipts Event1 | $17,651 | GrossReceiptsEvent1Amt |
| Charitable Contri Event1 | $17,651 | CharitableContriEvent1Amt |
| Food And Beverage Event1 | $3,591 | FoodAndBeverageEvent1Amt |
| Other Direct Expenses Event1 | $813 | OtherDirectExpensesEvent1Amt |
| Event2 | FOX LAKE SHOTGUN FOR A CURE | Event2Nm |
| Gross Receipts Event2 | $3,900 | GrossReceiptsEvent2Amt |
| Charitable Contri Event2 | $3,900 | CharitableContriEvent2Amt |
| Gross Receipts Total | $21,551 | GrossReceiptsTotalAmt |
| Charitable Contributions Tot | $21,551 | CharitableContributionsTotAmt |
| Food And Beverage Total Events | $3,591 | FoodAndBeverageTotalEventsAmt |
| Oth Direct Expnss Total Events | $813 | OthDirectExpnssTotalEventsAmt |
| Direct Expense Summary Events | $4,404 | DirectExpenseSummaryEventsAmt |
| Net Income Summary | -$4,404 | NetIncomeSummaryAmt |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | 0 | GrantRecordsMaintainedInd |
Recipient Table RecipientTable
Recipient Business Name RecipientBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WAUPUN AREA SCHOOL DISTRICT | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 950 WILCOX STREET | AddressLine1Txt |
| City | WAUPUN | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 53963 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient EIN | 396005069 | RecipientEIN |
| Cash Grant | $0 | CashGrantAmt |
| Non Cash Assistance | $137,814 | NonCashAssistanceAmt |
| Valuation Method Used | FMV | ValuationMethodUsedDesc |
| Non Cash Assistance | DONATION OF BUILDING ADDITION | NonCashAssistanceDesc |
| Purpose Of Grant | DONATION OF ROCK RIVER BUILDING ADDITION TO BE USED FOR MENTAL HEALTH SERVICES | PurposeOfGrantTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 1 | Total501c3OrgCnt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS REVIEWED AND SIGNED BY AN OFFICER AND EXECUTIVE DIRECTOR PRIOR TO ELECTONIC FILING. THE FORM 990 IS AVAILABLE FOR REVIEW BY ALL BOARD MEMBERS AT THE NEXT MEETING. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE FINANCIAL DATA AND GOVERNING DOCUMENTS OF THE ORGANIZATION ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | DONATED SERVICES EXPENSE -269,172. CHANGE IN VALUE OF BENEFICIAL INTEREST IN FUNDS HELD BY OTHERS 21,867. |
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