2022-11-02T11:49:50-05:00 2021-12-31 391742997 O'CONNOR WELLS & VANDER WERFF LLC 111 E MAIN STREET WAUPUN WI 53963 990 2021-01-01 391759669 CHURCH HEALTH SERVICES INC CHUR 9208871766 115 N CENTER STREET BEAVER DAM WI 53916 THEO O'CONNOR EXECUTIVE DIRECTOR 9208871766 2022-10-31 1 THEO OCONNOR 999009999 DIANE BANCROFT-DEYOUNG P00195537 9203249711 2022-10-31 X 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z SHIRLEY KITCHEN 115 N CENTER STREET BEAVER DAM WI 53916 1759519 0 X WWW.CHURCHCLINIC.ORG X 1993 WI CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. 13 13 31 20 0 0 448987 1505881 161079 253403 226 218 -3230 -4404 607062 1755098 0 137814 0 0 488583 601162 0 0 88850 134329 151326 622912 890302 -15850 864796 756271 1483035 183461 20710 572810 1462325 CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. 0 0 639413 137814 253621 CHURCH HEALTH SERVICES IS A FAITH BASED HEALTH CARE ORGANIZATION THAT CONDUCTS PRIMARY, DENTAL AND MENTAL HEALTH CLINICS FOR THE POOR, UNINSURED OR UNDERINSURED. 639413 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 1 31 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 WI X THEA O'CONNOR 9208871766 115 N CENTER STREET BEAVER DAM WI 53916 THEA O'CONNOR EXECUTIVE DIRECTOR 35.00 X 77442 0 5189 SHIRLEY KITCHEN PRESIDENT/BOARD MEMBER 1.00 X X 0 0 0 STEVE VESSEY VICE PRESIDENT/BOARD MEMBE 1.00 X X 0 0 0 TODD HEDBERG TREASURER/BOARD MEMBER 1.00 X X 0 0 0 RICK VANT HOFF SECRETARY/BOARD MEMBER 1.00 X X 0 0 0 JENNIFER CAMPBELL BOARD MEMBER 1.00 X 0 0 0 KAREN COLEY BOARD MEMBER 1.00 X 0 0 0 HEIDI WEISS BOARD MEMBER 1.00 X 0 0 0 BECKY GLEWEN BOARD MEMBER 1.00 X 0 0 0 TOM HEFFRON BOARD MEMBER 1.00 X 0 0 0 RICH ZIEMAN BOARD MEMBER 1.00 X 0 0 0 CATHY NELSON BOARD MEMBER 1.00 X 0 0 0 MARY VOGL-RAUSCHER BOARD MEMBER 1.00 X 0 0 0 STEVE WESTRA BOARD MEMBER 1.00 X 0 0 0 77442 0 5189 0 0 0 0 0 21551 30000 1454330 1505881 PROGRAM REVENUES 624100 253403 253403 253403 215 215 20 17 3 3 3 0 21551 4404 -4404 -4404 1755098 253621 0 -4404 137814 137814 77443 27105 30977 19361 444974 358441 34134 52399 8578 6001 1036 1541 31391 7122 14003 10266 38776 28715 4778 5283 125 125 9855 9855 1483 1483 13010 5658 7352 41894 20947 20947 26538 7627 18911 735 735 1971 1971 28011 20871 7140 7462 7462 MEDICAL SUPPLIES/SERVIC 15378 15378 MISCELLANEOUS EXPENSE 2558 280 2278 PRINTING, PUBLICATIONS, 2306 2306 890302 639413 162039 88850 92515 62225 40418 15397 4200 1750 10616 95200 782930 273662 540180 509268 31660 34646 36682 764549 756271 1483035 18575 20710 164886 0 183461 20710 X 500862 1424910 71948 37415 572810 1462325 756271 1483035 X 864796 2852 269172 -247305 X 0 1 X 1 0 X 530315 628068 533038 610066 849155 3150642 530315 628068 533038 610066 849155 3150642 193359 2957283 435 381 447 273 215 1751 -16399 -146 -17 -46 3 -16605 3135788 0.94310 0.96310 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: 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. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 15000 15000 628569 145519 483050 139361 128143 11218 509268 BENEFICIAL INTEREST IN FUNDS HELD BY OTHERS 764549 764549 X 2053393 2852 269172 26271 298295 1755098 0 1755098 1163878 269172 4404 273576 890302 0 890302 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. EVENING FUNDRAISER 17651 17651 3591 813 FOX LAKE SHOTGUN FOR A CURE 3900 3900 21551 21551 3591 813 4404 -4404 0 WAUPUN AREA SCHOOL DISTRICT 950 WILCOX STREET WAUPUN WI 53963 396005069 0 137814 FMV DONATION OF BUILDING ADDITION DONATION OF ROCK RIVER BUILDING ADDITION TO BE USED FOR MENTAL HEALTH SERVICES 1 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.