2021-10-29T09:51:51-05:00 2020-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-01-01 813565570 INCLUSA INC INCL 8776226700 3349 CHURCH ST STE 1 STEVENS POINT WI 54481 JASON TAYLOR CHIEF FINANCIAL OFFICER 8776226700 2021-10-27 1 JASON TAYLOR 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2021-10-08 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z MARK HILLIKER 3349 CHURCH STREET SUITE 1 STEVENS POINT WI 54481 660237571 0 X WWW.INCLUSA.ORG X 2016 WI IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 12 12 1286 11 0 0 49297 47676 646214344 659084122 688202 1105773 0 0 646951843 660237571 0 3488644 0 0 86323984 88720821 0 0 0 541176050 545250940 627500034 637460405 19451809 22777166 114460594 133376896 56045472 52204123 58415122 81172773 IN ORDER TO MAXIMIZE HEALTH OUTCOMES, INCLUSA PROACTIVELY PARTNERS WITH OTHERS TO BUILD VIBRANT AND INCLUSIVE COMMUNITIES THAT OFFER PEOPLE DIGNITY, CHOICE, AND CONNECTIONS. 0 0 613826618 3488644 659084122 INCLUSA, INC. PROACTIVELY PARTNERS WITH OTHERS TO BUILD A SHARED VISION OF LONG-TERM CARE THAT OFFERS THE PEOPLE WE SERVE CHOICE, CONNECTIONS, AND DIGNITY; FOSTERING FULL PARTICIPATION IN COMMUNITIES. INCLUSA, INC. PROVIDES MEDICAID MANAGED LONG-TERM CARE SERVICES AND SUPPORT TO NEARLY 15,370 ELDERS AND PEOPLE WITH PHYSICAL AND INTELLECTUAL/DEVELOPMENTAL DISABILITIES IN WISCONSIN. 613826618 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 553 0 1286 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JASON TAYLOR 7152041810 3349 CHURCH ST STE 1 STEVENS POINT WI 54481 DANA CYRA EXECUTIVE DIRECTOR OF QUALITY IMPROVEMENT 40.00 X 154922 0 29878 KATE NORBY EXECUTIVE DIRECTOR OF MEMBER EXPERIENCE 40.00 X 156364 0 27868 JANNA DUFFY EXECUTIVE DIRECTOR OF FINANCE 40.00 X 169755 0 6108 ERIN SMITH EXECUTIVE DIRECTOR OF CR/PR 40.00 X 158738 0 6691 NATASHA BURMEISTER DIRECTOR OF MEMBER SUPPORT 40.00 X 120879 0 33486 MARK HILLIKER CHIEF EXECUTIVE OFFICER 40.00 X 422726 0 53536 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 40.00 X 256850 0 50733 TIM GARRITY CHIEF INNOVATION OFFICER 40.00 X 254298 0 45384 MICHELLE FELLENZ CHIEF TLC OFFICER 40.00 X 251107 0 43147 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 40.00 X 242370 0 50064 JASON TAYLOR CHIEF FINANCIAL OFFICER 40.00 X 254958 0 10521 PATRICK HENNEGER CHIEF LEGAL OFFICER 40.00 X 248521 0 46158 KEN DAY PRESIDENT 2.00 X X 10400 0 0 JOAN FORDHAM VICE PRESIDENT 1.00 X X 2600 0 0 RON CARNEY SECRETARY/TREASURER 1.00 X X 2850 0 0 BETH ARIMOND DIRECTOR 1.00 X 2600 0 0 KEN CORNISH DIRECTOR 1.00 X 2600 0 0 WADE DULL DIRECTOR 1.00 X 2600 0 0 JOHN HALBEIB DIRECTOR 1.00 X 2600 0 0 TARA JOHNSON DIRECTOR 1.00 X 0 0 0 JOHN KRIESEL DIRECTOR 1.00 X 2600 0 0 LARRY LAEHN DIRECTOR 1.00 X 2600 0 0 GARY RANUM DIRECTOR 1.00 X 2600 0 0 JANIS RIBBENS DIRECTOR 1.00 X 2600 0 0 2728138 0 403574 21 0 1 0 WPS 1717 W BROADWAY MADISON WI 53713 ADMINISTRATIVE 3412538 REM WISCONSIN III INC 2005 W BELTLINE HWY STE 203 MADISON WI 53713 DIRECT CARE WORKFORCE, CRISIS DIVERSION, 1498064 RSM US LLP 5155 PAYSPHERE CIRCLE CHICAGO IL 60674 IT CONSULTATION 1404479 SKYLINE TECHNOLOGIES INC 1400 LOMBARDI AVE STE 104N GREEN BAY WI 54304 NEW SOFTWARE CREATION 856513 AURORA RESIDENTIAL ALTERNATIVES INC PO BOX 68 MENOMONIE WI 54751 DIRECT CARE WORKFORCE 649674 65 44676 3000 47676 CAPITATION FEE REVENUE 624100 611672400 611672400 ROOM AND BOARD REIMBURSEMENT 623000 47411722 47411722 659084122 1105773 1105773 660237571 659084122 0 1105773 3488644 3488644 1909587 1533780 375807 62776944 49940826 12836118 2436955 1935133 501822 17050580 13719917 3330663 4546755 3649350 897405 65433 65433 81712 81712 4390332 405150 3985182 147546 19319 128227 443220 253280 189940 3099905 3099905 2967463 2776415 191048 752813 634861 117952 1184328 532884 651444 325072 219412 105660 DIRECT MEMBER CARE EXPE 531216017 531216017 EMPLOYEE TRAINING 105026 22081 82945 OPERATING SUPPLIES 88530 83900 4630 BOARD EXPENSES 34383 34383 349160 295744 53416 637460405 613826618 23633787 0 230 372975 85127179 105894040 25743057 14505470 1055407 1159628 9327984 4666082 2319280 4661902 0 6434164 215441 348717 114460594 133376896 56045472 51973494 0 230629 56045472 52204123 X 58415122 81172773 58415122 81172773 114460594 133376896 22777166 -19515 0 X 0 1 X 1 0 X 44639 42884 49297 47676 184496 609812068 624400324 646214344 659084122 2539510858 609856707 624443208 646263641 659131798 2539695354 0 0 0 2539695354 231890 273349 688202 1105773 2299214 231890 273349 688202 1105773 2299214 610088597 624716557 646951843 660237571 2541994568 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 17500 17500 0 PART II-B, LINE 1: INCLUSA, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE NATIONAL MLTSS HEALTH PLAN ASSOCIATION. THE NATIONAL MLTSS ASSOCIATION IS COMPRISED OF A NUMBER OF HEALTH PLANS THAT PROVIDE SUPPORTS TO MEDICARE/MEDICAID POPULATIONS ACROSS THE U.S. THE DUES PAID TO THE ASSOCIATION ON AN ANNUAL BASIS SUPPORT STAFF HIRED BY THE ASSOCIATION TO ADVANCE ITS POLICY AGENDA AND TO CONTRACT WITH OUTSIDE EXPERTS WHO PROVIDE SUPPORT THROUGH POLICY ANALYSIS, MEETING WITH LEGISLATORS AND STAFF MEMBERS AT THE FEDERAL LEVEL, ATTENDING CONFERENCE AND COMMITTEE HEARINGS, DEVELOPING POLICY BRIEFS AND STATEMENTS ALIGNED WITH MLTSS ASSOCIATION GOALS, AND SECURING SUPPORT FROM OTHER LIKE-MINDED ORGANIZATIONS. 1083545 314308 769237 5220652 4351774 868878 3023787 3023787 4661902 1 VERNON AREA REHABILITATION CENTER INC (VARC) 811 ROGERS AVE VIROQUA WI 54665 391211167 501(C)(3) 115910 COVID RELATED PAYMENTS APTIV INC 2703 W STATE ST JANESVILLE WI 53546 930756626 501(C)(3) 92273 COVID RELATED PAYMENTS HUMAN SERVICES BOARD SERVING NORTH CENTRAL HEALTH CARE FACILITY 1408 BISSELL ST WAUSAU WI 54401 391267785 501(C)(3) 77737 COVID RELATED PAYMENTS OPPORTUNITY DEVELOPMENT CENTERS INC 1191 HUNTINGTON AVE WISCONSIN RAPIDS WI 54494 391044318 501(C)(3) 60994 COVID RELATED PAYMENTS REACH INC 2205 HEIMSTEAD RD EAU CLAIRE WI 54703 237433428 501(C)(3) 49340 COVID RELATED PAYMENTS CHALLENGE CENTER INC 6001 E 3RD ST SUPERIOR WI 54880 391658019 501(C)(3) 47981 COVID RELATED PAYMENTS HODAN COMMUNITY SERVICES INC 941 FOUNTAIN ST MINERAL POINT WI 53565 391172274 501(C)(3) 46576 COVID RELATED PAYMENTS KANDU INDUSTRIES INC 1741 ADEL ST JANESVILLE WI 53546 391023165 501(C)(3) 45116 COVID RELATED PAYMENTS REM WISCONSIN III INC W8137 STATE ROAD 33 PORTAGE WI 53901 411861498 OTHER 43587 COVID RELATED PAYMENTS AURORA COMMUNITY SERVICES INC DBA AURORA VOCATIONAL SERVICES 3375 KOTHLOW AVE STE 5 MENOMONIE WI 54751 264618269 OTHER 39091 COVID RELATED PAYMENTS CHIPPEWA RIVER INDUSTRIES INC 1000 LAKE WISSOTA DR CHIPPEWA FALLS WI 54729 263862131 501(C)(3) 39023 COVID RELATED PAYMENTS OPPORTUNITY OF NORTH CENTRAL WISCONSIN INC DBA OPPORTUNITY INC 1807 MILWAUKEE AVE WAUSAU WI 54403 390975675 501(C)(3) 38488 COVID RELATED PAYMENTS GRACE LUTHERAN FOUNDATION INC 3214 GALA ST EAU CLAIRE WI 54703 396040444 501(C)(3) 32579 COVID RELATED PAYMENTS CREATIVE COMMUNITY LIVING SERVICES INC CCLS 1524 LEE LN JANESVILLE WI 53546 391195540 501(C)(3) 31941 COVID RELATED PAYMENTS VENTURES UNLIMITED INC PO BOX 623 SHELL LAKE WI 54871 391593285 501(C)(3) 30350 COVID RELATED PAYMENTS CARE PARTNERS ASSISTED LIVING LLC 5855 DELIKOWSKI ST WESTON WI 54476 391980255 OTHER 29587 COVID RELATED PAYMENTS COUNTY OF CLARK DBA CLARK COUNTY REHAB AND LIVING CENTER W4266 COUNTY HIGHWAY X OWEN WI 54460 396005679 OTHER 27693 COVID RELATED PAYMENTS HEADWATERS INC 1441 E TIMBER DR RHINELANDER WI 54501 391658017 501(C)(3) 26064 COVID RELATED PAYMENTS HANDISHOP INDUSTRIES INC 1411 N SUPERIOR AVE TOMAH WI 54660 237195604 501(C)(3) 24870 COVID RELATED PAYMENTS GREENCO INDUSTRIES INC 2636 14TH ST MONROE WI 53566 391144785 501(C)(3) 23932 COVID RELATED PAYMENTS ENDEAVORS ADULT DEVELOPMENT CENTER 101 150TH ST BALSAM LAKE WI 54810 391101553 501(C)(3) 22918 COVID RELATED PAYMENTS CATHOLIC CHARITIES INC DIOCESE OF MADISON 140 SIESTA DR MONTELLO WI 53949 390807067 501(C)(3) 22377 COVID RELATED PAYMENTS 4U LLC DBA 4U DAY SERVICES 3100 MINNESOTA AVE STEVENS POINT WI 54481 770699586 OTHER 22355 COVID RELATED PAYMENTS COUNTRY TERRACE OF WISCONSIN INC 1916 TALEN ST MENOMONIE WI 54751 392042638 OTHER 21305 COVID RELATED PAYMENTS BOYCEVILLE GRATUS LLC 1872 SOUTHRIDGE AVE APT 3 MENOMONIE WI 54751 832012352 OTHER 20385 COVID RELATED PAYMENTS SOUTHWEST OPPORTUNITIES CENTER INC 1600 INDUSTRIAL PARK RD LANCASTER WI 53813 391627835 501(C)(3) 19901 COVID RELATED PAYMENTS RISE INCORPORATED 8406 SUNSET RD NE SPRING LAKE PARK MN 55432 410972476 501(C)(3) 19763 COVID RELATED PAYMENTS KSMS OUR HOUSE LLC 2711 12TH ST S WISCONSIN RAPIDS WI 54494 271518169 501(C)(3) 18744 COVID RELATED PAYMENTS CRAWFORD COUNTY OPPORTUNITY CENTER INC DBA OPPORTUNITY CENTER 730 N STATE ST PRAIRIE DU CHIEN WI 53821 391048842 501(C)(3) 17878 COVID RELATED PAYMENTS L E PHILLIPS CAREER DEVELOPMENT CENTER INC 1515 BALL ST EAU CLAIRE WI 54703 390971649 501(C)(3) 17677 COVID RELATED PAYMENTS PROACT INC 3195 NEIL ARMSTRONG BLVD EAGAN MN 55121 237239408 501(C)(3) 17609 COVID RELATED PAYMENTS INNOVATIVE SERVICES INC 1281 HANNAH ST GREEN BAY WI 54303 471752821 OTHER 15732 COVID RELATED PAYMENTS BETHANY ST JOSEPH CORPORATION 620 MALIN CT HOLMEN WI 54636 510201995 501(C)(3) 15311 COVID RELATED PAYMENTS LUCKY STAR 3 CORPORATION DBA CORNERSTONE FOUNDATION 102 LORRAINE CT RIDGEWAY WI 53582 391737066 OTHER 14904 COVID RELATED PAYMENTS BLACK RIVER INDUSTRIES INC 650 JENSEN DR MEDFORD WI 54451 391658018 501(C)(3) 13143 COVID RELATED PAYMENTS LUTHERAN SOCIAL SERVICES OF WISCONSIN AND UPPER MICHIGAN INC 6737 W WASHINGTON ST STE 2275 WEST ALLIS WI 53214 390816846 501(C)(3) 12957 COVID RELATED PAYMENTS BRIDGE FOR COMMUNITY LIFE INC 651 BRAKKE DR HUDSON WI 54016 900178808 501(C)(3) 12750 COVID RELATED PAYMENTS RICHLAND COUNTY CARE LLC DBA COULEE REGION ADULT DAY CENTER 1106 MAIN ST ONALASKA WI 54650 261459540 OTHER 12310 COVID RELATED PAYMENTS LINCOLN COUNTY DBA LINCOLN INDUSTRIES 2100 E 6TH ST MERRILL WI 54452 396005714 OTHER 11903 COVID RELATED PAYMENTS WESTLAKE ENTERPRISES INC 1502 E 16TH ST S LADYSMITH WI 54848 391147244 501(C)(3) 11722 COVID RELATED PAYMENTS HIGHLINE CORPORATION 5630 W US HIGHWAY 2 HURLEY WI 54534 391081871 501(C)(3) 11572 COVID RELATED PAYMENTS BETHANY LUTHERAN HOMES INC DBA EAGLE CREST COMMUNITIES 2571 7TH ST S LA CROSSE WI 54601 390909446 501(C)(3) 10402 COVID RELATED PAYMENTS CRYSTAL FOUNTAINS ASSISTED LIVING LLC 3750 BLUE VIOLET LN WISCONSIN RAPIDS WI 54494 020758862 OTHER 10268 COVID RELATED PAYMENTS RIVER CITY ESTATES 541 GARFIELD ST WISCONSIN RAPIDS WI 54494 205843186 OTHER 10209 COVID RELATED PAYMENTS DUNGARVIN WISCONSIN LLC 616 SAUK AVE BARABOO WI 53913 203944781 OTHER 9878 COVID RELATED PAYMENTS HOMES FOR INDEPENDENT LIVING 6089 LAKE ST SIDE A SOBIESKI WI 54171 392023082 OTHER 9208 COVID RELATED PAYMENTS NORTHWOODS INCORPORATED OF WISCONSIN N6510 US HWY 51 S PORTAGE WI 53901 391226726 501(C)(3) 9190 COVID RELATED PAYMENTS AURORA RESIDENTIAL ALTERNATIVES INC 1306 12TH AVE E MENOMONIE WI 54751 391572296 OTHER 8854 COVID RELATED PAYMENTS BETHEL HOME & SERVICES INC 620 GARFIELD AVE STE A VIROQUA WI 54665 390896624 OTHER 8770 COVID RELATED PAYMENTS REM WISCONSIN II INC 1606 SHANNON DR JANESVILLE WI 53546 411784261 OTHER 8764 COVID RELATED PAYMENTS LAKEVIEW HEALTH CENTER 856 GARLAND ST E WEST SALEM WI 54669 396005709 501(C)(3) 8516 COVID RELATED PAYMENTS BROTOLOC HEALTH CARE SYSTEMS INC DBA BROTOLOC NORTH INC 601 HAGEN AVE NEW RICHMOND WI 54017 391572628 OTHER 8343 COVID RELATED PAYMENTS CATHOLIC CHARITIES OF THE DIOCESE OF LA CROSSE INC 3710 EAST AVE S LA CROSSE WI 54601 391896823 501(C)(3) 7831 COVID RELATED PAYMENTS ST COLETTA OF WISCONSIN INC 621 E THEODORE ST JEFFERSON WI 53549 390816855 501(C)(3) 7672 COVID RELATED PAYMENTS NORTHERN VALLEY WORKSHOP INC DBA NORTHERN VALLEY INDUSTRIES INC 5404 SHERMAN ST WAUSAU WI 54401 391045865 501(C)(3) 7535 COVID RELATED PAYMENTS DIVERSIFIED SERVICES CENTER INC DBA DSI 7649 TOWER RD SIREN WI 54872 391606453 501(C)(3) 7287 COVID RELATED PAYMENTS BARRON COUNTY DEVELOPMENTAL SERVICES INC 175 N LAKE ST BARRON WI 54812 472572324 501(C)(3) 7282 COVID RELATED PAYMENTS SPRINGBROOK COMMUNITY ASSISTED LIVING INC 861 CRITTER CT ONALASKA WI 54650 204753996 OTHER 7278 COVID RELATED PAYMENTS VANYO INC DBA MONROE MANOR 508 E MONROE AVE BARRON WI 54812 411726145 OTHER 6936 COVID RELATED PAYMENTS KINDHEARTED HOME CARE LLC 120 S MILL ST MERRILL WI 54452 272629077 OTHER 6895 COVID RELATED PAYMENTS CLARITY CARE INC 2401 S PEACH AVE MARSHFIELD WI 54449 391569283 501(C)(3) 6425 COVID RELATED PAYMENTS ADAPTIVE COMMUNITIES INC 1915 N 6TH ST STE A B WAUSAU WI 54403 822733195 501(C)(3) 6295 COVID RELATED PAYMENTS CAHOOTS ADULT DAY SERVICE LLC PO BOX 313 AMHERST WI 54406 461574490 OTHER 6096 COVID RELATED PAYMENTS GUARDIANTRAC LLC DBA GT INDEPENDENCE 215 BROADUS ST STURGIS MI 49091 320112072 OTHER 5944 COVID RELATED PAYMENTS ABILITIES INC 220 W BLACKHAWK DR FORT ATKINSON WI 53538 391766728 OTHER 5920 COVID RELATED PAYMENTS WISCONSIN ILLINOIS SENIOR HOUSING INC DBA WELLINGTON PLACE AT BIRON 149500 CTY RD NN WAUSAU WI 54401 364016275 501(C)(3) 5810 COVID RELATED PAYMENTS SUPERIOR VOCATIONS CENTER INC 2320 HILL AVE SUPERIOR WI 54880 391077898 501(C)(3) 5761 COVID RELATED PAYMENTS A&J FAMILY HOMES AND SERVICES LLC S5407 EAGLE DR VIROQUA WI 54665 823464074 OTHER 5714 COVID RELATED PAYMENTS HOMME HEIGHTS INC DBA FOREST PARK VILLAGE 801 PARCHER ST WAUSAU WI 54403 391484989 501(C)(3) 5668 COVID RELATED PAYMENTS CLIENT'S CHOICE LLC 106 N ROSE ST BOYD WI 54726 262305167 OTHER 5572 COVID RELATED PAYMENTS UPLAND POINT CORPORATION 1345 STATE ROAD 23 MINERAL POINT WI 53565 391839279 OTHER 5374 COVID RELATED PAYMENTS COOPERATIVE EDUCATIONAL SERVICES AGENCY #2 1221 INNOVATION DR STE 205 WHITEWATER WI 53190 391487148 OTHER 5359 COVID RELATED PAYMENTS SUNSHINE HOUSE INC 55 W YEW ST STURGEON BAY WI 54235 391149038 501(C)(3) 5358 COVID RELATED PAYMENTS ASPIRO INC 1673 DOUSMAN ST GREEN BAY WI 54303 390987024 501(C)(3) 5357 COVID RELATED PAYMENTS ORC INDUSTRIES INC 2700 COMMERCE ST LA CROSSE WI 54603 391078145 501(C)(3) 5304 COVID RELATED PAYMENTS PARK PLACE ADULT DAY SERVICES 220 3RD AVE S STE 2 WISCONSIN RAPIDS WI 54495 391533745 501(C)(3) 5300 COVID RELATED PAYMENTS NEW VIEW OPPORTUNITY CENTER DBA NEW VIEW INDUSTRIES 222 W PARK ST GILLETT WI 54124 391208512 501(C)(3) 5294 COVID RELATED PAYMENTS COUNSELING & DEVELOPMENT CENTER INC 598 PETERSON DR PHILIPS WI 54555 391356642 501(C)(3) 5263 COVID RELATED PAYMENTS SOPHIES MANOR ASSISTED LIVING II INC 300 MICHIGAN AVE CENTURIA WI 54824 611548825 OTHER 5240 COVID RELATED PAYMENTS INDIANHEAD ENTERPRISES INC 1426 INDIANHEAD DR E MENOMONIE WI 54751 391369377 501(C)(3) 5194 COVID RELATED PAYMENTS 50 30 PART I, LINE 2: THE ORGANIZATION MAINTAINS A RECORD FOR EVERYTHING GRANTED OUT. THE ORGANIZATION IS A PASS THROUGH FOR CERTAIN FUNDING, SO FOR EACH PARTICULAR GRANT, THE ORGANIZATION FOLLOWS THE PASS THROUGH REQUIREMENTS FOR INFORMATION GATHERED AND STORED FOR EACH RECIPIENT. X X 0 0 0 0 0 0 0 0 0 DANA CYRA EXECUTIVE DIRECTOR OF QUALITY IMPROV 143201 0 10500 0 1221 0 6352 0 23526 0 184800 0 0 0 KATE NORBY EXECUTIVE DIRECTOR OF MEMBER EXPERIE 145211 0 10500 0 653 0 6352 0 21516 0 184232 0 0 0 JANNA DUFFY EXECUTIVE DIRECTOR OF FINANCE 158546 0 10500 0 709 0 5769 0 339 0 175863 0 0 0 ERIN SMITH EXECUTIVE DIRECTOR OF CR/PR 147954 0 10500 0 284 0 6352 0 339 0 165429 0 0 0 NATASHA BURMEISTER DIRECTOR OF MEMBER SUPPORT 116589 0 4290 0 0 0 5115 0 28371 0 154365 0 0 0 MARK HILLIKER CHIEF EXECUTIVE OFFICER 395397 0 25000 0 2329 0 11400 0 42136 0 476262 0 0 0 KRISTOPHER KUBNICK CHIEF COMMUNITY RESOURCES 245820 0 10500 0 530 0 10597 0 40136 0 307583 0 0 0 TIM GARRITY CHIEF INNOVATION OFFICER 242607 0 10500 0 1191 0 10389 0 34995 0 299682 0 0 0 MICHELLE FELLENZ CHIEF TLC OFFICER 239444 0 10500 0 1163 0 10182 0 32965 0 294254 0 0 0 JOSHUA JANDRAIN CHIEF INFORMATION OFFICER 231112 0 10500 0 758 0 10006 0 40058 0 292434 0 0 0 JASON TAYLOR CHIEF FINANCIAL OFFICER 243700 0 10500 0 758 0 10182 0 339 0 265479 0 0 0 PATRICK HENNEGER CHIEF LEGAL OFFICER 237515 0 10500 0 506 0 10182 0 35976 0 294679 0 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND THE CHIEF EXECUTIVE OFFICER. A COPY OF THE 990 IS PROVIDED TO THE GOVERNING BODY BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS SHALL ADOPT AND ALWAYS MAINTAIN A WRITTEN CONFLICT OF INTEREST POLICY ("THE POLICY") THAT IS CONSISTENT WITH BEST PRACTICES FOR CHARITABLE ORGANIZATIONS. ALL DIRECTORS, OFFICERS, AND COMMITTEE MEMBERS SHALL SIGN, AS A CONDITION TO SERVING THE CORPORATION IN HIS OR HER RESPECTIVE ROLE, A STATEMENT AGREEING TO BE BOUND BY THE TERMS OF THE POLICY. PURSUANT TO THE POLICY, ANY DIRECTOR, OFFICER, OR COMMITTEE MEMBER HAVING A MATERIAL FINANCIAL INTEREST IN A CONTRACT OR OTHER TRANSACTION PRESENTED TO THE BOARD OF DIRECTORS OR A COMMITTEE THEREOF FOR AUTHORIZATION, APPROVAL, OR RATIFICATION SHALL MAKE A PROMPT, FULL AND FRANK DISCLOSURE OF SUCH PERSON'S INTEREST TO THE BOARD OF DIRECTORS OR COMMITTEE PRIOR TO ITS ACTING ON SUCH CONTRACT OR TRANSACTION. IF THE CONFLICT IS CONFIRMED BY THE BOARD OF DIRECTORS, THE OFFICER OR COMMITTEE MEMBER IS NOT ALLOWED TO PARTICIPATE IN THE DISCUSSION OR VOTE ON THE MATTER. EACH DIRECTOR OF THE BOARD MUST ANNUALLY SIGN A STATEMENT WHICH AFFIRMS SUCH PERSON: (A) HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY (B) HAS READ AND UNDERSTANDS THE POLICY (C) HAS AGREED TO COMPLY WITH THE POLICY AND, (D) UNDERSTANDS THE CORPORATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. FORM 990, PART VI, SECTION B, LINE 15 INITIAL OFFICER COMPENSATION WAS ESTABLISHED USING THE SUPPORT OF A CONTRACTED EXPERT IN EXECUTIVE COMPENSATION. THE CONTRACTED EXPERT DEVELOPED SALARY RANGE INFORMATION FOR THE ORGANIZATION'S EXECUTIVES AND PROVIDED COMPENSATION RECOMMENDATIONS TO THE INCLUSA, INC. BOARD OF DIRECTORS. THE BOARD OF DIRECTORS SET THE CHIEF EXECUTIVE OFFICER'S SALARY BASED ON THIS RECOMMENDATION. THE CHIEF EXECUTIVE OFFICER WAS CHARGED WITH SETTING THE COMPENSATION FOR THE REMAINING EXECUTIVES, USING THE RECOMMENDATIONS PROVIDED BY THE CONTRACTED EXPERT. IN SUCCESSIVE YEARS, THE INCLUSA BOARD OF DIRECTORS HAS SET CHIEF EXECUTIVE OFFICER ANNUAL COMPENSATION USING INDUSTRY COMPARISONS AND OTHER MARKET INFORMATION TO AUGMENT THEIR DECISION PROCESS. THE CHIEF EXECUTIVE OFFICER USES SIMILAR INDUSTRY AND MARKET INFORMATION TO MAKE ANY ANNUAL CHANGES TO THE REMAINING EXECUTIVE STAFF MEMBERS. FORM 990, PART VI, SECTION C, LINE 19 INCLUSA MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ANNOVA INC 3349 CHURCH ST STE 1 STEVENS POINT WI 54481 842123943 CONSULTING SERVICES WI INCLUSA INC C -23105 332754 1.00000 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 ANNOVA INC D 125301 COST ANNOVA INC Q 623782 COST