2019-02-21T14:20:41-06:00 2018-06-30 410746749 CLIFTONLARSONALLEN LLP 10700 W RESEARCH DRIVE STE 200 MILWAUKEE WI 53226 990 2017-07-01 396069188 SHEBOYGAN SENIOR COMMUNITY INC SHEB 9204582137 3505 COUNTY ROAD Y SHEBOYGAN WI 53083 TARA HOLZEM OFFICER 9204582137 2019-02-08 1 KIMBERLY ANDERSON CPA P00188889 4144761880 2019-01-29 67.137.57.251 2019-02-08 10:43:54 CS P 286219E15AFA19FAACC75CA249A921020E689FD8 DF9D79168A30906DEA4AE9FC5B76B1EA8B502D89 2017 2019-02-21 02:37:17Z TARA HOLZEM 3505 COUNTY ROAD Y SHEBOYGAN WI 53083 7257816 0 X WWW.SHEBOYGANSENIORCOMMUNITY.COM X 1962 WI TO PROVIDE AND OPERATE A RETIREMENT HOME, HEALTH CARE CENTER, AND RELATED SERVICES IN THE GREATER SHEBOYGAN AREA FOR ELDERLY AND PHYSICALLY HANDICAPPED ADULTS, WHICH SHALL ENHANCE, HONOR AND PRESERVE THE DIGNITY OF THE INDIVIDUAL, AND WHERE SPIRITUAL, PHYSICAL AND SOCIAL NEEDS ARE SUPPLIED IN A SPIRIT OF CHRISTIAN LOVE AND CONCERN WITHOUT REGARD TO AGE, SEX, RACE, CREED OR COLOR. 13 13 203 44 0 0 39679 21605 7325061 7235002 339 1209 79038 0 7444117 7257816 0 0 0 0 4427120 4680469 0 0 0 3132427 2991705 7559547 7672174 -115430 -414358 17357533 16724664 15765062 15546551 1592471 1178113 X TO PROVIDE AND OPERATE A RETIREMENT HOME, HEALTH CARE CENTER, AND RELATED SERVICES IN THE GREATER SHEBOYGAN AREA FOR ELDERLY AND PHYSICALLY HANDICAPPED ADULTS, WHICH SHALL ENHANCE, HONOR AND PRESERVE THE DIGNITY OF THE INDIVIDUAL, AND WHERE SPIRITUAL, PHYSICAL AND SOCIAL NEEDS ARE SUPPLIED IN A SPIRIT OF CHRISTIAN LOVE AND CONCERN WITHOUT REGARD TO AGE, SEX, RACE, CREED OR COLOR. 0 0 6682776 7235002 OPERATION OF A FULL-TIME SKILLED NURSING HOME AND RESIDENTIAL CARE CENTER. TOTAL PATIENT DAYS: 28,497. 6682776 1 1 0 0 0 0 0 0 0 0 1 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 0 0 0 0 0 0 1 0 0 0 1 4 0 1 203 1 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 1 1 1 1 0 0 WI X TARA HOLZEM 9204582137 3505 CTY RD Y SHEBOYGAN WI 53083 LYNN COADY PRESIDENT 0.50 0.25 X X 0 0 0 DAVID VANDEWATER VICE PRESIDENT 0.50 0.25 X X 0 0 0 MARCY KERPE SECRETARY 0.50 0.25 X X 0 0 0 CINDY THOMPSON TREASURER 0.50 0.25 X X 0 0 0 STEVE HAMER DIRECTOR 0.50 0.25 X 0 0 0 BRIAN GENSCH DIRECTOR 0.50 0.25 X 0 0 0 KEITH ISKEN DIRECTOR 0.50 0.25 X 0 0 0 JAMES PRICE DIRECTOR 0.50 0.25 X 0 0 0 PERRY FRITZ DIRECTOR 0.50 0.25 X 0 0 0 PETER MUEHLEIS DIRECTOR 0.50 0.25 X 0 0 0 LAURA RECTOR DIRECTOR 0.50 0.25 X 0 0 0 ERIC STUART DIRECTOR 0.50 0.25 X 0 0 0 MEG TRAGER DIRECTOR 0.50 0.25 X 0 0 0 TARA HOLZEM BUSINESS MANAGER 39.75 0.25 X 60392 0 1242 PAUL TREFFERT EXECUTIVE DIRECTOR 39.75 0.25 X 115731 0 13612 176123 0 14854 1 0 0 0 REHABCARE GROUP INC PO BOX 277365 ATLANTA GA 30384 THERAPY 272995 SYSCO EASTERN WISCONSIN ONE SYSCO DRIVE JACKSON WI 53037 FOOD 249337 AEGIS THERAPIES PO BOX 8103 FORT SMITH AR 72902 THERAPY 218256 OMNICARE INC PO BOX 78000 DEPT 781668 DETROIT MI 48278 MEDICATION 145274 4 9768 11837 21605 SKILLED NURSING FACILI 900099 5361079 5361079 RESIDENTIAL CENTER 623000 1449248 1449248 INDEPENDENT LIVING 623990 253963 253963 OTHER SERVICES 900099 146289 146289 BEAUTY SHOP 812900 24423 24423 7235002 1209 1209 7257816 7235002 0 1209 X 191489 191489 3726213 3459629 266584 44977 40172 4805 409479 367334 42145 308311 275373 32938 3053 3053 25129 25129 777632 695147 82485 25163 25163 39610 39610 165650 165650 486754 486754 591852 496322 95530 68927 68927 SUPPLIES 627468 627468 DUES AND SUBSCRIPTIONS 91888 91888 BAD DEBT EXPENSE 35381 35381 EMPLOYMENT COSTS 33259 33259 19939 19939 7672174 6682776 989398 0 159507 364019 139425 231998 895388 536516 35401 36051 76155 75888 17208251 1728059 16051657 15480192 17357533 16724664 367938 412305 14032836 13769958 1364288 1364288 15765062 15546551 X 1512353 1094363 80118 83750 1592471 1178113 17357533 16724664 -414358 0 X X 0 1 X 1 0 X 19676 477831 497260 39679 21605 1056051 7156437 5556950 5773201 7325061 7235002 33046651 7176113 6034781 6270461 7364740 7256607 34102702 15000 15000 90944 425314 516258 105944 425314 531258 33571444 1305 4034 658 339 1209 7545 1305 4034 658 339 1209 7545 2668 44372 107039 79038 233117 7180086 6083187 6378158 7444117 7257816 34343364 0.97750 0.98550 0.00020 0.00030 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2013 AMOUNT: $ 2,668. CHANGE IN PRESENT VALUE OF DEVELOPMENT INCENTIVE RECEIVABLE - 2014 AMOUNT: $ 44,372. 2015 AMOUNT: $ 107,039. 2016 AMOUNT: $ 79,038. 572217 572217 15180150 1174027 14006123 907968 414539 493429 547916 139493 408423 15480192 DUE TO AFFILIATE 1364288 1364288 FORM 990, PART VI, SECTION B, LINE 11B A PDF COPY OF FORM 990 IS EMAILED TO THE BUSINESS MANAGER. THE BUSINESS MANAGER FORWARDS THE EMAIL TO THE BOARD OF DIRECTORS PRIOR TO FILING THE RETURN. THE 990 IS REVIEWED BY THE BUSINESS MANAGER PRIOR TO FILING. THE BUSINESS MANAGER CHECKS FORM 990 WITH INTERNAL REPORTS. FORM 990, PART VI, SECTION B, LINE 12C A NEW CONFLICT OF INTEREST POLICY IS FILLED OUT ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15A SHEBOYGAN SENIOR COMMUNITY, INC. USES DATA GATHERED FROM THEIR STATE ASSOCIATION (WISCONSIN ASSOCIATION OF HOMES AND SERVICES FOR THE AGING) BY MANAGEMENT RESOURCE ASSOCIATES (MRA), A THIRD PARTY INDEPENDENT, NOT FOR PROFIT, MANAGEMENT CONSULTING GROUP. THE DATA IS GATHERED FROM PARTICIPATING NOT FOR PROFIT HOMES THROUGHOUT THE STATE OF WISCONSIN. SALARY RECOMMENDATIONS FOR THE EXECUTIVE DIRECTOR ARE REVIEWED AND SET BY THE EXECUTIVE COMMITTEE IN AN EXECUTIVE SESSION WITHOUT THE EXECUTIVE DIRECTOR'S PRESENCE AFTER THE FULL ANNUAL PERFORMANCE EVALUATION, UTILIZING THE DATA DESCRIBED ABOVE. NO OTHER MANAGEMENT STAFF ARE REVIEWED IN THIS MANNER, THOUGH ALL SALARY AND EXPENSE DATA IS REVIEWED BY THE FINANCE COMMITTEE OF THE BOARD IN THEIR ANNUAL BUDGET PREPARATION AND APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THESE DOCUMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 695,147. MANAGEMENT AND GENERAL EXPENSES 82,485. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 777,632. FORM 990, PART XII, LINE 2C EXPLANATION THE BOARD OF DIRECTORS IS RESPONSIBLE FOR OVERSIGHT OF THE AUDIT AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. SHEBOYGAN SENIOR COMMUNITY FOUNDATION 3505 CTY RD Y SHEBOYGAN WI 53083 391450846 RAISE/RECEIVE FUNDS TO BE USED FOR GENERAL SUPPORT OF THIS ORGANIZATION WI 501(C)(3) LINE 12B, II N/A 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0