2017-11-15T07:58:25-06:00 2017-06-30 421229486 BROOKS LODDEN PC 1441 29TH STREET STE 305 WEST DES MOINES IA 502661357 990 2016-07-01 420680245 CHILDSERVE HABILITATION CENTER CHIL 5157278750 PO BOX 707 JOHNSTON IA 501310707 LLOYD VANDER KWAAK PRESIDENT/CEO 5157278750 2017-11-14 1 BRENT L ALEXANDER P00075113 5152237300 174.128.52.108 2017-11-14 16:27:52 CS P 380A664F5D883E29A3C6B4000ABE887F01EA73BB EAD7FFB25ED7C72B7A4B552AC656CE00B93BEB83 2016 2017-02-10 21:41:12Z LLOYD VANDER KWAAK PO BOX 707 JOHNSTON IA 501310707 19063085 0 X WWW.CHILDSERVE.ORG X 1928 IA TO ENHANCE THE WELL BEING OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS AND CHRONIC HEALTH CONDITIONS BY PROVIDING PEDIATRIC SKILLED NURSING CARE AND SPECIALTY SERVICES. 6 5 235 456 0 0 472949 237814 16086425 16782590 92759 78338 2721934 1605138 19374067 18703880 0 0 0 0 9823459 10122994 0 0 0 8672986 8197885 18496445 18320879 877622 383001 40380063 38835181 29067821 27209792 11312242 11625389 WE PARTNER WITH FAMILIES TO HELP CHILDREN WITH SPECIAL HEALTH CARE NEEDS LIVE A GREAT LIFE. 0 0 12008804 18387728 TWO LEVELS OF SKILLED NURSING SERVICES ARE PROVIDED, CONTINUING CARE AND TRANSITIONAL CARE. CONTINUING CARE IS LONG TERM SKILLED NURSING SERVICE FOR CHILDREN WITH SPECIALTY HEALTH CARE AND SUPPORT NEEDS. THE CONTINUING CARE UNIT IS LICENSED FOR 37 BEDS AND HAD A 99.48% OCCUPANCY RATE SERVING 44 DIFFERENT CHILDREN. TRANSITIONAL CARE PROVIDES SUB-ACUTE LEVEL OF CARE FOR CHILDREN WHO REQUIRE SHORT TERM INTENSIVE NURSING CARE AND REHABILITATION SERVICES. THE TRANSITIONAL CARE UNIT IS LICENSED FOR 21 BEDS AND SERVED 72 DIFFERENT CHILDREN. SKILLED NURSING SERVICES INCLUDE: PHYSICAL, MEDICAL, EDUCATIONAL, SOCIAL, PSYCHOLOGICAL, OCCUPATIONAL, RECREATIONAL, DIETARY AND SPEECH SERVICES. 12008804 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 20 0 1 235 1 0 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHILDSERVE 5157278750 PO BOX 707 JOHNSTON IA 501310707 DOUG DORNACKER PAST CHAIR 0.25 1.75 X X 0 0 0 SHIRLEY POERTNER VICE CHAIR 0.25 1.75 X X 0 0 0 LLOYD VANDER KWAAK PRESIDENT/CEO 21.00 19.00 X X 253539 183071 101905 DAVID MACKAMAN CHAIR 0.25 1.75 X X 0 0 0 JIM SANDERS TREASURER 0.25 1.75 X X 0 0 0 DOUG CRETSINGER SECRETARY 0.25 1.75 X X 0 0 0 TERESA WAHLIG SENIOR VICE PRESIDENT & CH 40.00 X 358666 0 46171 FREDERICK KLINGBEIL MEDICAL DIRECTOR, PEDIATRI 20.00 20.00 X 141829 141829 14476 TRACEY PAGE VICE PRESIDENT CLINICAL SE 40.00 X 155851 0 20471 909885 324900 183023 4 0 1 0 0 237814 237814 SKILLED NURSING CARE 621300 16782590 16782590 16782590 107543 107543 330000 359205 -29205 -29205 -29205 LEASE REVENUE 532420 1055598 1055598 FACILITY SUPPORT REVENUE 621300 381770 381770 DIETARY REVENUE 621300 147034 147034 20736 20736 1605138 18703880 18358523 0 107543 931340 595536 335804 7891155 7338803 552352 98643 98643 638243 637758 485 563613 537139 26474 1000 1000 605809 599338 6471 1059243 1040422 18821 343131 141517 201614 84749 74107 10642 68791 25060 43731 851091 851091 1206557 330596 875961 82339 79498 2841 ADMINISTRATION SUPPORT 3256663 3256663 EQUIPMENT RENTAL & MAIN 279290 273947 5343 FOUNDATION SUPPORT 98080 98080 WORKERS COMPENSATION 90106 88955 1151 171036 146485 24551 18320879 12008804 6312075 0 2058812 1339548 113700 511688 2571764 1539378 75489 66048 100359 118468 39337956 16065752 24244828 23272204 1838271 1409212 9376840 10578635 40380063 38835181 3535734 2843018 24632087 23866774 900000 500000 29067821 27209792 X 11312242 11625389 11312242 11625389 40380063 38835181 383001 -69854 0 X 0 1 X 1 0 X 177464 938506 1466550 472949 237814 3293283 16418671 17101987 19093170 18806618 18387728 89808174 16596135 18040493 20559720 19279567 18625542 93101457 0 0 0 93101457 19332 18651 14187 94500 107543 254213 19332 18651 14187 94500 107543 254213 16615467 18059144 20573907 19374067 18733085 93355670 0.99730 0.99820 0.00270 0.00180 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2640249 2640249 32602838 13136198 19466640 3736550 2608175 1128375 358319 321379 36940 23272204 LIFE INSURANCE PROCEEDS RECEIVABLE 195289 DUE FROM AFFILIATES 10359367 ACCRUED INTEREST RECEIVABLE 23979 10578635 LINE OF CREDIT 500000 500000 1 0 0 0 0 0 1 1 0 0 LLOYD VANDER KWAAK PRESIDENT/CEO 202753 146400 46721 33736 4065 2935 54527 39372 4649 3357 312715 225800 0 0 TERESA WAHLIG SENIOR VICE PRESIDENT & CH 305171 0 53495 0 0 0 41434 0 4737 0 404837 0 0 0 FREDERICK KLINGBEIL MEDICAL DIRECTOR, PEDIATRI 134954 134954 6875 6875 0 0 3752 3752 3486 3486 149067 149067 0 0 TRACEY PAGE VICE PRESIDENT CLINICAL SE 137213 0 18638 0 0 0 20471 0 0 0 176322 0 0 0 PART I, LINE 3 CHILDSERVE INC. (A RELATED ORGANIZATION) OBTAINS A COMPREHENSIVE MARKET BASED STUDY TO OBTAIN COMPENSATION DATA FOR EACH KEY EMPLOYEE FROM SIMILAR TYPE AGENCIES AND ORGANIZATIONS EVERY THREE YEARS. DURING THE YEARS WHEN THE STUDY IS NOT CONDUCTED, MARKET BASED INFORMATION SUCH AS CPI OR COMPARABLE DATA WILL BE USED ANNUALLY TO MAKE ADJUSTMENTS TO THE MIDPOINT. THE EXECUTIVE COMMITTEE OF CHILDSERVE INC.'S BOARD OF DIRECTORS HAS THE RESPONSIBILITY TO OVERSEE THE IMPLEMENTATION OF THE EXECUTIVE COMPENSATION POLICY. THE EXECUTIVE COMMITTEE WILL APPROVE THE COMPENSATION ARRANGEMENTS FOR THE PRESIDENT/CEO WITHOUT DISCUSSION OR VOTING PARTICIPATION OF THE PRESIDENT/CEO. PART I, LINE 6 INCENTIVE PAY IS BASED ON MEETING BUDGETED ORGANIZATIONAL NET EARNINGS. A CITY OF WINDSOR HEIGHTS IOWA 421271420 2013-03-14 7500000 CONSTRUCT, IMPROVE, & EQUIP FACILITIES 0 0 0 B CITY OF WINDSOR HEIGHTS IOWA 421271420 973605AM0 2015-04-24 7996556 REFUND PRIOR ISSUE (03/30/06) 0 0 0 C IOWA FINANCE AUTHORITY 521699886 46246K2S0 2015-04-24 10335677 REFUND PRIOR ISSUE (03/30/06) 0 0 0 A 461004 7514527 282256 147500 58455 7026316 2014 0 0 1 1 B 1030000 8034305 817211 159931 7057163 2007 1 0 1 1 C 10391663 1103437 206713 9081513 2007 1 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 A 0 0 0 1 1 0 0 0 1 B 0 1 1 0 0 0 0 0 1 C 0 1 1 0 0 0 0 0 1 A 1 B 1 C 1 SCHEDULE K, PART IV, ARBITRAGE, LINE 2C: (A) ISSUER NAME: CITY OF WINDSOR HEIGHTS, IOWA DATE THE REBATE COMPUTATION WAS PERFORMED: 10/01/2014 NOTE REGARDING THE REBATE COMPUTATION ON 10/01/2014: SINCE THE BOND PROCEEDS HAVE BEEN SPENT, THE DEBT SERVICE FUND WAS OPERATED ON A BONA FIDE BASIS, NO FURTHER REBATE CALCULATIONS ARE NECESSARY. SCHEDULE K, PART II, LINE 3: THE TOTAL PROCEEDS DO NOT AGREE TO THE ISSUE PRICE IN PART I, COLUMN (E) DUE TO INVESTMENT EARNINGS/MARKET VALUE FLUCTUATIONS. KIP ALBERTSON MEMBER OF CHILDSERVE INC BOARD OF DIRECTORS AND AN OFFICER AT BANKERS TRUST 222138 LOAN INTEREST AND ADMINISTRATIVE FEES FOR BUSINESS ACCOUNTS HELD AT BANKERS TRUST 0 FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S POLICY FOR REVIEW OF THE FORM 990 RETURN INCLUDES REVIEW BY THE INDEPENDENT AUDIT SUBCOMMITTEE OF THE FINANCE COMMITTEE AND DISTRIBUTION TO THE BOARD OF DIRECTORS PRIOR TO FILING THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS OF THE GOVERNING BOARD AND KEY EMPLOYEES ARE REQUIRED BY POLICY TO ACKNOWLEDGE IN WRITING THEIR UNDERSTANDING AND COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. THIS IS DONE ANNUALLY WITH 100% RESPONSE RATE REQUIRED. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS HAS THE RESPONSIBILITY TO OVERSEE THE IMPLEMENTATION OF THE EXECUTIVE COMPENSATION POLICY FOR THE THREE KEY EMPLOYEES: PRESIDENT/CEO, VICE PRESIDENT OF ADMINISTRATION, AND VICE PRESIDENT OF PROGRAMS. THE EXECUTIVE COMMITTEE WILL APPROVE THE COMPENSATION ARRANGEMENTS FOR THE PRESIDENT/CEO WITHOUT DISCUSSION OR VOTING PARTICIPATION OF THE PRESIDENT/CEO. THE EXECUTIVE COMMITTEE WILL DOCUMENT THE BASIS FOR EXECUTIVE COMPENSATION DETERMINATIONS CONCURRENTLY WITH APPROVAL. THE DOCUMENTATION CONTAINS THE COMPARABILITY DATA THAT WAS RELIED ON AND HOW THE DATA WAS OBTAINED. A COMPREHENSIVE MARKET BASED STUDY WILL OBTAIN COMPENSATION DATA FOR EACH KEY EMPLOYEE FROM SIMILAR TYPE AGENCIES AND ORGANIZATIONS EVERY THREE YEARS. DURING THE YEARS WHEN THE COMPREHENSIVE MARKET BASED STUDY IS NOT CONDUCTED, MARKET BASED INFORMATION SUCH AS THE CPI OR COMPARABLE DATA WILL BE USED ANNUALLY TO MAKE ADJUSTMENTS TO THE MIDPOINT. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. CHILDSERVE HOMES INC PO BOX 707 JOHNSTON IA 501310707 421264664 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 CHILDSERVE MEDICAL EQUIPMENT & SUPPLY INC PO BOX 707 JOHNSTON IA 501310707 421264666 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 CHILDSERVE THERAPY INC PO BOX 707 JOHNSTON IA 501310707 420680420 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 CHILDSERVE INC PO BOX 707 JOHNSTON IA 501310707 421271420 PARENT COMPANY FOR BENEFIT & SUPPORT OF PROGRAMS/ SERVICES OF CHILDSERVE IA 501(C)(3) LINE 10 0 CHILDSERVE COMMUNITY OPTIONS PO BOX 707 JOHNSTON IA 501310707 421390033 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 CHILDSERVE HOMECARE INC PO BOX 707 JOHNSTON IA 501310707 421478832 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 CHILDSERVE FOUNDATION INC PO BOX 707 JOHNSTON IA 501310707 421157665 DEVELOP, RECEIVE AND GRANT FINANCIAL ASSISTANCE TO CHILDSERVE ORGANIZATIONS IA 501(C)(3) LINE 12A, I CHILDSERVE INC 0 THE CHILDSERVE CLINIC INC PO BOX 707 JOHNSTON IA 501310707 455327981 SEE PART VII - SUPPLEMENTAL INFORMATION IA 501(C)(3) LINE 10 CHILDSERVE INC 0 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 1 0 1 1 CHILDSERVE FOUNDATION INC C 237814 BASED ON APPROVED NEEDS CHILDSERVE CLINIC INC J 64857 BASED ON SQUARE FOOTAGE CHILDSERVE COMMUNITY OPTIONS J 173634 BASED ON SQUARE FOOTAGE CHILDSERVE INC J 175675 BASED ON SQUARE FOOTAGE CHILDSERVE THERAPY INC J 545469 BASED ON SQUARE FOOTAGE CHILDSERVE HOMES INC L 235314 MAINTENANCE BASED ON HOURS USED CHILDSERVE COMMUNITY OPTIONS L 195497 MAINT & HSKPG BASED ON HOURS USED CHILDSERVE FOUNDATION INC P 98080 BASED ON PROPORTIONATE REVENUE CHILDSERVE INC P 3198640 BASED ON HISTORICAL SUPPORT % CHILDSERVE CLINIC INC R 1609221 ACTUAL CASH TRANSFERRED CHILDSERVE MEDICAL EQUIPMENT & SUPPLY S 334215 ACTUAL CASH TRANSFERRED CHILDSERVE COMMUNITY OPTIONS R 124829 ACTUAL CASH TRANSFERRED CHILDSERVE HOMECARE S 289558 ACTUAL CASH TRANSFERRED CHILDSERVE HOMES INC R 626673 ACTUAL CASH TRANSFERRED CHILDSERVE THERAPY INC S 261671 ACTUAL CASH TRANSFERRED CHILDSERVE FOUNDATION INC R 658755 ACTUAL CASH TRANSFERRED PART II, IDENTIFICATION OF RELATED TAX-EXEMPT ORGANIZATIONS: NAME OF RELATED ORGANIZATION: CHILDSERVE HOMES, INC. PRIMARY ACTIVITY: PROVIDE COMMUNITY BASED GROUP HOME LIVING FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS NAME OF RELATED ORGANIZATION: CHILDSERVE MEDICAL EQUIPMENT & SUPPLY, INC. PRIMARY ACTIVITY: PROVIDE MOBILITY EQUIPMENT, SPECIALTY MEDICAL SUPPLIES, AND SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS NAME OF RELATED ORGANIZATION: CHILDSERVE THERAPY, INC. PRIMARY ACTIVITY: PROVIDE SKILLED THERAPY AND AUDIOLOGY SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS NAME OF RELATED ORGANIZATION: CHILDSERVE COMMUNITY OPTIONS PRIMARY ACTIVITY: PROVIDE INTEGRATED SERVICES AND COMMUNITY CARE FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS NAME OF RELATED ORGANIZATION: CHILDSERVE HOMECARE, INC. PRIMARY ACTIVITY: PROVIDE SPECIALTY HOME HEALTH CARE FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS NAME OF RELATED ORGANIZATION: THE CHILDSERVE CLINIC, INC. PRIMARY ACTIVITY: IMPROVE ACCESS TO PEDIATRIC SUBSPECIALTY MEDICAL SERVICES, PEDIATRIC REHABILITATION SERVICES, AND IN-HOME FAMILY SUPPORT SERVICES