2017-08-15T12:45:26-05:00 2015-09-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2014-10-01 391412320 CAPITOL LAKES INC CAPI 8887246424 333 WEST MAIN STREET MADISON WI 53703 TIM CONROY EXECUTIVE DIRECTOR 8887246424 2017-08-04 1 KURT BENNION CPA P01469618 4252506100 2014 2021-01-29 14:40:06Z LARRY BOECK 1 WEST MAIN SUITE 303 MEDFORD OR 97501 22076147 0 X WWW.RETIREMENT.ORG X 1990 WI TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 6 6 381 234 0 0 2948 74655 18738492 20589111 355226 246225 21793 14260 19118459 20924251 0 0 0 0 9158851 9477016 0 0 0 14947316 15672147 24106167 25149163 -4987708 -4224912 61639091 58317825 103359008 104157130 -41719917 -45839305 CAPITOL LAKES IS A VIBRANT CONTINUING CARE RETIREMENT COMMUNITY COMMITTED TO THE ENRICHMENT OF RESIDENTS' LIVES. 0 0 21548645 0 20589111 CAPITOL LAKES IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING. 21548645 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 1 53 0 1 381 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X SHERI LOYA 5418577644 1 WEST MAIN SUITE 303 MEDFORD OR 97501 X LARRY BOECK CHAIR 1.00 4.00 X X 0 0 0 PAULA BONNER VICE CHAIR 1.00 0.00 X X 0 0 0 BRIAN PURTELL SECRETARY/TREASURER 1.00 0.00 X X 0 0 0 SUE CENTER DIRECTOR 1.00 1.00 X 0 0 0 DENISE GLOEDE DIRECTOR 1.00 0.00 X 0 0 0 JOE SILVERBERG DIRECTOR 1.00 0.00 X 0 0 0 TIM CONROY EXECUTIVE DIRECTOR 40.00 3.00 X 176200 0 25999 176200 0 25999 1 0 1 0 CONSONUS REHAB PO BOX 4800 UNIT 12 PORTLAND OR 97208 THERAPY SERVICES 1451035 PACIFIC RETIREMENT SERVICES 1 WEST MAIN SUITE 303 MEDFORD OR 97501 MANAGEMENT SERVICES 1092504 MCGANN CONSTRUCTION INC 3622 LEXINGTON AVENUE MADISON WI 53714 CONSTRUCTION 946629 COMPLETE CONTROL INC 640 25TH AVENUE N WISCONSIN RAPIDS WI 54495 HVAC SERVICES 145180 AVANT GARDENING AND LANDSCAPING 3055 SIGGELKOW ROAD MCFARLAND WI 53558 LANDSCAPING 112204 5 74655 74655 HEALTH CENTER 623000 10064179 10064179 SERVICE FEES 623000 8332511 8332511 ENTRANCE FEES 623000 1060430 1060430 DIETARY 623000 180531 180531 GARAGE AND CARPORT 623000 40882 40882 910578 910578 20589111 177260 177260 94836 94836 14260 0 14260 14260 14260 1126025 1151896 -25871 -25871 -25871 20924251 20589111 0 260485 224069 224069 7302102 6573299 728803 282073 250277 31796 1127968 973111 154857 540804 479127 61677 1091195 1091195 123410 123410 63490 63490 17418 17418 709359 352717 356642 337576 242 337334 681354 593143 88211 94295 94295 1419664 1417441 2223 111343 23861 87482 38661 30783 7878 3789663 3789663 3358796 3358796 183476 183476 HEALTH CENTER EXPENSES 2538713 2538713 DIETARY EXPENSES 881519 881519 FACILITY SERVICE EXPENS 232215 102477 129738 25149163 21548645 3600518 0 4829863 2843913 928754 4088194 2260726 2546949 47371 51909 631517 710345 64100548 21148566 45118391 42951982 6507850 3331646 1314619 1792887 61639091 58317825 2491428 1603515 5254045 5691193 47645000 46585000 5590000 5775000 42193535 44687422 103359008 104157130 X -42126709 -46762995 330465 847363 76327 76327 -41719917 -45839305 61639091 58317825 X -4224912 -236536 342060 X 0 1 X 1 0 X 729 2948 74655 78332 17806007 17830608 18572205 18738492 20589111 93536423 17806736 17830608 18572205 18741440 20663766 93614755 41383 41383 68494 8634 77128 68494 8634 41383 118511 93496244 222539 240532 186015 242661 286356 1178103 222539 240532 186015 242661 286356 1178103 1298 1298 18030573 18071140 18758220 18984101 20950122 94794156 0.98630 0.98610 0.01240 0.00000 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: NON OPERATING INCOME - 2010 AMOUNT: $ 1,298. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 25149164 25149164 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 250000 250000 250000 250000 1000000 1500000 8537600 8537600 50002665 18461034 31541631 4101631 2316466 1785165 1458652 371066 1087586 42951982 REFUNDABLE DEPOSITS 755212 DUE TO AFFILIATES 3223438 SWAP AGREEMENTS 5541827 OTHER CURRENT LIABILITIES 66199 ASSET RETIREMENT OBLIGATION 9500 CAPITAL LEASE 12349 REFUNDS DUE UPON REOCCUPANCY 35078897 44687422 X PART X, LINE 2: THE CORPORATION HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED ACTIVITIES. NO TAX PROVISION HAS BEEN MADE IN THE ACCOMPANYING STATEMENTS OF ACTIVITIES AND CHANGES IN NET ASSETS (DEFICIT). THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2014, THERE WAS NO SUCH UNCERTAIN TAX POSITIONS. 0 0 0 0 0 0 0 0 0 TIM CONROY EXECUTIVE DIRECTOR 155210 0 20990 0 0 0 12220 0 13779 0 202199 0 0 0 PART I, LINE 3 COMPENSATION WAS RECOMMENDED BY PACIFIC RETIREMENT SERVICE, INC. AND APPROVED BY CAPITOL LAKES BOARD AS PART OF THE ANNUAL BUDGET PROCESS. PART I, LINE 7 THE ORGANIZATION PAID BONUSES THIS YEAR. THE PROCESS FOR DETERMINING EXECUTIVE BONUSES IS DISCRETIONARY, IT IS DETERMINED BY THE VP OF OPERATIONS FOR PRS AND IT IS BASED ON THE PERFORMANCE OF THE COMMUNITY FOR THE YEAR. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V7V4 2008-04-01 44590000 SEE PART VI 0 0 0 A 3295000 45003953 3378734 771878 690604 724551 36018638 3479885 2014 1 0 1 1 A 0 1 1 1 0 0.00500 0.00500 0 0 1 A 0 0 1 1 1 1 KBC BANK 11.900000000000 0 0 0 1 1 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 03/01/2013 PART I, LINE 1, COLUMN F: THE BONDS REFUND THE ISSUER'S SERIES 1995 REDEVELOPMENT REVENUE BONDS, ISSUED ON 4/25/1995, AND THE ISSUER'S SERIES 1999 REVENUE BONDS, ISSUED ON 8/25/1999. PART II, LINE 3: THE AMOUNT DIFFERS FROM PART 1 (E) DUE TO INTEREST EARNED ON INVESTED PROCEEDS. PART III, LINE 7: AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS REPORT IN PART III, LINE 6, IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE. PART IV, LINE 2B: THE BONDS CONSIST OF BOTH A CURRENT REFUNDING, WHICH HAS MET AN EXCEPTION TO THE REBATE REQUIREMENT, AND A NEW MONEY FINANCING, WHICH WILL NOT MEET AN EXCEPTION TO THE REBATE REQUIREMENT. FORM 990, PART VI, SECTION A, LINE 3 CAPITOL LAKES, INC. DELEGATES MANAGEMENT TO PACIFIC RETIREMENT SERVICES. FORM 990, PART VI, SECTION A, LINE 6 CAPITOL LAKES, INC. HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES. FORM 990, PART VI, SECTION A, LINE 7A PACIFIC RETIREMENT SERVICES HAS THE RIGHT TO ELECT THE DIRECTORS OF THE BOARD OF CAPITOL LAKES, INC. FORM 990, PART VI, SECTION A, LINE 7B SOME DECISIONS OF THE BOARD ARE SUBJECT TO APPROVAL BY PACIFIC RETIREMENT SERVICES, AS OUTLINED IN ARTICLE IV SECTION 1 OF THE BYLAWS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS PREPARED BY THE ASSISTANT CONTROLLER AND REVIEWED BY THE CONTROLLER, CFO, AND BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2) KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OF KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE ED'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS). FORM 990, PART VI, SECTION C, LINE 19 ALL REQUESTS GO THROUGH CORPORATE COUNSEL. FORM 990, PART VII, SECTION A: NOTE THAT TIM CONROY IS A LEASED EMPLOYEE OF PACIFIC RETIREMENT SERVICES, INC. AND PERFORMS SERVICES ON BEHALF OF CAPITOL LAKES, INC. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN CAPITOL LAKES, INC. AND PACIFIC RETIREMENT SERVICES, INC. UNDER THE MANAGEMENT SERVICES AGREEMENT, HIS COMPENSATION IS REIMBURSED BY CAPITOL LAKES, INC. HIS COMPENSATION IS REPORTED IN PART VII SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY CAPITOL LAKES, INC., NOTWITHSTANDING THAT HE IS A LEASED EMPLOYEE OF PACIFIC RETIREMENT SERVICES, INC. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF CAPITOL LAKES FOUNDATION, INC. 516,898. CHANGE IN VALUE OF INTEREST RATE SWAP AGREEMENTS -174,838. 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