2016-11-07T10:32:27-06:00 2016-06-30 391173131 SCHENCK SC 712 RIVERFRONT DRIVE STE 301 SHEBOYGAN WI 53081 990 2015-07-01 390816900 PINE HAVEN CHRISTIAN HOME INC PINE 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 MARTIN HALVERSON OFFICER 9204672401 2016-11-02 1 TERRY T STRITTMATER CPA P00012661 9204580341 2015 2017-02-10 21:41:12Z MARTIN HALVERSON 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 17735549 0 X WWW.PINEHAVEN.ORG X 1950 WI PINE HAVEN CHRISTIAN COMMUNITIES WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 21 21 432 170 0 0 4729 1098178 14452767 16611212 13914 -103492 7401 0 14478811 17605898 0 0 0 0 8250112 9547752 0 0 1000 5029498 7587344 13279610 17135096 1199201 470802 40715121 43652800 27798061 30211789 12917060 13441011 PINE HAVEN CHRISTIAN COMMUNITIES WILL PROVIDE THE AGING POPULATION WE SERVE AN ENVIRONMENT THAT IS A CHRIST-CENTERED, SAFE HAVEN OFFERING QUALITY, COMPASSIONATE CARE. 0 0 15208529 16611212 PROVIDING HOUSING, HEALTH CARE AND OTHER RELATED SERVICES TO RESIDENTS IN A NON-PROFIT NURSING HOME AND ASSISTED LIVING FACILITIES. A CMS RECOGNIZED OVERALL 5-STAR NURSING HOME. 15208529 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 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 1 0 0 0 0 1 0 1 0 1 54 0 1 432 1 0 0 0 0 0 0 0 0 0 0 X 21 21 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 0 1 1 0 WI X MARTIN HALVERSON 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 CHRISTINE TEMPAS PRESIDENT 0.00 X X 0 0 0 ROBERT DESMIDT VICE PRESIDENT 0.00 X X 0 0 0 DAN NEERHOFF SECRETARY 0.00 X X 0 0 0 WENDY BAACKES TREASURER 0.00 X X 0 0 0 DAVE BRASSER BOARD MEMBER 0.00 X 0 0 0 JANE BUTEYN BOARD MEMBER 0.00 X 0 0 0 PAUL DAMKOT BOARD MEMBER 0.00 X 0 0 0 JACK HOFFMANN BOARD MEMBER 0.00 X 0 0 0 GLENN LEMMENES BOARD MEMBER 0.00 X 0 0 0 BETTY MOODY BOARD MEMBER 0.00 X 0 0 0 GENNY TEN PAS BOARD MEMBER 0.00 X 0 0 0 NORENE HUIBREGTSE BOARD MEMBER 0.00 X 0 0 0 MIKE FOLEY BOARD MEMBER 0.00 X 0 0 0 LARRY LORENZ BOARD MEMBER 0.00 X 0 0 0 LOIS OOSTDYKE BOARD MEMBER 0.00 X 0 0 0 JEFF RISSEEUW BOARD MEMBER 0.00 X 0 0 0 RANDY TEUNISSEN BOARD MEMBER 0.00 X 0 0 0 JEFF BROETZMANN BOARD MEMBER 0.00 X 0 0 0 ROGER BUYZE BOARD MEMBER 0.00 X 0 0 0 KEN KOEHLER BOARD MEMBER 0.00 X 0 0 0 RICH DAANE BOARD MEMBER 0.00 X 0 0 0 RON WALVOORT CHIEF EXECUTIVE OFFICER 40.00 X 143526 0 23932 MICHELE OOSTDYK ADMINISTRATOR 40.00 X 123254 0 23932 MARTIN HALVERSON CHIEF FINANCIAL OFFICER 40.00 X 98550 0 23932 ROGER LEYS FORMER CHIEF EXECUTIVE OFFICER 0.00 X 134915 0 829 500245 0 72625 3 1 1 0 REHAB CARE GROUP EAST INC PO BOX 503534 SAINT LOUIS MO 631503534 THERAPY 808961 ELITE NURSES INC 1987 SCHEUERING RD 8 DE PERE WI 54115 NURSING SERVICES 189670 2 261922 836256 836256 1098178 RES CENTER RES. FEES 623000 9460795 9460795 NURSING HOME RES. FEES 623000 5313914 5313914 RES CARE APARTMENT COMPLEX 623000 1836503 1836503 16611212 26159 26159 129651 -129651 -129651 -129651 17605898 16611212 0 -103492 378803 378803 7517916 6857937 659979 82423 71658 10765 983805 873046 110759 584805 508422 76383 13743 13743 20231 20231 50000 50000 92061 92061 144661 144661 283206 282511 695 88286 88286 897960 897960 1581491 1581186 305 189695 189695 NURSING AND MEDICAL 1488683 1488683 DIETARY - FOOD 755393 755393 UTILITIES 483594 439898 43696 TRANSFER TO PH FOUNDATI 441686 441686 1056654 820454 236200 17135096 15208529 1925567 1000 X 5758180 4877780 1063507 1126521 25646 11920 61607 34111 44104644 9977939 32781613 34126705 425852 0 208674 2209827 390042 1265936 40715121 43652800 2218222 1971844 25579839 28239945 27798061 30211789 X 12917060 12604755 0 836256 12917060 13441011 40715121 43652800 470802 53149 0 X X 0 1 X 1 0 X 22829 14118 19658 4729 1098178 1159512 12168630 12978233 13210591 14452767 16611212 69421433 12191459 12992351 13230249 14457496 17709390 70580945 0 0 0 70580945 61035 42678 30190 13914 26159 173976 61035 42678 30190 13914 26159 173976 9587 11412 8060 7401 36460 12262081 13046441 13268499 14478811 17735549 70791381 0.99700 0.99600 0.00250 0.00330 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUE - 2011 AMOUNT: $ 9,587. 2012 AMOUNT: $ 11,412. 2013 AMOUNT: $ 8,060. 2014 AMOUNT: $ 7,401. 2015 AMOUNT: $ 0. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1345944 1345944 38216184 8103862 30112322 3783239 1528360 2254879 759277 345717 413560 34126705 CERTIFICATES OF DEPOSIT-CURRENT ASSETS 2209827 C 2209827 17665836 53149 6789 59938 17605898 0 17605898 17141885 6789 6789 17135096 0 17135096 0 0 0 0 0 0 0 0 0 RON WALVOORT CHIEF EXECUTIVE OFFICER 143526 0 0 0 0 0 0 0 23932 0 167458 0 0 0 ROGER LEYS FORMER CHIEF EXECUTIVE OFFICER 134915 0 0 0 0 0 0 0 829 0 135744 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY - SERIES 2014 A 391337855 2014-05-01 10000000 REFINANCE 2009 BONDS 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY - SERIES 2014 B 391337855 2014-05-01 1000000 REFINANCE 2009 BONDS 0 0 0 C WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY - SERIES 2014 B 391337855 2014-05-01 18100000 NEW PROJECT 0 0 0 A 10000000 2015 1 0 1 1 B 1000000 2015 1 0 1 1 C 18100000 18100000 2015 0 0 1 1 A 0 0 0 0 1 0 0 0 0 B 0 0 0 0 1 0 0 0 0 C 0 0 0 0 1 0 0 0 0 A 0 B 0 C 0 X 1 836256 FAIR MARKET VALUE 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS MEMBERS FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF TRUSTEES FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C PINE HAVEN CHRISTIAN HOME HAS A BOARD OF DIRECTOR'S APPROVED "CODE OF ETHICS" DOCUMENT. THE CODE OF ETHICS INCLUDES A SECTION COVERING "CONFLICT OF INTEREST". IT PROVIDES A DEFINITION AND ALL EMPLOYEES ARE REQUIRED TO SIGN A STATEMENT EACH YEAR THAT THEY DO NOT HAVE A "CONFLICT OF INTEREST OR THEY DECLARE ANY EXISTING CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION FOR THE CEO AND OTHER KEY EMPLOYEES IS COMPARED TO INDUSTRY DATA COMPILED BY LEADING AGE WISCONSIN. THE SURVEY COMPARES COMPENSATION BASED ON THREE CRITERIA: GROSS REVENUES, GEOGRAPHIC AREA AND TOTAL BED RESPONSIBILITIES. FORM 990, PART VI, SECTION C, LINE 19 THE FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVALIABLE TO THE PUBLIC AT THIS TIME. FORM 990, PART XII, LINE 2C THERE IS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS. PINE HAVEN CHRISTIAN HOME FOUNDATION INC 531 GIDDINGS AVE SHEBOYGAN FALLS WI 53085 391963866 RAISE/RECEIVE FUNDS FOR THE GENERAL SUPPORT OF THIS ORGANIZATION WI 501(C)(3) 11 N/A 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 PINE HAVEN CHRISTIAN HOME FOUNDATION INC C 261922 ACTUAL AMOUNT RECEIVED PINE HAVEN CHRISTIAN HOME FOUNDATION INC D 710 ACTUAL AMOUNT BORROWED PINE HAVEN CHRISTIAN HOME FOUNDATION INC O 8649 ALLOCATION BASED ON HOURS WORKED PINE HAVEN CHRISTIAN HOME FOUNDATION INC R 441686 ACTUAL AMOUNT RECEIVED