2016-11-15T14:42:31-06:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 8215 GREENWAY BOULEVARD SUITE 600 MIDDLETON WI 53562 990 2015-01-01 391081800 EVERGREEN RETIREMENT COMMUNITY INC EVER 9202332340 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 JOHN M KRUEGER CPA 9202332340 2016-11-15 1 KIMBERLY ANDERSON CPA P00188889 6086628600 2016-11-15 2015 2017-02-10 21:41:12Z KENNETH A ARNESON 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 16289374 0 X WWW.EVERGREENOSHKOSH.COM X 1965 WI GUIDED BY CHRISTIAN VALUES, WE ARE AN INDUSTRY LEADER IN PROVIDING A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 YEARS AND OLDER. 18 18 405 155 0 0 520351 561007 14781236 15145788 0 -95917 448445 582579 15750032 16193457 767 1000 0 0 8650315 8782515 0 0 0 6888796 7123835 15539878 15907350 210154 286107 27270769 25941423 16926231 15246665 10344538 10694758 X GUIDED BY CHRISTIAN VALUES, WE ARE AN INDUSTRY LEADER IN PROVIDING A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 YEARS AND OLDER. 1 0 14143247 1000 15145788 EVERGREEN IS A NONPROFIT CONTINUING CARE RETIREMENT COMMUNITY (CCRC) SERVING OLDER ADULTS, AGES 55 AND OLDER. IDEAL FOR THOSE LOOKING FOR A LIFESTYLE OF CHOICE, FREEDOM, SAFETY, COMMUNITY AND VALUE, EVERGREEN IS MORE THAN JUST A SENIOR LIVING COMMUNITY.EVERGREEN'S 35-ACRE CAMPUS IS NOT ONLY HOME TO ALMOST 300 RESIDENTS, BUT IT IS ALSO A DESTINATION FOR FAMILIES, COMMUNITY MEMBERS, VOLUNTEERS, NONPROFIT GROUPS AND OTHER VISITORS.LOCATED IN A PLEASANT RESIDENTIAL NEIGHBORHOOD IN OSHKOSH, WISCONSIN AMONG BEAUTIFUL, NATURAL SURROUNDINGS AND BORDERED BY OUR OWN OAK SAVANNA WOODLANDS, EVERGREEN PROVIDES LIVELY OPPORTUNITIES FOR YOU AND YOUR FRIENDS TO LIVE AS YOU CHOOSE. CHOOSE FROM THREE STYLES OF INDEPENDENT LIVING ACCOMMODATIONS, FOUR LEVELS OF ASSISTED LIVING, SHORT-TERM REHAB AND POST SURGICAL CARE, LONG-TERM SKILLED NURSING, OR EVERGREEN AT HOME SERVICES TO MEET YOUR UNIQUE NEEDS.LIFE ENRICHMENT ABOUNDS AT EVERGREEN. THERAPEUTIC SWIMMING POOLS, AN AEROBIC STUDIO, LAPIDARY SHOP, AND SUPPERS WITH THE CHEF ARE JUST A FEW OF THE MANY OPPORTUNITIES THAT ENCOURAGE ACTIVE LIFESTYLES. PARTNERSHIPS WITH THE UNIVERSITY OF WISCONSIN OSHKOSH, LEARNING IN RETIREMENT AND THE OSHKOSH GALLERY WALK ALSO PROVIDE ENTERTAINING AND FULFILLING EXPERIENCES AND ENSURE THAT NO TWO DAYS ARE THE SAME. AT EVERGREEN, POSSIBILITIES AWAIT. 14143247 1 1 0 0 0 0 0 0 1 1 1 0 0 1 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 0 0 0 1 63 0 1 405 0 0 0 0 0 0 0 0 0 0 0 X 18 18 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 1 1 0 WI X X JOHN M KRUEGER 9202372110 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 BARRY YARBRO DIRECTOR 1.00 X 0 0 0 DEIRDRE DEWITT CHAIRMAN 1.00 X X 0 0 0 PAT DAY DIRECTOR 1.00 X 0 0 0 WILL DEPPIESSE VICE CHAIR 1.00 X X 0 0 0 MIKE GRACEFFA DIRECTOR 1.00 X 0 0 0 VERNICE HAASE DIRECTOR 1.00 X 0 0 0 ELIZABETH HARTMAN DIRECTOR 1.00 X 0 0 0 RANDY HEDGE DIRECTOR 1.00 X 0 0 0 GINI DAVIS DIRECTOR 1.00 X 0 0 0 RANDY HUSMAN DIRECTOR 1.00 1.00 X 0 0 0 STEVE DUNN DIRECTOR 1.00 X 0 0 0 SUE KREIBICH DIRECTOR 1.00 X 0 0 0 MARCIA LARSON DIRECTOR 1.00 X 0 0 0 FRED LILLY DIRECTOR 1.00 X 0 0 0 JAYNE LINDSAY DIRECTOR 1.00 X 0 0 0 ROY NEY DIRECTOR 1.00 X 0 0 0 BETTY PATERSON DIRECTOR 1.00 X 0 0 0 CHRIS VANSTRATEN DIRECTOR 1.00 X 0 0 0 SUSAN BOETTCHER DIRECTOR 1.00 X 0 0 0 SANDY MUINDE DIRECTOR 1.00 X 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 40.00 1.00 X 196328 0 20835 JOHN M KRUEGER VP OF FINANCE/IS & TREASUR 40.00 1.00 X 101437 0 40002 KRISTEN POUZAR EXECUTIVE ASSISTANT (THROUGH 11/22/15) 40.00 X 35865 0 11912 BROOKE KNOLL EXECUTIVE ASSISTANT (STARTING 11/23/15) 40.00 X 2769 0 445 336399 0 73194 2 0 1 0 REHABCARE GROUP EAST INC 680 SOUTH FOURTH STREET LOUISVILLE KY 40202 THERAPY 1035676 MIRON CONSTRUCTION CO INC BOX 1372 GREEN BAY WI 54305 CONSTRUCTION 875276 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING 462249 NORTHCENTRAL CONSTRUCTION CORP 631 SOUTH HICKORY STREET FOND DU LAC WI 54935 CONSTRUCTION 349243 BAY TOWEL 2580 SOUTH BROADWAY GREEN BAY WI 54304 LAUNDRY 193356 9 561007 561007 RESIDENT SERVICE FEES 623000 14541842 14541842 MANAGEMENT FEE INCOME 900099 603946 603946 15145788 95917 -95917 -95917 -95917 OTHER SERVICE REVENUE 900099 582579 582579 582579 16193457 15145788 0 486662 X 1000 1000 409967 409967 6725074 5877697 847377 276156 242261 33895 856850 749044 107806 514468 449644 64824 2458 2163 295 25590 22519 3071 2067631 1819515 248116 88018 77456 10562 145785 128291 17494 30761 27070 3691 661820 582402 79418 61689 54286 7403 323914 285044 38870 1663092 1463521 199571 117391 103304 14087 FOOD SUPPLIES 972540 972540 GENERAL SUPPLIES 294580 259230 35350 RESIDENT SUPPLIES 232956 232956 BAD DEBTS 151000 132880 18120 284610 250457 34153 15907350 14143247 1764103 0 1979245 2501414 156614 175441 1758194 1526211 813856 789744 121267 103734 138325 190191 42420639 23655634 18816699 18765005 3486569 1889683 27270769 25941423 1671793 1658509 2036544 1888338 11233389 10806679 7405 5888 1035415 9679 941685 877572 16926231 15246665 X 10344538 10694758 10344538 10694758 27270769 25941423 286107 64113 0 X X 0 1 X 1 0 X 604296 602837 590240 520351 561007 2878731 14234028 13662621 13992354 14781236 15145788 71816027 14838324 14265458 14582594 15301587 15706795 74694758 0 0 0 74694758 109993 106820 83777 73749 374339 109993 106820 83777 73749 374339 1207794 1602500 767701 446429 582579 4607003 16156111 15974778 15434072 15821765 16289374 79676100 0.93750 0.93450 0.00470 0.00580 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER REVENUE - 2011 AMOUNT: $ 1,207,794. 2012 AMOUNT: $ 835,581. 2013 AMOUNT: $ 148,437. 2014 AMOUNT: $ 446,429. 2015 AMOUNT: $ 582,579. MEAL REVENUE - 2012 AMOUNT: $ 544,020. 2013 AMOUNT: $ 301,343. EVERGREEN AT HOME - 2012 AMOUNT: $ 222,899. 2013 AMOUNT: $ 177,253. BED TAX - 2013 AMOUNT: $ 140,668. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 6358425 -6352 -186639 60173 25570 6079792 6209001 61620 169491 57134 24553 6358425 5589110 154659 544488 55706 23550 6209001 5228355 3850 474768 96676 21185 5589112 4428650 2320 914470 97937 19148 5228355 0.35200 0.64300 0.00500 0 1 1 388263 388263 27860612 12857937 15002675 1424294 998644 425650 12500181 9799053 2701128 247289 247289 18765005 DEFERRED FINANCING COSTS 162746 BOND FUNDS 1478577 DUE FROM EVERGREEN FOUNDATION, INC. 248360 1889683 LIABILITY ON INTEREST SWAP AGREEMENT 277572 PAYABLE TO FOUNDATION 600000 877572 X PART IV, LINE 2B: FOR 2015, THERE WAS A RESIDENT FUNDS SAVINGS ACCOUNT IN THE AMOUNT OF $4,301 AND A RESIDENT CHECKING FUND WITH A BALANCE OF $1,587. PART V, LINE 4: THE ENDOWMENT FUNDS ARE HELD BY THE RELATED FOUNDATION FOR THE BENEVOLENT NEEDS FOR RESIDENTS OF EVERGREEN RETIREMENT COMMUNITY WHO HAVE EXHAUSTED THEIR PERSONAL RESOURCES, WOODLANDS PRESERVATION, LIFECARE LEARNING, PASTORAL CARE, CREATIVE ARTS, AND GROUNDS BEAUTIFICATION. PART X, LINE 2: THE RETIREMENT COMMUNITY AND THE FOUNDATION ARE NONPROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE ANNUAL TAX FILINGS OF THE RETIREMENT COMMUNITY AND FOUNDATION ARE SUBJECT TO REVIEW BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE RETIREMENT COMMUNITY AND FOUNDATION ARE NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE RETIREMENT COMMUNITY AND FOUNDATION ARE NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR OTHER EXCISE TAXES. 1 X X 0 0 0 0 0 1 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 186663 0 9568 0 97 0 0 0 20835 0 217163 0 0 0 PART I, LINE 3 THE ORGANIZATIONAL PERFORMANCE COMMITTEE (OPC) OF THE BOARD IS RESPONSIBLE FOR CONDUCTING THE PERFORMANCE REVIEW OF THE CEO AND MAKING A WAGE RECOMMENDATION TO THE FULL BOARD OF DIRECTORS. THE OPC IS PROVIDED COMPARATIVE WAGE DATA ANNUALLY BY THE VICE PRESIDENT OF HUMAN RESOURCES. THE REVIEW PROCESS IS DOCUMENTED IN EXECUTIVE SESSION MINUTES. PART I, LINE 6 PRESIDENT/CEO (KEN ARNESON), VP OF FINANCE/IS & TREASURER (JOHN KRUEGER), AND EXECUTIVE ASSISTANT/SECRETARY (KRISTEN POUZAR) OF EVERGREEN RETIREMENT COMMUNITY, AS MEMBERS OF THE MANAGEMENT TEAM, RECEIVE AN ANNUAL BONUS, PART OF WHICH RELATES TO THE NET INCOME OF THE ORGANIZATION. A ELDERLY HOUSING AUTHORITY OF THE CITY OF OSHKOSH 391251777 2003-11-25 6600000 CONSTRUCTION OF SKILLED NURSING FACILITY AND FITNESS & AQUATIC CENTER 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2013-12-20 7000000 CAMPUS REMODEL (REPOSITIONING) 0 0 0 A 6600000 6600000 2004 1 0 1 1 B 7000000 138167 1260512 5601321 0 0 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 1 A 0 0 1 0 1 1 ASSOCIATED BANK NA 9.583333300000 0 0 0 0 0 B 0 1 0 0 1 0 0 0 1 A 0 B 0 FORM 990, PART III, LINE 2 HOME HEALTH AGENCY RECEIVED ITS MEDICARE CERTIFICATION SEPTEMBER 14, 2015. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE CHAIR AND VICE CHAIR OF THE BOARD AND THE CHAIRS OF THE THREE OTHER STANDING BOARD COMMITTEES. THE CHAIR SHALL SERVE AS THE CHAIR OF THE EXECUTIVE COMMITTEE. A QUORUM SHALL CONSIST OF THREE MEMBERS. THE COMMITTEE SHALL MEET AT THE CALL OF THE CHAIR OR ANY TWO EXECUTIVE COMMITTEE MEMBERS. THE COMMITTEE SHALL HAVE FULL AUTHORITY TO ACT ON BEHALF OF THE BOARD BETWEEN MEETINGS OF THE BOARD, EXCEPT THE ELECTION OF OFFICERS OR THE AUTHORITY TO DECLARE OR FILL ANY VACANCY ON THE BOARD. ALL ACTIONS OF THE COMMITTEE SHALL BE REPORTED AT THE NEXT REGULARLY SCHEDULED MEETING OF THE BOARD. THE COMMITTEE SHALL PERFORM SUCH OTHER FUNCTIONS AS MAY BE DELEGATED TO IT BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S TREASURER WILL REVIEW THE 990 IN DETAIL. AN ELECTRONIC VERSION OF THE FORM 990 WILL BE POSTED ON THE BOARD WEB PAGE WITH MEMBERS GIVEN THE OPPORTUNITY TO REVIEW IT PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT APPLIES TO ALL EMPLOYEES AND IT HAS A CODE OF CONDUCT POLICY THAT APPLIES TO ALL BOARD MEMBERS. HOWEVER, THE CODE OF CONDUCT POLICY IS NOT SUFFICIENT TO ANSWER YES TO FORM 990, PART VI, LINE 12C. BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE ANY CONFLICTS OF INTEREST AND TO CONDUCT BUSINESS WITH EVERGREEN IN A MANNER THAT SUPPORTS THE INTERESTS OF EVERGREEN AND AVOIDS UNFAIR PERSONAL ADVANTAGE. NON-COMPLIANCE WITH THE CODE OF CONDUCT MAY RESULT IN REMOVAL FROM THE BOARD FOLLOWING AN OPPORTUNITY FOR EXPLANATION TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATIONAL PERFORMANCE COMMITTEE (OPC) OF THE BOARD IS RESPONSIBLE FOR CONDUCTING THE PERFORMANCE REVIEW OF THE CEO AND MAKING A WAGE RECOMMENDATION TO THE FULL BOARD OF DIRECTORS. THE OPC IS PROVIDED COMPARATIVE WAGE DATA ANNUALLY BY THE VICE PRESIDENT OF HUMAN RESOURCES. THE REVIEW PROCESS IS DOCUMENTED IN EXECUTIVE SESSION MINUTES. VICE PRESIDENTS ARE REVIEWED BY THE PRESIDENT/CEO. THE SECRETARY OF THE BOARD IS THE EXECUTIVE ASSISTANT TO THE PRESIDENT/CEO AND IS REVIEWED BY THE PRESIDENT/CEO. PERIODIC WAGE & SALARY SURVEYS ARE CONDUCTED TO ASSURE COMPENSATION IS COMPARABLE TO INDUSTRY/AREA MARKET. FORMS ARE USED TO DOCUMENT ACCOMPLISHMENTS. FORM 990, PART VI, SECTION C, LINE 19 EVERGREEN RETIREMENT COMMUNITY, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FORM 990 AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST. REQUESTED DOCUMENTS ARE PROVIDED WITHIN A REASONABLE TIME FRAME. FORM 990, PART IX, LINE 11G CONTRACTS AND OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,814,182. MANAGEMENT AND GENERAL EXPENSES 247,389. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,061,571. CONSULTING FEES: PROGRAM SERVICE EXPENSES 5,333. MANAGEMENT AND GENERAL EXPENSES 727. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,060. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. EVERGREEN FOUNDATION INC 1130 NORTH WESTFIELD STREET OSHKOSH WI 54902 391388991 FUNDRAISING WI 501(C)(3) LINE 7 N/A 0 EVERGREEN VILLAGE INC 1130 NORTH WESTFIELD STREET OSHKOSH WI 54901 391505337 CO-OPERATIVE WI N/A C 0 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0