2015-11-16T11:17:57-06:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-01-01 391081800 EVERGREEN RETIREMENT COMMUNITY INC EVER 9202332340 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 JOHN M KRUEGER CPA 9202332340 2015-11-12 1 KIMBERLY ANDERSON CPA P00188889 6123764500 2014 2016-02-25 16:41:14Z KENNETH A ARNESON 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 15821765 0 X WWW.EVERGREENOSHKOSH.COM X 1965 WI TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 AND OLDER. 17 17 368 76 0 0 590240 520351 13992354 14781236 72879 0 770931 448445 15426404 15750032 0 767 0 0 8480366 8650315 0 0 0 6588968 6888796 15069334 15539878 357070 210154 27089417 27270769 16970564 16926231 10118853 10344538 X TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 YEARS AND OLDER. 1 0 13814173 767 14781236 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. 13814173 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 52 0 368 0 0 0 0 0 0 0 0 0 0 0 X 17 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 1 0 0 WI X JOHN M KRUEGER 9202372110 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 BARRY YARBRO CHAIRMAN 1.00 X X 0 0 0 DEIRDRE DEWITT VICE CHAIR 1.00 X X 0 0 0 PAT DAY DIRECTOR 1.00 X 0 0 0 WILL DEPPIESSE DIRECTOR 1.00 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 MARSHA HUGHES DIRECTOR 1.00 X 0 0 0 RANDY HUSMAN DIRECTOR 1.00 1.00 X 0 0 0 ALICE JENKINS 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 LUELLA REMMEL DIRECTOR 1.00 1.00 X 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 40.00 1.00 X 180990 0 21828 JOHN M KRUEGER VP OF FINANCE/IS & TREASUR 40.00 1.00 X 99435 0 41242 KRISTEN POUZAR EXECUTIVE ASSISTANT/SECRET 40.00 X 34681 0 12766 315106 0 75836 1 0 1 0 MIRON CONSTRUCTION CO INC BOX 1372 GREEN BAY WI 54305 CONSTRUCTION 2560450 REHABCARE SERVICES GROUP 680 SOUTH FOURTH STREET LOUISVILLE KY 40202 THERAPY 1165085 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING 404690 PACKER VALLEY BUILDERS INC 2277 CLAIRVILLE ROAD OSHKOSH WI 54904 CONSTRUCTION 256352 OMNICARE PHARMACY SERVICES PO BOX 715268 COLUMBUS OH 43271 PHARMACY SERVICES 189763 8 520351 520351 RESIDENT SERVICE FEES 623000 14169918 14169918 MANAGEMENT FEE INCOME 900099 611318 611318 14781236 73749 71733 2016 2016 2016 OTHER SERVICE REVENUE 900099 446429 446429 446429 15750032 14781236 0 448445 X 767 767 390941 390941 6688743 5621334 1067409 271155 227842 43313 763681 637724 125957 535795 454138 81657 3833 3833 34940 34940 2201925 2054245 147680 88605 88605 143821 127649 16172 137036 137036 676475 676475 72667 34179 38488 305762 305762 1572344 1572344 113084 113084 FOOD SUPPLIES 916718 916718 RESIDENT SUPPLIES 272999 272999 GENERAL SUPPLIES 250932 250932 BAD DEBTS 20004 20004 77651 77651 15539878 13814173 1725705 0 770470 1979245 134380 156614 2531157 1758194 1130246 813856 122094 121267 124037 138325 41266482 22449783 15619009 18816699 187592 6470432 3486569 27089417 27270769 1989754 1671793 1969403 2036544 11545389 11233389 8802 7405 1100000 1035415 357216 941685 16970564 16926231 X 10118853 10344538 10118853 10344538 27089417 27270769 210154 15531 0 X 0 1 X 1 0 X 529297 604296 602837 590240 520351 2847021 14138044 14234028 13662621 13992354 14781236 70808283 14667341 14838324 14265458 14582594 15301587 73655304 0 0 0 73655304 79971 109993 106820 83777 73749 454310 79971 109993 106820 83777 73749 454310 681702 1207794 1602500 767701 446429 4706126 15429014 16156111 15974778 15434072 15821765 78815740 0.93450 0.93310 0.00580 0.00590 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER REVENUE - 2010 AMOUNT: $ 681,702. 2011 AMOUNT: $ 1,207,794. 2012 AMOUNT: $ 835,581. 2013 AMOUNT: $ 148,437. 2014 AMOUNT: $ 446,429. 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 6209001 61620 169491 57134 24553 6358425 5589110 154659 544488 55706 23550 6209001 5228355 3850 474768 96676 21185 5589112 4428650 2320 914470 97937 19148 5228355 4234561 5215 242243 37007 16362 4428650 0.35900 0.63600 0.00500 0 1 1 378263 378263 27080987 11879507 15201480 1335578 945874 389704 12377908 9624402 2753506 93746 93746 18816699 DEFERRED FINANCING COSTS 175606 BOND FUNDS 3197021 DUE FROM EVERGREEN VILLAGE 52998 DUE FROM EVERGREEN FOUNDATION, INC. 60944 3486569 LIABILITY ON INTEREST SWAP AGREEMENT 341685 PAYABLE TO FOUNDATION 600000 941685 X PART IV, LINE 2B: FOR 2014, THERE WAS A RESIDENT FUNDS SAVINGS ACCOUNT IN THE AMOUNT OF $4,815 AND A RESIDENT CHECKING FUND WITH A BALANCE OF $2,590. 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 IS A NON-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 INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE ANNUAL TAX FILINGS OF THE RETIREMENT COMMUNITY IS SUBJECT TO REVIEW BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE RETIREMENT COMMUNITY IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE RETIREMENT COMMUNITY IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR OTHER EXCISE TAXES. THE TAX FILINGS FOR RETIREMENT COMMUNITY AND FOUNDATION FOR THE YEARS 2011 THROUGH 2014 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL OR STATE AUTHORITIES. 1 X X 0 0 0 0 0 1 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 173371 0 7522 0 97 0 3658 0 18170 0 202818 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 A 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 2364000 6600000 6600000 2004 1 0 1 1 B 7000000 138167 502122 6359711 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 STILL IN THE PROCESS OF STARTING A HOME HEALTH AGENCY FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE CHAIR AND VICE CHAIR OF THE BOARD AND THE CHAIRS OF THE THREE OTHER STANDING BOARD COMMITTEES. THE COMMITTEE HAS FULL AUTHORITY TO ACT ON BEHALF OF THE BOARD BETWEEN MEETINGS OF THE BOARD, WITH THE EXCEPTION OF THE ELECTION OF OFFICERS OR THE AUTHORITY TO DECLARE OR FILL ANY VACANCY ON THE BOARD. ALL ACTIONS OF THE COMMITTEE ARE REPORTED AT THE NEXT REGULARLY SCHEDULED MEETING OF THE BOARD. THE COMMITTEE PERFORMS 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 15A THE ORGANIZATIONAL PERFORMANCE COMMITTEE (OPC) OF THE BOARD IS RESPONSIBLE FOR CONDUCTING A 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. THIS PROCESS WAS LAST CONDUCTED IN 2013. THE 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/MARKET AREA. 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 2,046,919. MANAGEMENT AND GENERAL EXPENSES 134,734. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,181,653. CONSULTING FEES : PROGRAM SERVICE EXPENSES 7,326. MANAGEMENT AND GENERAL EXPENSES 12,946. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 20,272. 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 0 0 1 0 1 0 0 0 0 0 0 1 1 1 1 0 1 0 0