2014-11-10T10:29:03-06:00 2014-06-30 391173131 SCHENCK SC 712 RIVERFRONT DRIVE STE 301 SHEBOYGAN WI 53081 990 2013-07-01 390816900 PINE HAVEN CHRISTIAN HOME INC PINE 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 MARTIN HALVERSON OFFICER 9204672401 2014-10-31 1 TERRY T STRITTMATER CPA P00012661 9204580341 2013 2015-11-30 17:44:51Z MARTIN HALVERSON 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 13275499 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. 18 18 328 175 0 0 14118 19658 12978233 13210591 42678 37190 11412 8060 13046441 13275499 0 0 0 0 6959806 7404233 0 0 1000 4366322 4732051 11326128 12136284 1720313 1139215 22827994 24016490 12327748 12317394 10500246 11699096 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 10627585 13210591 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. 10627585 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 57 0 1 328 1 0 0 0 0 0 0 0 0 0 0 X 18 18 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 0 1 1 0 X MARTIN HALVERSON 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 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 DON DEMASTER BOARD MEMBER 0.00 X 0 0 0 ROBERT DESMIDT BOARD MEMBER 0.00 X 0 0 0 CAROL DULMES BOARD MEMBER 0.00 X 0 0 0 DARRELL HAUSE BOARD MEMBER 0.00 X 0 0 0 CARL HUENINK 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 CARL JOOSSE BOARD MEMBER 0.00 X 0 0 0 LARRY LORENZ BOARD MEMBER 0.00 X 0 0 0 DAN NEERHOFF 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 CHRISTINE TEMPAS BOARD MEMBER 0.00 X 0 0 0 RANDY TEUNISSEN BOARD MEMBER 0.00 X 0 0 0 BOB VANDER PUY BOARD MEMBER 0.00 X 0 0 0 NANCY VERSTRATE BOARD MEMBER 0.00 X 0 0 0 RICH DAANE PRESIDENT 0.00 X 0 0 0 VIRGIL NAVIS VICE PRESIDENT 0.00 X 0 0 0 JOHN ACKERMANN SECRETARY 0.00 X 0 0 0 WENDY BAACKES TREASURER 0.00 X 0 0 0 RON WALVOORT CHIEF FINANCIAL OFFICER 40.00 X 108405 0 24838 ROGER LEYS CHIEF EXECUTIVE OFFICER 40.00 X 128377 0 12221 MICHELE OOSTDYK ADMINISTRATOR 40.00 X 100120 0 24514 MARTIN HALVERSON CHIEF FINANCIAL OFFICER 40.00 X 0 0 0 336902 0 61573 3 0 0 0 REHAB CARE GROUP EAST INC PO BOX 503534 ST LOUIS MO 631503534 THERAPY 452181 1 19658 19658 RES CENTER RES. FEES 623000 7117561 7117561 NURSING HOME RES. FEES 623000 4423887 4423887 RES CARE APARTMENT COMPLEX 623000 1669143 1669143 13210591 30190 30190 7000 0 7000 7000 7000 MISCELLANEOUS REVENUE 900099 8060 8060 8060 13275499 13210591 0 45250 336902 286367 50535 5929744 5094034 835710 70558 60447 10111 593307 497577 95730 473722 405837 67885 22175 22175 82852 82852 118549 118549 214092 213397 695 35780 35780 605185 605185 900586 900281 305 152497 152497 NURSING AND MEDICAL 791563 791563 DIETARY - FOOD 550263 550263 UTILITIES 393886 392782 1104 SUPPLIES 269931 221580 48351 594692 455775 138917 12136284 10627585 1507699 1000 X 5828941 5733663 550331 624902 18115 18055 17252 73111 25219335 8705743 15227880 16513592 347455 407090 725391 207116 112629 438961 22827994 24016490 1267748 1350678 11060000 10966716 12327748 12317394 X 10500246 11699096 10500246 11699096 22827994 24016490 1139215 59635 0 X X 0 1 X 1 0 X 163946 6065 22829 14118 19658 226616 9481663 10800365 12168630 12978233 13210591 58639482 9645609 10806430 12191459 12992351 13230249 58866098 0 0 0 58866098 60130 61035 42678 30190 194033 60130 61035 42678 30190 194033 10438 9587 11412 8060 39497 9645609 10876998 12262081 13046441 13268499 59099628 0.99600 0.99580 0.00330 0.00290 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUE - 2010 AMOUNT: $ 10,438. 2011 AMOUNT: $ 9,587. 2012 AMOUNT: $ 11,412. 2013 AMOUNT: $ 8,060. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 0 0 0 1 0 0 0 0 SCHEDULE C, PART IV EXPENSES INCURRED IN CONTACTING GOVERNMENT REPRESENTATIVES CONSISTED SOLEY OF TIME EXPENDED BY SALARIED EMPLOYEES TO COMMUNICATE EITHER VERBALLY OR IN WRITING FOR AN APPROXIMATE TIME OF FOUR HOURS. 1920734 1920734 19702407 7225280 12477127 2062836 1480463 582373 1533358 1533358 16513592 13341394 59635 6260 65895 13275499 0 13275499 12142544 6260 6260 12136284 0 12136284 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 0 0 PINE HAVEN CHRISTIAN HOME FOUNDATION INC C 19658 ACTUAL AMOUNT RECEIVED PINE HAVEN CHRISTIAN HOME FOUNDATION INC D 36012 ACTUAL AMOUNT BORROWED PINE HAVEN CHRISTIAN HOME FOUNDATION INC O 9079 ALLOCATION BASED ON HOURS WORKED