2014-11-17T11:48:31-06:00 2013-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2013-01-01 391081800 EVERGREEN RETIREMENT COMMUNITY INC EVER 9202332340 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 JOHN M KRUEGER VP OF FINANCE/IS & TREASURER 9202332340 2014-11-12 1 KURT BENNION P01469618 6123764500 2013 2015-11-30 17:44:51Z KENNETH A ARNESON 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 15434092 0 X WWW.EVERGREENOSHKOSH.COM X 1965 WI TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 AND OLDER. 18 18 350 332 0 0 602837 590240 13662621 13992354 93005 72879 1614653 770931 15973116 15426404 0 0 0 0 8508846 8480366 0 0 0 6738110 6588968 15246956 15069334 726160 357070 19620705 27089417 10103359 16970564 9517346 10118853 X TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 YEARS AND OLDER. 1 0 13437743 0 13992354 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. 13437743 1 1 0 0 0 0 0 0 0 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 1 1 0 0 0 1 0 0 0 1 74 0 350 1 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 0 1 0 1 0 0 WI X JOHN M KRUEGER 9202372110 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 BARRY YARBRO CHAIRMAN 1.00 0.00 X X 0 0 0 DEIRDRE DEWITT VICE CHAIR 1.00 0.00 X X 0 0 0 BARBARA COOK DIRECTOR 1.00 1.00 X 0 0 0 PAT DAY DIRECTOR 1.00 0.00 X 0 0 0 WILL DEPPIESSE DIRECTOR 1.00 0.00 X 0 0 0 MIKE GRACEFFA DIRECTOR 1.00 0.00 X 0 0 0 VERNICE HAASE DIRECTOR 1.00 0.00 X 0 0 0 ELIZABETH HARTMAN DIRECTOR 1.00 0.00 X 0 0 0 RANDY HEDGE DIRECTOR 1.00 0.00 X 0 0 0 MARSHA HUGHES DIRECTOR 1.00 0.00 X 0 0 0 RANDY HUSMAN DIRECTOR 1.00 1.00 X 0 0 0 ALICE JENKINS DIRECTOR 1.00 0.00 X 0 0 0 SUE KREIBICH DIRECTOR 1.00 0.00 X 0 0 0 MARCIA LARSON DIRECTOR 1.00 0.00 X 0 0 0 FRED LILLY DIRECTOR 1.00 0.00 X 0 0 0 JAYNE LINDSAY DIRECTOR 1.00 0.00 X 0 0 0 ROY NEY DIRECTOR 1.00 0.00 X 0 0 0 BETTY PATERSON DIRECTOR 1.00 0.00 X 0 0 0 CHRIS VANSTRATEN DIRECTOR 1.00 0.00 X 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 40.00 1.00 X 169363 0 26586 JOHN M KRUEGER VP OF FINANCE/IS & TREASURER 40.00 1.00 X 97956 0 39843 KRISTEN POUZAR EXECUTIVE ASSISTANT/SECRETARY 40.00 0.00 X 34342 0 11742 301661 0 78171 1 0 1 0 REHABCARE SERVICES GROUP 680 SOUTH FOURTH STREET LOUISVILLE KY 40202 THERAPY 913740 MIRON CONSTRUCTION CO INC BOX 1372 GREEN BAY WI 54305 CONSTRUCTION 503449 HEALTHCARE SERVICES GROUP 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING 378000 PACKER VALLEY BUILDERS INC 2277 CLAIRVILLE ROAD OSHKOSH WI 54904 CONSTRUCTION 318182 AG ARCHITECTURE 1414 UNDERWOOD AVE SUITE 301 WAUWATOSA WI 53213 ARCHITECTURAL 229058 11 588340 1900 42448 590240 RESIDENT SERVICE REV 623000 13418003 13418003 MANAGEMENT FEE REV 900099 574351 574351 13992354 74517 74517 9260 6050 3210 3210 3210 1638 -1638 -1638 -1638 MEAL REVENUES 900099 301343 301343 EVERGREEN AT HOME 900099 177253 177253 OTHER REVENUE 900099 148437 148437 140688 140688 767721 15426404 13992354 0 843810 X 379832 379832 6592673 5402168 1190505 311847 255534 56313 698241 558037 140204 497773 421201 76572 3659 3659 23723 23723 21218 21218 2072596 1988512 84084 47368 47368 79662 56042 23620 120400 120400 550164 550164 29958 18265 11693 257375 257375 1435730 1435730 111616 111616 FOOD 813465 813465 SUPPLIES 529270 529270 BED TAX EXPENSE 191080 191080 PHARMACY 152140 152140 149544 149544 15069334 13437743 1631591 0 1532368 770470 120276 134380 1512169 2531157 1702174 1130246 84712 122094 67885 124037 36509297 20890288 14491830 15619009 59708 187592 49583 6470432 19620705 27089417 1543102 1989754 1733882 1969403 5016647 11545389 8074 8802 1200000 1100000 601654 357216 10103359 16970564 X 9517346 10118853 9517346 10118853 19620705 27089417 357070 244437 0 X 0 1 X 1 0 X 677283 529297 604296 602837 590240 3003953 14732057 14138044 14234028 13662621 13992354 70759104 15409340 14667341 14838324 14265458 14582594 73763057 0 0 0 73763057 88323 79971 109993 106820 83777 468884 88323 79971 109993 106820 83777 468884 559136 681702 1207794 1602500 767701 4818833 16056799 15429014 16156111 15974778 15434072 79050774 0.93310 0.93440 0.00590 0.00590 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER REVENUE MEAL REVENUE EVERGREEN AT HOME BED TAX RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 5589110 154659 544488 55706 23550 6209001 5228355 3850 474768 96676 21185 5589112 4428650 2320 914470 97937 19148 5228355 4234561 5215 242243 37007 16362 4428650 4214347 5245 75676 46670 14037 4234561 0.09130 0.90870 0 1 1 378264 378264 22122473 10985362 11137111 2287020 897740 1389280 11721540 9007186 2714354 15619009 RESIDENT FUNDS HELD IN TRUST 8802 DUE FROM EVERGREEN FOUNDATION, INC. 53547 BOND FUND 6380909 BOND INTEREST 27174 6470432 LIABILITY ON INTEREST SWAP AGREEMENT 357216 357216 X PART IV, LINE 2B: FOR 2013, THERE WAS A RESIDENT FUNDS SAVINGS ACCOUNT IN THE AMOUNT OF $5,838 AND A RESIDENT CHECKING FUND WITH A BALANCE OF $2,965. 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 2009 THROUGH 2012 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL OR STATE AUTHORITIES. X 0 1 X X X 0 0 0 0 0 1 0 0 0 KENNETH A ARNESON PRESIDENT/CEO 159844 0 9456 0 63 0 0 0 26586 0 195949 0 0 0 PART I, LINE 1A THE ORGANIZATION REIMBURSES THE PRESIDENT/CEO FOR HIS ROTARY CLUB DUES. THIS BENEFIT IS NOT INCLUDED IN HIS TAXABLE COMPENSATION. PART I, LINE 1B THE ORGANIZATION REQUIRES SUBSTANTIATION FROM THE PRESIDENT/CEO BEFORE THE EXPENSE IS PAID. THE AMOUNT IS DEEMED TO BE REASONABLE BECAUSE IT IS SUCH A SMALL DOLLAR AMOUNT - $206 FOR 2013, INCLUDING MEAL CHARGES. 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 X 1 408 FAIR MARKET VALUE X 40804 FAIR MARKET VALUE X 1196 FAIR MARKET VALUE 0 0 0 0 FORM 990, PART III, LINE 2 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 12 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 THERAPY SERVICES: PROGRAM SERVICE EXPENSES 1,013,789. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,013,789. BUILDING MAINTENANCE SERVICES: PROGRAM SERVICE EXPENSES 238,903. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 238,903. HOUSEKEEPING: PROGRAM SERVICE EXPENSES 378,000. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 378,000. LAUNDRY: PROGRAM SERVICE EXPENSES 145,133. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 145,133. OTHER FEES: PROGRAM SERVICE EXPENSES 212,687. MANAGEMENT AND GENERAL EXPENSES 84,084. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 296,771. 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 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 1