2013-10-30T14:52:47-05:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-01-01 391857036 GABRIEL'S VILLA INC GABR 9202354653 225 NORTH EAGLE STREET OSHKOSH WI 54902 THERESA M BERTRAM 9202325228 2013-10-23 1 CORY RUTLEDGE P01329381 6123764500 2012 2016-03-07 17:11:31Z THERESA M BERTRAM 225 NORTH EAGLE STREET OSHKOSH WI 54902 1791753 0 9386 X WWW.LUTHERANHOMES.COM X 1987 WI PROVIDE ASSISTED LIVING TO AGING PERSONS. 15 15 43 20 0 0 10273 1037 1670852 1647989 6410 137815 5458 4912 1692993 1791753 0 0 0 0 952611 949355 0 0 0 592519 533771 1545130 1483126 147863 308627 2546980 2657444 1388928 1190765 1158052 1466679 GABRIEL'S VILLA IS PART OF A FAMILY OF HEALTHCARE AND RESIDENTIAL SERVICE ORGANIZATIONS COMMITTED TO PROVIDING QUALITY CARE AND LIFE ENRICHING OPPORTUNITIES TO THE AGING AND THOSE IN NEED IN A CARING, CHRISTIAN ENVIRONMENT. 0 0 1060603 0 1647989 GABRIEL'S VILLA, INC. PROVIDES SUPERVISED CARE TO AGING PERSONS IN OSHKOSH, WI. THE ENTITY HAS 40 ASSISTED LIVING UNITS AT ITS FACILITY. 1060603 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 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 10 0 43 1 0 0 0 0 0 0 0 0 0 0 X 15 15 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X KIM MAKI 9202325238 225 NORTH EAGLE STREET OSHKOSH WI 54902 LOIS JAENKE 0.20 1.40 X X 0 0 0 JIM STAPEL 0.20 1.40 X X 0 0 0 DR JAN EDELSTEIN 0.20 1.40 X X 0 0 0 KAREN FREDRICK 0.20 1.40 X 0 0 0 MARK BEECHER 0.20 1.40 X 0 0 0 KATHLEEN BELLAIRE 0.20 1.40 X 0 0 0 THOMAS DUNHAM 0.20 1.40 X 0 0 0 WAYNE MUELLER 0.20 1.40 X 0 0 0 DR ROGER HEROLD 0.20 1.40 X 0 0 0 REV RICK HOPKINS 0.20 1.40 X 0 0 0 REV KAREN JEWEL 0.20 1.40 X 0 0 0 GEORGE KONTOS 0.20 1.40 X 0 0 0 JANE KUHN 0.20 1.40 X 0 0 0 DR SUZANNE MARNOCHA 0.20 1.40 X 0 0 0 REVEREND KEMP JONES 0.20 1.40 X X 0 0 0 DR RICHARD AMES 0.20 1.40 X 0 0 0 STEVE LAUTENSCHLAGER 0.20 1.40 X 0 0 0 JULIE VANDENBERG 4.50 36.00 X 0 67679 9147 CRAIG UBBELOHDE 4.50 36.00 X 0 80601 7554 RICHARD KERN 4.50 36.00 X 0 53168 4307 0 201448 21008 0 0 0 0 B KOTTKE CONSTRUCTION LLC 581 4TH STREET FOND DU LAC WI 54935 CONSTRUCTION SERVICES 131954 1 1037 1037 TENANT REVENUE 531110 1486022 1486022 SERVICE REVENUE 621610 161967 161967 1647989 5861 5861 131954 0 131954 131954 131954 BEAUTY SHOP REVENUE 900099 1681 1681 ASSESSMENT REVENUE 900099 1200 1200 MEAL REVENUE 900099 730 730 1301 1301 4912 1791753 1647989 0 142727 814701 650085 164616 23661 18880 4781 60344 48151 12193 50649 40415 10234 18696 18696 895 895 14393 14393 16489 11229 5260 10950 10950 110735 88601 22134 1474 1474 105426 104894 532 3386 261 3125 63575 63575 153240 153240 30660 30660 FINES AND PENALTIES 2400 2400 MICELLANEOUS EXPENSES 1059 1059 MAINTENANCE SUPPLIES 393 393 1483126 1060603 422523 0 330132 142930 535336 539191 32272 37255 52 7853 3940181 2265812 1607007 1674369 4000 4000 33838 27867 4343 223979 2546980 2657444 116303 98473 103826 107356 1156726 982100 12073 2836 1388928 1190765 X 1154052 1462679 4000 4000 1158052 1466679 2546980 2657444 308627 0 X 0 1 X 1 0 X 1418 7996 11232 10273 1037 31956 1536402 1572964 1632361 1670852 1647989 8060568 1537820 1580960 1643593 1681125 1649026 8092524 0 906895 935587 986311 1010585 983965 4823343 906895 935587 986311 1010585 983965 4823343 3269181 22052 8194 8057 6410 5861 50574 22052 8194 8057 6410 5861 50574 13896 4289 4888 5458 4912 33443 1573768 1593443 1656538 1692993 1659799 8176541 0.39980 0.39970 0.00620 0.00990 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: ALA CARTE SERVICES BEAUTY SHOP REVENUE ASSESSMENT FEES LAUNDRY COIN MISCELLANEOUS INCOME 0 83333 83333 2944504 1645773 1298731 69351 54247 15104 842377 565792 276585 616 616 1674369 DUE FROM AFFILIATE 223979 223979 DUE TO AFFILIATES 2836 2836 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ENTITY IS NOT A PRIVATE FOUNDATION, AND CONTRIBUTIONS TO THE ORGANIZATION QUALIFY AS CHARITABLE TAX DEDUCTIONS BY THE CONTRIBUTOR. THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARDS FOR CONTINGENCIES IN EVALUATING UNCERTAIN TAX POSITIONS. THE ORGANIZATION FILES INFORMATIONAL RETURNS AS A TAX-EXEMPT ORGANIZATION. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATIONAL RETURNS FOR THE YEARS 2008 TO 2011 ARE OPEN TO EXAMINATION BY THOSE AUTHORITIES. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS PLUS TWO OTHER MEMBERS OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL BE RESPONSIBLE FOR THE AGENDA FOR THE BOARD AND VOTING MEMBERSHIP MEETINGS. THIS COMMITTEE SHALL KEEP ITSELF INFORMED OF THE ENTIRE OPERATION OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS, AND SHALL EXECUTE SUCH ACTIONS AS MAY BE ASSIGNED TO IT BY THE BOARD. THE COMMITTEE SHALL ALSO CONCERN ITSELF WITH MATTERS NOT ASSIGNED TO OTHER COMMITTEES. FORM 990, PART VI, SECTION A, LINE 3 GABRIEL'S VILLA'S EXECUTIVE MANAGEMENT IS PROVIDED BY LUTHERAN HOMES OF OSHKOSH, THE SOLE MEMBER AND CONTROLLING ORGANIZATION OF GABRIEL'S VILLA. DAY-TO-DAY, ON-SITE MANAGEMENT IS PROVIDED BY AN ADMINISTRATOR EMPLOYED BY GABRIEL'S VILLA. FORM 990, PART VI, SECTION A, LINE 6 LUTHERAN HOMES OF OSHKOSH, INC., IS THE SOLE MEMBER OF GABRIEL'S VILLA, INC. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS OF GABRIEL'S VILLA, INC. ARE ELECTED BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC. FORM 990, PART VI, SECTION A, LINE 7B MAJOR STANDARD OPERATING PROCEDURES, MAJOR POLICIES, AND PROGRAMS OF GABRIEL'S VILLA, INC. ARE SUBMITTED TO THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC., FOR APPROVAL AND IMPLEMENTATION. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS REQUIRE THE APPROVAL OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC. FORM 990, PART VI, SECTION B, LINE 11 BEFORE IT WAS FILED, THE FORM 990 WAS REVIEWED BY THE CEO, THEN DISTRIBUTED TO EACH MEMBER OF THE BOARD OF DIRECTORS FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE CORPORATE SECRETARY DISTRIBUTES A CONFLICT OF INTEREST FORM TO EACH MEMBER OF THE BOARD OF DIRECTORS AND VARIOUS COMMITTEE MEMBERS THAT REQUIRES EACH TO IDENTIFY POTENTIAL CONFLICTS OR OTHER RELATED PARTY INTERESTS. THE REPORTS ARE REVIEWED BY THE SECRETARY AND CEO AND ANY CONFLICTS ARE BROUGHT TO THE BOARD'S ATTENTION. IF A BOARD MEMBER HAS A CONFLICT OF INTEREST IS REQUIRED TO DISCLOSE THE MATERIAL FACTS BEFORE THE BOARD DISCUSSES THE ISSUE. A MEMBER OF THE BOARD WHO HAS A CONFLICT OF INTEREST MAY NOT VOTE ON ANY SUCH ISSUE BEFORE THE BOARD. ANY QUESTION OF WHETHER THERE IS A CONFLICT IS RESOLVED BY THE BOARD OF DIRECTORS. IF THE BOARD OF DIRECTORS DETERMINES THAT A DIRECTOR HAS COMMITTED A SUBSTANTIAL VIOLATION OF THE CONFLICT OF INTEREST POLICY, THE INDIVIDUAL IS REMOVED FROM THE OFFICE OF DIRECTOR. IN ADDITION, ALL MANAGEMENT EMPLOYEES ARE INFORMED OF THE ORGANIZATION'S POLICY REGARDING RELATED PARTY TRANSACTIONS AND CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS AVAILABLE UPON REQUEST AND IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. THE ORGANIZATION'S FORM 1023 IS ALSO AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. LUTHERAN HOMES OF OSHKOSH INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391032234 MANAGMENT SERVICES WI 501(C)(3) LINE 9 N/A 0 BETHEL HOME INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391209707 SKILLED NURSING FACILITY WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 CARMEL RESIDENCE INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391448325 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA APARTMENTS INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 237148097 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA SOUTH INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391238670 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA III INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391270056 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 BETHEL FOUNDATION OF OSHKOSH INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 010938793 FUNDRAISING WI 501(C)(3) LINE 11A, I LUTHERAN HOMES OF OSHKOSH INC 0 EDEN REHABILIATION SUITES AND GREENHOUSE HOMES INC 3151 EDEN COURT OSHKOSH WI 54902 900506872 SKILLED NURSING FACILITY WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 0 0 1 1 1 0 0 0 0 1 1 0 1 1 1 1 1 0 0