2013-11-11T09:20:05-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2012-01-01 391081800 EVERGREEN RETIREMENT COMMUNITY INC EVER 9202332340 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 JOHN M KRUEGER 9202332340 2013-11-01 1 CORY RUTLEDGE P01329381 6123764500 2012 2016-02-24 21:20:13Z KEN ARNESON 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 15983928 0 X WWW.EVERGREENOSHKOSH.COM X 1965 WI TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 AND OLDER. 18 18 376 110 0 0 604296 602837 14234028 13662621 38851 93005 1211006 1614653 16088181 15973116 0 0 0 0 8731706 8508846 0 0 0 6727270 6738110 15458976 15246956 629205 726160 19336408 19620705 10625314 10103359 8711094 9517346 X TO PROVIDE A CONTINUUM OF POSSIBILITIES FOR INDIVIDUALS 55 YEARS AND OLDER. 0 0 13690849 0 13662621 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. 13690849 1 1 0 0 0 0 0 0 0 1 1 0 0 0 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 1 1 0 0 1 67 0 376 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 1 0 0 1 0 1 0 0 WI X JOHN M KRUEGER 9202372110 1130 NORTH WESTFIELD STREET OSHKOSH WI 549023217 BARRY YARBRO 1.00 0.00 X X 0 0 0 DEIRDRE DEWITT 1.00 0.00 X X 0 0 0 BARBARA COOK 1.00 1.00 X 0 0 0 PAT DAY 1.00 0.00 X 0 0 0 WILL DEPPIESSE 1.00 0.00 X 0 0 0 VERNICE HAASE 1.00 0.00 X 0 0 0 RANDY HEDGE 1.00 0.00 X 0 0 0 MARSHA HUGHES 1.00 0.00 X 0 0 0 RANDY HUSMAN 1.00 1.00 X 0 0 0 ALICE JENKINS 1.00 0.00 X 0 0 0 SUE KREIBICH 1.00 0.00 X 0 0 0 MARCIA LARSON 1.00 0.00 X 0 0 0 FRED LILLY 1.00 0.00 X 0 0 0 JAYNE LINDSAY 1.00 0.00 X 0 0 0 DANIEL MCINTOSH 1.00 0.00 X 0 0 0 ROY NEY 1.00 0.00 X 0 0 0 BETTY PATERSON 1.00 0.00 X 0 0 0 CHRIS VANSTRATEN 1.00 0.00 X 0 0 0 SUSAN VETTE 1.00 0.00 X 0 0 0 KEN ARNESON 40.00 1.00 X 169619 0 10363 JOHN M KRUEGER 40.00 1.00 X 123364 0 10135 ERIN STANDLEY 40.00 0.00 X 50834 0 1809 KRISTEN POUZAR 40.00 0.00 X 39147 0 1716 382964 0 24023 2 0 1 0 REHABCARE GROUP 680 SOUTH FOURTH STREET LOUISVILLE KY 40202 THERAPY SERVICES 830675 PACKER VALLEY BUILDERS INC 2277 CLAIRVILLE ROAD OSHKOSH WI 54904 BUILDING CONTRACTORS 561140 KINDRED REHAB SERVICES INC BOX 277365 ATLANTA GA 30384 THERAPY SERVICES 277607 D & M FLOORING 309 ALLEGIANCE COURT APPLETON WI 54913 FLOORING & INSTALLATION 194865 HEALTHCARE SERVICES 3220 TILLMAN DRIVE BENSALEM PA 19020 HOUSEKEEPING SERVICES 166821 8 602837 602837 RESIDENT SERVICE REV 623000 13662621 13662621 13662621 88624 88624 18196 6043 12153 12153 12153 9150 4769 4381 4381 4381 MANAGEMENT FEE REV 900099 544020 544020 INSURANCE PROCEEDS 900099 245775 245775 EVERGREEN AT HOME 900099 222899 222899 589806 589806 1602500 15973116 13662621 0 1707658 X 406987 406987 6487701 5385791 1101910 307433 251877 55556 810578 672164 138414 496147 425807 70340 2975 2975 20219 20219 22185 22185 2274175 2161612 112563 58316 58316 74173 53895 20278 84551 84551 523032 523032 43536 31869 11667 306321 306321 1412591 1412591 110699 110699 FOOD 847641 847641 SUPPLIES 540431 540431 BED TAX EXPENSE 220320 220320 PHARMACY 123946 123946 72999 72999 15246956 13690849 1556107 0 606757 1532368 100007 120276 1809281 1512169 1714142 1702174 85958 84712 156679 67885 33968792 19476962 14742893 14491830 120691 109291 19336408 19620705 1319208 1543102 1802715 1733882 8476 8074 6829703 6216647 665212 601654 10625314 10103359 X 8711094 9517346 8711094 9517346 19336408 19620705 X 726160 63558 16534 X 0 1 X 1 0 X 502069 677283 529297 604296 602837 2915782 12791914 14732057 14138044 14234028 13662621 69558664 13293983 15409340 14667341 14838324 14265458 72474446 0 0 0 72474446 69665 88323 79971 109993 106820 454772 69665 88323 79971 109993 106820 454772 584540 559136 681702 1207794 1602500 4635672 13948188 16056799 15429014 16156111 15974778 77564890 0.93440 0.95170 0.00590 0.00570 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: OTHER REVENUE MANAGEMENT FEE REVENUE EVERGREEN AT HOME INSURANCE PROCEEDS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 5228355 3850 474768 96676 21185 5589112 4428650 2320 914470 97937 19148 5228355 4234561 5215 242243 37007 16362 4428650 4214347 5245 75676 46670 14037 4234561 3195963 1018775 58012 50445 7958 4214347 0.10140 0.89860 0.00000 0 1 1 374864 374864 21076200 10252097 10824103 11207875 8379207 2828668 1309853 845658 464195 14491830 LIABILITY ON INTEREST SWAP AGREEMENT 601654 601654 X PART IV, LINE 2B: FOR 2012, THERE WAS A RESIDENT FUNDS SAVINGS ACCOUNT IN THE AMOUNT OF $6,015. THERE WAS ALSO A RESIDENT CHECKING FUND WITH A BALANCE OF $2,059. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 2008 THROUGH 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL OR STATE AUTHORITIES. X X X 0 0 0 0 0 0 0 0 0 KEN ARNESON 151642 0 3274 0 14703 0 10080 0 283 0 179982 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. 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 A 2064000 6600000 6600000 2004 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 1 1 ASSOCIATED BANK NA 9.583333300000 0 0 0 0 0 A 1 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 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. THE VICE PRESIDENT, TOP MANAGEMENT OFFICIALS AND OTHER OFFICERS 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. OTHER FEES FORM 990, PART IX, LINE 11G THERAPY SERVICES: PROGRAM SERVICE EXPENSES 1,103,576. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,103,576. BUILDING MAINTENANCE SERVICES: PROGRAM SERVICE EXPENSES 294,741. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 294,741. HOUSEKEEPING: PROGRAM SERVICE EXPENSES 167,137. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 167,137. LAUNDRY: PROGRAM SERVICE EXPENSES 136,768. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 136,768. SPECIAL PROJECT: PROGRAM SERVICE EXPENSES 243,547. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 243,547. OTHER FEES: PROGRAM SERVICE EXPENSES 215,843. MANAGEMENT AND GENERAL EXPENSES 112,563. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 328,406. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET RENTAL INCOME AND GAIN ON SALE 16,534. EVERGREEN FOUNDATION INC 1130 NORTH WESTFIELD STREET OSHKOSH WI 54902 391388991 FUNDRAISING WI 501(C)(3) LINE 7 EVERGREEN RETIREMENT COMMUNITY INC 1 EVERGREEN VILLAGE INC 1130 NORTH WESTFIELD STREET OSHKOSH WI 54901 391505337 CO-OPERATIVE WI EVERGREEN RETIREMENT COMMUNITY INC C 841846 2742314 1.00000 0 0 0 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 1 EVERGREEN FOUNDATION INC C 602837 CASH RECEIVED EVERGREEN FOUNDATION INC L 122969 CASH TRANSFERED EVERGREEN VILLIAGE INC L 421051 CASH TRANSFERED