2012-10-22T09:19:19-05:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-01-01 391857036 GABRIEL'S VILLA INC GABR 9202325220 225 NORTH EAGLE STREET OSHKOSH WI 54902 KRIS KRENTZ 9202325220 2012-10-04 1 CORY RUTLEDGE P01329381 6123764500 2011 2016-02-24 21:20:13Z KRIS KRENTZ 225 NORTH EAGLE STREET OSHKOSH WI 54902 1692993 0 9386 X WWW.LUTHERANHOMES.COM X 1987 WI PROVIDE ASSISTED LIVING TO THE ELDERLY. 15 15 47 15 0 0 11232 10273 1632361 1670852 8057 6410 4888 5458 1656538 1692993 0 0 0 0 942626 952611 0 0 0 551925 592519 1494551 1545130 161987 147863 2578691 2546980 1561080 1388928 1017611 1158052 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 1093411 0 1670877 GABRIEL'S VILLA PROVIDES SUPERVISED CARE TO THE ELDERLY IN OSHKOSH, WI. THE ENTITY HAS 39 ASSISTED LIVING UNITS. 1093411 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 11 0 47 1 0 0 0 0 0 0 0 0 0 0 X 15 15 0 0 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 1.50 X X 0 0 0 JIM STAPEL 1.50 X X 0 0 0 REVEREND KEMP JONES 1.50 X X 0 0 0 DR RICHARD AMES 1.50 X 0 0 0 MARK BEECHER 1.50 X 0 0 0 KATHLEEN BELLAIRE 1.50 X 0 0 0 THOMAS DUNHAM 1.50 X 0 0 0 DR JAN EDELSTEIN 1.50 X 0 0 0 DR ROGER HEROLD 1.50 X 0 0 0 REVEREND RICK HOPKINS 1.50 X 0 0 0 REVEREND KAREN JEWEL 1.50 X 0 0 0 GEORGE KONTOS 1.50 X 0 0 0 JANE KUHN 1.50 X 0 0 0 STEVE LAUTENSCHLAGER 1.50 X 0 0 0 DR SUZANNE MARNOCHA 1.50 X 0 0 0 DAVE KOCH 1.50 X X 0 0 0 BRUCE BAIN 1.50 X X 0 0 0 REVEREND JOY MORTENSEN-WIEBE 1.50 X X 0 0 0 RICHARD CAMPBELL 1.50 X 0 0 0 DENNIS WENDT 1.50 X 0 0 0 BARBARA SKAAR 1.50 X 0 0 0 CRAIG UBBELOHDE 40.00 X 0 242558 32171 RICHARD KERN 40.00 X 0 98520 9540 JULIE VANDENBERG 40.00 X 0 67104 6574 0 408182 48285 0 0 1 0 0 7926 2347 10273 TENANT REVENUE 531110 1525007 1525007 SERVICE REVENUE 621610 145845 145845 1670852 6410 6410 BEAUTY SHOP REVENUE 900099 1955 1955 MICELLANEOUS REVENUE 900099 1465 1465 LAUNDRY REVENUE 900099 1202 1202 836 836 5458 1692993 1670852 0 11868 812924 645438 167486 23560 18706 4854 65282 51832 13450 50845 40369 10476 25656 25656 6225 6225 13334 13334 19066 13979 5087 10487 10487 124029 99821 24208 348 348 110647 109587 1060 3276 196 3080 73556 73556 165968 165968 35503 35503 MICELLANEOUS EXPENSES 4424 4424 1545130 1093411 451719 0 382952 330132 429781 535336 5834 32272 5152 52 3783337 2176330 1703725 1607007 11422 4000 39810 33838 15 4343 2578691 2546980 108527 116303 1321370 1156726 106441 103826 24742 12073 1561080 1388928 X 1006189 1154052 11422 4000 1017611 1158052 2578691 2546980 X 147863 -7422 X 0 1 1 X 0 X 1418 7996 11232 10273 30919 1390573 1536402 1572964 1632361 1670852 7803152 1390573 1537820 1580960 1643593 1681125 7834071 0 819553 906895 935587 986311 1010585 4658931 819553 906895 935587 986311 1010585 4658931 3175140 33827 22052 8194 8057 6410 78540 33827 22052 8194 8057 6410 78540 3150 13896 4289 4888 5458 31681 1427550 1573768 1593443 1656538 1692993 7944292 0.39970 0.40270 0.00990 0.01250 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: ALA CARTE SERVICES BEAUTY SHOP REVENUE ASSESSMENT FEES LAUNDRY COIN MISCELLANEOUS INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 83333 83333 2866902 1617597 1249305 69351 50455 18896 745150 508278 236872 18601 18601 1607007 DUE TO AFFILIATES 12073 12073 PART IV, LINE 2B: RESIDENTS' CUSTODIAL ACCOUNTS CONSIST OF AMOUNTS ON DEPOSIT WITH GABRIEL'S VILLA, INC. BY RESIDENTS FOR SAFEKEEPING. THESE FUNDS CAN BE WITHDRAWN AT ANY TIME BY RESIDENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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 2009 TO 2010 ARE OPEN TO EXAMINATION BY THOSE AUTHORITIES. 0 0 0 0 0 0 0 0 0 CRAIG UBBELOHDE 0 216397 0 20600 0 5561 0 7350 0 24821 0 274729 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY THE ORGANIZATION'S SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC.. THE FOLLOWING WERE USED BY LUTHERAN HOMES OF OSHKOSH, INC. TO ESTABLISH THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION COMMITTEE 2. COMPENSATION SURVEY OR STUDY 3. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE 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 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 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 CFO, 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 AND SUPERVISORY EMPLOYEES ARE INFORMED OF THE ORGANIZATION'S POLICY REGARDING RELATED PARTY TRANSACTIONS AND CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, FINANCIAL STATEMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INVESTMENT IN FOUNDATION -7,422. TOTAL TO FORM 990, PART XI, LINE 5: -7,422. ALLOCATION OF TIME BETWEEN RELATED ORGANIZATIONS FORM 990, PART VII, SECTION A EACH OFFICER OF GABRIEL'S VILLA, INC., ALSO SERVES AS AN OFFICER OF ITS RELATED ORGANIZATIONS. SEE SCHEDULE R, PART II FOR A LIST OF THOSE RELATED ORGANIZATIONS. EACH OFFICER SERVES EACH ORGANIZATION DURING THE WEEK, FOR A TOTAL OF APPROXIMATELY 40 HOURS PER WEEK. EACH BOARD MEMBER OF GABRIEL'S VILLA, INC., ALSO SERVES ON THE BOARD OF DIRECTORS OF ITS RELATED ORGANIZATIONS. SEE SCHEDULE R, PART II FOR A LIST OF THOSE RELATED ORGANIZATIONS. EACH BOARD MEMBER SERVES EACH ORGANIZATION DURING THE WEEK, FOR A TOTAL OF APPROXIMATELY 1.5 HOURS PER WEEK. 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 ELDERLY HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA APARTMENTS INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 237148097 ELDERLY HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA SOUTH INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391238670 ELDERLY HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA III INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 391270056 ELDERLY 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 1 1 0 1 1 1 1 1 0 0