2011-11-10T10:25:37-06:00 2011-06-30 SCHENCK SC 712 RIVERFRONT DRIVE STE 301 SHEBOYGAN WI 53081 990 2010-07-01 390816900 PINE HAVEN CHRISTIAN HOME INC PINE 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 RON WALVOORT 9204672401 2011-11-08 1 TERRY T STRITTMATER CPA 9204580341 2010 2016-02-24 21:20:13Z RON WALVOORT 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 10876999 0 X WWW.PINEHAVEN.ORG X 1950 WI PINE HAVEN CHRISTIAN HOME PROVIDES NURSING AND ASSISTED LIVING HOUSING AND SERVICES TO SENIORS. 18 18 262 93 0 0 163946 6065 9481663 10800366 0 60130 0 10438 9645609 10876999 0 0 0 0 6305238 6388261 0 0 8500 3225972 3601014 9531210 9989275 114399 887724 18996733 19942727 12623471 12630161 6373262 7312566 PINE HAVEN CHRISTIAN HOME PROVIDES SKILLED NURSING AND ASSISTED LIVING HOUSING AND SERVICES TO SENIORS. 0 0 8893902 10800366 PROVIDING HOUSING, HEALTH CARE AND OTHER RELATED SERVICES TO RESIDENTS IN A NON-PROFIT NURSING HOME AND ASSISTED LIVING FACILITIES. 8893902 1 0 0 1 0 0 0 0 0 1 1 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 0 1 39 0 1 262 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 0 1 1 1 0 0 1 1 0 X X RON WALVOORT 9204672401 531 GIDDINGS AVENUE SHEBOYGAN FALLS WI 53085 JOHN ACKERMANN X 0 0 0 WENDY BAACKES X 0 0 0 JOHN DAANE X 0 0 0 PAUL DAMKOT X 0 0 0 DON DEMASTER X 0 0 0 DARRELL HAUSE X 0 0 0 CARL HUENINK X 0 0 0 NORENE HUIBREGTSE X 0 0 0 CARL JOOSSE X 0 0 0 VIRGIL NAVIS X 0 0 0 DAN NEERHOFF X 0 0 0 JEFF RISSEEUW X 0 0 0 BOB VANDER PUY X 0 0 0 NANCY VERSTRATE X 0 0 0 CAROL DULMES X 0 0 0 RICH DAANE X 0 0 0 JERITH BUTEYN-GIER X 0 0 0 DIRK ZYLMAN X 0 0 0 RON WALVOORT 40.00 X 82430 0 25238 CATHY KELLING 40.00 X 84896 0 8730 ROGER LEYS 40.00 X 105406 0 125 272732 0 34093 1 0 0 0 SYSCO FOODS OF EASTERN WI 1 SYSCO DRIVE JACKSON WI 53037 FOOD SERVICE 462431 PRINCIPAL FINANCIAL GROUP 1234 STREET DES MOINES IA 50392 INSURANCE 298878 UNITED HEALTHCARE INSURANCE CO DEPT CH 10151 PALATINE IL 600550151 INSURANCE 241705 SHORELAND BUILDERS INC W1591 DE MASTER ROAD OOSTBURG WI 53070 CONSTRUCTION 235527 REHABCARE GROUP INC PO BOX 503534 ST LOUIS MO 631503534 THERAPY SERVICES 233612 7 6065 6065 6065 RES CENTER RESIDENT FE 623000 5855972 5855972 NURSING HOME RES. FEES 623000 3677485 3677485 RES CARE APARTMENT COM 623000 1266909 1266909 10800366 60130 60130 MISCELLANEOUS REVENUE 900099 10438 10438 10438 10876999 10800366 0 70568 272732 272732 5001244 4689780 309432 2032 15833 14008 1825 649090 567334 81315 441 449362 395733 53562 67 3078 3078 35990 34813 1177 30654 30654 94882 94142 740 231304 231304 29677 29677 390646 390646 686672 686569 103 147814 147589 225 NURSING AND MEDICAL 456671 456671 DIETARY - FOOD 418589 418589 UTILITIES 320702 319433 1034 235 SUPPLIES 214903 167205 47205 493 MISCELLANEOUS 179359 102495 76864 360073 306546 50540 2987 9989275 8893902 1086873 8500 X 1293373 1813143 328300 408665 12547 13850 87966 87068 20882232 6467854 14096017 14414378 243888 291392 2291411 2649259 643231 264972 18996733 19942727 703471 830161 11920000 11800000 12623471 12630161 X 6373262 7312566 6373262 7312566 18996733 19942727 X 887724 51579 X X 0 1 1 X 0 X 109085 68379 71418 163946 6065 418893 7993942 8958396 9893073 9481663 10800365 47127439 8103027 9026775 9964491 9645609 10806430 47546332 0 0 0 47546332 60913 90796 60130 211839 60913 90796 60130 211839 10435 19415 38196 10438 78484 8174375 9136986 10002687 9645609 10876998 47836655 0.99390 0.99390 0.00440 0.00430 X 0 1 0 0 0 0 1 0 0 0 0 PART IV, SUPPLEMENTAL INFORMATION: 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. 1682322 1682322 17409160 5323893 12085267 1790750 1143961 646789 14414378 CERTIFICATES OF DEPOSIT-CURRENT ASSETS 1394767 C LONG-TERM INVESTMENTS 1254492 C 2649259 10876999 9989275 887724 51579 51579 939303 10928579 51579 51579 10877000 0 10877000 9989275 0 9989275 0 9989275 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 THE CHIEF FINANCIAL OFFICER REVIEWS THE 990 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. THE ADMINISTRATOR HAS TAUGHT THIS CLASS FOR TWO YEARS. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION FOR THE CEO AND OTHER KEY EMPLOYEES IS COMPARED TO INDUSTRY DATA COMPILED BY THE WISCONSIN ASSOCIATION OF HOMES AND SERVICES FOR THE AGED. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 51,579. 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 FUNDRAISING WI 501(C)(3) 11 N/A 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 PINE HAVEN CHRISTIAN HOME FOUNDATION INC D 15793 ACTUAL AMOUNT BORROWED PINE HAVEN CHRISTIAN HOME FOUNDATION INC N 4960 ALLOCATION BASED ON HOURS WORKED PINE HAVEN CHRISTIAN HOME FOUNDATION INC P 16733 ACTUAL EXPENSE INCURRED