2024-10-15T15:09:19-05:00 2023-11-30 390758449 WIPFLI LLP 170 N RADNOR-CHESTER RD SUITE 200 RADNOR PA 19087 990 2022-12-01 911859494 MIDDLETON GLEN INC MIDD 6088367998 6720 CENTURY AVENUE MIDDLETON WI 53562 TIMOTHY CONROY PRESIDENT 6088367998 2024-10-07 1 0 SOLOMON MARDAKHAEV P01806552 6105653930 2024-10-02 2022 2024-10-15 13:58:12Z TIMOTHY CONROY 6720 CENTURY AVENUE MIDDLETON WI 53562 1493169 0 X WWW.MIDDLETONGLEN.COM X 1995 WI MIDDLETON GLEN IS AN INDEPENDENT SENIOR HOUSING COMMUNITY THAT OFFERS RESIDENCY, CARE, AND SERVICES AT THE COMMUNITY TO QUALIFIED PERSON AGE FIFTY-FIVE (55) AND OLDER. 7 6 15 30 0 0 62936 1140 1288019 1347036 139913 144993 0 0 1490868 1493169 0 0 0 0 403343 469730 0 0 0 982976 1050727 1386319 1520457 104549 -27288 10889759 11394601 12393824 12816698 -1504065 -1422097 MIDDLETON GLEN, A NOT-FOR-PROFIT RETIREMENT COMMUNITY, PROVIDES A UNIQUE INDEPENDENT LIFESTYLE WITH VALUE AND AMENITIES IN A DESIRABLE NEIGHBORHOOD. 0 0 1217673 0 1347036 MIDDLETON GLEN IS AN INDEPENDENT SENIOR HOUSING COMMUNITY THAT OFFERS RESIDENCY, CARE, AND SERVICES AT THE COMMUNITY TO QUALIFIED PERSONS AGE FIFTY-FIVE (55) AND OLDER. THE COMMUNITY HAD A 99% OCCUPANCY RATE FOR 2022/2023. 1217673 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 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 1 0 0 0 1 26 0 15 0 0 0 0 0 0 0 0 0 0 0 0 0 X 7 6 0 1 0 0 1 1 0 1 1 0 0 0 1 1 1 0 0 0 0 0 X NUMBERS 4 NONPROFITS INC 6083471147 1273 SCENIC RIDGE DR VERONA WI 53593 TIMOTHY CONROY PRESIDENT 1.00 41.00 X X 0 279824 50975 DENNIS SAMPSON TREASURER 1.00 1.00 X X 0 0 0 JOHANNA DEKEYSER SECRETARY 1.00 X X 0 0 0 ANN BLISS DIRECTOR 1.00 X 0 0 0 CAROL GROB DIRECTOR 1.00 1.00 X 0 0 0 KIM KAUKL DIRECTOR 1.00 X 0 0 0 INGOLF WALLOW DIRECTOR 1.00 1.00 X 0 0 0 0 279824 50975 0 0 1 0 0 1140 1140 SERVICE FEES 531110 1248060 1248060 ELDERLY HOUSING SERVIC 531110 98976 98976 1347036 140811 140811 4182 0 4182 4182 4182 1493169 1347036 0 144993 379843 261045 118798 13959 2074 11885 47875 17375 30500 28053 13869 14184 61743 61743 17119 17119 10116 10116 180 180 118377 67699 50678 23532 23500 32 3378 3378 92838 92838 1230 1230 93308 93308 418517 418517 34763 34763 SUPPLIES 102783 85513 17270 REPAIRS AND MAINTENANCE 32675 32675 40168 11524 28644 1520457 1217673 302784 0 148653 133928 148512 150405 32018 13213 6398 5555 11533190 5689472 5945114 5843718 4170666 4618289 438398 629493 10889759 11394601 102147 170279 2424312 2263126 9867365 10383293 12393824 12816698 X -1504065 -1422097 -1504065 -1422097 10889759 11394601 X -27288 103880 5376 X 0 1 X 1 0 X 1030 515 700 62936 1140 66321 1232865 1207444 1249100 1288019 1347036 6324464 1233895 1207959 1249800 1350955 1348176 6390785 77760 77760 81852 200 237572 400987 415146 470874 403086 456983 2147076 478747 492906 552726 403086 457183 2384648 4006137 26541 19078 40017 139913 140811 366360 26541 19078 40017 139913 140811 366360 1260436 1227037 1289817 1490868 1488987 6757145 0.59290 0.58540 0.05420 0.03810 X 494984 494984 10142148 5294044 4848104 790988 395428 395560 105070 105070 5843718 DUE TO AFFILIATE 415684 INTEREST RATE SWAP AGREEMENT 213809 629493 REFUNDABLE ENTRANCE FEES 9987043 REFUNDABLE RESERVATION DEPOSITS 249300 DUE TO AFFILIATE 145615 ENTRANCE FEES BOARD VALUATION ADJUSTMENT 1335 10383293 X 1602245 103880 5376 109256 1492989 180 180 1493169 1520277 0 1520277 180 180 1520457 PART X, LINE 2: THE ORGANIZATION ASSESSES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OR THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENTS 5,376. 0 0 0 0 0 0 0 0 0 TIMOTHY CONROY PRESIDENT 0 249337 0 30487 0 0 0 20500 0 30475 0 330799 0 0 PART I, LINE 3: COMPENSATION IS DETERMINED BY PACIFIC RETIREMENT SERVICES INC, A RELATED ORGANIZATION TO CAPITAL LAKES. PACIFIC RETIREMENT SERVICES INC USED A COMPENSATION/WAGES GRID THEY PREPARE AND MAINTAIN WHICH IS THEN PROVIDED TO THEIR BOARD FOR APPROVAL. ANY BONUSES ARE DISCRETIONARY AND ARE DETERMINED BY THE VP OF OPERATIONS FOR PACIFIC RETIREMENT SERVICES INC BASED ON PERFORMANCE OF THE COMMUNITY FOR THE YEAR. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS A MANAGEMENT CONTRACT WITH CAPITOL LAKES, INC. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS TWO CLASSES OF MEMBERS: SPONSOR MEMBER AND RESIDENTIAL MEMBERS. FORM 990, PART VI, SECTION A, LINE 7A THE SPONSOR MEMBER, WHO IS CAPITOL LAKES, INC. CAN APPOINT FOUR OF THE SEVEN BOARD MEMBERS. THE OTHER THREE BOARD MEMBERS ARE ELECTED BY THE RESIDENTIAL MEMBERS AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED AND APPROVED BY THE CONTROLLER AND EXECUTIVE DIRECTOR. EMAIL COPIES AND PAPER COPIES WERE PROVIDED TO THE BOARD MEMBERS AFTER FILING. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE POLICY OF MIDDLETON GLEN AND SENIOR HOUSING OF MIDDLETON (MG/SH) THAT MEMBERS OF THE BOARDS OF DIRECTORS OF THE VARIOUS FACILITIES AVOID CONFLICTS OF INTEREST. IF CONFLICTS DO OCCUR, THE MEMBER(S) WILL DISCLOSE IN WRITING TO THE BOARD OR COMMITTEE AUTHORIZED TO APPROVE THE TRANSACTION ANY DIRECT OR INDIRECT INTEREST IN ANY TRANSACTION BEING CONSIDERED OR WHICH SHOULD BE CONSIDERED BY THE INDIVIDUAL BOARD OF DIRECTORS AND THE MEMBER(S) SHOULD ABSTAIN IN ANY DECISION TO WHICH THE CONFLICT APPLIES. THE DISCLOSURE SHOULD BE NOTED IN THE MINUTES WITH THE WRITTEN DISCLOSURE ATTACHED. EACH DIRECTOR, PRINCIPAL OFFICER, AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD-DELEGATED POWERS SHALL ANNUALLY SIGN A STATEMENT THAT AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES THAT ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY, AUDITED FINANCIAL STATEMENTS, EXEMPT APPLICATION, AND TAX RETURNS ARE MADE AVAILABLE TO THE PUBLIC UPON REASONABLE REQUEST. FORM 990, PART VI, LINE 13 WHISTLEBLOWER PROTECTION AND DOCUMENT RETENTION POLICIES ARE PROVIDED BY CAPITOL LAKES, THE CORPORATION'S SPONSOR AND MANAGEMENT SERVICES PROVIDER. FORM 990, PART VI, LINE 14 WHISTLEBLOWER PROTECTION AND DOCUMENT RETENTION POLICIES ARE PROVIDED BY CAPITOL LAKES, THE CORPORATION'S SPONSOR AND MANAGEMENT SERVICES PROVIDER. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENTS 5,376. PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931067253 SUPPORTING ORGANIZATION OR 501(C)(3) LINE 12C, III-FI N/A 0 PACIFIC RETIREMENT SERVICES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 472352652 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 PACIFIC RETIREMENT SERVICES INC 1 ROGUE VALLEY MANOR 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930453216 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 THE CUMBERLAND REST INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 750891470 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 CASCADE MANOR INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930557803 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931179254 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 HOLLADAY PARK PLAZA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930513697 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 ROGUE VALLEY MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930712867 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 ROGUE VALLEY MANOR 1 UNIVERSITY RETIREMENT COMMUNITY FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931301816 PUBLIC FOUNDATION CA 501(C)(3) LINE 7 UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1 HOLLADAY PARK PLAZA FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 264529118 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 HOLLADAY PARK PLAZA 1 MIRABELLA WASHINGTON FOUNDATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 450574348 PUBLIC FOUNDATION WA 501(C)(3) LINE 7 MIRABELLA 1 CASCADE MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931330100 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CASCADE MANOR INC 1 CAPITOL LAKES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 383781089 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 CAPITOL LAKES INC 1 MIRABELLA 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 342030255 SENIOR HOUSING WA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 MIRABELLA PORTLAND FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 452508860 PUBLIC FOUNDATION OR 501(C)(3) LINE 7 MIRABELLA AT SOUTH WATERFRONT 1 MIRABELLA AT SOUTH WATERFRONT 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 711016384 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 COMMUNITY VOLUNTEER NETWORK 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930892261 COMMUNITY SERVICES OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930864466 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM ASHLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 930942933 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM GRANTS PASS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943136037 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM ROSEBURG HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943179782 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM MYRTLE CREEK HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943162074 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM BEND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943163349 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM EAGLE POINT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943191447 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM KLAMATH FALLS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943196455 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM MEDFORD II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943212537 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM LIVELY OAKS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943194409 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM REEDSPORT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943212538 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM YREKA HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943212540 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM EUGENE HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943247154 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM FORT WORTH I HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311520436 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM BEND II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 943260016 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM FORT WORTH II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311587415 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM MEDFORD III HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311587418 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM ROSEBURG II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311587420 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM GRANTS PASS II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311662259 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM DAVIS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311662208 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM MYRTLE CREEK II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311715321 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM PORTLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 311780332 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM PORTLAND II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 300037898 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM CENTRAL POINT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 300315618 SENIOR HOUSING OR 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 RVM MANSFIELD HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 900292647 SENIOR HOUSING TX 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 CAPITOL LAKES INC 333 WEST MAIN STREET MADISON WI 53703 391412320 RETIREMENT COMMUNITY WI 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 SENIOR HOUSING OF MIDDLETON INC 3111 PHEASANT BRANCH RD MIDDLETON WI 53562 470825736 INDEPENDENT LIVING COMMUNITY WI 501(C)(3) LINE 10 CAPITOL LAKES INC 1 MIRABELLA AT ASU INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 813784956 SENIOR HOUSING AZ 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 BAY AREA SENIOR SERVICES INC 1 BALDWIN AVE SAN MATEO CA 94401 943008774 SENIOR HOUSING CA 501(C)(3) LINE 10 PACIFIC RETIREMENT SERVICES INC 1 CREST PARK INC 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931169683 REAL ESTATE OR N/A C 1 PRS MANAGEMENT 1 WEST MAIN ST SUITE 303 MEDFORD OR 97501 931328250 MANAGEMENT COMPANY OR N/A C 1 0 0 0 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 0 SENIOR HOUSING OF MIDDLETON INC P 1292701 CASH SENIOR HOUSING OF MIDDLETON INC Q 1292701 CASH