2011-07-09T15:16:16-05:00 2010-09-30 990 2009-10-01 391412320 CAPITOL LAKES INC CAPI 5418577854 1200 MIRA MAR AVENUE MEDFORD OR 97405 BRIAN MCLEMORE 5418577854 2011-07-11 2009 2016-02-24 21:20:13Z BRIAN MCLEMORE 1200 MIRA MAR AVE MEDFORD OR 97504 17769311 0 X WWW.RETIREMENT.ORG X 1990 WI CAPITOL LAKES INC.'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 3 3 272 0 0 0 5047 0 17070710 17553930 146017 118720 0 17221774 17672650 0 0 8776650 8362630 0 0 13543552 14198175 22320202 22560805 -5098428 -4888155 73887170 72909793 84470194 90869226 -10583024 -17959433 CAPITOL LAKES INC.'S PRIMARY EXEMPT PURPOSE IS TO PROVIDE CARE AND HOUSING FOR THE ELDERLY. 0 0 8054831 2470497 HEALTH CARE CENTER HAS BEEN ESTABLISHED TO CARE FOR THE NEEDS OF ALL RESIDENTS OF CAPITOL LAKES 1930091 302788 A FOOD PROGRAM HAS BEEN ESTABLISHED TO PROVIDE QUALITY AND NUTRITIONAL MEALS FOR ALL RESIDENTS OF CAPITOL LAKES 2199968 4061 RESIDENTIAL COMMUNAL CARE FOR THE OVER 250 RESIDENTS OF CAPITOL LAKES 12184890 1 0 0 0 0 0 0 0 0 1 1 0 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 0 0 0 1 22 0 1 272 1 0 0 0 0 0 0 0 0 0 0 3 3 1 1 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 WI X CAPITOL LAKES INC 5418577854 1200 MIRA MAR AVE MEDFORD OR 97504 William Bagley 1.00 X X 0 0 0 Len Merryman 1.00 X X 0 0 0 Larry Boeck 1.00 X X 0 0 0 ANTHONY SABATINI 40.00 X 155008 0 21108 LINDA LANE 40.00 X 132386 0 0 KATHY GROTH 40.00 X 102705 0 0 390099 0 21108 3 0 1 0 Consonus Rehab 4560 SE International Way Milwaukee OR 97222 THERAPY 1477678 McGann Construction Inc 3622 Lexington Ave MADISON WI 53714 CONSTRUCTION 831375 Sysco Foods of Baraboo LLC PO Box 90 BARABOO WI 53913 FOOD SUPPLIES 689724 Mallatt Homecare Pharmacy 3250 Kingsley Way Madison WI 53713 PHARMACY SUPPLIES 423971 Physicians Plus Insurance Corp PO Box 630693 Cincinatti OH 452630693 MEDICAL SUPPLIES 139284 5 HEALTH CENTER REVENUE 531110 9442445 9442445 SERVICES FEES 531110 6288229 6288229 ENTRANCE FEES 531110 1081691 1081691 OTHER REVENUE 531110 741565 741565 17553930 215381 215381 96661 -96661 -96661 -96661 17672650 17457269 0 215381 6538442 5738946 799496 219177 191540 27637 1123545 962052 161493 481466 424102 57364 996280 996280 51089 51089 186216 186216 323973 323973 31776 20291 11485 207954 2206 205748 5260 5260 29772 10790 18982 3790882 3790882 3026659 3026659 CONTRACT SERVICES 1905579 1701019 204560 OTHER HEALTH SERVICE EX 812653 812653 UTILITIES 774627 774627 OTHER DIETARY EXPENSES 730875 730875 BAD DEBT 281052 281052 1043528 529477 514051 22560805 12184890 10375915 0 2995266 1384138 2465241 1871111 26375 24673 164758 335491 54340314 7237559 48132248 47102755 5268358 8427200 14834924 13764425 73887170 72909793 3328592 3502137 16899818 19238150 58470000 58470000 5771784 9658939 84470194 90869226 X -10956632 -18362470 297281 326710 76327 76327 -10583024 -17959433 73887170 72909793 X 0 1 1 X 0 X 3191 8940 5858 5047 23036 16218699 16441247 7767598 17070710 16812365 74310619 16221890 16450187 7773456 17075757 16812365 74333655 0 0 0 74333655 362609 428073 244758 197403 215381 1448224 362609 428073 244758 197403 215381 1448224 509394 758683 741565 2009642 17093893 17636943 8018214 17273160 17769311 77791521 0.95550 0.96030 0.01860 0.01860 X 54340314 7237559 47102755 47102755 SHORT TERM INVESTMENT 8427200 F 8427200 RESTRICTED CASH 390834 ASSETS RESTRICTED UNDER BOND INDUENTURE AGREEMENT 11970846 BOND ISSUE COSTs (NET) 1357912 INTEREST IN NET ASSETS OF CAPITOL LAKES FOUNDATION 26242 DUE FROM AFFILIATES 18591 13764425 REFUNDABLE DEPOSITS 159261 DUE TO AFFILIATES 2917836 SWAP AGREEMENTS 6285283 OTHER CURRENT LIABILITIES 36477 ASSET RETIREMENT OBLIGATION 260082 9658939 17672650 22560805 -4888155 -2488253 -2488253 -7376408 17769311 0 17769311 -96661 -96661 17672650 22657466 96661 96661 22560805 0 22560805 Part XI, Line 8 - Other Adjustments: SWAP LOSS: -2730150. CHANGE IN NET ASSETS OF CAPITOL LAKES FOUNDATION: 26242. NON OPERATING REVENUE: 21526. UNREALIZED GAIN ON INVESTMENT: 194129. DISPOSAL OF ASSETSS 1 0 0 0 0 0 0 0 0 0 ANTHONY SABATINI 155008 0 0 0 0 0 0 0 21108 0 176116 0 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VEZ7 2002-04-02 8000000 SERIES - 2002 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V7V4 2008-04-01 15210000 SERIES - 2008A 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V7W2 2008-04-01 29380000 SERIES - 2008B 0 0 WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V7X0 2008-04-01 6985000 SERIES - 2008C 0 0 8000000 241948 7758052 2008 1 0 1 0 15210000 1147113 550394 13512493 2010 0 0 0 0 29380000 1980325 3707534 7888171 1064998 15188972 1 0 0 0 6985000 426470 329461 6229069 2010 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 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 0 0 Form 990, Part VI, Section A, line 2 LARRY BOECK USES WILLIAM BAGLEY AS HIS ACCOUNTANT WILLIAM BAGLEY AND LEN MERRYMAN OWN PROPERTY TOGETHER Form 990, Part VI, Section A, line 3 CAPITOL LAKES DELEGATES DAY TO DAY MANAGEMENT TO PACIFIC RETIREMENT SERVICES Form 990, Part VI, Section A, line 7a PACIFIC RETIREMENT SERVICES CAN APPOINT BOARD MEMBERS Form 990, Part VI, Section A, line 7b SOME DECISIONS OF THE BOARD ARE SUBJECT TO APPROVAL BY PACIFIC RETIREMENT SERVICES Form 990, Part VI, Section B, line 11 THE FORM 990 IS CURRENTLY BEING REVEIWED BY CONTROLLER AND THE BOARD OF DIRECTORS Form 990, Part VI, Section B, line 12c CORPORATE COUNSEL ISSUES POLICY ANNUALLY TO KEY EMPLOYEES AND BOARD MEMBERS ORGANIZATION'S BOARD REVEIWS AND APPROVES ANNUAL BUDGET Form 990, Part VI, Section C, line 18 ALL REQUESTS GO THROUGH THE CORPORATE COUNSEL Form 990, Part VI, Section C, line 19 ALL REQUESTS GO THROUGH THE CORPORATE COUNSEL FORM 990, PART XI, LINE 2C PACIFIC RETIREMENT SERVICE'S AUDIT COMMITTEE SELECTS AUDITORS Pacific Retirement Services 1200 Mira Mar Ave Medford OR 97504 Supporting Org OR 501(c)(3) 13 Pacific Retirement Services PRS 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services RVM 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Trinity 1200 Mira Mar Ave Medford OR 97504 Senior Housing TX 501(c)(3) 9 Pacific Retirement Services Cascade Manor 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services URCAD 1200 Mira Mar Ave Medford OR 97504 Senior Housing CA 501(c)(3) 9 Pacific Retirement Services Holladay Park Plaza 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Capitol Lakes 1200 Mira Mar Ave Medford OR 97504 Senior Housing WI 501(c)(3) 9 Pacific Retirement Services RVM Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation OR 501(c)(3) 9 Pacific Retirement Services URCAD Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation CA 501(c)(3) 9 Pacific Retirement Services Trinity Terrace Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation TX 501(c)(3) 9 Pacific Retirement Services HPP Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation OR 501(c)(3) 9 Pacific Retirement Services Mirabella Washington Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation WA 501(c)(3) 9 Pacific Retirement Services Cascade Manor Foundation Inc 1200 Mira Mar Ave Medford OR 97504 Public Foundation OR 501(c)(3) 9 Pacific Retirement Services Capitol Lakes Foundation 1200 Mira Mar Ave Medford OR 97504 Public Foundation OR 501(c)(3) 9 Pacific Retirement Services Mira Bella 1200 Mira Mar Ave Medford OR 97504 Senior Housing WA 501(c)(3) 9 Pacific Retirement Services Mira Bella South Waterfront 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Mira Bella San Francisco Bay 1200 Mira Mar Ave Medford OR 97504 Senior Housing CA 501(c)(3) 9 Pacific Retirement Services FGP RVM Comm SvcsAP 1200 Mira Mar Ave Medford OR 97504 Community Services OR 501(c)(3) 9 Pacific Retirement Services RSVP 1200 Mira Mar Ave Medford OR 97504 Community Services OR 501(c)(3) 9 Pacific Retirement Services Ross Knotts 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Don Lewis 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Foothill 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Oak Grove 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Valley ViewMyrtle Creek 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Pilot Butte 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Royal Loto 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Klamath View 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Larson Creek 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Lively OaksGlenridge Terrace 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Timber RidgeRVM Reedsport Housing Co 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Sierra Vista 1200 Mira Mar Ave Medford OR 97504 Senior Housing CA 501(c)(3) 9 Pacific Retirement Services Kingsley Court 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Silverstone 1200 Mira Mar Ave Medford OR 97504 Senior Housing TX 501(c)(3) 9 Pacific Retirement Services Pilot Butte II 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Fairview Fort Worth II Housing Corp 1200 Mira Mar Ave Medford OR 97504 Senior Housing TX 501(c)(3) 9 Pacific Retirement Services Quail Ridge 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Meadow Creek RVM Roseburg II 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Foothill II 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Shasta Point 1200 Mira Mar Ave Medford OR 97504 Senior Housing CA 501(c)(3) 9 Pacific Retirement Services Valley View II RVM Myrtle Creek II (Plaza) 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Columbia TerraceRVM Portland 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Woodland Heights 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Central Point 1200 Mira Mar Ave Medford OR 97504 Senior Housing OR 501(c)(3) 9 Pacific Retirement Services Magnolia Heights 1200 Mira Mar Ave Medford OR 97504 Senior Housing TX 501(c)(3) 9 Pacific Retirement Services Middleton Glen Inc 1200 Mira Mar Ave Medford OR 97504 Senior Housing WI 501(c)(3) 9 Pacific Retirement Services Senior Housing of Middleton Inc 1200 Mira Mar Ave Medford OR 97504 Senior Housing WI 501(c)(3) 9 Pacific Retirement Services PRS School of Aging Services Inc 1200 Mira Mar Ave Medford OR 97504 School OR 501(c)(3) 9 Pacific Retirement Services Corbinton Retirement 1200 Mira Mar Ave Medford OR 97504 Senior Housing NC 501(c)(3) 9 Pacific Retirement Services Mirabella Marin 1200 Mira Mar Ave Medford OR 97504 Senior Housing CA 501(c)(3) 9 Pacific Retirement Services Crest Park 1200 Mira Mar Ave Medford OR 97504 931169683 Hotel OR Pacific Retirement Services C 1.00000 RS INC 1200 Mira Mar Ave Medford OR 97504 931328250 Management Co OR Pacific Retirement Services C 1.00000 Centennial Inc 1200 Mira Mar Ave Medford OR 97504 510554651 Golf Course OR Pacific Retirement Services C 1.00000 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 MIDDLETON GLEN K 34556 PACIFIC RETIREMENT SERVICES O 13316 OTHER AFFILIATES O 2758 PACIFIC RETIREMENT SERVICES L 1386386