TY 2022 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN SUITE 303 MEDFORD,OR97502	MANAGEMENT SERVICES	430,314
ORRICK HERRINGTON & SUTCLIFFE PO BOX 848066 LOS ANGELES,CA90084	LEGAL SERVICES	270,537
COMPLETE CONTROL 640 25TH AVE WISCONSIN RAPIDS,WI54495	MAINTENANCE SERVICES	154,337


2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 3

- TIN:

SCHEDULE A
(Form 990)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
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Attach to Form 990 or Form 990-EZ.
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Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2022

Open to Public
Inspection

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990).)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 33 1/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 33 1/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box on lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.

Cat. No. 11285F

Schedule A (Form 990) 2022

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) ..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..
11	Total support. Add lines 7 through 10

Gross receipts from related activities, etc. (see instructions) ..................

First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2022 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2020 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2022. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2021. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2022. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization ............ right arrow

10%-facts-and-circumstances test—2021. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization ............ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990) 2022

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .	207,383	258,965	234,440	2,392,786	325,088	3,418,662
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose	22,577,973	21,500,974	21,732,097	21,524,631	21,328,284	108,663,959
3	Gross receipts from activities that are not an unrelated trade or business under section 513 .....
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge
6	Total. Add lines 1 through 5	22,785,356	21,759,939	21,966,537	23,917,417	21,653,372	112,082,621
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons						0
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.						0
c	Add lines 7a and 7b..						0
8	Public support. (Subtract line 7c from line 6.)						112,082,621

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) 2022	(f) Total
9	Amounts from line 6...	22,785,356	21,759,939	21,966,537	23,917,417	21,653,372	112,082,621
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..	97,996	73,154	72,645	110,174	150,710	504,679
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.	97,996	73,154	72,645	110,174	150,710	504,679
11	Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..				9,897,149	111,842	10,008,991
13	Total support. (Add lines 9, 10c, 11, and 12.)..	22,883,352	21,833,093	22,039,182	33,924,740	21,915,924	122,596,291

First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here................................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2022 (line 8, column (f) divided by line 13, column (f)) .........

91.420 %

Public support percentage from 2021 Schedule A, Part III, line 15 ...............

91.600 %

Section D. Computation of Investment Income Percentage

Investment income percentage for 2022 (line 10c, column (f) divided by line 13, column (f)) ......

0.410 %

Investment income percentage from 2021 Schedule A, Part III, line 17 .............

0.340 %

19a

33 1/3% support tests-2022. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2021. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions .... right arrow

Schedule A (Form 990) 2022

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990) 2022

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described on lines 11b and 11c below, the governing body of a supported organization?

11a

A family member of a person described on 11a above?

11b

A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the officers, directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in line 2 above, did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer lines 2a and 2b below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described on line 2a, above constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer lines 3a and 3b below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations?If "Yes" or "No", provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990) 2022

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by 0.035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990) 2022

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes	1
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity	2
3 Administrative expenses paid to accomplish exempt purposes of supported organizations	3
4 Amounts paid to acquire exempt-use assets	4
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI)	5
6 Other distributions (describe in Part VI). See instructions	6
7Total annual distributions. Add lines 1 through 6.	7
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions	8
9 Distributable amount for 2022 from Section C, line 6	9
10 Line 8 amount divided by Line 9 amount	10

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2022	(iii) Distributable Amount for 2022
1 Distributable amount for 2022 from Section C, line 6
2 Underdistributions, if any, for years prior to 2022 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2022:
a From 2017.......
b From 2018.......
c From 2019.......
d From 2020.......
e From 2021.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2022 distributable amount
i Carryover from 2017 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2022 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2022 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2022, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2022. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2023. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2018.....
b Excess from 2019.....
c Excess from 2020.....
d Excess from 2021.....
e Excess from 2022.....

Schedule A (Form 990) (2022)

Schedule A (Form 990) 2022

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation
SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME:	GAIN ON REFINANCING MANAGEMENT FEES

Schedule A (Form 990) 2022

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2022

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990) (2022)

Schedule B (Form 990) (2022) Page 2

Name of organization CAPITOL LAKES INC

Part I Contributors	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	,	$ RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990) (2022)

Schedule B (Form 990) (2022)

Page 3

Name of organization CAPITOL LAKES INC		Employer identification number 39-1412320

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (See instructions)	(d) Date received
		$
Schedule B (Form 990) (2022)

Schedule B (Form 990) (2022)

Page 4


Name of organization CAPITOL LAKES INC			Employer identification number 39-1412320
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990) (2022)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

Political campaign activity expenditures. See instructions .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities. See instructions ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990) 2021

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(a) Filing organization's totals	(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................	0
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................	0
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................	0
d	Other exempt purpose expenditures ...............................................................................	24,508,647
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................	24,508,647
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.	1,000,000
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................	250,000
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................	0
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................	0
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................		Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) Total

2a	Lobbying nontaxable amount	1,000,000	1,000,000	1,000,000	1,000,000	4,000,000

b	Lobbying ceiling amount (150% of line 2a, column(e))					6,000,000

c	Total lobbying expenditures

d	Grassroots nontaxable amount	250,000	250,000	250,000	250,000	1,000,000

e	Grassroots ceiling amount (150% of line 2d, column (e))					1,500,000

f	Grassroots lobbying expenditures

Schedule C (Form 990) 2021

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Total. Add lines 1c through 1i ....................................................................................................

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures. See Instructions .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation

Schedule C (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet

Attach to Form 990.
SchDMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of grants from (during year)
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

Assets included in Form 990, Part X ............................... SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2021

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
c	Beginning balance .............................	1c
d	Additions during the year ............................	1d
e	Distributions during the year ..........................	1e
f	Ending balance ................................	1f

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....

Part V

Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Term endowment SchDMd Bullet

The percentages on lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) Unrelated organizations .................

3a(i)

(ii) Related organizations .................

3a(ii)

If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	8,537,600		8,537,600
b	Buildings ....	58,315,813	39,322,624	18,993,189
c	Leasehold improvements
d	Equipment ....	4,336,061	3,344,553	991,508
e	Other .....	555,654		555,654
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				29,077,951

Schedule D (Form 990) 2021

Page 3

Part VII

Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b) Book value	(c) Method of valuation: Cost or end-of-year market value
(1) Financial derivatives.........
(2) Closely-held equity interests........
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment	(b) Book value	(c) Method of valuation: Cost or end-of-year market value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	47,759,433
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII

Schedule D (Form 990) 2021

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1..................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b....................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities .........	2a
b	Prior year adjustments ............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d....................		2e
3	Subtract line 2e from line 1...................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.....................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference

Explanation

PART IV, LINE 2B:

RESIDENT SECURITY DEPOSITS ARE HELD IN A SEPARATE BANK ACCOUNT. WHEN THE RESIDENT LEAVES THE FACILITY THE SECURITY DEPOSIT, MINUS ANY AMOUNTS RETAINED FOR REPAIRS, IS REFUNDED.

PART X, LINE 2:

THE CORPORATION RECOGNIZES THE TAX BENEFIT FROM UNCERTAIN TAX POSITIONS ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITIONS WILL BE SUSTAINED ON EXAMINATION BY THE TAX AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE TAX BENEFIT IS MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50% LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. THE CORPORATION RECOGNIZES INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN OPERATING EXPENSES. AT SEPTEMBER 30, 2023 AND 2022, THERE WERE NO SUCH UNCERTAIN TAX POSITIONS.

Schedule D (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2022

Open to Public Inspection

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? .............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ....................

Any related organization? .......................

If "Yes," on line 5a or 5b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ..................

Any related organization? ......................

If "Yes," on line 6a or 6b, describe in Part III.

For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................

If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2022

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1TIM CONROY EXECUTIVE DIRECTOR	(i) (ii)	249,337 ------------- 0	30,487 ------------- 0	0 ------------- 0	20,500 ------------- 0	30,475 ------------- 0	330,799 ------------- 0	0 ------------- 0
2KRISTIN VATER HEALTH CENTER ADMINISTRATOR	(i) (ii)	143,830 ------------- 0	10,911 ------------- 0	0 ------------- 0	15,657 ------------- 0	10,258 ------------- 0	180,656 ------------- 0	0 ------------- 0
3STEVEN MELLSTROM HUMAN RESOURCES DIRECTOR	(i) (ii)	128,913 ------------- 0	5,075 ------------- 0	0 ------------- 0	0 ------------- 0	20,309 ------------- 0	154,297 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2022

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.

Return Reference	Explanation
PART I, LINE 3	COMPENSATION WAS RECOMMENDED BY PACIFIC RETIREMENT SERVICES, INC. AND APPROVED BY CAPITOL LAKES' BOARD AS PART OF THE ANNUAL BUDGET PROCESS.
PART I, LINE 7	THE ORGANIZATION PAID BONUSES THIS YEAR. THE PROCESS FOR DETERMINING EXECUTIVE BONUSES IS DISCRETIONARY. IT IS DETERMINED BY THE VP OF OPERATIONS FOR PRS AND IT IS BASED ON THE PERFORMANCE OF THE COMMUNITY FOR THE YEAR.

Schedule J (Form 990) 2022

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Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization
CAPITOL LAKES INC

Employer identification number
39-1412320

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY	39-1337855	97712JFS7	05-26-2022	33,880,000	SEE PART VI		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	33,880,000
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	659,600
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............
11 Other spent proceeds .............	33,220,400
12 Other unspent proceeds .............
13 Year of substantial completion .............
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2020, a current refunding issue)? ........	X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2020, an advance refunding issue)? ........		X
16 Has the final allocation of proceeds been made? ..........		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2021

Page 2

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............	X
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............	X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?	X
c Are there any research agreements that may result in private business use of bond-financed property? .............		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	2.300 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %
6 Total of lines 4 and 5 .............	2.300 %
7 Does the bond issue meet the private security or payment test? ...		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......	X
b Exception to rebate? ........	X
c No rebate due? .........		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....	X

Schedule K (Form 990) 2021

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference	Explanation
PART I, COLUMN F:	BOND PROCEEDS WERE ISSUED TO REFUND A PRIOR LOAN ISSUED ON NOVEMBER 30, 2016.
PART II, LINE 13:	BECAUSE THE BONDS WERE ISSUED FOR A CURRENT REFUNDING PURPOSE, A SUBSTANTIAL COMPLETION DATE IS NOT APPLICABLE.
PART III, LINE 7:	AS PROVIDED IN TREASURY REGULATION SECTION 1.141-4(C)(2)(I)(B), THE AMOUNT OF PRIVATE PAYMENTS TAKEN INTO ACCOUNT UNDER THE PRIVATE SECURITY OR PAYMENT TEST MAY NOT EXCEED THE AMOUNT OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE. ACCORDINGLY, THE AMOUNT OF PRIVATE PAYMENTS FOR THE REPORTING PERIOD DOES NOT EXCEED THE AMOUNT STATED IN PART III, LINE 6. THE ORGANIZATION HAS NOT UNDERTAKEN AN ANALYSIS OF THE PRIVATE SECURITY OR PAYMENT TEST WITH RESPECT TO THE BONDS, AS THE LEVEL OF PRIVATE BUSINESS USE AND/OR UNRELATED TRADE OR BUSINESS USE REPORTED IN PART III, LINE 6 IS NOT IN EXCESS OF AMOUNTS PERMITTED UNDER SECTION 145 OF THE CODE.

Schedule K (Form 990) 2021

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SCHEDULE O
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 3	CAPITOL LAKES' BOARD DELEGATES MANAGEMENT DUTIES TO PACIFIC RETIREMENT SERVICES, INC.
FORM 990, PART VI, SECTION A, LINE 4	THE BYLAWS WERE AMENDED IN JANUARY 2023 TO STANDARDIZE THEM, CONSISTENT WITH OTHER SUBSIDIARIES OF PACIFIC RETIREMENT SERVICES, THE SOLE MEMBER. THESE AMENDMENTS INCLUDED UPDATING THE SOLE MEMBER'S EXCLUSIVE POWERS AND THOSE ACTIONS THAT REQUIRE THE SOLE MEMBER'S APPROVAL. ADDITIONALLY, (A) THE MINIMUM NUMBER OF DIRECTORS WAS CHANGED FROM 7 TO 3, (B) THE MAXIMUM NUMBER OF DIRECTORS WAS REMOVED, (C) THE NUMBER OF RESIDENT DIRECTORS WAS CHANGED FROM 2 TO 1, AND (D) THE CFO REPLACED THE TREASURER AS AN OFFICER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 6	THE ORGANIZATION HAS ONE MEMBER, PACIFIC RETIREMENT SERVICES, INC.
FORM 990, PART VI, SECTION A, LINE 7A	PACIFIC RETIREMENT SERVICES, INC. HAS THE RIGHT TO ELECT THE DIRECTORS OF THE BOARD OF CAPITOL LAKES, INC.
FORM 990, PART VI, SECTION A, LINE 7B	THE FOLLOWING ACTIONS ARE RESERVED TO PACIFIC RETIREMENT SERVICES, INC., THE SOLE MEMBER: (A) AMEND, RESTATE OR REPEAL THE BYLAWS, OR ADOPT NEW BYLAWS; (B) COORDINATE THE ACTIVITIES OF THE ORGANIZATION, AND ENGAGE IN THE OVERALL PLANNING, POLICY DEVELOPMENT, BUDGETING, AND RESOURCE ALLOCATION FOR THE ORGANIZATION; (C) APPOINT OUTSIDE AUDITORS FOR THE ORGANIZATION; (D) ELECT OR APPOINT THE ORGANIZATION'S DIRECTORS, INCLUDING THE RESIDENT DIRECTOR AND THE PRS REPRESENTATIVE DIRECTOR, AND FILL VACANCIES CAUSED BY THE DEATH, REMOVAL OR RESIGNATION OF A DIRECTOR; AND (E) REMOVE ANY OF THE ORGANIZATION'S DIRECTORS OR OFFICERS. THE PRIOR APPROVAL OF THE MEMBER IS REQUIRED BEFORE THE BOARD OF DIRECTORS MAY (A) APPROVE ANY MERGER OR CONSOLIDATION OF THE ORGANIZATION WITH ANOTHER ENTITY, OR ANY PARTIAL OR TOTAL LIQUIDATION OF THE ORGANIZATION'S ASSETS; (B) INCUR ANY DEBT, OR ENTER INTO ANY CONTRACT, NOT CONTEMPLATED BY THE ANNUAL BUDGET IF THE DOLLAR AMOUNT EXCEEDS THE SUM OF $100,000; (C) MAKE ANY GIFT OR GRATUITOUS TRANSFER IN EXCESS OF $15,000 IN ANY CALENDAR YEAR; (D) CREATE A TAXABLE OR TAX-EXEMPT SUBSIDIARY OR AFFILIATED ORGANIZATION; (E) ACQUIRE A CONTROLLING INTEREST IN ANOTHER ENTITY; OR (F) APPROVE ANY AMENDMENT, REPEAL, OR RESTATE OF THE ORGANIZATION'S ARTICLES OF INCORPORATION, OR ADOPT ANY NEW ARTICLES OF INCORPORATION.
FORM 990, PART VI, SECTION B, LINE 11B	THE FORM 990 WAS REVIEWED BY THE CORPORATE DIRECTOR OF ACCOUNTING, VICE PRESIDENT OF ACCOUNTING, CFO, AND THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION B, LINE 12C	THE CONFLICT OF INTEREST POLICY AND QUESTIONNAIRE ARE SENT TO ALL BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY. THERE ARE TWO POLICIES RELATED TO CONFLICTS OF INTEREST: 1) BOARD OF DIRECTORS; 2)KEY EMPLOYEES, WHICH IDENTIFY THE PURPOSE, DEFINITIONS, AND PROCEDURES. IF A CONFLICT IS SELF-IDENTIFIED BY A BOARD MEMBER OR KEY EMPLOYEE IN THE QUESTIONNAIRE AND/OR MEETING, PROCEDURES ARE FOLLOWED AND DOCUMENTED ACCORDING TO THE POLICY.
FORM 990, PART VI, SECTION B, LINE 15A	A COMPENSATION COMMITTEE OF THE PRS BOARD EXISTS TO DETERMINE COMPENSATION FOR THE EXECUTIVE DIRECTOR OF EACH COMMUNITY. THIS COMMITTEE IS COMPRISED OF THE OFFICERS OF THE PRS BOARD OF DIRECTORS. THE COMMITTEE HAS A CHARTER THAT OUTLINES ITS DUTIES AND RESPONSIBILITIES. IT ALSO HAS AGENDA ELEMENTS THAT DESCRIBE THE ACTIVITIES THAT THE COMMITTEE UNDERTAKES DURING THE YEAR. THE VP OF HUMAN RESOURCES PROVIDED SALARY STUDIES FROM THE FOLLOWING RESOURCES TO THE COMMITTEE RELATIVE TO EXECUTIVE DIRECTOR COMPENSATION: SALARY.COM, PAYSCALE.COM, 990 REVIEW (LIKE SIZE ORGANIZATIONS), CEMO (CHIEF EXECUTIVE OFFICERS OF MULTI-FACILITY ORGANIZATIONS) SALARY STUDY RESULTS, AND INDUSTRY STATE ASSOCIATION SALARY STUDY RESULTS BASED ON GEOGRAPHICAL LOCATION. THE RECOMMENDATION FOR BASE COMPENSATION AND BONUS ARE PROVIDED BY THE EXECUTIVE DIRECTOR'S DIRECT SUPERVISOR (COO OR VP OF OPERATIONS).
FORM 990, PART VI, SECTION C, LINE 19	CORPORATE FINANCIAL DATA AND GOVERNANCE INFORMATION IS NOT PUBLIC INFORMATION, AND AS SUCH, IS RELEASED ONLY PURSUANT TO LEGAL REGULATION, COURT ORDER, OR OTHER APPLICABLE LAW, AND AS DIRECTED BY CORPORATE COUNSEL.
FORM 990, PART VII, SECTION A:	NOTE THAT TIM CONROY AND KRISTIN VATER ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC. AND PERFORM SERVICES ON BEHALF OF CAPITOL LAKES, INC. PURSUANT TO A MANAGEMENT SERVICES AGREEMENT BETWEEN CAPITOL LAKES, INC. AND PACIFIC RETIREMENT SERVICES, INC. UNDER THE MANAGEMENT SERVICES AGREEMENT, THEIR COMPENSATION IS REIMBURSED BY CAPITOL LAKES, INC. COMPENSATION HAS BEEN REPORTED IN PART VII, SECTION A IN ORDER TO HIGHLIGHT AMOUNTS PAID BY CAPITOL LAKES, INC., NOTWITHSTANDING THAT THEY ARE LEASED EMPLOYEES OF PACIFIC RETIREMENT SERVICES, INC.
FORM 990, PART XI, LINE 9:	CHANGES IN INTEREST IN NET ASSETS OF FOUNDATION -78,269.
FORM 990, PART XII, LINE 2C:	THE PROCESS AND AUTHORITY FOR SELECTING THE FINANCIAL STATEMENT AUDITOR AND FOR OVERSEEING THE FINANCIAL STATEMENT AUDIT DID NOT CHANGE DURING THE FISCAL YEAR.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990) 2021

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SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

CAPITOL LAKES INC

Employer identification number

39-1412320

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)PACIFIC RETIREMENT SERVICES INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-1067253	SUPPORTING ORGANIZATION	OR	501(C)(3)	LINE 12C, III-FI	N/A		No
(2)PACIFIC RETIREMENT SERVICES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 47-2352652	PUBLIC FOUNDATION	OR	501(C)(3)	LINE 7	PACIFIC RETIREMENT SERVICES INC		No
(3)ROGUE VALLEY MANOR 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0453216	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(4)THE CUMBERLAND REST INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 75-0891470	SENIOR HOUSING	TX	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(5)CASCADE MANOR INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0557803	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(6)UNIVERSITY RETIREMENT COMMUNITY AT DAVIS 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-1179254	SENIOR HOUSING	CA	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(7)HOLLADAY PARK PLAZA 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0513697	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(8)ROGUE VALLEY MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0712867	PUBLIC FOUNDATION	OR	501(C)(3)	LINE 7	ROGUE VALLEY MANOR		No
(9)UNIVERSITY RETIREMENT COMMUNITY FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-1301816	PUBLIC FOUNDATION	CA	501(C)(3)	LINE 7	UNIVERSITY RETIREMENT COMMUNITY AT DAVIS		No
(10)MIRABELLA WASHINGTON FOUNDATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 45-0574348	PUBLIC FOUNDATION	WA	501(C)(3)	LINE 7	MIRABELLA		No
(11)CASCADE MANOR FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-1330100	PUBLIC FOUNDATION	OR	501(C)(3)	LINE 7	CASCADE MANOR INC		No
(12)CAPITOL LAKES FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 38-3781089	PUBLIC FOUNDATION	OR	501(C)(3)	LINE 7	CAPITOL LAKES INC	Yes
(13)MIRABELLA 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 34-2030255	SENIOR HOUSING	WA	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(14)MIRABELLA PORTLAND FOUNDATION INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 45-2508860	PUBLIC FOUNDATION	OR	501(C)(3)	LINE 7	MIRABELLA AT SOUTH WATERFRONT		No
(15)MIRABELLA AT SOUTH WATERFRONT 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 71-1016384	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(16)COMMUNITY VOLUNTEER NETWORK 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0892261	COMMUNITY SERVICES	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(17)RVM HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0864466	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(18)RVM ASHLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 93-0942933	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(19)RVM GRANTS PASS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3136037	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(20)RVM ROSEBURG HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3179782	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(21)RVM MYRTLE CREEK HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3162074	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(22)RVM BEND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3163349	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(23)RVM EAGLE POINT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3191447	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(24)RVM KLAMATH FALLS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3196455	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(25)RVM MEDFORD II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3212537	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(26)RVM LIVELY OAKS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3194409	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(27)RVM REEDSPORT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3212538	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(28)RVM YREKA HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3212540	SENIOR HOUSING	CA	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(29)RVM EUGENE HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3247154	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(30)RVM FORT WORTH I HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1520436	SENIOR HOUSING	TX	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(31)RVM BEND II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 94-3260016	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(32)RVM FORT WORTH II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1587415	SENIOR HOUSING	TX	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(33)RVM MEDFORD III HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1587418	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(34)RVM ROSEBURG II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1587420	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(35)RVM GRANTS PASS II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1662259	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(36)RVM DAVIS HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1662208	SENIOR HOUSING	CA	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(37)RVM MYRTLE CREEK II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1715321	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(38)RVM PORTLAND HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 31-1780332	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(39)RVM PORTLAND II HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 30-0037898	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(40)RVM CENTRAL POINT HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 30-0315618	SENIOR HOUSING	OR	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(41)RVM MANSFIELD HOUSING CORPORATION 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 90-0292647	SENIOR HOUSING	TX	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(42)MIDDLETON GLEN INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 91-1859494	SENIOR HOUSING	WI	501(C)(3)	LINE 10	CAPITOL LAKES INC	Yes
(43)SENIOR HOUSING OF MIDDLETON INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 47-0825736	SENIOR HOUSING	WI	501(C)(3)	LINE 10	CAPITOL LAKES INC	Yes
(44)MIRABELLA AT ASU INC 1 WEST MAIN ST SUITE 303 MEDFORD,OR97501 81-3784956	SENIOR HOUSING	AZ	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No
(45)BAY AREA SENIOR SERVICES INC 1 BALDWIN AVE SAN MATEO,CA94401 94-3008774	SENIOR HOUSING	CA	501(C)(3)	LINE 10	PACIFIC RETIREMENT SERVICES INC		No

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2021

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	Yes	No
(1) PRS MANAGEMENT 1 WEST MAIN SUITE 303 MEDFORD,OR97501 93-1328250	MANAGEMENT COMPANY	OR	N/A	C					No

Schedule R (Form 990) 2021

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................

b Gift, grant, or capital contribution to related organization(s) ............................

c Gift, grant, or capital contribution from related organization(s) ............................

Yes

d Loans or loan guarantees to or for related organization(s) ............................

e Loans or loan guarantees by related organization(s) ............................

f Dividends from related organization(s) ............................

g Sale of assets to related organization(s) ............................

h Purchase of assets from related organization(s) ............................

i Exchange of assets with related organization(s) ............................

j Lease of facilities, equipment, or other assets to related organization(s) .......................

k Lease of facilities, equipment, or other assets from related organization(s) ......................

l Performance of services or membership or fundraising solicitations for related organization(s) .....................

m Performance of services or membership or fundraising solicitations by related organization(s) .................

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................

Yes

o Sharing of paid employees with related organization(s) ............................

Yes

p Reimbursement paid to related organization(s) for expenses ............................

Yes

q Reimbursement paid by related organization(s) for expenses ............................

Yes

r Other transfer of cash or property to related organization(s) ............................

s Other transfer of cash or property from related organization(s) ............................

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) CAPITOL LAKES FOUNDATION INC	C	109,028	CASH

Schedule R (Form 990) 2021

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Schedule R (Form 990) 2021

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

Return Reference	Explanation

Schedule R (Form 990) 2021

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO PROVIDE CARE AND HOUSING FOR THE ELDERLY.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	6
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	6
5	Total number of individuals employed in calendar year 2021 (Part V, line 2a) ......	5	439
6	Total number of volunteers (estimate if necessary) .............	6	75
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,392,786	325,088
9	Program service revenue (Part VIII, line 2g) .........	21,524,631	21,328,284
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	58,041	19,804
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	9,914,307	129,515
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	33,889,765	21,802,691
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	12,365,530	11,406,330
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	12,619,062	13,102,317
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	24,984,592	24,508,647
19	Revenue less expenses. Subtract line 18 from line 12.......	8,905,173	-2,705,956
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	43,546,740	41,854,865
21	Total liabilities (Part X, line 26).............	93,765,208	94,705,164
22	Net assets or fund balances. Subtract line 21 from line 20.....	-50,218,468	-52,850,299

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 19,477,170 including grants of $ 0 ) (Revenue $ 21,328,284 )
	CAPITOL LAKES IS A CONTINUING CARE RETIREMENT COMMUNITY, DEDICATED TO ENHANCING OUR RESIDENTS' QUALITY OF LIFE IN A STIMULATING, SECURE ENVIRONMENT. WE PROVIDE HIGH-QUALITY SERVICES INCLUDING HOUSING, NUTRITIOUS MEALS, NURSING, HOUSEKEEPING, MAINTENANCE, AND OTHER SUPPORT TO THOSE WE SERVE. OUR LEVELS OF SERVICE INCLUDE INDEPENDENT LIVING, ASSISTED LIVING, AND SKILLED NURSING.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses19,477,170

(A) Name and title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)				(D) Reportable compensation from the organization (W-2/1099-MISC/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(1) TIM CONROY...................................................................... EXECUTIVE DIRECTOR	39.00 ................. 1.00			X		279,824	0	50,975
(2) KRISTIN VATER...................................................................... HEALTH CENTER ADMINISTRATOR	39.00 ................. 1.00				X	154,741	0	25,915
(3) STEVEN MELLSTROM...................................................................... HUMAN RESOURCES DIRECTOR	40.00 ................. 0.00				X	133,988	0	20,309
(4) TSERING DAMDUL...................................................................... REGISTERED NURSE	40.00 ................. 0.00				X	122,152	0	20,309
(5) HOLLY JOHNSON...................................................................... SALES DIRECTOR	40.00 ................. 0.00				X	117,588	0	20,309
(6) DAYLE TESSNER...................................................................... DIRECTOR OF NURSING	40.00 ................. 0.00				X	123,243	0	6,370
(7) SUE CENTER...................................................................... CHAIR	1.00 ................. 1.00	X	X			0	0	0
(8) CLAY NORRBOM...................................................................... VICE CHAIR	1.00 ................. 0.00	X	X			0	0	0
(9) SALLY DREW...................................................................... SECRETARY/TREASURER	1.00 ................. 0.00	X	X			0	0	0
(10) MARTY FOX...................................................................... RESIDENT DIRECTOR	1.00 ................. 0.00	X				0	0	0
(11) STEVE JOHANNSEN...................................................................... DIRECTOR	1.00 ................. 0.00	X				0	0	0
(12) HARRY PETERSON...................................................................... DIRECTOR	1.00 ................. 0.00	X				0	0	0

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	931,536	0	144,187

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	109,028
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f	216,060

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		325,088

		Business Code
2a	SERVICE FEES	623000	12,708,451	12,708,451
b	HEALTH CENTER	623000	6,100,719	6,100,719
c	ENTRANCE FEES	623000	1,661,771	1,661,771
d	ALL OTHER	623000	342,250	342,250
e	DIETARY	623000	240,579	240,579
f	All other program service revenue.		274,514	274,514
g	Total. Add lines 2a–2f .....		21,328,284

3 Investment income (including dividends, interest, and othersimilar amounts) ......			133,013			133,013
4 Income from investment of tax-exempt bond proceeds			24			24
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		17,673	6a
b	Less: rental expenses		0	6b
c	Rental income or (loss)		17,673	6c
d	Net rental income or (loss).......			17,673			17,673
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory		2,300,000	7a
b	Less: cost or other basis and sales expenses	29,577	2,383,656	7b
c	Gain or (loss)	-29,577	-83,656	7c
d	Net gain or (loss).........			-113,233			-113,233
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	MANAGEMENT FEES		561000	111,842			111,842
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			111,842
12	Total revenue. See instructions.....			21,802,691	21,328,284	0	149,319

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	303,915		303,915
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........	8,843,643	7,815,808	1,027,835
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	394,205	327,963	66,242
9	Other employee benefits .......	1,184,340	1,023,685	160,655
10	Payroll taxes ...........	680,227	590,471	89,756
11	Fees for services (non-employees):
a	Management ......	1,625,140		1,625,140
b	Legal .........	73,891		73,891
c	Accounting ...........	29,138		29,138
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	7,241		7,241
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	1,123,307	642,765	480,542
12	Advertising and promotion ....	391,597		391,597
13	Office expenses .......	697,650	585,635	112,015
14	Information technology ......	251,088		251,088
15	Royalties ..
16	Occupancy ...........	1,569,463	1,568,291	1,172
17	Travel ............	94,158	21,034	73,124
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	44,079	25,908	18,171
20	Interest ...........	1,811,586	1,811,586
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	2,402,106	2,402,106
23	Insurance ...	212,295	212,295
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	HEALTH CENTER EXPENSE	1,169,240	1,169,240
b	OTHER DIETARY EXPENSE	989,302	989,302
c	OTHER FACILITY SERVICE	406,338	86,383	319,955
d	PROGRAM FUND EXPENSES	204,698	204,698
e	All other expenses
25	Total functional expenses. Add lines 1 through 24e	24,508,647	19,477,170	5,031,477	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			5,566,464	1	2,765,632
2	Savings and temporary cash investments .........			608,196	2	1,198,309
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			862,169	4	1,453,323
5	Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			115,297	8	81,619
9	Prepaid expenses and deferred charges ......			542,172	9	345,433
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	71,745,128
b	Less: accumulated depreciation	10b	42,667,177	30,735,674	10c	29,077,951
11	Investments—publicly traded securities .			4,362,204	11	6,256,303
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			754,564	15	676,295
16	Total assets. Add lines 1 through 15 (must equal line 33)...			43,546,740	16	41,854,865

17	Accounts payable and accrued expenses .....	2,751,256	17	2,721,341
18	Grants payable ...		18
19	Deferred revenue .........	10,074,113	19	10,503,612
20	Tax-exempt bond liabilities .........	32,945,386	20	32,987,100
21	Escrow or custodial account liability. Complete Part IV of Schedule D	625,075	21	733,678
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D	47,369,378	25	47,759,433
26	Total liabilities. Add lines 17 through 25..	93,765,208	26	94,705,164

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	-51,008,170	27	-53,573,094
28	Net assets with donor restrictions ...........	789,702	28	722,795
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	-50,218,468	32	-52,850,299
33	Total liabilities and net assets/fund balances ........	43,546,740	33	41,854,865