Lake Shore Health Services in Sturgeon Bay, Wisconsin (WI)

Lake Shore Health Services
Employer Identification Number (EIN)	391886580
Name of Organization	Lake Shore Health Services
Address	Sturgeon Bay, WI 54235
Tax Period	2004
Asset Amount	$1,242,386
Amount of Income	$63,649
Form 990 Revenue Amount	$63,649
National Taxonomy of Exempt Entities (NTEE)	Health - General and Rehabilitative: Nonmonetary Support (Not Elsewhere Classified)

Non-representatives - add comments:

Financial snapshot ($)

Revenue for 2004

Assets at end of 2004

Expenses for 2004

Functional Expenses for 2004 ($)

Income-Producing Activities for 2004

	2000	2001	2002	2003	2004
Revenue, Expenses, and Changes in Net Assets or Fund Balances
Total revenue	$64,440	$62,916	$34,015	$62,617	$63,649
Contributions, gifts, grants, and similar amounts received	$0	$0	$0	$0	$0
Contributions to donor advised funds
Direct public support	$0	$0	$0	$0	$0
Indirect public support	$0	$0	$0	$0	$0
Government contributions (grants)	$0	$0	$0	$0	$0
Program service revenue including government fees and contracts	$0	$0	$0	$61,800	$61,800
Membership dues and assessments	$0	$0	$0	$0	$0
Interest on savings and temporary cash investments	$516	$951	$658	$817	$1,849
Dividends and interest from securities	$0	$0	$0	$0	$0
Net rental income or (loss)	$60,255	$61,965	$33,357	$0	$0
Gross rents	$60,255	$61,965	$61,800	$0	$0
Less: rental expenses	$0	$0	$28,443	$0	$0
Other investment income	$0	$0	$0	$0	$0
Gain or (loss) from sales of assets other than inventory	$0	$0	$0	$0	$0
Gross amount from sales of assets other than inventory	$0	$0	$0	$0	$0
Less: cost or other basis and sales expenses	$0	$0	$0	$0	$0
Net income or (loss) from special events and activities	$0	$0	$0	$0	$0
Gross revenue	$0	$0	$0	$0	$0
Less: direct expenses other than fundraising expenses	$0	$0	$0	$0	$0
Gross profit or (loss) from sales of inventory	$0	$0	$0	$0	$0
Gross sales of inventory, less returns and allowances	$0	$0	$0	$0	$0
Less: cost of goods sold	$0	$0	$0	$0	$0
Other revenue	$3,669	$0	$0	$0	$0
Total expenses	$108,774	$88,069	$61,897	$96,959	$93,216
Program services	$14,908	$6,243	$0	$29,616	$31,201
Management and general	$93,866	$81,826	$61,897	$67,343	$62,015
Fundraising	$0	$0	$0	$0	$0
Payments to affiliates	$0	$0	$0	$0	$0
Net assets or fund balances at end of year	$1,375,696	$1,334,177	$1,306,295	$1,271,953	$1,242,386
Excess or (deficit) for the year	$-44,334	$-25,153	$-27,882	$-34,342	$-29,567
Net assets or fund balances at beginning of year	$1,420,030	$1,359,330	$1,334,177	$1,306,295	$1,271,953
Other changes in net assets or fund balances	$0	$0	$0	$0	$0

	Total	Program services	Management and general	Fundraising
Statement of Functional Expenses (for 2004)
Total functional expenses	$93,216	$31,201	$62,015	$0
Grants paid from donor advised funds
Other grants and allocations		$0
Specific assistance to individuals		$0
Benefits paid to or for members		$0
Compensation of current officers, directors, key employees, etc.	$0	$0	$0	$0
Compensation of former officers, directors, key employees, etc.
Compensation and other distributions, not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)
Salaries and wages of employees not included above	$0	$0	$0	$0
Pension plan contributions not included above	$0	$0	$0	$0
Employee benefits not included above	$0	$0	$0	$0
Payroll taxes	$0	$0	$0	$0
Professional fundraising fees	$0	$0	$0	$0
Accounting fees	$0	$0	$0	$0
Legal fees	$0	$0	$0	$0
Supplies	$0	$0	$0	$0
Telephone	$302	$0	$302	$0
Postage and shipping	$350	$0	$350	$0
Occupancy	$40,667	$14,233	$26,434	$0
Equipment rental and maintenance	$2,246	$0	$2,246	$0
Printing and publications	$0	$0	$0	$0
Travel	$0	$0	$0	$0
Conferences, conventions, and meetings	$0	$0	$0	$0
Interest	$0	$0	$0	$0
Depreciation, depletion, etc.	$28,116	$9,431	$18,685	$0
Other expenses not covered above	$21,535	$7,537	$13,998	$0

	2000	2001	2002	2003	2004
Balance Sheets
Total assets	$1,376,098	$1,335,967	$1,308,065	$1,272,865	$1,244,266
Cash - non-interest-bearing	$49,985	$72,427	$84,562	$88,201	$88,043
Savings and temporary cash investments	$0	$0	$0	$0	$0
Accounts receivable less allowance for doubtful accounts	$3,900	$2,600	$1,427	$1,202	$877
Pledges receivable less allowance for doubtful accounts	$0	$0	$0	$0	$0
Grants receivable	$0	$0	$0	$0	$0
Receivables from current and former officers, directors, trustees, and key employees	$0	$0	$0	$0	$0
Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B)
Other notes and loans receivable less allowance for doubtful accounts	$0	$0	$0	$0	$0
Inventories for sale or use	$0	$0	$0	$0	$0
Prepaid expenses and deferred charges	$0	$0	$0	$0	$0
Investments - publicly-traded securities
Investments - other securities	$0	$0	$0	$0	$0
Investments - land, buildings, and equipment less accumulated depreciation	$0	$0	$0	$0	$0
Investments - other	$0	$0	$0	$0	$0
Land, buildings, and equipment less accumulated depreciation	$1,321,911	$1,260,940	$1,222,076	$1,183,462	$1,155,346
Other assets, including program-related investments	$302	$0	$0	$0	$0
Total liabilities	$402	$1,790	$1,770	$912	$1,880
Accounts payable and accrued expenses	$402	$1,790	$1,455	$729	$1,512
Grants payable	$0	$0	$0	$0	$0
Deferred revenue	$0	$0	$0	$0	$0
Loans from officers, directors, trustees, and key employees	$0	$0	$0	$0	$0
Tax-exempt bond liabilities	$0	$0	$0	$0	$0
Mortgages and other notes payable	$0	$0	$0	$0	$0
Other liabilities	$0	$0	$315	$183	$368
Total liabilities and net assets/fund balances	$1,376,098	$1,335,967	$1,308,065	$1,272,865	$1,244,266
Total net assets or fund balances	$1,375,696	$1,334,177	$1,306,295	$1,271,953	$1,242,386

	2000	2001	2002	2003	2004
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
Total revenue	$0	$0	$0	$0	$63,649
Total revenue, gains, and other support per audited financial statements	$0	$0	$0	$0	$63,649
Other expenses	$0	$0	$0	$0	$0
Net unrealized gains on investments	$0	$0	$0	$0	$0
Donated services and use of facilities	$0	$0	$0	$0	$0
Recoveries of prior year grants	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0
Other revenue	$0	$0	$0	$0	$0
Investment expenses	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0

	2000	2001	2002	2003	2004
Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
Total expenses	$0	$0	$0	$0	$93,216
Total expenses and losses per audited financial statements	$0	$0	$0	$0	$93,216
Other revenue	$0	$0	$0	$0	$0
Donated services and use of facilities	$0	$0	$0	$0	$0
Prior year adjustments	$0	$0	$0	$0	$0
Losses	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0
Other expenses	$0	$0	$0	$0	$0
Investment expenses	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0

Current Officers, Directors, Trustees, and Key Employees

Total number of officers, directors, and trustees permitted to vote on organization business at board meetings	0
Are any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, related to each other through family or business relationships?
Do any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated employees listed in Schedule A, Part I, or highest compensated professional and other independent contractors listed in Schedule A, Part II-A or II-B, receive compensation from any other organizations, whether tax exempt or taxable, that are related to the organization?
Does the organization have a written conflict of interest policy?

Other Information
Did the organization have unrelated business gross income of $1,000 or more during the year covered by this return, and has it filed a tax return on Form 990-T for this year?	No
Was there a liquidation, dissolution, termination, or substantial contraction during the year?	Yes
Is the organization related (other than by association with a statewide or nationwide organization) through common membership, governing bodies, trustees, officers, etc., to any other exempt or nonexempt organization?	Yes
Direct and indirect political expenditures	$0
Did the organization file Form 1120-POL for this year?	No
Were substantially all dues nondeductible by members?
Did the organization make only in-house lobbying expenditures of $2,000 or less?
Dues, assessments, and similar amounts from members	$0
Section 162(e) lobbying and political expenditures	$0
Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices	$0
Taxable amount of lobbying and political expenditures	$0
Does the organization elect to pay the section 6033(e) tax on the amount above?
If section 6033(e)(1)(A) dues notices were sent, does the organization agree to add the amount above to its reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for the following tax year?
Initiation fees and capital contributions	$0
Gross receipts for public use of club facilities	$0
At any time during the year, did the organization, directly or indirectly, own a controlled entity within the meaning of section 512(b)(13)?
Amount of tax imposed on the organization during the year under: section 4911	$0
Amount of tax imposed on the organization during the year under: section 4912	$0
Amount of tax imposed on the organization during the year under: section 4955	$0
Did the organization engage in any section 4958 excess benefit transaction during the year or did it become aware of an excess benefit transaction from a prior year?	No
Amount of tax imposed on the organization managers or disqualified persons during the year under sections 4912, 4955, and 4958	$0
Amount of tax above, reimbursed by the organization	$0
At any time during the tax year, was the organization a party to a prohibited tax shelter transaction?
Did the organization acquire a direct or indirect interest in any applicable insurance contract?
Did the supporting organization, or a fund maintained by a sponsoring organization, have excess business holdings at any time during the year?
Number of employees employed in the pay period that includes March 12, 2006	0

	Unrelated business income		Excluded by section 512, 513, or 514		Related or exempt function income
Analysis of Income-Producing Activities (for 2004)
	Business code	Amount	Exclusion code	Amount	Related or exempt function income
Total		$0		$1,849	$61,800
Program service revenue
Program service revenue 1	000000	$0	00	$0	$61,800
Program service revenue 2	000000	$0	00	$0	$0
Program service revenue 3	000000	$0	00	$0	$0
Program service revenue 4	000000	$0	00	$0	$0
Program service revenue 5	000000	$0	00	$0	$0
Medicare/Medicaid payments	000000	$0	00	$0	$0
Fees and contracts from government agencies	000000	$0	00	$0	$0
Membership dues and assessments	000000	$0	00	$0	$0
Interest on savings and temporary cash investments	000000	$0	Dividends, interest, payments with respect to securities loans, annuities, income from notional principal contracts, loan commitment fees, and other substantially similar income from ordinary and routine investments excluded by section 512(b)(1)	$1,849	$0
Dividends and interest from securities	000000	$0	00	$0	$0
Net rental income or (loss) from real estate
debt-financed property	000000	$0	00	$0	$0
not debt-financed property	000000	$0	00	$0	$0
Net rental income or (loss) from personal property	000000	$0	00	$0	$0
Other investment income	000000	$0	00	$0	$0
Gain or (loss) from sales of assets other than inventory	000000	$0	00	$0	$0
Net income or (loss) from special events	000000	$0	00	$0	$0
Gross profit or (loss) from sales of inventory	000000	$0	00	$0	$0
Other revenue	000000	$0	00	$0	$0

EIN of corporation, partnership, or disregarded entity	Percentage of ownership interest	Total income	End-of-year assets
Information Regarding Taxable Subsidiaries and Disregarded Entities (for 2004)
	0%	$0	$0
	0%	$0	$0
	0%	$0	$0
	0%	$0	$0

Compensation	Contributions to employee benefit plans & deferred compensation	Expense account and other allowances
Compensation of the Five Highest Paid Employees Other Than Officers, Directors, and Trustees (for 2004)
$0	$0	$0
$0	$0	$0
$0	$0	$0
$0	$0	$0
$0	$0	$0

Total number of other employees paid over $50,000	0

Total number of other employees paid over $50,000

Statements About Activities (for 2004)
Expenses paid or incurred in connection with the lobbying activities	$0
Did the organization receive or hold an easement for conservation purposes, including easements to preserve open space, the environment, historic land areas or historic structures?
Did the organization provide credit counseling, debt management, credit repair, or debt negotiation services?
Did the organization maintain any donor advised funds?
Did the organization make any taxable distributions under section 4966?
Did the organization make a distribution to a donor, donor advisor, or related person?
The total number of donor advised funds owned at the end of the tax year
The aggregate value of assets held in all donor advised funds owned at the end of the tax year
The total number of separate funds or accounts owned at the end of the tax year (excluding donor advised funds included above) where donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts
The aggregate value of assets held in all funds or accounts included above at the end of the tax year

Reason for Non-Private Foundation Status
The organization is not a private foundation because it is	Not controlled by disqualified persons/supports non private foundation

	1999	2000	2001	2002	2003
Support Schedule
Total	$167,155	$76,468	$30,426	$0	$0
Gifts, grants, and contributions received	$0	$0	$0	$0	$0
Membership fees received	$0	$0	$0	$0	$0
Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is related to the organization's charitable, etc., purpose	$97,520	$12,544	$-736	$0	$0
Gross income from interest, dividends, amounts received from payments on securities loans (section 512(a)(5)), rents, royalties, and unrelated business taxable income (less section 511 taxes) from businesses acquired by the organization after June 30, 1975	$60,063	$60,255	$31,162	$0	$0
Net income from unrelated business activities not included above	$0	$0	$0	$0	$0
Tax revenues levied for the organization's benefit and either paid to it or expended on its behalf	$0	$0	$0	$0	$0
The value of services or facilities furnished to the organization by a governmental unit without charge. Do not include the value of services or facilities generally furnished to the public without charge	$0	$0	$0	$0	$0
Other income	$9,572	$3,669	$0	$0	$0

Lobbying Expenditures by Electing Public Charities (for 2004)
Total exempt purpose expenditures	$0
Total lobbying expenditures	$0
Total lobbying expenditures to influence public opinion (grassroots lobbying)	$0
Total lobbying expenditures to influence a legislative body (direct lobbying)	$0
Other exempt purpose expenditures	$0
Lobbying nontaxable amount	$0
Grassroots nontaxable amount	$0

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