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ObjectId: 201423189349304732 - Submission: 2014-11-14
TIN: 22-1802017
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.
Attach to Form 990.
See separate instructions.
Information about Schedule R (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
13
Open to Public Inspection
Name of the organization
HARTWYCK WEST NURSING HOME INC
Employer identification number
22-1802017
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?
Yes
No
(1)
JFK HEALTH SYSTEM INC
98 JAMES STREET
EDISON
,
NJ
08820
22-2421432
HEALTHCARE
NJ
501(C)(3)
11a
N/A
No
(2)
THE COMMUNITY HOSPITAL GROUP INC
98 JAMES STREET
EDISON
,
NJ
08820
22-6019101
HEALTHCARE
NJ
501(C)(3)
3
JFKHS
No
(3)
MUHLENBERG REGIONAL MEDICAL CENTER INC
98 JAMES STREET
EDISON
,
NJ
08820
22-1487258
HEALTHCARE
NJ
501(C)(3)
9
JFKHS
No
(4)
MUHLENBERG FOUNDATION INC
98 JAMES STREET
EDISON
,
NJ
08820
51-0212678
FUNDRAISING
NJ
501(C)(3)
11a
MRMC
No
(5)
JFK MEDICAL CENTER FOUNDATION INC
98 JAMES STREET
EDISON
,
NJ
08820
22-2315044
FUNDRAISING
NJ
501(C)(3)
11a
JFKHS
No
(6)
JFK HEALTH SYSTEM REALTY CORPORATION
98 JAMES STREET
EDISON
,
NJ
08820
52-1703518
INACTIVE
NJ
501(C)(25)
JFKHS
No
(7)
ROBERT WOOD JOHNSON JR LIFESTYLE
98 JAMES STREET
EDISON
,
NJ
08820
22-2421433
HEALTHCARE
NJ
501(C)(3)
9
JFKHS
No
(8)
JFK ASSISTED LIVING
98 JAMES STREET
EDISON
,
NJ
08820
22-3715324
HEALTHCARE
NJ
501(C)(3)
9
HARTWYCK WES
Yes
(9)
HARTWYCK AT OAK TREE INC
98 JAMES STREET
EDISON
,
NJ
08820
22-2666023
HEALTHCARE
NJ
501(C)(3)
9
JFKHS
No
(10)
HARTWYCK AT JFK INC
98 JAMES STREET
EDISON
,
NJ
08820
20-4144804
HEALTHCARE
NJ
501(C)(3)
11b
JFKHS
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2013
Page 2
Schedule R (Form 990) 2013
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
(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)
(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
Yes
No
Yes
No
(1)
MSO - SEE PART VII
INACTIVE
NJ
JFKHS
RELATED
No
No
(2)
MEDIPLEX - SEE PART VII
RENTALS
NJ
JFK HEALTHSHARE
EXCLUDED
No
No
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?
Yes
No
(1)
ATLANTIC INSURANCE EXCHANGE LTD
98 JAMES STREET
EDISON
,
NJ
08820
99-9999999
INSURANCE
BD
JFKHS
C Corp
No
(2)
CENTRAL JERSEY MEDICAL GROUP PA
98 JAMES STREET
EDISON
,
NJ
08820
22-3477610
INACTIVE
NJ
MRMC
C Corp
No
(3)
JFK MEDICAL GROUP PC
98 JAMES STREET
EDISON
,
NJ
08820
22-3482637
CAPTIVE PR
NJ
JFKMC
C Corp
No
(4)
JFK HARTWYCK MGT & CONSULTING INC
98 JAMES STREET
EDISON
,
NJ
08820
22-3812130
INACTIVE
NJ
HARTWYCK WEST
C Corp
100.000 %
Yes
(5)
JFK HEALTHSHARE INC
98 JAMES STREET
EDISON
,
NJ
08820
22-2528967
MANAGEMENT
NJ
JFKHS
C Corp
No
(6)
MIDTOWN SHOPS INC
98 JAMES STREET
EDISON
,
NJ
08820
22-1536954
RETAIL COMPLEX
NJ
MRMC
C CORP
No
(7)
PRIMARY CARE NETWORK
98 JAMES STREET
EDISON
,
NJ
08820
52-2069919
PHYSICIAN HEALTH
NJ
JFKMC
C CORP
No
(8)
JFK MEDICAL ASSOCIATES PA
98 JAMES STREET
EDISON
,
NJ
08820
46-2219798
PHYSICIAN PRACTIC
NJ
JFKHS
C CORP
No
Schedule R (Form 990) 2013
Page 3
Schedule R (Form 990) 2013
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
No
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
.
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1a
No
b
Gift, grant, or capital contribution to related organization(s)
.
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1b
No
c
Gift, grant, or capital contribution from related organization(s)
.
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1c
Yes
d
Loans or loan guarantees to or for related organization(s)
.
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1d
No
e
Loans or loan guarantees by related organization(s)
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1e
No
f
Dividends from related organization(s)
.
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1f
No
g
Sale of assets to related organization(s)
.
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1g
No
h
Purchase of assets from related organization(s)
.
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1h
No
i
Exchange of assets with related organization(s)
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1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
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1j
No
k
Lease of facilities, equipment, or other assets from related organization(s)
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1k
No
l
Performance of services or membership or fundraising solicitations for related organization(s)
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1l
No
m
Performance of services or membership or fundraising solicitations by related organization(s)
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1m
No
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
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1n
No
o
Sharing of paid employees with related organization(s)
.
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1o
Yes
p
Reimbursement paid to related organization(s) for expenses
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1p
Yes
q
Reimbursement paid by related organization(s) for expenses
.
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1q
Yes
r
Other transfer of cash or property to related organization(s)
.
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1r
No
s
Other transfer of cash or property from related organization(s)
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1s
No
2
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)
THE COMMUNITY HOSPITAL GROUP INC
P
862,771
SEE PART VII
(2)
HARTWYCK AT OAK TREE INC
Q
100,000
SEE PART VII
(3)
JFK ASSISTED LIVING INC
Q
974,500
SEE PART VII
(4)
JFK MEDICAL CENTER FOUNDATION INC
C
16,448
SEE PART VII
Schedule R (Form 990) 2013
Page 4
Schedule R (Form 990) 2013
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)
(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)
(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
Yes
No
Yes
No
Yes
No
Schedule R (Form 990) 2013
Page 5
Schedule R (Form 990) 2013
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference
Explanation
SCHEDULE R, PART III
LINE 1 INFORMATION: MANAGEMENT SERVICES ORGANIZATION OF CENTRAL JERSEY, LLC 98 JAMES STREET EDISON, NJ 08820 EIN: 22-3489091 LINE 2 INFORMATION: MEDIPLEX SURGICAL CENTER ASSOCIATION, LP 98 JAMES STREET EDISON, NJ 08820 EIN: 22-2846980
SCHEDULE R, PART V, LINE 2
ALL TRANSACTIONS WITH RELATED ORGANIZATIONS ARE VALUED AT ACTUAL AMOUNTS.
Schedule R (Form 990) 2013
Additional Data
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