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ObjectId: 201431359349300543 - Submission: 2014-05-15
TIN: 34-1784017
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
Attach to Form 990.
See separate instructions.
OMB No. 1545-0047
20
12
Open to Public Inspection
Name of the organization
COMMUNITY HEALTH ASSOCIATES INC
Employer identification number
34-1784017
Part I
Identification of Disregarded Entities
(Complete if the organization answered "Yes" to 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" to 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)
NORTH CENTRAL OHIO FAMILY CARE CENTER INC
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
34-1807906
PHYSICIAN OFFICE
OH
501(C)(3)
LINE 11A, I
GALION COMMUNITY HOSPITAL
Yes
(2)
GALION COMMUNITY HOSPITAL
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
34-4451872
HOSPITAL SERVICES
OH
501(C)(3)
LINE 3
AVITA HEALTH SYSTEM
Yes
(3)
AVITA HEALTH FOUNDATION
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
20-0934451
FUNDRAISING FOR GALION COMMUNITY HOSPITAL
OH
501(C)(3)
LINE 7
GALION COMMUNITY HOSPITAL
Yes
(4)
AVITA HEALTH SYSTEM
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
27-4385692
HEALTHCARE
OH
501(C)(3)
LINE 11A, I
N/A
No
(5)
CRAWFORD COUNTY SHARED HEALTH SERVICES INC
1220 NORTH MARKET STREET
GALION
,
OH
44833
34-1484014
HOME HEALTH & HOSPICE
OH
501(C)(3)
LINE 9
GALION COMMUNITY HOSPITAL
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Page 2
Schedule R (Form 990) 2012
Page
2
Part III
Identification of Related Organizations Taxable as a Partnership
(Complete if the organization answered "Yes" to 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 VUBI
amount in box 20 of
Schedule K-1
(Form 1065)
(j)
General or
managing
partner?
(k)
Percentage
ownership
Yes
No
Yes
No
(1)
GALION COMMUNITY PAIN MANAGEMENT LLC
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
30-0602607
HOSPITAL SUPPORT
OH
N/A
(2)
GALION COMMUNITY VASCULAR SERVICES LLC
269 PORTLAND WAY SOUTH
GALION
,
OH
44833
61-1613817
HOSPITAL SUPPORT
OH
N/A
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust
(Complete if the organization answered "Yes" to 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
Schedule R (Form 990) 2012
Page 3
Schedule R (Form 990) 2012
Page
3
Part V
Transactions With Related Organizations
(Complete if the organization answered "Yes" to 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
Yes
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 other organization
(b)
Transaction
type (a-s)
(c)
Amount involved
(d)
Method of determining amount involved
(1)
GALION COMMUNITY HOSPITAL
C
1,862,131
FORGIVENESS OF PAYABLE
Schedule R (Form 990) 2012
Page 4
Schedule R (Form 990) 2012
Page
4
Part VI
Unrelated Organizations Taxable as a Partnership
(Complete if the organization answered "Yes" to 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 section 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 VUBI
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) 2012
Page 5
Schedule R (Form 990) 2012
Page
5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier
Return Reference
Explanation
Additional Data
Software ID:
Software Version: