Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
SchKMediumBullet Attach to Form 990. SchKMediumBullet See separate instructions.
SchKMediumBulletInformation about Schedule K (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public
Inspection
Name of the organization
Cumberland County Hospital System Inc
 
Employer identification number
56-0845796
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
Yes No Yes No Yes No
A North Carolina Medical Care Commission
  		52-1309402 65821DAL5 09-23-2008 285,335,000 To refund bonds issued 5/4/2006 X     X   X
B North Carolina Medical Care Commission
  		52-1309402 65821DPP0 12-19-2012 124,978,739 To refund bonds issued 9/23/2008   X   X   X
Part II
Proceeds
A B C D
1 Amount of bonds retired ................. 133,335,000      
2 Amount of bonds legally defeased ...........        
3 Total proceeds of issue .................. 285,335,000 124,978,739    
4 Gross proceeds in reserve funds ............        
5 Capitalized interest from proceeds ............        
6 Proceeds in refunding escrows ............        
7 Issuance costs from proceeds ............ 3,722,838 1,630,191    
8 Credit enhancement from proceeds ............        
9 Working capital expenditures from proceeds ............        
10 Capital expenditures from proceeds ............ 10,007,178      
11 Other spent proceeds ............ 271,604,984 123,348,548    
12 Other unspent proceeds ............        
13 Year of substantial completion ............ 2008
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? ..... X     X        
15 Were the bonds issued as part of an advance refunding issue? ....   X X          
16 Has the final allocation of proceeds been made? ............ X   X          
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ............ X   X          


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   X        
2 Are there any lease arrangements that may result in private business use of bond-financed property? ........   X   X        
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2013
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Schedule K (Form 990) 2013
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Part III
Private Business Use (Continued)
A B C D
Yes No Yes No Yes No Yes No
3a Are there any management or service contracts that may result in private business use of bond-financed property? ............ X   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   X          
c Are there any research agreements that may result in private business use of bond-financed property? ..................   X   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 ..... SchKMediumBullet 0.380 % 0.380 %    
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 ..........SchKMediumBullet        
6 Total of lines 4 and 5 ............ 0.380 % 0.380 %    
7 Does the bond issue meet the private security or payment test? ....   X   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   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   X        
Part IV
Arbitrage
A B C D
Yes No Yes No Yes No Yes No
1 Has the issuer filed Form 8038-T? .....   X   X        
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .....   X X          
b Exception to rebate? .....   X   X        
c No rebate due? ....... X     X        
If you checked "No rebate due" in line 2c, provide in
Part VI the date the rebate computation was performed
3 Is the bond issue a variable rate issue? .... X     X        
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X   X        
b Name of provider .....  
  		 
  		 
  		 
 
c Term of hedge .........        
d Was the hedge superintegrated? .....                
e Was the hedge terminated? ........                
Schedule K (Form 990) 2013
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Schedule K (Form 990) 2013
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Part IV
Arbitrage (Continued)
A B C D
Yes No Yes No Yes No Yes No
5a Were gross proceeds invested in a guaranteed investment contract (GIC)? X     X        
b Name of provider ........ Morgan Stanley
  		 
  		 
  		 
 
c Term of GIC ........ 110.0000000000 %      
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ...... X              
6 Were any gross proceeds invested beyond an available temporary period?   X   X        
7 Has the organization established written procedures to monitor the requirements of section 148? .....   X   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   X        
Part VI
Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference Explanation
Date Rebate Computation Performed Issuer Name: North Carolina Medical Care Commission Date the Rebate Computation was Performed: 11/20/2012
Schedule K Supplental Information Part IV, Line 6, column B - This question is being answered without regard to a yield-restricted advance refunding escrow financed with proceeds of the bonds.
Schedule K (Form 990) 2013

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