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ObjectId: 201601319349302075 - Submission: 2016-05-10
TIN: 39-0816848
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.
Information about Schedule R (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
14
Open to Public Inspection
Name of the organization
MERCY HEALTH SYSTEM CORPORATION
Employer identification number
39-0816848
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)
MERCY ALLIANCE INC
1000 MINERAL POINT AVE
JANESVILLE
,
WI
53548
39-1679859
SUPPORT OF HEALTHCARE
WI
501(C)(3)
LINE 11A, I
MERCYROCKFORD HEALTH SYSTEM CORPORATION
No
(2)
MERCY FOUNDATION INC
1000 MINERAL POINT AVE
JANESVILLE
,
WI
53548
23-7275336
SUPPORT OF HEALTHCARE
WI
501(C)(3)
LINE 11A, I
MERCY HEALTH SYSTEM CORPORATION
No
(3)
MERCY HEALTH SYSTEM ASSOCIATION OF VOLUNTEERS
1000 MINERAL POINT AVE
JANESVILLE
,
WI
53548
39-0912682
SUPPORT OF HEALTHCARE
WI
501(C)(3)
LINE 11C, III-FI
MERCY HEALTH SYSTEM CORPORATION
No
(4)
MERCY ASSISTED CARE INC
901 MINERAL POINT AVE
JANESVILLE
,
WI
53548
39-1035110
HEALTHCARE
WI
501(C)(3)
LINE 9
MERCY ALLIANCE INC
No
(5)
MERCY HARVARD HOSPITAL INC
901 GRANT STREET
HARVARD
,
IL
60033
31-1551871
HEALTHCARE
IL
501(C)(3)
LINE 3
MERCY ALLIANCE INC
No
(6)
HARVARD MEMORIAL HOSPITAL FOUNDATION
901 GRANT STREET
HARVARD
,
IL
60033
36-4308662
SUPPORT OF HEALTHCARE
IL
501(C)(3)
LINE 11A, I
MERCY HARVARD HOSPITAL INC
No
(7)
MERCY CRYSTAL LAKE HOSPITAL AND MEDICAL CENTER
1000 MINERAL POINT AVE
JANESVILLE
,
WI
535475003
20-1673011
NONE
IL
501(C)(3)
LINE 3
MERCY ALLIANCE INC
No
(8)
MERCYROCKFORD HEALTH SYSTEM CORPORATION
2400 N ROCKTON AVE
ROCKFORD
,
IL
61103
47-2158680
SUPPORT OF HEALTHCARE
IL
501(C)(3)
LINE 11A, I
N/A
No
(9)
ROCKFORD MEMORIAL HOSPITAL
2400 N ROCKTON AVE
ROCKFORD
,
IL
61103
36-2167847
HEALTHCARE
IL
501(C)(3)
LINE 3
ROCKFORD HEALTH SYSTEM
No
(10)
ROCKFORD HEALTH SYSTEM
2400 N ROCKTON AVE
ROCKFORD
,
IL
61103
36-3197915
SUPPORT OF HEALTHCARE
IL
501(C)(3)
LINE 11C, III-FI
MERCYROCKFORD HEALTH SYSTEM CORPORATION
No
(11)
ROCKFORD MEMORIAL DEVELOPMENT FOUNDATION
2400 N ROCKTON AVE
ROCKFORD
,
IL
61103
36-3197918
SUPPORT OF HEALTHCARE
IL
501(C)(3)
LINE 11A, I
ROCKFORD HEALTH SYSTEM
No
(12)
VISITING NURSES ASSN OF THE ROCKFORD AREA
4223 E STATE STREET
ROCKFORD
,
IL
61108
36-2167945
HEALTHCARE
IL
501(C)(3)
LINE 9
ROCKFORD HEALTH SYSTEM
No
(13)
ROCKFORD HEALTH PHYSICIANS
2400 N ROCKTON AVE
ROCKFORD
,
IL
61103
36-3097436
HEALTHCARE
IL
501(C)(3)
LINE 3
ROCKFORD HEALTH SYSTEM
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2014
Page 2
Schedule R (Form 990) 2014
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
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)
JANESVILLE MEDICAL CENTER INC
1000 MINERAL POINT AVE
JANESVILLE
,
WI
53548
39-1520130
MANAGEMENT OF UNION EMPLOYEES
WI
MERCY HEALTH SYSTEM CORPORATION
C
200
100.000 %
Yes
(2)
MERCYCARE INSURANCE COMPANY
580 N WASHINGTON ST
JANESVILLE
,
WI
53546
39-1768192
INSURANCE
WI
MERCY HEALTH SYSTEM CORPORATION
C
101,883,691
46,162,778
100.000 %
Yes
(3)
MERCYCARE HMO INC - CONSOLIDATED WITH MERCYCARE INSURANCE CO
580 N WASHINGTON ST
JANESVILLE
,
WI
53546
20-1482553
INSURANCE
WI
MERCY HEALTH SYSTEM CORPORATION
C
100.000 %
Yes
(4)
ROCKFORD HEALTH INSURANCE LTD
WELLESLEY HOUSE SO 2ND FL
PEMBROOKE, HM
BD
INSURANCE
BD
N/A
C
No
Schedule R (Form 990) 2014
Page 3
Schedule R (Form 990) 2014
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
.....................
1a
Yes
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
No
d
Loans or loan guarantees to or for related organization(s)
............................
1d
No
e
Loans or loan guarantees by related organization(s)
............................
1e
Yes
f
Dividends from related organization(s)
............................
1f
No
g
Sale of assets to related organization(s)
............................
1g
No
h
Purchase of assets from related organization(s)
............................
1h
No
i
Exchange of assets with related organization(s)
............................
1i
No
j
Lease of facilities, equipment, or other assets to related organization(s)
.......................
1j
Yes
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
Yes
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
No
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
No
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
Yes
o
Sharing of paid employees with related organization(s)
............................
1o
Yes
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
Yes
r
Other transfer of cash or property to related organization(s)
............................
1r
No
s
Other transfer of cash or property from related organization(s)
............................
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)
MERCYCARE INSURANCE COMPANY
Q
7,663,492
COST OF SERVICES PROVIDED
Schedule R (Form 990) 2014
Page 4
Schedule R (Form 990) 2014
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) 2014
Page 5
Schedule R (Form 990) 2014
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) 2014
Additional Data
Software ID:
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