efile Public Visual Render
ObjectId: 201603199349311750 - Submission: 2016-11-14
TIN: 04-2452600
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Attach to Form 990, 990-EZ, or 990-PF.
Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
15
Name of the organization
HARVARD PILGRIM HEALTH CARE INC
Employer identification number
04-2452600
Organization type
(check one):
Filers of:
Section:
Form 990 or 990-EZ
501(c)(
) (enter number) organization
4947(a)(1) nonexempt charitable trust
not
treated as a private foundation
527 political organization
Form 990-PF
501(c)(3) exempt private foundation
4947(a)(1) nonexempt charitable trust treated as a private foundation
501(c)(3) taxable private foundation
Check if your organization is covered by the
General Rule
or a
Special Rule.
Note.
Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.
Special Rules
For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33
1
/3
% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of
(1)
$5,000 or
(2)
2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000
exclusively
for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions
exclusively
for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an
exclusively
religious, charitable, etc., purpose. Do not complete any of the parts unless the
General Rule
applies to this organization because it received
nonexclusively
religious, charitable, etc., contributions totaling $5,000 or more during the year
.........
$
Caution.
An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it
must
answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613X
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page 2
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
2
Name of organization
HARVARD PILGRIM HEALTH CARE INC
Employer identification number
04-2452600
Part I
Contributors
(see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
RESTRICTED
,
$
RESTRICTED
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
(a)
No.
(b)
Name, address, and ZIP + 4
(c)
Total contributions
(d)
Type of contribution
$
Person
Payroll
Noncash
(Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page 3
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
3
Name of organization
HARVARD PILGRIM HEALTH CARE INC
Employer identification number
04-2452600
Part II
Noncash Property
(see instructions). Use duplicate copies of Part II if additional space is needed.
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
(a)
No.from Part I
(b)
Description of noncash property given
(c)
FMV (or estimate)
(see instructions)
(d)
Date received
$
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page 4
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Page
4
Name of organization
HARVARD PILGRIM HEALTH CARE INC
Employer identification number
04-2452600
Part III
Exclusively
religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns
(a)
through
(e) and
the following line entry. For organizations completing Part III, enter the total of
exclusively
religious, charitable, etc., contributions of
$1,000 or less
for the year. (Enter this information once. See instructions.)
$
Use duplicate copies of Part III if additional space is needed.
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
(a)
No.from Part I
(b) Purpose of gift
(c) Use of gift
(d) Description of how gift is held
(e) Transfer of gift
Transferee's name, address, and ZIP 4
Relationship of transferor to transferee
Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
Additional Data
Software ID:
Software Version: