efile Public Visual Render
ObjectId: 201613199349302586 - Submission: 2016-11-14
TIN: 39-1028657
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
15
Open to Public Inspection
Name of the organization
Gundersen Clinic Ltd
Employer identification number
39-1028657
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)
GUNDERSEN LUTHERAN MEDICAL CENTER INC
1910 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-0813416
HEALTH CARE
WI
501(C)(3)
LINE 3
GLHS
No
(2)
GUNDERSEN LUTHERAN MEDICAL FNDTN INC
1836 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1249705
FOUNDATION
WI
501(C)(3)
LINE 7
GLHS
No
(3)
GUNDERSEN LUTHERAN ADM SERVICES INC
1910 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1606449
SUPTNG. ORG.
WI
501(C)(3)
LINE 11B,II
GLHS
No
(4)
GUNDERSEN LUTHERAN CREDENTIALING SVS INC
1910 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1856898
CREDENTIALING
WI
501(C)(3)
LN 11C,III
GLHS
No
(5)
TRI-COUNTY MEMORIAL HOSPITAL INC
18601 LINCOLN STREET
WHITEHALL
,
WI
54773
39-0704510
HEALTH CARE
WI
501(C)(3)
LINE 3
GLHS
No
(6)
TRI-STATE REGIONAL AMBULANCE INC
235 CAUSEWAY BLVD
LA CROSSE
,
WI
54603
39-1962965
MDCL TRANSPO.
WI
501(C)(3)
LINE 9
GLHS
No
(7)
STJOSEPH'S HEALTH SERVICES INC
400 WATER AVENUE
HILLSBORO
,
WI
54634
39-0929538
HEALTH CARE
WI
501(C)(3)
LINE 3
GLHS
No
(8)
ST JOSEPH MEMORIAL FOUNDATION INC
400 WATER AVENUE
HILLSBORO
,
WI
54634
39-1455787
FOUNDATION
WI
501(C)(3)
LINE 11A, I
S JOSEPH HS
No
(9)
TRI-COUNTY MEMORIAL FOUNDATION INC
18601 LINCOLN STREET
WHITEHALL
,
WI
54773
30-0093022
FOUNDATION
WI
501(C)(3)
LINE 11A, I
TRI-COUNTY
No
(10)
GUNDERSEN LUTHERAN EXPRESS CARE INC
1836 SOUTH AVE
LA CROSSE
,
WI
54601
90-0102388
HEALTH CARE
WI
501(C)(3)
LINE 11
GLHS
No
(11)
GUNDERSEN HEALTH PLAN MN INC
1900 SOUTH AVE
LA CROSSE
,
WI
54601
45-2633920
HEALTH INS
MN
501(C)(4)
GHP
No
(12)
MEMORIAL HOSPITAL OF BOSCOBEL
205 PARKER STREET
BOSCOBEL
,
WI
53805
39-0845590
HEALTH CARE
WI
501(C)(3)
LINE 3
GLHS
No
(13)
MEMORIAL HOSPITAL OF BOSCOBEL FNDT INC
205 PARKER STREET
BOSCOBEL
,
WI
53805
39-1688793
FUNDRAISING
WI
501(C)(3)
LINE 7
NA
No
(14)
BOSCOBEL AREA HEALTH CARE PARTNERS
205 PARKER STREET
BOSCOBEL
,
WI
53805
45-0498844
FUNDRAISING
WI
501(C)(3)
LINE 7
NA
No
(15)
HARMONY COMMUNITY HEALTHCARE INC
815 MAIN AVENUE S
HARMONY
,
MN
55939
41-0711606
HEALTH CARE
MN
501(C)(3)
LINE 9
GLHS
No
(16)
TWEETEN LUTHERAN HEALTHCARE CENTER INC
125 FIFTH AVENUE SE
SPRING GROVE
,
MN
55974
41-1565003
HEALTH CARE
MN
501(C)(3)
LINE 9
GLHS
No
(17)
TRI-STATE AMBULANCE INC
235 CAUSEWAY BLVD
LA CROSSE
,
WI
54603
39-1965415
MDCL TRANSPO.
WI
501(C)(3)
LINE 3
GLHS
No
(18)
LUTHERAN REAL ESTATE HOLDING CORPORATION
1910 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1480826
HOUSING
WI
501(C)(3)
LN 11C, III
GLHS
No
(19)
LUTHERAN HOUSING OF LA CROSSE INC
1900 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1751934
INDP LIVING
WI
501(C)(3)
LINE 9
LRHC
No
(20)
COMMUNITY HOUSING OF LA CROSSE INC
1900 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1586700
INDP LIVING
WI
501(C)(3)
LINE 9
LRHC
No
(21)
GUNDERSEN HEALTH PLAN INC
1836 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1807071
HEALTH INS.
WI
501(C)(4)
GLHS
No
(22)
PALMER LUTHERAN HEALTH CENTER INC
112 JEFFERSON STREET
WEST UNION
,
IA
52175
42-1320763
HEALTH CARE
IA
501(C)(3)
LINE 3
GLHS
No
(23)
GUNDERSEN LUTHERAN HEALTH SYSTEM Inc
1836 SOUTH AVENUE
LA CROSSE
,
WI
54601
39-1866425
SUPTNG. ORG.
WI
501(C)(3)
LINE 11B,II
NA
No
(24)
PALMER MEMORIAL FOUNDATION
112 Jefferson Street
West Union
,
IA
52175
42-1032878
FOUNDATION
IA
501(c)(3)
Line 7
PLHC
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2015
Page 2
Schedule R (Form 990) 2015
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)
GUNDERSEN LUTHERAN ENVISION LLC
1836 SOUTH AVENUE
LA CROSSSE
,
WI
54601
26-4706546
RENEW. ENERGY
WI
GLHS
C CORP
0
0
No
(2)
DEGEN BERGLUND INC
1709 LOSEY BLVD S
LA CROSSE
,
WI
54601
39-0971110
RTL PHARMACY
WI
GLHS
C CORP
0
0
No
Schedule R (Form 990) 2015
Page 3
Schedule R (Form 990) 2015
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
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
Yes
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
Yes
d
Loans or loan guarantees to or for related organization(s)
............................
1d
No
e
Loans or loan guarantees by related organization(s)
............................
1e
No
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
Yes
m
Performance of services or membership or fundraising solicitations by related organization(s)
.................
1m
Yes
n
Sharing of facilities, equipment, mailing lists, or other assets with related organization(s)
...................
1n
No
o
Sharing of paid employees with related organization(s)
............................
1o
No
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)
Gundersen Health Plan Inc
p
47,910,719
FAIR VALUE
(2)
Gundersen Health Plan MN Inc
p
1,386,371
FAIR VALUE
Schedule R (Form 990) 2015
Page 4
Schedule R (Form 990) 2015
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) 2015
Page 5
Schedule R (Form 990) 2015
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) 2015
Additional Data
Software ID:
Software Version: