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ObjectId: 201613199349311241 - Submission: 2016-11-14
TIN: 61-0659432
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
DELTA DENTAL OF KENTUCKY INC
Employer identification number
61-0659432
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
(1)
DENTAL CHOICE PROPERTIES LLC
10100 LINN STATION RD SUITE
LOUISVILLE
,
KY
40223
61-0659432
NO BUSINESS ACTIVITY
KY
DELTA DENTAL OF KENTUCKY
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)
RENAISSANCE HEALTH SERVICE CORPORATION
PO BOX 30416
LANSING
,
MI
489097916
38-1675667
PROMOTING DENTAL CARE
MI
501(C)(4)
N/A
N/A
No
(2)
DELTA DENTAL PLAN OF MICHIGAN INC
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
38-1791480
PROVIDE DENTAL SERVICE PLANS
MI
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(3)
DELTA DENTAL OF TENNESSEE INC
po BOX 30416
lanSING
,
MI
489097916
62-0812197
PROVIDE DENTAL SERVICE PLANS
TN
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(4)
DELTA DENTAL PLAN OF NEW MEXICO INC
PO BOX 30416
LANSING
,
MI
489097916
85-0224562
PROVIDE DENTAL SERVICE PLANS
NM
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(5)
DELTA DENTAL OF NORTH CAROLINA
PO BOX 30416
LANSING
,
MI
489097916
56-1018068
PROVIDE DENTAL SERVICE PLANS
NC
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(6)
DELTA DENTAL PLAN OF OHIO inc
PO BOX 30416
LANSING
,
MI
489097916
31-0685339
PROVIDE DENTAL SERVICE PLANS
OH
501(C)(4)
N/A
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(7)
DELTA DENTAL PLAN OF INDIANA inc
PO BOX 30416
LANSING
,
MI
489097916
35-1545647
PROVIDE DENTAL SERVICE PLANS
IN
501(C)(4)
N/A
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(8)
DELTA DENTAL FUND
PO BOX 30416
LANSING
,
MI
489097916
38-2337000
SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS
MI
501(C)(3)
11A TYPE II
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(9)
DELTA DENTAL PLAN OF ARKANSAS
PO BOX 30416
LANSING
,
MI
489097916
71-0561140
PROVIDE DENTAL SERVICE PLANS
AR
501(C)(4)
NA
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(10)
DELTA DENTAL OF ARKANSAS FOUNDATION
PO BOX 30416
LANSING
,
MI
489097916
26-1569324
PROVIDE DENTAL SERVICE PLANS
AR
501(C)(3)
PF
RENAISSANCE HEALTH SERVICE CORPORATION
Yes
(11)
RENAISSANCE FAMILY FOUNDATION INC
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
46-1376165
Emphasize DENTAL HEALTH IN COMMUNITIES
IN
501(c)(3)
PF
RENAISSANCE HOLDING COMPANY
Yes
(12)
SMILE 180 FOUNDATION
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
47-1654054
Emphasize DENTAL HEALTH IN COMMUNITIES
TN
501(c)(3)
Line 11a, I
DELTA DENTAL OF TENNESSEE INC
Yes
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)
DENTAL CHOICE INC
10100 LINN STATION RD SUITE 700
LOUISVILLE
,
KY
40223
61-1105118
PROVIDE DENTAL SERVICE PLANS
KY
N/A
C
312,439
7,809,742
100.000 %
Yes
(2)
DENTAL CHOICE AGENCY INC
10100 LINN STATION RD SUITE 700
LOUISVILLE
,
KY
40223
61-1336003
PRIMARY GENERAL AGENCY FOR DDKY & DENTAL CHOICE
KY
N/A
C
-6,720
100.000 %
Yes
(3)
RENAISSANCE HOLDING COMPANY
PO BOX 30381
LANSING
,
MI
48909
41-2177193
HOLDING COMPANY
MI
RENAISSANCE HEALTH SERVICE CORPORATION
C
82,600
7,119,211
5.900 %
Yes
(4)
Renaissance Life & Health Insurance Company of America
PO BOX 30416
LANSING
,
MI
489097916
47-0397286
INSURANCE
IN
RENAISSANCE HOLDING COMPANY
C
Yes
(5)
Renaissance Health Insurance Company of New York
PO BOX 30416
LANSING
,
MI
48909
13-4098096
INSURANCE
NY
RENAISSANCE HOLDING COMPANY
C
Yes
(6)
FORE HOLDING CORPORATION
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
20-4116122
EMPLOYEE BENEFITS
TN
DELTA DENTAL OF TENNESSEE
C
Yes
(7)
OMEGA ADMINISTRATORS INC
1513 COUNTRY CLUB ROAD
SHERWOOD
,
AR
72120
04-3740469
PROVIDE THIRD-PARTY ADMINISTRATIVE SERVICES
AR
DELTA DENTAL OF ARKANSAS
C
Yes
(8)
GLM HOLDING COMPANY
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
47-2557772
INVESTMENT IN SUBSIDIARIES
MI
DELTA DENTAL OF MICHIGAN
C
Yes
(9)
DEWPOINT INC
300 S WASHIGNTON SQUARE
LANSING
,
MI
48933
38-3300595
COMPUTER CONSULTING
MI
GLM HOLDING COMPANY
C
Yes
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
No
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
No
d
Loans or loan guarantees to or for related organization(s)
............................
1d
Yes
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
No
k
Lease of facilities, equipment, or other assets from related organization(s)
......................
1k
No
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
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)
DENTAL CHOICE INC
L
345,073
ACTUAL COST
(2)
DELTA DENTAL OF NORTH CAROLINA
D
720,000
ACTUAL COST
(3)
DELTA DENTAL PLAN OF MICHIGAN
M
2,899,602
ACTUAL COST
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
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