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ObjectId: 201701329349304240 - Submission: 2017-05-12
TIN: 25-0974311
Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax Exempt Bonds
Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Part VI.
Attach to Form 990.
Information about Schedule K (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
REBECCA RESIDENCE
Employer identification number
25-0974311
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
Allegheny County Hospital Development Authority
25-1327925
01728A2Y1
02-11-2016
40,250,000
See Part VI
X
X
X
Part II
Proceeds
A
B
C
D
1
Amount of bonds retired
..................
0
2
Amount of bonds legally defeased
..............
0
3
Total proceeds of issue
..................
40,409,404
4
Gross proceeds in reserve funds
.............
0
5
Capitalized interest from proceeds
.............
0
6
Proceeds in refunding escrows
...............
0
7
Issuance costs from proceeds
...............
285,166
8
Credit enhancement from proceeds
.............
64,834
9
Working capital expenditures from proceeds
.............
0
10
Capital expenditures from proceeds
.............
16,136,343
11
Other spent proceeds
.............
0
12
Other unspent proceeds
.............
23,923,061
13
Year of substantial completion
.............
2017
Yes
No
Yes
No
Yes
No
Yes
No
14
Were the bonds issued as part of a current refunding issue?
....
X
15
Were the bonds issued as part of an advance refunding issue?
.....
X
16
Has the final allocation of proceeds been made?
..........
X
17
Does the organization maintain adequate books and records to support the final allocation of proceeds?
..................
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
2
Are there any lease arrangements that may result in private business use of bond-financed property?
...............
X
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2015
Page 2
Schedule K (Form 990) 2015
Page
2
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
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?
c
Are there any research agreements that may result in private business use of bond-financed property?
.............
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
....
0 %
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
.........
0 %
6
Total of lines 4 and 5
.............
0 %
7
Does the bond issue meet the private security or payment test?
...
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
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
Part IV
Arbitrage
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
1
Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate?
...
X
2
If "No" to line 1, did the following apply?
....
a
Rebate not due yet?
.......
X
b
Exception to rebate?
........
X
c
No rebate due?
.........
X
If "Yes" to line 2c, provide in Part VI the date the rebate
computation was performed
......
3
Is the bond issue a variable rate issue?
.....
X
4a
Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?
X
b
Name of provider
..........
c
Term of hedge
.........
d
Was the hedge superintegrated?
......
e
Was the hedge terminated?
........
Schedule K (Form 990) 2015
Page 3
Schedule K (Form 990) 2015
Page
3
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
b
Name of provider
..........
c
Term of GIC
.........
d
Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied?
........
6
Were any gross proceeds invested beyond an available temporary period?
X
7
Has the organization established written procedures to monitor the requirements of section 148?
...
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
Part VI
Supplemental Information.
Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference
Explanation
Schedule K, Part I, Column f-02/11/2016 40,250,000 Allegheny County Hospital Development Authority
The proceeds of the sale of the bonds will be loaned to Rebecca Residence for the purpose of providing funds for a project consisting of the payment and reimbursements of costs incurred in connection with (a) the construction, equipping, and furnishing of an independent living retirement community to be owned and operated by Rebecca Residence, (b) the acquisition, renovation, and equipping of a building expected to be used for short-term and long-term rehabilitation and personal care and to be owned and operated by Concordia of Monroeville, (c) the acquisition, renovation, and equipping of a building expected to be used for short-term rehabilitation care and to be owned and operated by Concordia Lutheran Health and Human Care, (d) miscellaneous capital expenditures by members of the Obligated Group, and (e) the issuance of the Bonds, including, but not limited to, costs incurred in connection with obtaining credit enhancement.
Schedule K (Form 990) 2015
Additional Data
Software ID:
15000352
Software Version:
v1.00