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ObjectId: 201701359349305775 - Submission: 2017-05-15
TIN: 41-1936717
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
Living Services Foundation
Employer identification number
41-1936717
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)
Living Services Foundation Mora LLC
110 North 7th Street
Mora
,
MN
55051
26-3614974
Leasing of skilled nursing and assisted living facility.
DE
544,103
5,200,943
Living Services Foundation
(2)
Living Services Foundation New London LLC
100 Glen Oaks Drive
New London
,
MN
56273
20-4504668
Leasing of skilled nursing, assisted and independent living facility.
DE
765,299
7,310,533
Living Services Foundation
(3)
Living Services Foundation Winsted LLC
551 4th Street North
Winsted
,
MN
55395
20-8684862
Leasing of skilled nursing and assisted living facility.
DE
1,309,396
12,985,374
Living Services Foundation
(4)
Living Services Foundation Minneota LLC
700 North Monroe Street
Minneota
,
MN
56264
26-3614760
Operation of skilled nursing, assisted lving, and home health agency.
DE
4,373,759
3,711,529
Living Services Foundation
(5)
Living Services Foundation Wahpeton LLC
711 14th Avenue North
Wahpeton
,
ND
58075
45-3638196
Leasing of assisted living facility
DE
0
0
Benedictine Health Systems (from March 2016)
(6)
Living Services Foundation Byron LLC
4000 Lexington Avenue Ste 201
Shoreview
,
MN
55126
47-2337717
Operation of assisted living facility
DE
0
0
Benedictine Health Systems (from March 2016)
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)
Benedictine Living Community of Winsted
1995 East Rum River Drive South
Cambridge
,
MN
55008
27-4219293
Skilled nursing care center and memory care assisted living
MN
501(c)(3)
Line 9
Benedictine Health Systems
No
(2)
Benedictine Living Community of New London
1995 East Rum River Drive South
Cambridge
,
MN
55008
27-4218436
Skilled nursing care center, assisted living, and senior apartments.
MN
501(c)(3)
Line 9
Benedictine Health Systems
No
(3)
Benedictine Living Community of Mora
1995 East Rum River Drive South
Cambridge
,
MN
55008
27-4219119
Skilled nursing care center and assisted living facility.
MN
501(c)(3)
Line 9
Benedictine Health Systems
No
(4)
Benedictine Health System
1995 East Rum River Drive South
Cambridge
,
MN
55008
41-1531892
Health Care System
MN
501(c)(3)
Line 11c, III-FI
No
(5)
Benedictine Living Community of Wahpeton
1995 East Rum River Drive South
Cambridge
,
MN
55008
45-4274091
Assisted living and basic care facility
MN
501(c)(3)
Line 9
Benedictine Health Systems
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
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
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
No
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
No
o
Sharing of paid employees with related organization(s)
............................
1o
No
p
Reimbursement paid to related organization(s) for expenses
............................
1p
No
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
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, Part I - Disregarded Entities:
The Wahpeton and Byron facilities were sold to Benedictine Health System in March 2016.
Schedule R (Form 990) 2015
Additional Data
Software ID:
Software Version: