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ObjectId: 201733039349300918 - Submission: 2017-10-30
TIN: 14-1338470
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
16
Open to Public Inspection
Name of the organization
HEALTHALLIANCE HOSPITAL MARY'S AVENUE CAMPUS
Employer identification number
14-1338470
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)
WMC HEALTH NETWORK - ROCKLAND INC
100 WOODS ROAD
VALHALLA
,
NY
10595
32-0467873
SUPPORTING
NY
501(C)(3)
12A
NA
No
(2)
WMC HEALTH NETWORK - ULSTER INC
100 WOODS ROAD
VALHALLA
,
NY
10595
32-0477183
SUPPORTING
NY
501(C)(3)
12A
WCHCC
No
(3)
WESTCHESTER COUNTY HEALTH CARE CORP
100 WOODS ROAD
VALHALLA
,
NY
10595
13-3964321
HEALTHCARE
NY
115
N/A
NA
No
(4)
WMC NEW YORK INC
100 WOODS ROAD
VALHALLA
,
NY
10595
13-4107894
FUNDRAISING
NY
501(C)(3)
12A
WCHCC
No
(5)
NORTH ROAD LHCSA INC
241 NORTH ROAD
POUGHKEEPSIE
,
NY
12601
46-5293268
HOMECARE SVCS
NY
501(C)(3)
10
WCHCC
No
(6)
MID-HUDSON VALLEY EARLY EDUCATION CENTER
241 NORTH ROAD
POUGHKEEPSIE
,
NY
12601
46-5534882
PRESCHOOL
NY
501(C)(3)
10
WCHCC
No
(7)
WESTCHESTER MEDICAL CENTER FOUNDATION
100 WOODS ROAD
VALHALLA
,
NY
10595
13-4095845
FUNDRAISING
NY
501(C)(3)
7
WCHCC
No
(8)
HEALTHALLIANCE INC
741 GRANT AVENUE
LAKE KATRINE
,
NY
12449
26-1850453
SUPPORTING
NY
501(C)(3)
12A
WCHCC
No
(9)
HEALTHALLIANCE HOSPITAL BROADWAY CAMPUS
396 BROADWAY
KINGSTON
,
NY
12401
14-1349558
EXEMPT HOSP
NY
501(C)(3)
3
HA INC
Yes
(10)
MARGARETVILLE MEMORIAL HOSPITAL
42084 STATE ROUTE 28
MARGARETVILLE
,
NY
12455
15-0552726
EXEMPT HOSP
NY
501(C)(3)
3
HA INC
Yes
(11)
HEALTHALLIANCE SENIOR LIVING CORP
396 BROADWAY
KINGSTON
,
NY
12401
30-0164277
RTMNT COMM
NY
501(C)(3)
10
HA INC
Yes
(12)
MARGARETVILLE NURSING HOME INC
42158 STATE HIGHWAY 28
MARGARETVILLE
,
NY
12455
22-3143565
NURSING HOME
NY
501(C)(3)
10
MMH
Yes
(13)
MARGARETVILLE HEALTH FOUNDATION
42084 STATE HIGHWAY 28
MARGARETVILLE
,
NY
12455
26-1998454
SUPPORT FDN
NY
501(C)(3)
12A
MMH
Yes
(14)
FASC FOUNDATION
741 GRANT AVENUE
LAKE KATRINE
,
NY
12449
26-4201295
SUPPORT FDN
NY
501(C)(3)
7
HAH BWAY
Yes
(15)
GOOD SAMARITAN FDN FOR BETTER HEALTH
255 LAFAYETTE AVE
SUFFERN
,
NY
10901
13-3400353
SUPPORT FDN
NY
501(C)(3)
7
BSCHSI
No
(16)
BON SECOURS COMMUNITY HOSPITAL FDN
255 LAFAYETTE AVE
SUFFERN
,
NY
10901
81-0667395
SUPPORT FDN
NY
501(C)(3)
7
BSCHSI
Yes
(17)
BON SECOURS WARWICK HEALTH FOUNDATION
255 LAFAYETTE AVE
SUFFERN
,
NY
10901
14-1972807
SUPPORT FDN
NY
501(C)(3)
7
BSCHSI
Yes
(18)
BON SECOURS CHARITY HEALTH SYSTEM INC
255 LAFAYETTE AVE
SUFFERN
,
NY
10901
91-2135195
SUPPORTING
NY
501(C)(3)
12C, III-FI
WCHCC
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2016
Page 2
Schedule R (Form 990) 2016
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)
HUDSON RIVER WEST INSURANCE (BARBADOS)
38 PINE ROAD
BELLEVILLE ST MICHAEL
BB
CAP INSURANCE
BB
BSCHSI
C CORP
Yes
(2)
KINGSTON INSURANCE (BARBADOS) LIMITED
38 PINE ROAD
BELLEVILLE ST MICHAEL
BB
CAP INSURANCE
BB
HEALTHALLIANCE
C CORP
Yes
(3)
NORTHEAST PROVIDER SOLUTIONS INC
100 WOODS ROAD
VALHALLA
,
NY
10595
13-3991673
MSO & HEARING AID
NY
NA
C CORP
Yes
(4)
WMC ADVANCED PHYSICIAN SERVICES PC
19 BRADHURST AVENUE
HAWTHORNE
,
NY
10595
26-4709927
PHYSICIAN OFFICES
NY
NA
C CORP
Yes
(5)
WESTCHESTER MEDICAL REGIONAL PHYS SVCS
241 NORTH ROAD
POUGHKEEPSIE
,
NY
10532
46-5522536
PHYSICIAN OFFICES
NY
NA
C CORP
Yes
(6)
WCHCC (BERMUDA) LIMITED
VICTORIA HALL 11 VICTORIA STREET
HAMILTON
BD
CAP INSURANCE
BD
NA
C CORP
Yes
(7)
KINGSTON REGIONAL HEALTH CARE ENTERPRISE
396 BROADWAY
KINGSTON
,
NY
12401
16-1514994
INVESTMENT
NY
HAH BWAY
C CORP
Yes
(8)
MID HUDSON PHYSICIANS PC
396 BROADWAY
KINGSTON
,
NY
12401
20-3564769
MEDICAL SVCS
NY
HAH BWAY
C CORP
Yes
Schedule R (Form 990) 2016
Page 3
Schedule R (Form 990) 2016
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
Yes
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
No
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
No
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
Yes
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
Yes
s
Other transfer of cash or property from related organization(s)
............................
1s
Yes
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)
HEALTHALLIANCE HOSPITAL BROADWAY CAMPUS
R
4,871,681
ALLOCATED COST
Schedule R (Form 990) 2016
Page 4
Schedule R (Form 990) 2016
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) 2016
Page 5
Schedule R (Form 990) 2016
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R (see instructions).
Return Reference
Explanation
Schedule R, Part II, Bon Secours Charity Health System, Inc. (BSCHS)
Healthalliance, Inc. has a brother-sister relationship with BSCHS's six subordinates in a group exemption within BSCHS. SCHEDULE R, PART II, HASLC ON MARCH 24, 2016 HEALTHALLIANCE SENIOR LIVING CORP (HASLC) BECAME A SELF-SPONSORED CONTINUING CARE RETIREMENT COMMUNITY (CCRC) NAMED WOODLAND POND INC. AND THE RELATIONSHIP WITH HEALTHALLIANCE, INC. AS THE FORMER SOLE CORPORATE MEMBER OF HASLC WAS TERMINATED WITH NO CONSIDERATION PROVIDED BY EITHER PARTY. ALL POWERS PREVIOUSLY HELD BY THE OFFICERS OF THE BOARD OF DIRECTORS OF HEALTHALLIANCE, INC. HAVE BEEN TRANSFERRED TO WOODLAND POND,INC.'S BOARD OF DIRECTORS. THE CHANGE IN OWNERSHIP REQUIRED THE UNAMINOUS APPROVAL OF THE BOARDS OF DIRECTORS OF HEALTHALLIANCE, INC. AND WOODLAND PONDS, INC. AS WELL AS THE NEW YORK STATE DEPARTMENT OF HEALTH, ULSTER COUNTY INDUSTRIAL DEVELOPMENT AGENCY, ULSTER COUNTY CAPITAL RESOURCE CORPORATION, AND BONDHOLDER.
Schedule R (Form 990) 2016
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