efile Public Visual Render
ObjectId: 201733139349301003 - Submission: 2017-11-09
TIN: 94-1461312
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
Delta Dental of California
Employer identification number
94-1461312
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)
CELEBRATION DENTAL SERVICES LLC
100 First Street
San Francisco
,
CA
94105
59-3410497
DENTAL Services
FL
Delta Dental of California
(2)
DENTEGRA INSURANCE HOLDINGS LLC
100 First Street
San Francisco
,
CA
94105
94-3386049
Holding Company
DE
DENTEGRA INSurance company
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)
Delta Dental Community Care Foundation
100 First Street
San Francisco
,
CA
94105
37-1570764
Charitable Organization
CA
501(c)(3)
PF
Dentegra Group Inc
No
(2)
Delta Dental of Pennsylvania
One Delta Drive
Mechanicsburg
,
PA
17055
23-1667011
Dental Insurance
PA
501(c)(4)
Dentegra Group Inc
No
(3)
Delta Dental of Delaware
One Delta Drive
Mechanicsburg
,
PA
17055
51-0228088
Dental Insurance
DE
501(c)(4)
Dentegra Group Inc
No
(4)
Delta Dental of West Virginia
One Delta Drive
Mechanicsburg
,
PA
17055
55-0523124
Dental Insurance
WV
501(c)(4)
Dentegra Group Inc
No
(5)
Delta Dental of the District of Columbia
One Delta Drive
Mechanicsburg
,
PA
17055
52-1479587
Dental Insurance
DC
501(c)(4)
Dentegra Group Inc
No
(6)
DELTA DENTAL OF NEW YORK
ONE Delta Drive
MEchanicsburg
,
PA
17055
11-1980218
dental Insurance
NY
501(c)(4)
dentegra Group Inc
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
(1)
PACA Management LLC
One Delta Drive
Mechanicsburg
,
PA
17055
94-3277375
Insurance Management
DE
Delta Dental of California
Related
No
Yes
50.000 %
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)
DENTEGRA GROUP INC
100 First Street
San Francisco
,
CA
94105
94-3386049
Holding Company
DE
N/A
C
No
(2)
DENTEGRA INSURANCE COMPANY
100 First Street
San Francisco
,
CA
94105
75-1233841
INSURANCE COMpany
DE
DDC Insurance Holdings Inc
C
No
(3)
DENTEGRA INsurance Company of New England
100 First Street
San Francisco
,
CA
94105
04-2890218
INSURANCE COMpany
MA
DDC Insurance Holdings Inc
C
No
(4)
DELTA DENTAL INSURANCE COmpany
100 First Street
San Francisco
,
CA
94105
94-2761537
INSURANCE COMpany
DE
DDC Insurance Holdings Inc
C
No
(5)
ALPHA DENTAL OF NEVADA INC
100 First Street
san Francisco
,
CA
94105
88-0244893
INSURANCE COMpany
NV
DDC Insurance Holdings Inc
C
No
(6)
ALPHA DENTAL OF UTAH INC
100 First Street
san Francisco
,
CA
94105
86-0672505
INSURANCE COMpany
UT
DDC Insurance Holdings Inc
C
No
(7)
ALPHA DENTAL PROGRAMS INC
100 First Street
san Francisco
,
CA
94105
74-2447512
INSURANCE COMpany
TX
DDC Insurance Holdings Inc
C
No
(8)
ALPHA DENTAL OF ALABAMA INC
100 First Street
san Francisco
,
CA
94105
63-0796079
INSURANCE COMpany
AL
DDC Insurance Holdings Inc
C
No
(9)
ALPHA DENTAL OF NEW MEXICO INC
100 First Street
san Francisco
,
CA
94105
33-0279230
INSURANCE COMpany
NM
DDC Insurance Holdings Inc
C
No
(10)
ALPHA DENTAL OF ARIZONA INC
100 First Street
san Francisco
,
CA
94105
93-0939835
INSURANCE COMpany
AZ
DDC Insurance Holdings Inc
C
No
(11)
DENTEGRA SEGUROS DENTALES SA
Insurgentes Sur 826 Piso 15
Col Del Valle
,
FC DF 01300
MX
INSURANCE COMpany
MX
DENTEGRA INSURANCE COMPANY
C
No
(12)
Delta Dental of Puerto Rico Inc
14 Calle 2 Suite 200
Guaynabo
00968
RQ
66-0436769
Insurance Company
RQ
Delta Dental of California
C
63.990 %
No
(13)
Delta Reinsurance Corporation
CGI Tower 2nd Floor
Warrens
,
St. Michael
BB
98-0096711
Insurance Company
BB
Delta Dental of Pennsylvania
C
0.400 %
No
(14)
SERVICIOS DENTALES DENTEGRA SA DE CV
INSURGENTES SUR 826 PISO 15
Col Del Valle
,
FC DF 01300
MX
Insurance Administration
MX
Dentegra Insurance COMPANY
C
No
(15)
DDC Insurance Holdings Inc
100 First Street
San Francisco
,
CA
94105
27-4251930
Holding Company
DE
Delta Dental of California
C
100.000 %
No
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
Yes
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
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
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)
Alpha Dental of Alabama Inc
L
16,312
(2)
Alpha Dental of Alabama Inc
Q
648
(3)
Alpha Dental of Arizona Inc
L
198,210
(4)
Alpha Dental of Arizona Inc
Q
6,713
(5)
Alpha Dental of Nevada Inc
L
218,134
(6)
Alpha Dental of Nevada Inc
Q
9,036
(7)
Alpha Dental of New Mexico Inc
L
25,313
(8)
Alpha Dental of New Mexico Inc
Q
3,134
(9)
Alpha Dental of Utah Inc
L
101,692
(10)
Alpha Dental of Utah Inc
Q
18,558
(11)
Alpha Dental Programs Inc
L
4,115,210
(12)
Alpha Dental Programs Inc
Q
260,959
(13)
Celebration Dental Services
Q
56,515
(14)
Delta Dental Community Care Foundation
B
672,053
(15)
Delta Dental Insurance Company
A
1,974,590
(16)
Delta Dental Insurance Company
L
23,904,708
(17)
Delta Dental Insurance Company
M
35,564,993
(18)
Delta Dental Insurance Company
P
784,602
(19)
Delta Dental Insurance Company
Q
40,892,457
(20)
Delta Dental of Delaware
Q
48,941
(21)
Delta Dental of District of Columbia
P
621
(22)
Delta Dental of District of Columbia
Q
23,640
(23)
Delta Dental of New York
L
802,365
(24)
Delta Dental of New York
P
6,197
(25)
Delta Dental of New York
Q
1,506,452
(26)
Delta Dental of Pennsylvania
L
14,630,645
(27)
Delta Dental of Pennsylvania
M
11,615,278
(28)
Delta Dental of Pennsylvania
P
1,175,358
(29)
Delta Dental of Pennsylvania
Q
18,546,064
(30)
Delta Dental of Puerto Rico
L
630,900
(31)
Delta Dental of Puerto Rico
M
170,560
(32)
Delta Dental of Puerto Rico
P
72,383
(33)
Delta Dental of Puerto Rico
Q
67,016
(34)
Delta Dental of West Virginia
Q
58,102
(35)
Dentegra Insurance Company
A
1,006,831
(36)
Dentegra Insurance Company
B
10,000,000
(37)
Dentegra Insurance Company
L
4,423,105
(38)
Dentegra Insurance Company
M
13,072,000
(39)
Dentegra Insurance Company
Q
304,747
(40)
Dentegra Insurance Company - NE
M
218,490
(41)
Dentegra Insurance Company - NE
Q
856
(42)
Dentegra Seguros Dentales SA
L
304,889
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 (Form 990) 2016
Additional Data
Software ID:
Software Version: