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ObjectId: 201743179349302604 - Submission: 2017-11-13
TIN: 16-1523353
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
Mount St Mary's Hospital
of Niagara Falls
Employer identification number
16-1523353
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)
Catholic Health System Inc
144 Genesee Street
Buffalo
,
NY
14203
22-2565278
Health Care Delivery System
NY
501(c)(3)
Line 10
No
(2)
Mercy Hospital of Buffalo
565 Abbott Road
Buffalo
,
NY
14220
16-0756336
Acute Care Hospital
NY
501(c)(3)
Line 3
Catholic Health System Inc
No
(3)
Sisters Of Charity Hospital
2157 Main Street
Buffalo
,
NY
14214
16-0743187
Acute Care Hospital
NY
501(c)(3)
Line 3
Catholic Health System Inc
No
(4)
Kenmore Mercy Hospital
2950 Elmwood Avenue
Kenmore
,
NY
14217
16-0762843
Acute Care Hospital
NY
501(c)(3)
Line 3
Catholic Health System Inc
No
(5)
Nazareth Home of Franciscan Sisters
291 North Street
Buffalo
,
NY
14201
16-0813142
Skilled Nursing Facility
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(6)
St Elizabeth Home for the Aged
5539 Broadway
Lancaster
,
NY
14086
16-0743154
Adult Home
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(7)
St Francis Home of Williamsville
147 Reist St
Williamsville
,
NY
14221
16-0743153
Skilled Nursing Facility
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(8)
St Francis of Buffalo Inc
34 Benwood Ave
Buffalo
,
NY
14214
16-1523535
Skilled Nursing Facility
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(9)
St Vincent Manor
319 Washington Avenue
Dunkirk
,
NY
14048
16-0743167
Adult Home
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(10)
WNY Catholic Long Term Care Inc
6400 Powers Rd
Orchard Park
,
NY
14127
16-1434368
Skilled Nursing Facility
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(11)
Niagara Homemaker Services (Mercy Home Care)
144 Genesee Street
Buffalo
,
NY
14203
16-1317960
Home Care Provider
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(12)
McAuley Seton Home Care
144 Genesee Street
Buffalo
,
NY
14203
16-1310062
Home Care Provider
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(13)
Catholic Health System Infusion Pharmacy Inc
6350 Transit Road
Depew
,
NY
14043
20-0198518
Home Care Infusion Services
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(14)
OLV Renaissance Corporation
144 Genesee Street
Buffalo
,
NY
14203
20-0167745
Real Estate Holding Company
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(15)
CHS Program of All-Inclusive Care for the Elderly Inc
55 Melroy Avenue
Lackawanna
,
NY
14218
26-1252884
All-inclusive Care for the Elderly
NY
501(c)(3)
Line 3
Catholic Health System Inc
No
(16)
Trinity Medical WNY PC
2625 Harlem Rd
Cheektowaga
,
NY
14225
27-2576645
Primary Care Provider
NY
501(c)(3)
Line 12a, I
Catholic Health System Inc
No
(17)
KMH Homes Inc
144 Genesee Street
Buffalo
,
NY
14203
16-1387890
Real Estate Holding Company
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(18)
Mount St Mary's Hospital Foundation Inc
5300 Military Road
Lewiston
,
NY
14092
16-1360884
Foundation
NY
501(c)(3)
Line 7
Mount St Mary's Hospital of Niagara Falls
No
(19)
Mount St Mary's Hospital Child Care Center
5310 Military Road
Lewiston
,
NY
14092
16-1523352
Child Care
NY
501(c)(3)
Line 10
Catholic Health System Inc
No
(20)
Board of Associates of Mount St Mary's Hospital Inc
5300 Military Road
Lewiston
,
NY
14092
16-1582926
Fund Raising
NY
501(c)(3)
Line 12a, I
Mount St Mary's Hospital of Niagara Falls
No
(21)
The St Francis Guild of Mount St Mary's Hospital of Niagara Falls Inc
5300 Military Road
Lewiston
,
NY
14092
51-0217790
Fund Raising
NY
501(c)(3)
Line 12a, I
Mount St Mary's Hospital of Niagara Falls
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
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
No
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
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
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:
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