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ObjectId: 201743199349310249 - Submission: 2017-11-15
TIN: 15-0533578
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
LITTLE FALLS HOSPITAL
Employer identification number
15-0533578
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)
BASSETT HEALTHCARE NETWORK
ONE ROCKEFELLER PLAZA 31ST FLOOR
NEW YORK
,
NY
10020
13-3218680
SUPPORTING ORGANIZATION
NY
501 (C) 3
11 C
N/A
No
(2)
FRIENDS OF BASSETT
ONE ATWELL ROAD
COOPERSTOWN
,
NY
13326
23-7041610
FUND RAISING ORGANIZATION
NY
501 (C) 3
7
BASSETT HEALTHCARE NETWORK
No
(3)
MARY IMOGENE BASSETT HOSPITAL
ONE ATWELL ROAD
COOPERSTOWN
,
NY
13326
13-5596796
HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES
NY
501 (C) 3
3
BASSETT HEALTHCARE NETWORK
No
(4)
AURELIA OSBORN FOX MEMORIAL HOSPITAL SOCIETY
ONE NORTON AVENUE
ONEONTA
,
NY
13820
15-0539039
HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES
NY
501 (C) 3
3
BASSETT HEALTHCARE NETWORK
No
(5)
TEMPLETON FOUNDATION
ONE ATWELL ROAD
COOPERSTOWN
,
NY
13326
13-3317084
FACILITIES / OFFICE SPACE
NY
501 (C) 3
9
BASSETT HEALTHCARE NETWORK
No
(6)
BASSETT REGIONAL CORPORATION
ONE ATWELL ROAD
COOPERSTOWN
,
NY
13326
13-3522783
PROVIDES EXCELLENCE IN THE COORDINATION PLANNING AND POLICY DIRECTION FOR
NY
501 (C) 3
11 (B)
BASSETT HEALTHCARE NETWORK
No
(7)
COBLESKILL REGIONAL HOSPITAL
178 GRANDVIEW DRIVE
COBLESKILL
,
NY
12043
14-1772971
HEALTHCARE SERVICES OFFERING INPATEINT AND OUTPATIENT SERVICES
NY
501 (C) 3
3
BASSETT REGIONAL CORPORATION
No
(8)
O'CONNOR HOSPITAL
460 ANDES ROAD
DELHI
,
NY
13753
16-1540394
HEALTH CARE ORGANIZATION OFFERING INPATIENT AND OUTPATIENT SERVICES
NY
501 (C) 3
3
BASSETT REGIONAL CORPORATION
No
(9)
TRI TOWN REGIONAL HEALTHCARE
43 PEARL STREET
SYNDEY
,
NY
13838
26-0169584
HEALTHCARE SERVICES OFFERING OUTPATIENT SERVICES
NY
501 (C) 3
3
BASSETT REGIONAL CORPORATION
No
(10)
VALLEY HEALTH SERVICES
690 GERMAN STREET
HERKIMER
,
NY
13350
22-2511614
NURSING HOME
NY
501 (C) 3
3
BASSETT REGIONAL CORPORATION
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
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
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
Yes
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) 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
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