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ObjectId: 201823179349304587 - Submission: 2018-11-13
TIN: 38-1791480
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.
Go to
www.irs.gov/Form990
for the latest information.
OMB No. 1545-0047
20
17
Open to Public Inspection
Name of the organization
DELTA DENTAL PLAN OF MICHIGAN INC
Employer identification number
38-1791480
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)
RENAISSANCE HEALTH SERVICE CORPORATION
PO BOX 30416
LANSING
,
MI
489097916
38-1675667
PROMOTING DENTAL CARE
MI
501(C)(4)
N/A
N/A
No
(2)
DELTA DENTAL PLAN OF OHIO INC
PO BOX 30416
LANSING
,
MI
489097916
31-0685339
PROVIDE DENTAL SERVICE PLANS
OH
501(C)(4)
N/A
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(3)
DELTA DENTAL PLAN OF INDIANA INC
PO BOX 30416
LANSING
,
MI
489097916
35-1545647
PROVIDE DENTAL SERVICE PLANS
IN
501(C)(4)
N/A
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(4)
DELTA DENTAL OF TENNESSEE
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
62-0812197
PROVIDE DENTAL SERVICE PLANS
TN
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(5)
DELTA DENTAL FUND
PO BOX 30416
LANSING
,
MI
489097916
38-2337000
SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS
MI
501(C)(3)
LINE 12B, II
DELTA DENTAL PLAN OF MICHIGAN INC
Yes
(6)
DELTA DENTAL PLAN OF NEW MEXICO INC
2500 LOUISIANA BLVD NE
ALBUQUERQUE
,
NM
87110
85-0224562
PROVIDE DENTAL SERVICE PLANS
NM
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(7)
DELTA DENTAL OF KENTUCKY INC
10100 LINN STATION ROAD NO 700
LOUISVILLE
,
KY
40223
61-0659432
PROVIDE DENTAL SERVICE PLANS
KY
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(8)
DELTA DENTAL OF NORTH CAROLINA
4242 SIX FORKS ROAD
RALEIGH
,
NC
27609
56-1018068
PROVIDE DENTAL SERVICE PLANS
NC
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(9)
DELTA DENTAL PLAN OF ARKANSAS INC
1513 COUNTRY CLUB RD
SHERWOOD
,
AR
72120
71-0561140
PROVIDE DENTAL SERVICE PLANS
AR
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(10)
DELTA DENTAL OF ARKANSAS FOUNDATION INC
1513 COUNTRY CLUB RD
SHERWOOD
,
AR
72120
26-1569324
EMPHASIZE DENTAL HEALTH IN COMMUNITIES
AR
501(C)(3)
PF
DELTA DENTAL OF ARKANSAS
No
(11)
RENAISSANCE FAMILY FOUNDATION INC
4100 OKEMOS RD
OKEMOS
,
MI
48864
46-1376165
EMPHASIZE DENTAL HEALTH IN COMMUNITIES
IN
501(C)(3)
PF
RENAISSANCE HOLDING COMPANY
No
(12)
SMILE 180 FOUNDATION
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
47-1654054
EMPHASIZE DENTAL HEALTH IN COMMUNITIES
TN
501(C)(3)
LINE 12A, I
DELTA DENTAL OF TENNESSEE INC
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2017
Page 2
Schedule R (Form 990) 2017
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)
CHESME LLC
124 N BRIDGE ST
DEWITT
,
MI
48820
20-0061957
CAPITAL MANAGEMENT
MI
GLM HOLDING COMPANY
RELATED
213,601
3,120,455
No
No
79.000 %
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)
RENAISSANCE HOLDING COMPANY
PO BOX 30381
LANSING
,
MI
48909
41-2177193
HOLDING COMPANY
MI
RENAISSNCE HEALTH SERVICE CORPORATION
C
-651,618
37,858,683
58.000 %
Yes
(2)
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA
PO BOX 30381
LANSING
,
MI
48909
47-0397286
INSURANCE
IN
RENAISSANCE HOLDING COMPANY
C
3,926,892
58,687,727
58.000 %
Yes
(3)
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK
PO BOX 30381
LANSING
,
MI
48909
13-4098096
INSURANCE
NY
RENAISSANCE HOLDING COMPANY
C
333,592
6,040,094
58.000 %
Yes
(4)
FORE HOLDING CORPORATION
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
20-4116122
HOLDING COMPANY
TN
N/A
C
No
(5)
DENTAL CHOICE INC
10100 LINN STATION ROAD SUITE 700
LOUISVILLE
,
KY
40223
61-1105118
PROVIDE DENTAL SERVICE PLANS
KY
N/A
C
No
(6)
DENTAL CHOICE AGENCY INC
10100 LINN STATION RD SUITE 700
LOUISVILLE
,
KY
40223
61-1336003
PRIMARY GENERAL AGENCY FOR DDKY & DENTAL CHOICE
KY
N/A
C
No
(7)
OMEGA ADMINISTRATORS INC
1513 COUNTRY CLUB ROAD
SHERWOOD
,
AR
72120
04-3740469
PROVIDING THIRD-PARTY ADMINISTRATIVE SERVICES
AR
N/A
C
No
(8)
GLM HOLDING COMPANY
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
47-2557772
INVESTMENT IN SUBSIDIARIES
MI
DELTA DENTAL OF MICHIGAN
C
-18,082
20,281,924
75.000 %
Yes
(9)
DEWPOINT INC
300 S WASHINGTON SQUARE
LANSING
,
MI
48933
38-3300595
IT CONSULTING
MI
GLM HOLDING COMPANY
C
5,595,476
36,572,036
75.000 %
Yes
Schedule R (Form 990) 2017
Page 3
Schedule R (Form 990) 2017
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
Yes
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
No
q
Reimbursement paid by related organization(s) for expenses
............................
1q
No
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)
DELTA DENTAL OF TENNESSEE
L
4,145,439
ACTUAL COST
(2)
DELTA DENTAL PLAN OF OHIO INC
L
29,724,843
ACTUAL COST
(3)
DELTA DENTAL PLAN OF INDIANA INC
L
11,056,946
ACTUAL COST
(4)
DELTA DENTAL FUND
L
368,562
ACTUAL COST
(5)
RENAISSANCE LIFE AND HEALTH INSURANCE COMPANY OF AMERICA
L
4,955,356
ACTUAL COST
(6)
DELTA DENTAL PLAN OF NEW MEXICO INC
L
1,445,503
ACTUAL COST
(7)
DELTA DENTAL OF KENTUCKY INC
L
2,297,726
ACTUAL COST
(8)
DELTA DENTAL OF NORTH CAROLINA
L
2,521,275
ACTUAL COST
(9)
RENAISSANCE ELECTRONIC SERVICES LLC
L
96,852
ACTUAL COST
(10)
DELTA DENTAL PLAN OF ARKANSAS INC
L
6,041,078
ACTUAL COST
(11)
DELTA DENTAL OF NORTH CAROLINA
D
810,000
ACTUAL LOAN AMOUNT
(12)
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK
L
69,160
ACTUAL COST
(13)
RENAISSANCE HOLDING COMPANY
L
611,738
ACTUAL COST
(14)
DELTA DENTAL OF NORTH CAROLINA
A
147,600
ACTUAL COST
(15)
RENAISSANCE HEALTH SERVICE CORPORATION
L
18,009
ACTUAL COST
(16)
DELTA DENTAL FUND
B
10,000,000
ACTUAL COST
Schedule R (Form 990) 2017
Page 4
Schedule R (Form 990) 2017
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) 2017
Page 5
Schedule R (Form 990) 2017
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) 2017
Additional Data
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