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ObjectId: 201823199349311632 - Submission: 2018-11-15
TIN: 20-8316475
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
MAPLE GROVE HOSPITAL CORPORATION
Employer identification number
20-8316475
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)
NORTH MEMORIAL HEALTH CARE
3300 OAKDALE AVENUE NORTH
ROBBINSDALE
,
MN
55422
41-0729979
ACUTE CARE
MN
501(C)(3)
LINE 3
NORTH MEMORIAL
No
(2)
NORTH MEMORIAL FOUNDATION
3300 OAKDALE AVENUE NORTH
ROBBINSDALE
,
MN
55422
41-1777966
FUNDRAISING
MN
501(C)(3)
LINE 7
NORTH MEMORIAL
No
(3)
ASSOCIATED HEALTH ASSURANCE
3300 OAKDALE AVENUE NORTH
ROBBINSDALE
,
MN
55422
98-0343815
INSURANCE
BD
501(C)(3)
LINE 12B, II
NORTH MEMORIAL
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)
NORTH MEMORIAL AMBULATORY SURGERY CENTER AT MAPLE GROVE LLC
9855 HOSPITAL DRIVE
MAPLE GROVE
,
MN
55369
26-0393039
OUTPATIENT SURGERY
MN
N/A
(2)
MINNESOTA DIAGNOSTIC IMAGING PARTNERS LLC
2955 XENIUM LANE SUITE 40
PLYMOUTH
,
MN
55441
35-2162215
RADIOLOGY
MN
N/A
(3)
NORTH RADIATION THERAPY CENTER
6950 FRANCE AVE S SUITE 200
EDINA
,
MN
55435
74-3069974
RADIOLOGY
MN
N/A
(4)
BLAINE URGENCY CENTER LLC
480 OSBORNE RD NE
FRIDLEY
,
MN
55432
46-1630126
URGENT CARE
MN
N/A
(5)
PLYMOUTH CITY CENTER MEDICAL BUILDING
5700 SMETANA DRIVE SUITE 120
MINNETONKA
,
MN
55343
46-3883617
MEDICAL OFFICE BUILDING
MN
N/A
(6)
MINNETONKA AMBULATORY SURGERY CENTER
3300 OAKDALE AVE NORTH
ROBBINSDALE
,
MN
55422
46-5653486
OUTPATIENT SURGERY
MN
N/A
(7)
CRYSTAL IMAGING CENTER LLC
2955 XENIUM LANE SUITE 40
PLYMOUTH
,
MN
55441
45-4265124
RADIOLOGY
MN
N/A
(8)
MULTICARE SLEEP CENTER LLC
10600 OLD COUNTY ROAD 15
PLYMOUTH
,
MN
55441
27-4833673
OUTPATIENT SLEEP CENTER
MN
N/A
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)
OAKDALE HEALTH ENTERPRISES INC
3300 OAKDALE AVENUE NORTH
ROBBINSDALE
,
MN
55422
41-1546422
AMBULANCE
MN
N/A
C
No
(2)
NORTH COLLABORATIVE CARE
3300 OAKDALE AVENUE NORTH
ROBBINSDALE
,
MN
55422
46-1680666
PRIMARY CARE
MN
N/A
C
No
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
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
Yes
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
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
No
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
No
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
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)
NORTH MEMORIAL HEALTH CARE (CASH TRANSFER)
B
22,800,000
CASH
(2)
NORTH MEMORIAL HEALTH CARE (DEBT GUARANTEE)
E
89,512,500
AMOUNT GUARANTEE
(3)
NORTH MEMORIAL HEALTH CARE (LEASE PAYMENTS)
K
458,957
AMOUNT PAID
(4)
NORTH MEMORIAL HEALTH CARE (MANAGEMENT FEE)
R
18,560,617
AMOUNT PAID
(5)
NORTH MEMORIAL HEALTH CARE (SALARY REIMBURSEMENT)
P
11,880,518
AMOUNT PAID
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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