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ObjectId: 201833109349301428 - Submission: 2018-11-06
TIN: 26-1710013
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
MOSAIC HOUSING CORPORATION 17
Employer identification number
26-1710013
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)
MOSAIC
4980 S 118 STREET
OMAHA
,
NE
68137
11-3669999
SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
NE
501(C)(3)
LINE 10
N/A
No
(2)
MOSAIC FOUNDATION
4980 S 118 STREET
OMAHA
,
NE
68137
36-3837360
FUNDRAISING & INVESTMENT ASSET MANAGEMENT
NE
501(C)(3)
LINE 12A, I
MOSAIC
Yes
(3)
THE OAKS OF DUNN COUNTY
4980 S 118 STREET
OMAHA
,
NE
68137
39-1913323
SENIOR LIVING SERVICES
WI
501(C)(3)
LINE 10
MOSAIC
Yes
(4)
MOSAIC HOUSING CORPORATION I
4980 S 118 STREET
OMAHA
,
NE
68137
36-3756911
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(5)
MOSAIC HOUSING CORPORATION II
4980 S 118 STREET
OMAHA
,
NE
68137
47-0773689
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(6)
MOSAIC HOUSING CORPORATION IV
4980 S 118 STREET
OMAHA
,
NE
68137
91-1823422
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(7)
MOSAIC HOUSING CORPORATION VII
4980 S 118 STREET
OMAHA
,
NE
68137
47-0828015
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(8)
MOSAIC HOUSING CORPORATION VIII
4980 S 118 STREET
OMAHA
,
NE
68137
47-0828012
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(9)
MOSAIC HOUSING CORPORATION IX
4980 S 118 STREET
OMAHA
,
NE
68137
74-2838413
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(10)
MOSAIC HOUSING CORPORATION X
4980 S 118 STREET
OMAHA
,
NE
68137
74-2908789
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(11)
MOSAIC HOUSING CORPORATION XI
4980 S 118 STREET
OMAHA
,
NE
68137
31-1706640
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(12)
MOSAIC HOUSING CORPORATION XII
4980 S 118 STREET
OMAHA
,
NE
68137
48-1297244
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(13)
MOSAIC HOUSING CORPORATION XIII
4980 S 118 STREET
OMAHA
,
NE
68137
42-1626679
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(14)
MOSAIC HOUSING CORPORATION XIV
4980 S 118 STREET
OMAHA
,
NE
68137
20-4417891
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(15)
MOSAIC HOUSING CORPORATION XV
4980 S 118 STREET
OMAHA
,
NE
68137
20-5765691
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(16)
MOSAIC HOUSING CORPORATION XVI
4980 S 118 STREET
OMAHA
,
NE
68137
20-5765731
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(17)
MOSAIC HOUSING CORPORATION XVIII
4980 S 118 STREET
OMAHA
,
NE
68137
26-1710184
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(18)
MOSAIC HOUSING CORPORATION XIX
4980 S 118 STREET
OMAHA
,
NE
68137
26-1710259
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(19)
MOSAIC HOUSING CORPORATION XX
4980 S 118 STREET
OMAHA
,
NE
68137
26-4555206
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(20)
MOSAIC HOUSING CORPORATION XXI
4980 S 118 STREET
OMAHA
,
NE
68137
26-4555313
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(21)
MOSAIC HOUSING CORPORATION XXII
4980 S 118 STREET
OMAHA
,
NE
68137
27-3483415
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(22)
MOSAIC HOUSING CORPORATION XXIII
4980 S 118 STREET
OMAHA
,
NE
68137
71-0875364
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(23)
MOSAIC ILLINOIS HOUSING I
4980 S 118 STREET
OMAHA
,
NE
68137
20-2997161
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(24)
MOSAIC ILLINOIS HOUSING II
4980 S 118 STREET
OMAHA
,
NE
68137
20-4417645
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(25)
MOSAIC ILLINOIS HOUSING OF MACOMB I
4980 S 118 STREET
OMAHA
,
NE
68137
20-4841909
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(26)
MOSAIC ILLINOIS HOUSING OF ROCKFORD I
4980 S 118 STREET
OMAHA
,
NE
68137
20-4841856
LOW INCOME HOUSING
NE
501(C)(3)
LINE 10
MOSAIC
Yes
(27)
MOSAIC VEBA
4980 S 118 STREET
OMAHA
,
NE
68137
38-3831874
EMPLOYEE WELFARE BENEFIT PLAN
NE
501(C)(9)
N/A
MOSAIC
Yes
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)
MOSAIC RESIDENTIAL SERVICES OF NEBRASKA LLC
4980 S 118 ST
OMAHA
,
NE
68137
27-1695051
LOW INCOME HOUSING
NE
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)
EASE-E MEDICALINC
731 SOUTH 8TH STREET
CANON CITY
,
CO
81212
47-0842353
SALE OF MEDICAL EQUIPMENT & SUPPLIES
NE
N/A
C
Yes
(2)
MOSAIC HOUSING CORPORATION V
4980 S 118 ST
OMAHA
,
NE
68137
47-0805545
LOW INCOME HOUSING
NE
N/A
C
Yes
(3)
BICO
4980 S 118 ST
OMAHA
,
NE
68137
CAPTIVE INSURANCE
BD
N/A
C
Yes
(4)
CHARITABLE REMAINDER TRUSTS (5)
INVESTMENT MANAGEMENT
NE
N/A
T
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
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
No
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
No
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) 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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