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ObjectId: 201913199349302206 - Submission: 2019-11-15
TIN: 22-1487322
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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
Complete if the organization answered "Yes" to Form 990, Part
Ⅵ
, line 24a. Provide descriptions,
explanations, and any additional information in Part
Ⅵ
.
Attach to Form 990.
Go to
www.irs.gov/Form990
for the latest information.
OMB No. 1545-0047
20
18
Open to Public
Inspection
Name of the organization
HOLY NAME MEDICAL CENTER
Employer identification number
22-1487322
Part
Ⅰ
Bond Issues
(a)
Issuer name
(b)
Issuer EIN
(c)
CUSIP #
(d)
Date issued
(e)
Issue price
(f)
Description of purpose
(g)
Defeased
(h)
On
behalf of
issuer
(i)
Pool
financing
Yes
No
Yes
No
Yes
No
A
NJ HEALTH CARE FACILITIES FINANCING AUTHORITY
22-1987084
64579FH89
09-02-2010
55,971,065
SEE SUPPLEMENTAL INFO
X
X
X
B
NJ HEALTH CARE FACILITIES FINANCING AUTHORITY
22-1987084
07-12-2016
54,425,000
SEE SUPPLEMENTAL INFO
X
X
X
Part
Ⅱ
Proceeds
A
B
C
D
1
Amount of bonds retired
..................
47,290,816
61,783,892
2
Amount of bonds legally defeased
..............
0
0
3
Total proceeds of issue
..................
55,971,117
54,425,000
4
Gross proceeds in reserve funds
.............
0
0
5
Capitalized interest from proceeds
.............
0
0
6
Proceeds in refunding escrows
...............
0
0
7
Issuance costs from proceeds
...............
1,242,174
597,834
8
Credit enhancement from proceeds
.............
0
0
9
Working capital expenditures from proceeds
.............
0
0
10
Capital expenditures from proceeds
.............
7,560,834
0
11
Other spent proceeds
.............
47,290,816
0
12
Other unspent proceeds
.............
0
0
13
Year of substantial completion
.............
2010
2016
Yes
No
Yes
No
Yes
No
Yes
No
14
Were the bonds issued as part of a current refunding issue?
....
X
X
15
Were the bonds issued as part of an advance refunding issue?
.....
X
X
16
Has the final allocation of proceeds been made?
..........
X
X
17
Does the organization maintain adequate books and records to support the final allocation of proceeds?
..................
X
X
Part
Ⅲ
Private Business Use
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
1
Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds?
.............
X
X
2
Are there any lease arrangements that may result in private business use of bond-financed property?
...............
X
X
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2018
Page 2
Schedule K (Form 990) 2018
Page
2
Part
Ⅲ
Private Business Use
(Continued)
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
3a
Are there any management or service contracts that may result in private business use of bond-financed property?
.............
X
X
b
If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
X
X
c
Are there any research agreements that may result in private business use of bond-financed property?
.............
X
X
d
If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
X
X
4
Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government
....
0.600 %
0.600 %
5
Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government
.........
6
Total of lines 4 and 5
.............
0.600 %
0.600 %
7
Does the bond issue meet the private security or payment test?
...
X
X
8a
Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were
issued?
.............
X
X
b
If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of.
..
c
If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2?
.............
X
X
9
Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
........
X
X
Part
Ⅳ
Arbitrage
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
1
Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate?
...
X
X
2
If "No" to line 1, did the following apply?
....
a
Rebate not due yet?
.......
X
b
Exception to rebate?
........
X
c
No rebate due?
.........
X
If "Yes" to line 2c, provide in Part
Ⅵ
the date the rebate
computation was performed
......
3
Is the bond issue a variable rate issue?
.....
X
X
4a
Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?
X
X
b
Name of provider
..........
0
0
c
Term of hedge
.........
d
Was the hedge superintegrated?
......
e
Was the hedge terminated?
........
Schedule K (Form 990) 2018
Page 3
Schedule K (Form 990) 2018
Page
3
Part
Ⅳ
Arbitrage
(Continued)
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
5a
Were gross proceeds invested in a guaranteed investment contract (GIC)?
X
X
b
Name of provider
..........
0
0
c
Term of GIC
.........
d
Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied?
........
6
Were any gross proceeds invested beyond an available temporary period?
X
X
7
Has the organization established written procedures to monitor the requirements of section 148?
...
X
X
Part
Ⅴ
Procedures To Undertake Corrective Action
---------------------------------------------------------------------------------------------------------------
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?
X
X
Part
Ⅵ
Supplemental Information.
Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference
Explanation
Schedule K (Form 990) 2018
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