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ObjectId: 201923129349302842 - Submission: 2019-11-08
TIN: 62-0812197
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 instructions and the latest information.
OMB No. 1545-0047
20
18
Open to Public Inspection
Name of the organization
DELTA DENTAL OF TENNESSEE INC
Employer identification number
62-0812197
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
(1)
LIQUID CORN LLC
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
20-3349680
OWNS SUITE 244
TN
0
157
FORE HOLDING CORPORATION
(2)
PREMIER INSURANCE SERVICES LLC
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
11-3662057
INSURANCE BROKER
TN
-1,250
49,916
FORE HOLDING CORPORATION
(3)
SUITE 244 PARTNERS LLC
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
20-3643584
HOLDS THE LEASE TO SUITE 244 AT LP FIELD (TITANS STADIUM)
TN
0
0
FORE HOLDING CORPORATION
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)
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
No
(2)
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
No
(3)
DELTA DENTAL PLAN OF MICHIGAN INC
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
38-1791480
PROVIDE DENTAL SERVICE PLANS
MI
501(C)(4)
N/A
RENAISSANCE HEALTH SERVICE CORPORATION
No
(4)
DELTA DENTAL FUND
PO BOX 30416
LANSING
,
MI
489097916
38-2337000
SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS
MI
501(C)(3)
LINE 12A, I
DELTA DENTAL PLAN OF MICHIGAN INC
No
(5)
RENAISSANCE HEALTH SERVICE CORPORATION
PO BOX 30416
LANSING
,
MI
489097916
38-1675667
PROMOTING DENTAL CARE
MI
501(C)(4)
N/A
N/A
No
(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
RENAISSANCE HEALTH SERVICE CORPORATION
No
(11)
RENAISSANCE FAMILY FOUNDATION INC
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
46-1376165
EMPHASIZE DENTAL HEALTH IN COMMUNITIES
MI
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
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2018
Page 2
Schedule R (Form 990) 2018
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
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)
FORE HOLDING CORPORATION
240 VENTURE CIRCLE
NASHVILLE
,
TN
37228
20-4116122
HOLDING COMPANY
TN
DELTA DENTAL OF TENNESSEE
C
-307,883
11,159,863
100.000 %
Yes
(2)
RENAISSANCE HOLDING COMPANY
PO BOX 30381
LANSING
,
MI
48909
41-2177193
HOLDING COMPANY
MI
N/A
C
No
(3)
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA
PO BOX 30381
LANSING
,
MI
48909
47-0397286
INSURANCE
IN
N/A
C
No
(4)
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK
PO BOX 30381
LANSING
,
MI
48909
13-4098096
INSURANCE
NY
N/A
C
No
(5)
DENTAL CHOICE INC
10100 LINN STATION RD 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)
THE 4100 GROUP
4100 OKEMOS ROAD
OKEMOS
,
MI
48864
47-2557772
INVESTMENT IN SUBSIDIARIES
MI
N/A
C
No
(9)
DEWPOINT INC
300 S WASHINGTON SQUARE
LANSING
,
MI
48933
38-3300595
IT CONSULTING
MI
N/A
C
No
Schedule R (Form 990) 2018
Page 3
Schedule R (Form 990) 2018
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
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
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 PLAN OF MICHIGAN INC
M
4,615,698
ACTUAL COST
(2)
SMILE 180 FOUNDATION
B
3,900,000
ACTUAL COST
(3)
SMILE 180 FOUNDATION
O
218,945
ACTUAL COST
(4)
DELTA DENTAL OF NORTH CAROLINA
A
56,800
ACTUAL COST
(5)
DELTA DENTAL OF NORTH CAROLINA
D
40,000
ACTUAL COST
Schedule R (Form 990) 2018
Page 4
Schedule R (Form 990) 2018
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) 2018
Page 5
Schedule R (Form 990) 2018
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) 2018
Additional Data
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