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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
SchKMediumBullet Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet Attach to Form 990.
SchKMediumBulletGo to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2018
Open to Public
Inspection
Name of the organization
Mountain States Health Alliance
dba Johnson City Medical Center
Employer identification number
62-0476282
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 Hlth & Edu Facil Bd 2012
  		62-1464028 478271JV2 09-18-2012 94,745,050 Construction & Equip   X   X   X
Part Ⅱ
Proceeds
A B C D
1 Amount of bonds retired .................. 37,880,000      
2 Amount of bonds legally defeased ..............        
3 Total proceeds of issue .................. 95,337,514      
4 Gross proceeds in reserve funds .............        
5 Capitalized interest from proceeds .............        
6 Proceeds in refunding escrows ...............        
7 Issuance costs from proceeds ............... 1,889,665      
8 Credit enhancement from proceeds .............        
9 Working capital expenditures from proceeds .............        
10 Capital expenditures from proceeds ............. 89,474,759      
11 Other spent proceeds .............        
12 Other unspent proceeds .............        
13 Year of substantial completion ............. 2016
Yes No Yes No Yes No Yes No
14 Were the bonds issued as part of a current refunding issue? ....   X            
15 Were the bonds issued as part of an advance refunding issue? .....   X            
16 Has the final allocation of proceeds been made? .......... X              
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .................. 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            
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............   X            
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2018
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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              
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              
c Are there any research agreements that may result in private business use of bond-financed property? .............   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?                
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 ....SchKMediumBullet        
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 ......... SchKMediumBullet        
6 Total of lines 4 and 5 .............        
7 Does the bond issue meet the private security or payment test? ...   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            
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? .............                
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              
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            
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? .....                
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?   X            
b Name of provider ..........  
  		 
  		 
  		 
 
c Term of hedge .........        
d Was the hedge superintegrated? ......                
e Was the hedge terminated? ........                
Schedule K (Form 990) 2018
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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            
b Name of provider ..........  
  		 
  		 
  		 
 
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            
7 Has the organization established written procedures to monitor the requirements of section 148? ... 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              
Part Ⅵ
Supplemental Information. Provide additional information for responses to questions on Schedule K (see instructions).
Return Reference Explanation
Part VI Schedule K - Date Rebate Computation Performed Hlth & Edu. Facil. Bd. 2012A&B&C 11/28/17Schedule K - Additional Information Hlth & Edu. Facil. Bd. 2012A&B&CConstruct and equip surgery center at Johnson City Medical Center;Construct and equip hospital facilities, including refinancing of taxble indebtedness relating thereto1. Comment on Part I, Line A.In 2012, when the bonds referenced in Schedule K were issued, Mountain States Health Alliance owned and/or operated hospitals in a number of different locations both in Tennessee and in Virginia. As a result, Mountain States Health Alliance utilized conduit governmental bond issuers in multiple jurisdictions in order to finance improvements to its hospital facilities. In 2012, Mountain States Health Alliance was the conduit borrower of tax-exempt bonds issued by multiple issuers in Tennessee and Virginia. For federal tax purposes, even though different government issuers were involved, these multiple issues in each year were required to be treated, and were treated, as a single "issue" because they met the single "issue" test under the applicable federal tax regulations. Therefore, multiple issuers are listed under Line A because the bonds that were issued were part of a single "issue" for federal tax purposes.Additional Issuer EIN: 54-1276910Additional CUSIP#s: 478271JWO; 977220AA02. Comment on Part II, Line 3. Line 3 for the listed bond issues does not match the applicable issue price for such bond issue because of interest earnings earned on the proceeds of such bonds.
Schedule K (Form 990) 2018

Additional Data


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