SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2018
Open to Public Inspection
Name of the organization
FORT MADISON COMMUNITY HOSPITAL
 
Employer identification number

42-1081055
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)FORT MADISON COMMUNITY HOSPITAL FOUNDATION
5445 AVENUE O PO BOX 174

FORT MADISON,IA52627
42-1446727 		SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) LINE 12A, I FORT MADISON COMMUNITY HOSPITAL
 
Yes
 
(2)GREAT RIVER HEALTH SYSTEM INC
1221 SOUTH GEAR AVENUE

WEST BURLINGTON,IA52655
42-1193185 		HOLDING COMPANY IA 501(C)(3) LINE 12B, II N/A
 
No
(3)GREAT RIVER MEDICAL CENTER
1221 SOUTH GEAR AVENUE

WEST BURLINGTON,IA52655
42-0680407 		HOSPITAL IA 501(C)(3) LINE 3 GREAT RIVER HEALTH SYSTEM INC
 
Yes
 
(4)GRMC FOUNDATION CORP
1221 SOUTH GEAR AVENUE

WEST BURLINGTON,IA52655
42-1193186 		SUPPORT RELATED ORGANIZATIONS IA 501(C)(3) LINE 12B, II GREAT RIVER HEALTH SYSTEM INC
 
Yes
 
(5)GREAT RIVER FOUNDATION INC
1221 SOUTH GEAR AVENUE

WEST BURLINGTON,IA52655
42-1469162 		SUPPORT FORT MADISON COMMUNITY HOSPITAL IA 501(C)(3) LINE 12B, II GREAT RIVER HEALTH SYSTEM INC
 
Yes
 
(6)GRHS-FMCH COMMUNITY HEALTH FOUNDATION
5445 AVENUE O

FORT MADISON,IA52627
83-2357759 		SPONSORS HEALTH INITIATIVES IN LEE COUNTY, IA IA 501(C)(3) LINE 12B, II GREAT RIVER HEALTH SYSTEM 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












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) RIVERVIEW SYSTEMS LTD

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1191960 		MEDICAL SERVICES IA N/A
 C       Yes  
(2) GREAT RIVER MEDICAL SERVICES INC

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1493449 		MEDICAL SERVICE IA N/A
 C       Yes  
(3) MUTUAL CONSULTING AND MANAGEMENT SERVICES

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1349668 		MANAGEMENT SERVICES IA N/A
 C       Yes  
(4) HEALTH CARE REALTY

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1193532 		REAL ESTATE IA N/A
 C       Yes  
(5) HERITAGE PARK PHARMACY

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1191957 		PHARMACY IA N/A
 C       Yes  
(6) HERITAGE MEDICAL EQUIPMENT AND SUPPLY

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1191958 		MEDICAL SUPPLY IA N/A
 C       Yes  
(7) SOUTHEASTERN IOWA MEDICAL SERVICES

1221 SOUTH GEAR AVENUE
WEST BURLINGTON,IA52655
42-1307141 		PHYSICIAN CLINICS IA N/A
 C       Yes  
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
Yes
 
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
 
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
 
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
Yes
 
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
 
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) GREAT RIVER MEDICAL CENTER

 A 47,903 FAIR MARKET VALUE
(2) GRHS-FMCH COMMUNITY HEALTH FOUNDATION

 B 2,000,000 FAIR MARKET VALUE
(3) GREAT RIVER HEALTH SYSTEM INC

 C 12,800,000 FAIR MARKET VALUE
(4) GREAT RIVER MEDICAL CENTER

 E 3,100,000 FAIR MARKET VALUE
(5) MUTUAL CONSULTING AND MANAGEMENT SERVICES INC

 O 186,510 FAIR MARKET VALUE
(6) MUTUAL CONSULTING AND MANAGEMENT SERVICES INC

 P 417,358 FAIR MARKET VALUE
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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