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ObjectId: 202113199349329431 - Submission: 2021-11-15
TIN: 37-1119538
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
20
Open to Public Inspection
Name of the organization
THE CARLE FOUNDATION HOSPITAL
Employer identification number
37-1119538
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)
THE CARLE FOUNDATION
611 W PARK ST
URBANA
,
IL
61801
37-0673465
PARENT/INVMGT
IL
501(c)(3)
12c, III-FI
NA
No
(2)
THE CARLE DEVELOPMENT FOUNDATION
611 W PARK ST
URBANA
,
IL
61801
37-1159978
FUNDRAISING
IL
501(c)(3)
7
TCF
Yes
(3)
CARLE HEALTH CARE INCORPORATED
611 W PARK ST
URBANA
,
IL
61801
37-1140016
VAR MED SVCS
IL
501(C)(3)
10
TCF
Yes
(4)
CARLE RETIREMENT CENTERS INC
611 W PARK ST
URBANA
,
IL
61801
37-1160033
RTRMT LIVING
IL
501(C)(3)
10
TCF
Yes
(5)
CARLE COMMUNITY HEALTH CORPORATION
611 W PARK ST
URBANA
,
IL
61801
36-4458371
FNDN MISSION
IL
501(C)(3)
12a, Type I
TCDF
Yes
(6)
HOOPESTON COMMUNITY MEMORIAL HOSPITAL
701 E ORANGE ST
HOOPESTON
,
IL
60942
36-3637465
HOSPITAL SVCS
IL
501(C)(3)
3
TCF
Yes
(7)
RICHLAND MEMORIAL HOSPITAL INC
800 EAST LOCUST STREET
OLNEY
,
IL
64250
37-1363001
HOSPITAL SVCS
IL
501(C)(3)
3
TCF
Yes
(8)
CARLE BROMENN MEDICAL CENTER
611 W Park Street
Urbana
,
IL
618012595
85-0682363
Hospital SVCS
IL
501c(3)
3
TCF
Yes
(9)
CARLE EUREKA HOSPITAL
611 W Park Street
Urbana
,
IL
618012595
85-0688306
Hospital svcs
IL
501c(3)
3
TCF
Yes
(10)
COMMUNITY CANCER CENTER LLC
407 E VERNON AVE
NORMAL
,
IL
61761
37-1363717
Cancer trmt
IL
501c(3)
12a Type I
TCF
Yes
(11)
COMMUNITY CANCER CENTER FOUNDATION
407 E VERNON AVE
NORMAL
,
IL
61761
36-4425147
Fundraising
IL
501c(3)
7
CCC LLC
Yes
(12)
CARLE WEST PHYSICIAN GROUP INC
611 W Park Street
Urbana
,
IL
618012595
85-0703768
Phys Services
IL
501c(3)
10
CHCI
Yes
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2020
Page 2
Schedule R (Form 990) 2020
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)
CHAMPAIGN SURGICNTR
611 w park st
urbana
,
IL
618012595
20-1915925
surgical ctr
IL
NA
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)
HEALTH SYSTEMS INSURANCE LIMITED
governors sq 2nd fl bldg 3
grand cayman
ky1-1102
CJ
INSURANCE
CJ
NA
C CORP
Yes
(2)
CARLE RISK MANAGEMENT COMPANY
611 W PARK ST
URBANA
,
IL
618012595
37-1217973
RISK MANAGEMENT
IL
TCFH
C CORP
2,872,155
303,469
100.000 %
Yes
(3)
EVALIDATA INC
611 W PARK ST
URBANA
,
IL
618012595
46-2022658
PHYS CREDENTIAL
IL
TCFH
C CORP
369,472
51,802
100.000 %
Yes
(4)
CHA HOLDING INC
3310 SOUTH FIELDS DR
CHAMPAIGN
,
IL
61822
47-1854275
HOLDING CO
IL
NA
C CORP
Yes
(5)
CARLE HOLDING COMPANY INC
611 W PARK ST
URBANA
,
IL
618012595
37-1188284
HOLDING CO
IL
NA
C CORP
Yes
(6)
HEALTH ALLIANCE MEDICAL PLANS INC
3310 SOUTH FIELDS DR
CHAMPAIGN
,
IL
61822
37-1260731
HEALTH COVERAGE
IL
NA
C CORP
Yes
(7)
HEALTH ALLIANCE CONNECT INC
3310 SOUTH FIELDS DR
CHAMPAIGN
,
IL
61822
46-4796891
HEALTH CARE COORD
IL
NA
C CORP
Yes
(8)
HEALTH ALLIANCE NORTHWEST HOLDING
820 N CHELAN AVE
WENATCHEE
,
WA
98801
46-1717578
HOLDING CO
WA
NA
C CORP
Yes
(9)
HEALTH ALLIANCE NORTHWEST HEALTH PLAN
820 N CHELAN AVE
WENATCHEE
,
WA
98801
46-1966323
HEALTH COVERAGE
WA
NA
C CORP
Yes
(10)
HEALTH ALLIANCE MIDWEST INC
3310 South Fields Dr
Champaign
,
IL
61822
37-1354502
HEALTH COVERAGE
IL
NA
C CORP
Yes
(11)
BROMENN PHYSICIANS MANAGEMENT CORP
611 W Park Street
Urbana
,
IL
618012595
37-1313150
Health Care Pship
IL
TCF
C Corp
Yes
(12)
CARLE HEALTH PHYSICIAN PARTNERS INC
611 W Park Street
Urbana
,
IL
618012595
85-0718392
PHYS SERVICES
IL
TCF
C Corp
Yes
(13)
FIRST CAROLINA CARE INSURANCE COMPANY
42 Memorial Drive
Pinehurst
,
NC
28374
33-1160597
Insurance
IL
CHA Holding
C Corp
Yes
Schedule R (Form 990) 2020
Page 3
Schedule R (Form 990) 2020
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
No
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
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
Yes
l
Performance of services or membership or fundraising solicitations for related organization(s)
.....................
1l
Yes
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
No
p
Reimbursement paid to related organization(s) for expenses
............................
1p
Yes
q
Reimbursement paid by related organization(s) for expenses
............................
1q
Yes
r
Other transfer of cash or property to related organization(s)
............................
1r
Yes
s
Other transfer of cash or property from related organization(s)
............................
1s
Yes
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)
HEALTH ALLIANCE MEDICAL PLANS
A
6,148
BOOK
(2)
CARLE COMMUNITY HEALTH CORP
C
2,618,160
BOOK
(3)
CARLE FOUNDATION DEVELOPMENT
C
1,111,134
BOOK
(4)
HEALTH ALLIANCE MEDICAL PLANS
L
119,075,906
BOOK
(5)
HEALTH ALLIANCE CONNECT INC
L
53,039,025
BOOK
(6)
CARLE HEALTH CARE INCORPORATED
L
3,498,989
BOOK
(7)
HOOPESTON COMMUNITY MEMORIAL HOSPITAL
L
1,044,531
BOOK
(8)
CHAMPAIGN SURGICENTER LLC
L
845,710
BOOK
(9)
CARLE HEALTH CARE INCORPORATED
M
12,805,163
BOOK
(10)
HEALTH SYSTEMS INSURANCE LIMITED
M
924,051
BOOK
(11)
CARLE HEALTH CARE INCORPORATED
P
1,106,036
BOOK
(12)
HOOPESTON COMMUNITY MEMORIAL HOSPITAL
Q
75,960
BOOK
(13)
HOOPESTON COMMUNITY MEMORIAL HOSPITAL
R
882,800
BOOK
(14)
CARLE HEALTH CARE INCORPORATED
R
466,623
BOOK
(15)
CHAMPAIGN SURGICENTER LLC
R
209,496
BOOK
(16)
RICHLAND MEMORIAL HOSPITAL
R
72,631
BOOK
(17)
RICHLAND MEMORIAL HOSPITAL
S
237,241
BOOK
Schedule R (Form 990) 2020
Page 4
Schedule R (Form 990) 2020
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) 2020
Page 5
Schedule R (Form 990) 2020
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
Schedule R, Supplemental Information
SCHEDULE R, PART II CARLE HEALTH CARE INCORPORATED PRIMARY ACTIVITY: EMERGENCY TRANSPORT, DAY CARE, PHYSICIAN SERVICES.
Schedule R (Form 990) 2020
Additional Data
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