efile Public Visual Render
ObjectId: 202221309349303157 - Submission: 2022-05-10
TIN: 55-0689535
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
LIABILITY INSURANCE TRUST FOR MONONGALIA
HEALTH SYSTEM
Employer identification number
55-0689535
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)
MONONGALIA HEALTH SYSTEM
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
55-0621551
PARENT/MANAGEMENT COMPANY
WV
501(C)(3)
LINE 12C, III-FI
No
(2)
MONONGALIA COUNTY GENERAL HOSPITAL CO
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
23-7441353
HOSPITAL
WV
501(C)(3)
LINE 3
MONONGALIA HEALTH SYSTEM INC
No
(3)
MON ELDER SERVICES INC
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
31-1520863
RETIREMENT COMMUNITY
WV
501(C)(3)
LINE 12C, III-FI
MONONGALIA HEALTH SYSTEM INC
No
(4)
THE FOUNDATION OF MONONGALIA GENERAL HOSPITAL
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
55-0570338
RAISE FUNDS FOR MONONGALIA GENERAL HOSPITAL
WV
501(C)(3)
LINE 7
MONONGALIA COUNTY GENERAL HOSPITAL CO
No
(5)
PRESTON MEMORIAL HOSPITAL
300 SOUTH PRICE STREET
KINGWOOD
,
WV
26537
31-1097818
HOSPITAL
WV
501(C)(3)
LINE 3
MONONGALIA HEALTH SYSTEM INC
No
(6)
PRESTON MEMORIAL MEDICAL GROUP
300 SOUTH PRICE STREET
KINGWOOD
,
WV
26537
55-0717988
PRIMARY AND URGENT CARE
WV
501(C)(3)
LINE 3
PRESTON MEMORIAL HOSPITAL
No
(7)
PRESTON MEMORIAL HEALTH FOUNDATION
300 SOUTH PRICE STREET
KINGWOOD
,
WV
26537
55-0740121
RAISE FUNDS FOR PRESTON HOSPITAL
WV
501(C)(3)
LINE 12B, II
PRESTON MEMORIAL HOSPITAL
No
(8)
AUXILIARY OF MONONGALIA GENERAL HOSPITAL
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
55-0362965
RAISE FUNDS FOR MONONGALIA GENERAL HOSPITAL
WV
501(C)(3)
LINE 12A, I
MONONGALIA COUNTY GENERAL HOSPITAL CO
No
(9)
STONEWALL JACKSON MEMORIAL HOSPITAL
230 HOSPITAL PLAZA
WESTON
,
WV
26452
55-0422958
HOSPITAL
WV
501(C)(3)
LINE 3
MONONGALIA HEALTH SYSTEM INC
No
(10)
MON HEALTH MARION NEIGHBORHOOD HOSPITAL
140 MIDDLETOWN LOOP
WHITEHALL
,
WV
26554
85-3994078
HOSPITAL
WV
501(C)(3)
LINE 3
MONONGALIA HEALTH SYSTEM INC
No
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)
MGH SURGERY LLC
2000 MON HEALTH MEDICAL PARK DR
MORGANTOWN
,
WV
26505
47-2736896
SURGERY CENTER
WV
N/A
No
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)
MON HEALTH CARE INC
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26508
55-0654973
HOME MEDICAL EQUIPMENT PROVIDER
WV
N/A
C
No
(2)
STONEWALL HOME OXYGEN THERAPY INC
100 MARKET PLACE MALL SUITE 8
WESTON
,
WV
26452
55-0754278
OXYGEN THERAPY SERVICES
WV
N/A
C
No
(3)
FAIRMONT HOME EQUIPMENT AND SUPPLY
1200 JD ANDERSON DRIVE
MORGANTOWN
,
WV
26505
55-0763259
EQUIPMENT RENT & SVC
WV
N/A
C
No
(4)
MORGANTOWN PHYSICAL THERAPY ASSOC INC
943 MAPLE DRIVE
MORGANTOWN
,
WV
26505
55-0614636
REHABILITATION SERVICES
WV
N/A
C
No
(5)
CARE PARTNER'S INC
511 BURROUGHS STREET SUITE 102
MORGANTOWN
,
WV
26505
55-0754326
HOME HEALTH
WV
N/A
C
No
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
No
b
Gift, grant, or capital contribution to related organization(s)
............................
1b
No
c
Gift, grant, or capital contribution from related organization(s)
............................
1c
No
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
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
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
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 (Form 990) 2020
Additional Data
Software ID:
Software Version: