efile Public Visual Render
ObjectId: 202242279349303759 - Submission: 2022-08-15
TIN: 56-0845796
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
CUMBERLAND COUNTY HOSPITAL SYSTEM INC
Employer identification number
56-0845796
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)
BLADEN COUNTY HEALTHCARE LLC
PO BOX 2000
FAYETTEVILLE
,
NC
28302
80-0164702
HEALTH SERVICES
NC
42,708,726
36,697,487
CCHS
(2)
CUMBERLAND HEALTH AFF LLC (INACTIVE)
PO BOX 2000
FAYETTEVILLE
,
NC
28302
56-2275588
HEALTH SERVICES
NC
0
0
CCHS
(3)
VALLEY HEALTH FACILITIES LLC (INACTIVE)
PO BOX 2000
FAYETTEVILLE
,
NC
28302
20-4268819
HEALTH SERVICES
NC
0
0
CCHS
(4)
HOKE HEALTHCARE LLC
PO BOX 2000
FAYETTEVILLE
,
NC
28302
27-2763125
HEALTH SERVICES
NC
77,963,883
126,448,474
CCHS
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)
CAPE FEAR VALLEY MEDICAL FOUNDATION
PO BOX 87526
FAYETTEVILLE
,
NC
28304
56-1947017
FUNDRAISING
NC
501(C)(3)
7
CCHS
Yes
(2)
BLADEN COUNTY HOSPITAL FOUNDATION INC
PO BOX 398
ELIZABETHTOWN
,
NC
28337
56-1833893
FUNDRAISING
NC
501(C)(3)
7
CCHS
Yes
(3)
HARNETT HEALTH SYSTEM INC
PO BOX 1706
DUNN
,
NC
28335
56-0603898
HEALTH SERVICES
NC
501(C)(3)
3
CCHS
Yes
(4)
HARNETT HEALTH SYSTEM FOUNDATION
800 TILGMAN DRIVE
DUNN
,
NC
28334
20-1929953
FUNDRAISING
NC
501(C)(3)
7
N/A
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)
FAYETTEVILLE AMB SURGERY CENTER
1781 METROMEDICAL DRIVE
FAYETTEVILLE
,
NC
28304
56-1754482
HEALTHCARE
NC
CCHS
RELATED
1,014,896
6,421,310
No
Yes
68.320 %
(2)
THE MED IMAGING CENTER LLC
3186 VILLAGE DRIVE STE 101
FAYETTEVILLE
,
NC
28304
26-4473832
HEALTHCARE
NC
CCHS
RELATED
481,808
474,613
No
No
67.800 %
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)
HIGHSMITH-RAINEY MED ARTS CENTER ASSOC
PO BOX 2000
FAYETTEVILLE
,
NC
28302
56-1747424
RENTAL ASSOC.
NC
CCHS
C
100,732
724,998
100.000 %
Yes
(2)
CUMBERLAND HLTH PARTNERS INC (INACTIVE)
PO BOX 2000
FAYETTEVILLE
,
NC
28302
56-2043978
BEHAVIORAL HEALTH
NC
CCHS
C
100.000 %
Yes
(3)
CAPE FEAR INSURANCE LTD
PO BOX 30600 SMB WEST BAY RD
GRAND CAYMAN
CJ
98-0449284
INSURANCE
CJ
CCHS
C
-5,674,134
64,198,763
100.000 %
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
No
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
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
Yes
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)
CAPE FEAR VALLEY MEDICAL FOUNDATION
B
240,000
CASH
(2)
CAPE FEAR VALLEY MEDICAL FOUNDATION
C
260,691
CASH
(3)
CAPE FEAR VALLEY MEDICAL FOUNDATION
N
8,168
CASH
(4)
CAPE FEAR VALLEY MEDICAL FOUNDATION
O
295,692
CASH
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
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