SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
right arrowComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
right arrowAttach to Form 990.
right arrow Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2022
Open to Public Inspection
Name of the organization
TRI-COUNTY MEMORIAL HOSPITAL INC
 
Employer identification number

39-0704510
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)BELLIN GUNDERSEN HEALTH SYSTEM INC
1836 SOUTH AVENUE

LA CROSSE,WI54601
92-0504278
PARENT WI 501(C)(3) LINE 12B, II N/A
 
No
(2)BELLIN HEALTH SYSTEMS INC
744 SOUTH WEBSTER AVE

GREEN BAY,WI54301
39-1512904
SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(C)(3) LINE 12B, II N/A
 
No
(3)BELLIN COLLEGE INC
3201 EATON ROAD

GREEN BAY,WI54311
39-1620530
NURSING COLLEGE WI 501(C)(3) LINE 2 BELLIN HEALTH SYSTEMS INC
 
Yes
 
(4)BELLIN MEMORIAL HOSPITAL INC
744 SOUTH WEBSTER AVE

GREEN BAY,WI54301
39-0884478
HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC
 
Yes
 
(5)BELLIN PSYCHIATRIC CENTER INC
PO BOX 23725

GREEN BAY,WI54305
39-1657627
PSYCHIATRIC HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC
 
Yes
 
(6)THE BELLIN HEALTH FOUNDATION INC
744 SOUTH WEBSTER AVE

GREEN BAY,WI54301
39-1809171
FOUNDATION WI 501(C)(3) LINE 7 BELLIN HEALTH SYSTEMS INC
 
Yes
 
(7)GUNDERSEN LUTHERAN HEALTH SYSTEM INC
1836 SOUTH AVENUE

LA CROSSE,WI54601
39-1866425
SUPPORTING ORGANIZATION WI   LINE 12B, II N/A
 
No
(8)GUNDERSEN ADMINISTRATIVE SERVICES INC
1910 SOUTH AVENUE

LA CROSSE,WI54601
39-1606449
SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12B, II GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(9)GUNDERSEN CLINIC LTD
1836 SOUTH AVENUE

LA CROSSE,WI54601
39-1028657
HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(10)GUNDERSEN LUTHERAN CREDENTIALING SERVICES INC
1910 SOUTH AVENUE

LA CROSSE,WI54601
39-1856898
CREDENTIALING SERVICES WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(11)GUNDERSEN LUTHERAN MEDICAL CENTER INC
1910 SOUTH AVENUE

LA CROSSE,WI54601
39-0813416
HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(12)GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC
1836 SOUTH AVENUE

LA CROSSE,WI54601
39-1249705
FOUNDATION WI 501(C)(3) LINE 7 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(13)LAKE MICHIGAN HEALTH SERVICES INC
744 SOUTH WEBSTER AVE

GREEN BAY,WI54301
39-1512903
SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(C)(3) LINE 12B, II BELLIN HEALTH SYSTEMS INC
 
Yes
 
(14)LUTHERAN HOUSING OF LA CROSSE INC
1900 SOUTH AVENUE

LA CROSSE,WI54601
39-1751934
INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP
 
Yes
 
(15)LUTHERAN REAL ESTATE HOLDING CORPORATION
1910 SOUTH AVENUE

LA CROSSE,WI56401
39-1480826
HOUSING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(16)COMMUNITY HOUSING OF LA CROSSE INC
1900 SOUTH AVENUE

LA CROSSE,WI54601
39-1586700
INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP
 
Yes
 
(17)TWEETEN LUTHERAN HEALTHCARE CENTER INC
125 FIFTH AVENUE SE

SPRING GROVE,MN55974
41-1565003
HEALTH CARE MN 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(18)HARMONY COMMUNITY HEALTHCARE INC
815 MAIN AVENUE S

HARMONY,MN55939
41-0711606
HEALTH CARE MN 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(19)MEMORIAL HEALTHCARE FOUNDATION INC
PO BOX 40

FRIENDSHIP,WI53934
39-1775074
FOUNDATION WI 501(C)(3) LINE 12A, I MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC
 
Yes
 
(20)MEMORIAL HOSPITAL OF BOSCOBEL
205 PARKER STREET

BOSCOBEL,WI53805
39-0845590
HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(21)MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC
402 W LAKE STREET

FRIENDSHIP,WI53934
39-0944012
HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTERHAN HEALTH SYSTEM INC
 
Yes
 
(22)OCONTO HOSPITAL & MEDICAL CENTER INC
820 ARBUTUS AVENUE

OCONTO,WI54153
06-1745397
HOSPITAL WI 501(C)(3) LINE 3 BELLIN MEMORIAL HOSPITAL INC
 
Yes
 
(23)SAINT ELIZABETH'S HOSPITAL OF WABASHA
1200 5TH GRANT BOULEVARD WEST

WABASHA,MN55981
41-0693877
HEALTH CARE MN 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(24)ST JOSEPH'S HEALTH SERVICES INC
400 WATER AVENUE

HILLSBORO,WI54634
39-0929538
HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(25)ST JOSEPH'S MEMORIAL FOUNDATION INC
400 WATER AVENUE

HILLSBORO,WI54634
39-1455787
FOUNDATION WI 501(C)(3) LINE 12A, I ST JOSEPH'S HEALTH SERVICES INC
 
Yes
 
(26)TRI-COUNTY MEMORIAL FOUNDATION INC
18601 LINCOLN STREET

WHITEHALL,WI54773
30-0093022
FOUNDATION WI 501(C)(3) LINE 12A, I TRI-COUNTY MEMORIAL HOSPITAL INC
 
Yes
 
(27)TRI-STATE AMBULANCE INC
235 CAUSEWAY BLVD

LA CROSSE,WI54603
39-1965415
MEDICAL TRANSPORTATION WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(28)TRI-STATE REGIONAL AMBULANCE INC
235 CAUSEWAY BLVD

LA CROSSE,WI54603
39-1962965
MEDICAL TRANSPORTATION WI 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
(29)PALMER LUTHERAN HEALTH CENTER
112 JEFFERSON STREET

WEST UNION,IA52175
42-1320763
HEALTH CARE IA 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC
 
Yes
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2022
Page 2
Schedule R (Form 990) 2022
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) BELLIN INVESTMENTS INC

744 SOUTH WEBSTER AVE
GREEN BAY,WI54301
39-1564939
OTHER WI N/A
C         No
(2) BEL-REGIONAL HOME MEDICAL INC

617 S ROOSEVELT
GREEN BAY,WI54301
39-1504766
DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI N/A
C         No
(3) GUNDERSEN ENVISION LLC

1836 SOUTH AVENUE
LA CROSSE,WI54601
26-4706546
RENEWABLE ENERGY WI N/A
C         No








Schedule R (Form 990) 2022
Page 3
Schedule R (Form 990) 2022
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
Yes
 
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
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
Yes
 
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) 2022
Page 4
Schedule R (Form 990) 2022
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) 2022
Page 5
Schedule R (Form 990) 2022
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) 2022

Additional Data


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