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ObjectId: 202413149349300106 - Submission: 2024-11-09
TIN: 55-0359755
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Schedule K
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information on Tax-Exempt Bonds
Complete if the organization answered "Yes" to Form 990, Part
Ⅵ
, line 24a. Provide descriptions,
explanations, and any additional information in Part
Ⅵ
.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
23
Open to Public
Inspection
Name of the organization
Jefferson Memorial Hospital
Employer identification number
55-0359755
Part
Ⅰ
Bond Issues
(a)
Issuer name
(b)
Issuer EIN
(c)
CUSIP #
(d)
Date issued
(e)
Issue price
(f)
Description of purpose
(g)
Defeased
(h)
On
behalf of
issuer
(i)
Pool
financing
Yes
No
Yes
No
Yes
No
A
West Virginia Hospital Finance Authority
62-1256910
000000000
08-01-2012
2,293,805
2012 C - Refund 2008 D Bond
B
West Virginia Hospital Finance Authority
62-1256910
956622P32
08-01-2018
26,285,349
2018 E - Refund 2012 E issuances
Part
Ⅱ
Proceeds
A
B
C
D
1
Amount of bonds retired
..................
1,238,095
8,953,178
2
Amount of bonds legally defeased
..............
3
Total proceeds of issue
..................
2,293,805
26,355,064
4
Gross proceeds in reserve funds
.............
5
Capitalized interest from proceeds
.............
6
Proceeds in refunding escrows
...............
7
Issuance costs from proceeds
...............
9,650
184,331
8
Credit enhancement from proceeds
.............
9
Working capital expenditures from proceeds
.............
10
Capital expenditures from proceeds
.............
11
Other spent proceeds
.............
2,284,155
26,101,018
12
Other unspent proceeds
.............
13
Year of substantial completion
.............
2008
2008
Yes
No
Yes
No
Yes
No
Yes
No
14
Were the bonds issued as part of a current refunding issue of tax-exempt
bonds (or, if issued prior to 2020, a current refunding issue)?
........
X
X
15
Were the bonds issued as part of an advance refunding issue of taxable
bonds (or, if issued prior to 2020, an advance refunding issue)?
........
X
X
16
Has the final allocation of proceeds been made?
..........
X
X
17
Does the organization maintain adequate books and records to support the final allocation of proceeds?
..................
X
X
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50193E
Schedule K (Form 990) 2023
Page 2
Schedule K (Form 990) 2023
Page
2
Part
Ⅲ
Private Business Use
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
1
Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds?
.............
X
X
2
Are there any lease arrangements that may result in private business use of bond-financed property?
...............
X
X
3a
Are there any management or service contracts that may result in private business use of bond-financed property?
.............
X
X
b
If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
X
X
c
Are there any research agreements that may result in private business use of bond-financed property?
.............
X
X
d
If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
X
X
4
Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government
....
5
Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government
.........
6
Total of lines 4 and 5
.............
7
Does the bond issue meet the private security or payment test?
...
X
X
8a
Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were
issued?
.............
X
X
b
If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of.
..
2.040 %
c
If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2?
.............
X
9
Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under
Regulations sections 1.141-12 and 1.145-2?
........
X
X
Part
Ⅳ
Arbitrage
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
1
Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate?
...
X
X
2
If "No" to line 1, did the following apply?
....
a
Rebate not due yet?
.......
X
X
b
Exception to rebate?
........
X
X
c
No rebate due?
.........
X
X
If "Yes" to line 2c, provide in Part
Ⅵ
the date the rebate
computation was performed
......
3
Is the bond issue a variable rate issue?
.....
X
X
Schedule K (Form 990) 2023
Page 3
Schedule K (Form 990) 2023
Page
3
Part
Ⅳ
Arbitrage
(Continued)
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
4a
Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?
X
X
b
Name of provider
..........
c
Term of hedge
.........
d
Was the hedge superintegrated?
......
e
Was the hedge terminated?
........
5a
Were gross proceeds invested in a guaranteed investment contract (GIC)?
X
X
b
Name of provider
..........
c
Term of GIC
.........
d
Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied?
........
6
Were any gross proceeds invested beyond an available temporary period?
X
X
7
Has the organization established written procedures to monitor the requirements of section 148?
...
X
X
Part
Ⅴ
Procedures To Undertake Corrective Action
A
B
C
D
Yes
No
Yes
No
Yes
No
Yes
No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?
X
X
Part
Ⅵ
Supplemental Information.
Provide additional information for responses to questions on Schedule K. (See instructions).
Return Reference
Explanation
Part I
Prior to 2022 filings - West Virginia University Hospitals, Inc. WVUH, as parent company to City Hospital, Inc., The Charles Town General Hospital dba Jefferson Medical Center, and University Healthcare Foundation, Inc., reported bond issuances allocated to WVUH subsidiaries. During 2022 corporate organizational documents updated the structure of the West VIrginia United Health System, as a result The Charles Town General Hospital dba Jefferson Medical Center will be reporting bond issuances allocated to them going forward. All other members of the obligated group will be reporting issuances allocated to them. Several bond issuances were issued in multiple series and each series is reported in this tax return separately. For each series identified in Schedule K, Part I, the taxpayer will reconcile the series amount reported in this tax return and the tax return filed by other members of the obligated group to the applicable 8038 filed with the IRS for each bond issuance.
Part I Line A
The 2012 Series C Bonds issue price 23,770,000 were issued collectively with 2012 Series A Bonds issue price 38,145,000 and 2012 Series B Bonds issue price 50,080,000 totaling 111,995,000 total issue price for all three series reported on Form 8038 for August 1, 2012 issuance. The full Series A Bonds were allocated to United Hospital Center, Inc. UHC and were refunded with tax-exempt bonds in 2018 that is reported on the UHC Schedule K. The full Series B Bonds were allocated toCamden-Clark Memorial Hospital Corporation d/b/a Camden Clark Medical Center CCMC and were refunded with taxable debt in 2015. The 2012 C Bonds was allocated to City Hospital 80.46 Jefferson Medical Center 9.65, and University Healthcare Foundation 9.89.
Part I Line B
The 2018 Series E Bonds issue price 57,910,000 were issued collectively with 2018 Series C Bonds issue price 56,880,000 and 2018 Series D Bonds issue price 23,680,000 totaling 138,470,000 total issue price for all three series reported on Form 8038 for August 7/31/18 issuance. The 2018 E Series was allocated between City Hospital, Inc 54.61 and Jefferson Medical Center 45.39. The Series C Bonds were allocated to CCMC and will be reported on its Schedule K. The Series D Bonds were allocated to UHC and will be reported on its Schedule K.
Part IV Line 2c
Column A - A rebate calculation was prepared for the issuance date through August 1, 2022. The report indicates that no rebate is due. The next computation date is August 1, 2027. Column B - A rebate calculation was prepared for the issuance date through July 31, 2023. The report indicates that no rebate is due. The next computation date is July 31, 2028.
Part II Line 3
Column B - The amount reported is greater than the amount of bonds issued as a result of a balance that remained in the debt service fund. These amounts funds will be applied to future payments of principal and interest.
Schedule K (Form 990) 2023
Additional Data
Software ID:
23017659
Software Version:
23.1.0.0