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Object ID: 202233139349303518 - Rendered 2024-04-30
TIN: 39-0812532
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
21
Open to Public Inspection
Name of the organization
CHILDREN'S HOSPITAL OF WISCONSIN INC
Employer identification number
39-0812532
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)
EVERGREEN LIGHTNING LLC
9000 W WISCONSIN AVE PO BOX 1997
MILWAUKEE
,
WI
53201
85-3040699
REAL ESTATE HOLDING COMPANY
WI
-10,772
-10,772
CHILDREN'S HOSPITAL OF WISCONSIN INC
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)
CHILDREN'S HOSPITAL & HEALTH SYSTEM INC
PO BOX 1997 MS 900
MILWAUKEE
,
WI
532011997
39-1500074
AMBULATORY SURGERY CTR, URGENT CARE, & OPERATIONAL SPPT SVCS
WI
501(C)(3)
LINE 3
N/A
No
(2)
CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC
PO BOX 1997 MS 900
MILWAUKEE
,
WI
532011997
39-1500075
FUND DEVELOPMENT
WI
501(C)(3)
LINE 7
CHILDREN'S HOSPITAL & HEALTH SYSTEM INC
Yes
(3)
CHILDREN'S MEDICAL GROUP INC
PO BOX 1997 MS 900
MILWAUKEE
,
WI
532011997
39-1789197
PEDIATRIC PHYSICIAN SERVICES
WI
501(C)(3)
LINE 3
CHILDREN'S HOSPITAL & HEALTH SYSTEM INC
Yes
(4)
CHILDREN'S SERVICE SOCIETY OF WISCONSIN
PO BOX 1997 MS 900
MILWAUKEE
,
WI
532011997
39-0806380
CHILD WELL-BEING SERVICES
WI
501(C)(3)
LINE 7
CHILDREN'S HOSPITAL & HEALTH SYSTEM INC
Yes
(5)
CHORUS COMMUNITY HEALTH PLANS INC
PO BOX 1997 MS 900
MILWAUKEE
,
WI
532011997
27-1494977
WISCONSIN MEDICAID HMO
WI
501(C)(3)
LINE 10
CHILDREN'S HOSPITAL & HEALTH SYSTEM INC
Yes
(6)
MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS INC
8701 WATERTOWN PLANK ROAD
MILWAUKEE
,
WI
53226
39-1341366
GRADUATE MEDICAL EDUCATION SUPPORT
WI
501(C)(3)
LINE 12A, I
N/A
No
(7)
CHILDREN'S SPECIALTY GROUP INC
999 N 92ND ST SUITE C740
MILWAUKEE
,
WI
53226
39-1990012
PEDIATRIC PHYSICIAN SERVICES
WI
501(C)(3)
LINE 12A, I
N/A
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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)
WEST ALLIS PRESCRIPTION CENTER INC
6737 W WASHINGTON ST STE 1100
WEST ALLIS
,
WI
53214
46-3421597
PHARMACY
WI
N/A
C
No
(2)
WAUWATOSA PRESCRIPTION CENTER INC SKYWALK PHARMACY
9000 W WISCONSIN AVE
WAUWATOSA
,
WI
53226
06-1654484
PHARMACY
WI
N/A
C
No
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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
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
Yes
e
Loans or loan guarantees by related organization(s)
............................
1e
Yes
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
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
No
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)
CHILDREN'S SERVICE SOCIETY OF WISCONSIN
B
8,913,054
CASH PAID/RECEIVED
(2)
CHILDREN'S MEDICAL GROUP INC
B
13,396,351
CASH PAID/RECEIVED
(3)
CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC
C
9,052,012
CASH PAID/RECEIVED
(4)
CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC
E
460,814,619
NET BOOK VALUE
(5)
CHILDREN'S COMMUNITY HEALTH PLAN INC - PATIENT REIMBURSEMENT
L
31,942,719
CASH PAID/RECEIVED
(6)
CHILDREN'S MEDICAL GROUP INC
Q
228,413
CASH PAID/RECEIVED
(7)
CHILDREN'S MEDICAL GROUP INC
S
76,000,000
CASH PAID/RECEIVED
(8)
CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION INC
S
35,900,000
CASH PAID/RECEIVED
(9)
CHILDREN'S SERVICE SOCIETY OF WISCONSIN
S
40,020,859
CASH PAID/RECEIVED
(10)
CHILDREN'S COMMUNITY HEALTH PLAN INC - ASSESSMENT PASS THROUGH PAYMENTS
S
20,045,075
CASH PAID/RECEIVED
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
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) 2021
Schedule R (Form 990) 2021
Page
5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference
Explanation
SCHEDULE R, PART V, LINE 1E
PURSUANT TO AN AMENDED AND RESTATED MASTER TRUST INDENTURE DATED DECEMBER 1, 2017, CHILDREN'S HOSPITAL OF WISCONSIN, INC. AND CHILDREN'S HOSPITAL OF WISCONSIN FOUNDATION, INC. ARE MEMBERS OF AN OBLIGATED GROUP WHICH JOINTLY AND SEVERALLY GUARANTEE CERTAIN DEBT ISSUED BY A MEMBER OF THE OBLIGATED GROUP THROUGH THE WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY. PAYMENT OF SCHEDULED PRINCIPAL AND INTEREST IS SECURED BY A PLEDGE OF THE HOSPITAL'S AND FOUNDATION'S GROSS UNRESTRICTED RECEIPTS.
Schedule R (Form 990) 2021
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